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Cureus Mar 2024Objectives An observational, retrospective, longitudinal, and analytical study aimed to evaluate the effectiveness of the erector spinae plane (ESP) block in managing...
Objectives An observational, retrospective, longitudinal, and analytical study aimed to evaluate the effectiveness of the erector spinae plane (ESP) block in managing pain in patients with vertebral fractures secondary to tumoral activity. This study included patients treated at the Pain Clinic who underwent ESP block. The objectives were to describe demographic characteristics, oncological diagnosis, vertebral fracture features, imaging techniques, medications used, and the level of ESP block. Additionally, pain levels were assessed using a numerical analog scale, and the consumption of opioid analgesic medications before and after the ESP block, during follow-up consultations, along with patient satisfaction. Methodology This retrospective, observational, and analytical study was conducted at the Pain Clinic of the National Cancer Institute of Mexico. Patients with vertebral fractures secondary to tumor activity were included, with data collected from March 2020 to September 2023. A consecutive non-probabilistic sampling method was employed, and specific inclusion and exclusion criteria were applied. Data were analyzed using descriptive statistics and the Wilcoxon signed-rank test for quantitative variables, with a significance level of p ≤ 0.05. IBM SPSS Statistics v. 26.0 (IBM Corp., Armonk, NY) software was utilized. Results A sample comprising 16 individuals was obtained, with an equal distribution between males and females. Fracture levels displayed variation, with L3 (12.5%) and T6 (12.5%) being the most prevalent. The ESP approach was primarily conducted using ultrasound (68.8%), while fluoroscopy and computed tomography were utilized in 25.0% and 6.3% of cases, respectively. Predominantly, methylprednisolone and ropivacaine (75.0%) were administered, with phenol used in 18.8% and a combination of methylprednisolone and bupivacaine in 6.3%. Patient satisfaction levels were reported at 81.3% (satisfied or very satisfied). Statistically significant disparities were noted between baseline and incidental pain reduction and oral opioid equivalent dosage in milligrams of morphine per day (MME/day) before and after ESP block (p ≤ 0.05). Conclusions This research provides promising preliminary evidence supporting the effectiveness of ESP block for pain management in vertebral fractures secondary to tumoral activity, enhancing the quality and safety of care for oncology patients. The absence of complications, significant improvement in pain, and reduction in opioid dependence underscore the clinical relevance of this therapeutic approach. An observational, retrospective, longitudinal, and analytical study aimed to evaluate the effectiveness of the ESP block in managing pain in patients with vertebral fractures secondary to tumoral activity. This study included patients treated at the Pain Clinic who underwent ESP block. The objectives were to describe demographic characteristics, oncological diagnosis, vertebral fracture features, imaging techniques, medications used, and the level of ESP block. Additionally, pain levels were assessed using a numerical analogue scale, and the consumption of opioid analgesic medications before and after the ESP block, during follow-up consultations, along with patient satisfaction.
PubMed: 38586726
DOI: 10.7759/cureus.55599 -
Pediatrics Jul 2024Surgery is one of the most common indications for opioid prescribing to pediatric patients. We identified which procedures account for the most pediatric surgical opioid...
BACKGROUND AND OBJECTIVES
Surgery is one of the most common indications for opioid prescribing to pediatric patients. We identified which procedures account for the most pediatric surgical opioid prescribing.
METHODS
We conducted a cross-sectional analysis of commercial and Medicaid claims in the Merative MarketScan Commercial and Multi-State Medicaid Databases. Analyses included surgical procedures for patients aged 0 to 21 years from December 1, 2020, to November 30, 2021. Procedures were identified using a novel crosswalk between 3664 procedure codes and 1082 procedure types. For each procedure type in the crosswalk, we calculated the total amount of opioids in prescriptions dispensed within 3 days of discharge from surgery, as measured in morphine milligram equivalents (MMEs). We then calculated the share of all MMEs accounted for by each procedure type. We conducted analyses separately among patients aged 0 to 11 and 12 to 21 years.
RESULTS
Among 107 597 procedures for patients aged 0 to 11 years, the top 3 procedures accounted for 59.1% of MMEs in opioid prescriptions dispensed after surgery: Tonsillectomy and/or adenoidectomy (50.3%), open treatment of upper extremity fracture (5.3%), and removal of deep implants (3.5%). Among 111 406 procedures for patients aged 12 to 21 years, the top 3 procedures accounted for 33.1% of MMEs: Tonsillectomy and/or adenoidectomy (12.7%), knee arthroscopy (12.6%), and cesarean delivery (7.8%).
CONCLUSIONS
Pediatric surgical opioid prescribing is concentrated among a small number of procedures. Targeting these procedures in opioid stewardship initiatives could help minimize the risks of opioid prescribing while maintaining effective postoperative pain control.
Topics: Humans; Child; Adolescent; Child, Preschool; Analgesics, Opioid; Infant; Cross-Sectional Studies; Pain, Postoperative; Practice Patterns, Physicians'; Young Adult; Female; Male; United States; Infant, Newborn; Drug Prescriptions; Surgical Procedures, Operative; Medicaid
PubMed: 38919985
DOI: 10.1542/peds.2024-065814 -
The Canadian Journal of Hospital... 2024Opioids are a common treatment for older adults living with pain. Given high rates of polypharmacy and chronic comorbidities, older adults are at risk of opioid... (Review)
Review
BACKGROUND
Opioids are a common treatment for older adults living with pain. Given high rates of polypharmacy and chronic comorbidities, older adults are at risk of opioid overdose. Evidence is now available that take-home naloxone (THN) supports reduction of opioid-related harms. It is unknown what THN initiatives are available for older adults, especially those living with chronic pain.
