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Proceedings (Baylor University. Medical... 2023We hypothesized that patients who received an adductor canal block (ACB) in the operating room following unilateral total knee arthroplasty would have a lower oral...
BACKGROUND
We hypothesized that patients who received an adductor canal block (ACB) in the operating room following unilateral total knee arthroplasty would have a lower oral morphine milligram equivalent (MME) consumption during the postanesthesia care unit (PACU) phase 1 recovery period compared to patients who received an ACB in the PACU.
METHODS
This was a retrospective cohort study of patients who underwent robotic-assisted unilateral total knee arthroplasty under general anesthesia between March 1, 2020, and February 28, 2021, and received postoperative ACB either in the operating room or the PACU.
RESULTS
A total of 36 and 178 patients received postoperative ACB in the operating room and PACU, respectively, and had median and interquartile range MME consumption in the PACU of 22.5 (20-40) mg and 30.0 (20-40) mg ( = 0.76), respectively. Patients who had an ACB performed in the operating room and PACU had median and interquartile ranges of time spent in the PACU of 101 (75-178) minutes and 186 (125-272) minutes ( < 0.01), respectively.
CONCLUSION
Patients who received an ACB in the operating room did not have a lower OME consumption than patients who received an ACB in the PACU but did have a shorter PACU length of stay.
PubMed: 37829221
DOI: 10.1080/08998280.2023.2249372 -
Physical Chemistry Chemical Physics :... Jul 2023Nanoparticles have become increasingly important for a variety of applications, including medical diagnosis and treatment, energy harvesting and storage, catalysis, and... (Review)
Review
Nanoparticles have become increasingly important for a variety of applications, including medical diagnosis and treatment, energy harvesting and storage, catalysis, and additive manufacturing. The development of nanoparticles with different compositions, sizes, and surface properties is essential to optimize their performance for specific applications. Pulsed laser ablation in liquid is a green chemistry approach that allows for the production of ligand-free nanoparticles with diverse shapes and phases. Despite these numerous advantages, the current production rate of this method remains limited, with typical rates in the milligram per hour range. To unlock the full potential of this technique for various applications, researchers have dedicated efforts to scaling up production rates to the gram-per-hour range. Achieving this goal necessitates a thorough understanding of the factors that limit pulsed laser ablation in liquid (PLAL) productivity, including laser, target, liquid, chamber, and scanner parameters. This perspective article explores these factors and provides a roadmap for increasing PLAL productivity that can be adapted to specific applications. By carefully controlling these parameters and developing new strategies for scaling up production, researchers can unlock the full potential of pulsed laser ablation in liquids.
PubMed: 37435616
DOI: 10.1039/d3cp01214j -
Frontiers in Public Health 2024Opioids are vital to pain management and sedation after trauma-related hospitalization. However, there are many confounding clinical, social, and environmental factors...
Opioids are vital to pain management and sedation after trauma-related hospitalization. However, there are many confounding clinical, social, and environmental factors that exacerbate pain, post-injury care needs, and receipt of opioid prescriptions following orthopaedic trauma. This retrospective study sought to characterize differences in opioid prescribing and dosing in a national Medicaid eligible sample from 2010-2018. The study population included adults, discharged after orthopaedic trauma hospitalization, and receiving an opioid prescription within 30 days of discharge. Patients were identified using the International Classification of Diseases (ICD-9; ICD-10) codes for inpatient diagnosis and procedure. Filled opioid prescriptions were identified from National Drug Codes and converted to morphine milligram equivalents (MME). Opioid receipt and dosage (e.g., morphine milligram equivalents [MME]) were examined as the main outcomes using regressions and analyzed by year, sex, race/ethnicity, residence rurality-urbanicity, and geographic region. The study population consisted of 86,091 injured Medicaid-enrolled adults; 35.3% received an opioid prescription within 30 days of discharge. Male patients (OR = 1.12, 95% CI: 1.07-1.18) and those between 31-50 years of age (OR = 1.15, 95% CI: 1.08-1.22) were found to have increased odds ratio of receiving an opioid within 30 days of discharge, compared to female and younger patients, respectively. Patients with disabilities (OR = 0.75, 95% CI: 0.71-0.80), prolonged hospitalizations, and both Black (OR = 0.87, 95% CI: 0.83-0.92) and Hispanic patients (OR = 0.72, 95% CI: 0.66-0.77), relative to white patients, had lower odds ratio of receiving an opioid prescription following trauma. Additionally, Black and Hispanic patients received lower prescription doses compared to white patients. Individuals hospitalized in the Southeastern United States and those between the ages of 51-65 age group were found to be prescribed lower average daily MME. There were significant variations in opioid prescribing practices by race, sex, and region. National guidelines for use of opioids and other pain management interventions in adults after trauma hospitalization may help limit practice variation and reduce implicit bias and potential harms in outpatient opioid usage.
Topics: Adult; United States; Humans; Male; Female; Middle Aged; Aged; Infant, Newborn; Analgesics, Opioid; Retrospective Studies; Medicaid; Orthopedics; Practice Patterns, Physicians'; Patient Discharge; Morphine Derivatives; Endrin
PubMed: 38596512
DOI: 10.3389/fpubh.2024.1327934 -
Medical Care Oct 2023In 2018, Nevada implemented opioid prescribing legislation (AB474) to support the uptake of CDC pain care guidelines. We studied the law's association with doses over...
BACKGROUND
In 2018, Nevada implemented opioid prescribing legislation (AB474) to support the uptake of CDC pain care guidelines. We studied the law's association with doses over threshold levels of morphine milligram equivalents (MMEs) and with time to dose increases and decreases, among long-term opioid patients.
METHODS
A difference-in-difference study examined dosing changes across opioid prescription episodes (ie, prescriptions within 30 day and within the same dosing threshold). Patients with at least 120 days supply over 6 months in Nevada and Colorado Medicaid pharmacy claims were included. Using a logistic regression model, we compare the predicted probabilities that opioid episodes exceeded 50 MME before and after implementation of the law, in both states. Adjusted hazard ratios (aHR) from a gap time survival model estimated time to escalate above 50 MME among low-dose episodes (<50 MME), and time to de-escalate below 50 MME among high-dose episodes (≥50 MME).
RESULTS
Among 453,577 episodes (74,292 patients), the Nevada law was associated with a 2.9% reduction in prescriptions over 50 MME (95% CI: -3.5, -2.3) compared with Colorado. While the law was also associated with slower escalation (Nevada: aHR = 0.75; 95% CI: 0.72, 0.77, Colorado: aHR = 1.04; 95% CI: 1.01, 1.06), it was also associated with slower de-escalation (Nevada: aHR = 0.87; 95% CI: 0.84, 0.89, Colorado: aHR = 0.97; 95% CI: 0.96, 0.99).
CONCLUSIONS
Slower dose escalations, rather than faster dose de-escalation, likely explain post-law reductions in doses over 50 MME. Slower dose de-escalations may be due to longer days supply post-policy.
Topics: Humans; Analgesics, Opioid; Pain, Postoperative; Practice Patterns, Physicians'; Retrospective Studies; United States; Drug Administration Schedule
PubMed: 37582299
DOI: 10.1097/MLR.0000000000001907 -
The American Journal of Drug and... Nov 2023There is currently no format-independent method to determine delta-9-tetrahydrocannabinol (THC) in milligrams for self-report studies. Validate self-report method for...
There is currently no format-independent method to determine delta-9-tetrahydrocannabinol (THC) in milligrams for self-report studies. Validate self-report method for quantifying mg THC from commercially available cannabis products using product labeling, which includes both net weight and product potency. 53 adult cannabis users (24 M, 29F), 21-39 years of age ( = 28.38, SD = 4.15), were instructed to report daily use via a weekly survey for two consecutive weeks, provide product label photographs, abstain from use for 24 h, submit a urine sample and complete the Cannabis Use Disorder Identification Test - Revised (CUDIT-R) and the Marijuana Craving Questionnaire - Short Form (MCQ-SF). Milligrams of THC were determined by multiplying quantity of product used by its THC concentration. Urine was analyzed for the urine metabolite 11-nor-carboxy-THC (THC-COOH) via liquid chromatography mass spectroscopy. THC and THC-COOH values were log10 transformed prior to correlational analyses. Median daily THC consumption was 102.53 mg ( = 203.68, SD = 268.13). Thirty-three (62%) of the 53 participants reported using two or more formats over the 2-week period. There was a significant positive correlation between log10 THC-COOH and log10 THC mg (r(41) = .59, < .001), log10 THC mg and MCQ-SF score (r(41) = .59, < .001), and log10 THC mg dose and CUDIT-R score, (r(41) = .39, = .010). Our label-based methodology provides consumption information across all modalities of cannabis use in standard units that can be combined across products for calculation of dose. It is a viable and valid method for quantifying mg of THC consumed and can be utilized in any region where cannabis is legal, and labeling is regulated.
Topics: Adult; Humans; Cannabis; Dronabinol; Self Report; Gas Chromatography-Mass Spectrometry; Hallucinogens; Cannabinoid Receptor Agonists; Substance Abuse Detection
PubMed: 37506343
DOI: 10.1080/00952990.2023.2232525 -
JAMA Health Forum Oct 2023Insurers are increasingly limiting the duration of opioid prescriptions for acute pain. Among patients undergoing surgery, it is unclear whether implementation of these...
IMPORTANCE
Insurers are increasingly limiting the duration of opioid prescriptions for acute pain. Among patients undergoing surgery, it is unclear whether implementation of these limits is associated with changes in opioid prescribing and patient-reported outcomes, such as pain.
OBJECTIVE
To assess changes in surgical opioid prescribing and patient-reported outcomes after implementation of an opioid prescribing limit by a large commercial insurer in Michigan.
DESIGN, SETTING, AND PARTICIPANTS
This was a cross-sectional study with an interrupted time series analysis. Data analyses were conducted from October 1, 2022, to February 28, 2023. The primary data source was the Michigan Surgical Quality Collaborative, a statewide registry containing data on opioid prescribing and patient-reported outcomes from adults undergoing common general surgical procedures. This registry is linked to Michigan's prescription drug monitoring program database, allowing observation of opioid dispensing. The study included 6045 adults who were covered by the commercial insurer and underwent surgery from January 1, 2017, to October 31, 2019.
EXPOSURE
Policy limiting opioid prescriptions to a 5-day supply in February 2018.
MAIN OUTCOMES AND MEASURES
Among all patients, segmented regression models were used to assess for level or slope changes during February 2018 in 3 patient-reported outcomes: pain in the week after surgery (assessed on a scale of 1-4: 1 = none, 2 = minimal, 3 = moderate, and 4 = severe), satisfaction with surgical experience (scale of 0-10, with 10 being the highest satisfaction), and amount of regret regarding undergoing surgery (scale of 1-5, with 1 being the highest level of regret). Among patients with a discharge opioid prescription and a dispensed opioid prescription (prescription filled within 3 days of discharge), additional outcomes included total morphine milligram equivalents in these prescriptions, a standardized measure of opioid volume.
RESULTS
Among the 6045 patients included in the study, mean (SD) age was 48.7 (12.6) years and 3595 (59.5%) were female. Limit implementation was not associated with changes in patient-reported satisfaction or regret and was associated with only a slight level decrease in patient-reported pain score (-0.15 [95% CI, -0.26 to -0.03]). Among 4396 patients (72.7%) with a discharge and dispensed opioid prescription, limit implementation was associated with a -22.3 (95% CI, -32.8 to -11.9) and -26.1 (95% CI, -40.9 to -11.3) level decrease in monthly mean total morphine milligram equivalents of discharge and dispensed opioid prescriptions, respectively. These decreases corresponded approximately to 3 to 3.5 pills containing 5 mg of oxycodone.
CONCLUSIONS
This cross-sectional analysis of data from adults undergoing general surgical procedures found that implementation of an insurer's limit was associated with modest reductions in opioid prescribing but not with worsened patient-reported outcomes. Whether these findings generalize to other procedures warrants further study.
Topics: Adult; Humans; Female; Middle Aged; Male; Analgesics, Opioid; Cross-Sectional Studies; Insurance Carriers; Pain, Postoperative; Practice Patterns, Physicians'; Oxycodone; Patient Reported Outcome Measures
PubMed: 37831460
DOI: 10.1001/jamahealthforum.2023.3541 -
The Journal of Knee Surgery May 2024Increased exposure to opioids around total knee arthroplasty (TKA) can lead to a risk of long-term dependence. We hypothesized that performing simultaneous bilateral... (Review)
Review
Increased exposure to opioids around total knee arthroplasty (TKA) can lead to a risk of long-term dependence. We hypothesized that performing simultaneous bilateral total knee arthroplasty (simBTKA) over staged surgery (staged bilateral total knee arthroplasty [stgBTKA]) may decrease the total amount of opiates used. We retrospectively reviewed 29 patients who underwent simBTKAs performed between February 2015 and November 2020 and identified 23 that did not use opioids ≤90 days prior to surgery. These were frequency matched for gender and body mass index to 50 stgBTKAs completed within 6 months who also were opioid-free ≤90 days prior to their first surgery. Using our state's prescription database, we reviewed postsurgery opioid refills and morphine milligram equivalents (MMEs) for the two groups and compared their initial MME prescription at discharge and their total MME consumption 6 months postoperatively. Total MME consumption for the stgBTKA group included all prescriptions following the first and 6 months after the second surgery, whereas for the simBTKA group, total consumption included the 6 months after their two same-day surgeries. The simBTKA group had more MMEs prescribed initially (median = 375) than did the stgBTKA group after second surgery (median = 300; < 0.007), larger postoperative-refill MMEs in the first 30 days (median = 300) than stgBTKA (median = 0; = 0.221) and increased total MME consumption 6 months after surgery (median = 675) compared with stgBTKA after second surgery (median = 450; = 0.077). However, both groups had similar monthly consumptions rates, with medians I MMEs/month of 112 for simBTKA versus 96 for stgBTKA ( = 0.585). Our results suggest there is no significant difference in opioid consumption between simBTKA and stgBTKA. In fact, we found that simBTKA patients received larger opioid amounts in the immediate postoperative period as well as slightly larger amounts at 30 days.
Topics: Humans; Analgesics, Opioid; Arthroplasty, Replacement, Knee; Retrospective Studies; Pain, Postoperative; Postoperative Period; Practice Patterns, Physicians'; Endrin
PubMed: 37852291
DOI: 10.1055/s-0043-1775872 -
The Journal of Trauma and Acute Care... Mar 2024Alcohol withdrawal syndrome (AWS) represents significant cost to the hospitalized trauma population from a clinical and financial perspective. Historically, AWS has been...
BACKGROUND
Alcohol withdrawal syndrome (AWS) represents significant cost to the hospitalized trauma population from a clinical and financial perspective. Historically, AWS has been managed with benzodiazepines. Despite their efficacy, benzodiazepines carry a heavy adverse effect profile. Recently, benzodiazepine-sparing protocols for the prophylaxis and treatment of AWS have been used in medical patient populations. Most existing benzodiazepine-sparing protocols use phenobarbital, while ours primarily uses gabapentin and clonidine, and no such protocol has been developed and examined for safety and efficacy specifically within a trauma population.
METHODS
In December of 2019, we implemented our benzodiazepine-sparing protocol for trauma patients identified at risk for alcohol withdrawal on admission. Trauma patients at risk for AWS admitted to an academic Level 1 trauma center before (conventional) and after (benzodiazepine-sparing [BS]) protocol implementation were compared. Outcomes examined include morphine milligram equivalent dosing rates and lorazepam equivalent dosing rates as well as the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scores, hospital length of stay, intensive care unit length of stay, and ventilator days.
RESULTS
A total of 387 conventional and 134 benzodiazepine sparing patients were compared. Injury Severity Score (13 vs. 16, p = 0.10) and admission alcohol levels (99 vs. 149, p = 0.06) were similar. Patients in the BS pathway had a lower maximum daily CIWA-Ar (2.7 vs. 1.5, p = 0.04). While mean morphine milligram equivalent per day was not different between groups (31.5 vs. 33.6, p = 0.49), mean lorazepam equivalents per day was significantly lower in the BS group (1.1 vs. 0.2, p < 0.01). Length of stay and vent days were not different between the groups.
CONCLUSION
Implementation of a benzodiazepine-sparing pathway that uses primarily clonidine and gabapentin to prevent and treat alcohol withdrawal syndrome in trauma patients is safe, reduces the daily maximum CIWA-Ar, and significantly decreases the need for benzodiazepines. Future studies will focus on outcomes affected by avoiding AWS and benzodiazepines in the trauma population.
LEVEL OF EVIDENCE
Therapeutic/Care Management; Level IV.
Topics: Humans; Benzodiazepines; Substance Withdrawal Syndrome; Alcoholism; Lorazepam; Gabapentin; Clonidine; Alcohol Withdrawal Delirium; Retrospective Studies; Ethanol; Morphine Derivatives
PubMed: 37934662
DOI: 10.1097/TA.0000000000004188 -
American Journal of Obstetrics and... Apr 2024Although cesarean delivery is the most common surgery performed in the United States, prescribing practices for analgesia vary. Strategies to manage postpartum pain have...
BACKGROUND
Although cesarean delivery is the most common surgery performed in the United States, prescribing practices for analgesia vary. Strategies to manage postpartum pain have mostly focused on the immediate postpartum period when patients are still admitted to the hospital. At discharge, most providers prescribe a fixed number of opioid tablets. Most patients do not use all the opioids that they are prescribed at hospital discharge. This leads to an excess of opioids in the community, which can ultimately lead to misuse and diversion.
OBJECTIVE
This study aimed to determine whether a transition from universal opioid prescribing to a personalized, patient-specific protocol decreases morphine milligram equivalents prescribed at hospital discharge after cesarean delivery while adequately controlling pain.
STUDY DESIGN
This was a prospective cohort study of patients undergoing cesarean delivery before and after the implementation of a personalized opioid-prescribing practice at the time of hospital discharge. Each patient was prescribed scheduled ibuprofen and acetaminophen, with a prescription for oxycodone tablets equal to 5 times the morphine milligram equivalents used in the 24 hours before discharge, calculated via an electronic order set. The previous traditional cohorts were routinely prescribed 30 tablets of acetaminophen-codeine 300/30 mg. The primary outcome was morphine milligram equivalents prescribed at discharge. A hotline to address pain control issues after discharge was established, and calls, emergency department visits, and readmissions were examined. Statistical analyses was performed using chi-square and Wilcoxon rank-sum test, with a P value of <.05 considered statistically significant.
RESULTS
Overall, 412 patients underwent cesarean delivery in the 6 weeks after initiation of the personalized prescribing protocol and were compared with 367 patients before the change. The median morphine milligram equivalents prescribed at discharge was lower with personalized prescribing (37.5 [interquartile range, 0-75] vs 135 [interquartile range, 135-135]; P<.001). Moreover, 176 patients (43%) were not prescribed opioids at discharge, which was a substantial change as all 367 patients in the traditional cohort received opioids at discharge (P<.001). Of note, 9 hotline phone calls were received; none required additional opioids after a 24-hour trial of scheduled ibuprofen, which none had taken before the call. In addition, 11 patients (2.7%) presented to the emergency department for pain evaluation, of which none required readmission or an outpatient prescription of opioids.
CONCLUSION
A personalized protocol for opioid prescriptions after cesarean delivery decreased the total morphine milligram equivalents and the number of opioid tablets at discharge, without hospital readmissions or need for rescue opioid prescriptions after discharge. Opioids released into our community will be reduced by more than 90,000 tablets per year, without demonstrable adverse effect.
Topics: Pregnancy; Female; Humans; United States; Analgesics, Opioid; Acetaminophen; Ibuprofen; Prospective Studies; Outpatients; Electronic Health Records; Pain, Postoperative; Practice Patterns, Physicians'; Oxycodone; Prescriptions
PubMed: 37778679
DOI: 10.1016/j.ajog.2023.09.092 -
The American Surgeon Dec 2023The opioid overdose epidemic remains one of the leading focuses of the United States' public health agenda. Current literature has suggested that many surgical...
The opioid overdose epidemic remains one of the leading focuses of the United States' public health agenda. Current literature has suggested that many surgical procedures are associated with an increased risk of chronic opioid use in the post-operative period of opioid-naïve patients. We aimed to assess whether providing feedback on the average morphine milligram equivalents (MMED) and opioid utilization by selected post-operative patients would impact the provider opioid prescribing patterns. An opioid stewardship educational intervention provided didactic and email feedback to general surgeons about their prescribing patterns and summary feedback on opioid usage among post-operative patients from the pre-intervention period. We used descriptive statistics, Chi Square, Fisher's Exact test, Wilcoxon Rank Sum, two sample t test, and Spearman's rho to analyze the data gathered. A total of 5142 patients with an average age of 43.9 years were included in the study period. Women accounted for 3096 (60.2%) and 2046 (39.8%) were men. The surgeries during the study period included 1928 (37.5%) appendectomies and 3214 (62.5%) cholecystectomies. The predominant surgical approach was laparoscopic 5028 (97.8%). In both groups, the total MMED and total number of pills prescribed decreased significantly after the intervention was implemented. There were no refill prescriptions nor 30-day readmissions among those discharged with an opioid prescription in either study phase. An intervention that provided general surgeons with feedback about their post-operative prescription patterns and data on post-operative opioid utilization by patients decreased prescribed MMED.
Topics: Male; Humans; Female; Adult; Analgesics, Opioid; Feedback; Pain, Postoperative; Practice Patterns, Physicians'; Opioid-Related Disorders
PubMed: 36418926
DOI: 10.1177/00031348221129511