OBJECTIVE
To summarize the literature regarding THN, with a focus on older adults using opioids for pain, including facilitators of and barriers to THN access, knowledge gaps, and pharmacist-led initiatives.
DATA SOURCES
A scoping review, guided by an established framework and PRISMA-ScR guidelines, was performed. Methods involved searching 6 bibliographic databases (MEDLINE, Embase, Scopus, APA PsycINFO, Web of Science Core Collection, and PubMed), reference harvesting, and citation tracking. Searches were conducted up to March 2023, with no date limits applied; only English publications were included.
STUDY SELECTION AND DATA EXTRACTION
Study eligibility was determined according to preset criteria, including age; discrepancies were resolved by discussion and consensus. Data were extracted and categorized through thematic analysis.
DATA SYNTHESIS
Four studies met the eligibility criteria. All 4 studies detailed THN programs in primary care settings involving older adults taking opioids for pain management. Two of the studies highlighted patient-specific risk factors for opioid overdose, including concomitant use of benzodiazepines and/or gabapentinoids, mean morphine milligram equivalents per day of at least 50, and previous opioid overdose. Two of the studies assessed patient knowledge of opioid overdose management and attitudes toward THN. Educational programs increased patients' interest in THN.
CONCLUSIONS
The literature about THN for older adults living with pain is limited, and no literature was found on pharmacist-led initiatives in this area. Future research on THN provision for older adults, including pharmacist-led initiatives, could help to optimize care for older adults living with pain.
PubMed: 38482391
DOI: 10.4212/cjhp.3506 -
Biochimie Aug 2023The enzyme Homoserine dehydrogenase from Paracoccidioides brasiliensis (PbHSD), an interesting enzyme in the search for new antifungal drugs against...
The enzyme Homoserine dehydrogenase from Paracoccidioides brasiliensis (PbHSD), an interesting enzyme in the search for new antifungal drugs against paracoccidioidomycosis, was expressed by E. coli. Thirty milligrams of PbHSD with 94% of purity were obtained per liter of culture medium. The analysis by CD spectroscopy indicates a composition of 45.5 ± 7.3% of α-helices and 10.5 ± 7.0% β-strands. Gel filtration chromatography indicates a homodimer as biological unity. Fluorescence emission spectroscopy has shown stability of PbHSD in the presence of urea until C of 4.13 ± 0.21 M, and a broad pH range in which there is no conformational change. The protein analysis by differential scanning calorimetry indicates high stability at room temperature, but low stability at high temperatures, suffering irreversible denaturation, with T = 58.65 ± 0.87 °C. Kinetic studies of PbHSD by molecular absorption spectroscopy in UV/Vis have shown an optimum pH between 9.35 and 9.50, with Michaelian behavior, presenting K of 224 ± 15 μM and specific activity at optimum pH of 2.10 ± 0.07 μmol/min/mg for homoserine. Therefore, protein expression and purification were efficient, and the structural characterization has shown that PbHSD presents native conformation with enzymatic activity in kinetic assays.
Topics: Paracoccidioides; Homoserine Dehydrogenase; Escherichia coli; Kinetics; Spectrometry, Fluorescence
PubMed: 36934778
DOI: 10.1016/j.biochi.2023.03.003 -
Chemistry (Weinheim An Der Bergstrasse,... May 2024Ecklonialactones, Eiseniachlorides, and Egregiachlorides are synthesized in living organisms via the lipoxygenase-mediated oxidation of polyunsaturated fatty acids....
Ecklonialactones, Eiseniachlorides, and Egregiachlorides are synthesized in living organisms via the lipoxygenase-mediated oxidation of polyunsaturated fatty acids. Originally isolated and identified from brown seaweed (Ecklonia stolonifera, Eisenia bicyclis, and Egregia menziesii), and later replicated on milligram scale through chemical synthesis, the full biological activities of these compounds remain to be elucidated. To bridge this gap in knowledge, we propose a unified methodology to synthesize the 14-membered macrocyclic structures of Ecklonialactones, Eiseniachlorides and analogs using a versatile and convergent approach. This study delineates the synthesis of Ecklonialactone A, B, C, D, and Eiseniachlorides A and B, as well as ent-Ecklonialactone B, 16-epi-Ecklonialactone B and 12,13-diepi-Ecklonialactone B.
PubMed: 38770615
DOI: 10.1002/chem.202401632 -
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 -
Journal of Cardiothoracic and Vascular... Aug 2023The objective of this study was to assess the quality of pain control and outcomes in patients who underwent coronary artery bypass graft (CABG) over a period of 96...
OBJECTIVES
The objective of this study was to assess the quality of pain control and outcomes in patients who underwent coronary artery bypass graft (CABG) over a period of 96 hours preimplementation of a cardiac enhanced recovery after surgery (C-ERAS) protocol compared with postimplementation.
DESIGN
Single-center, retrospective cohort study.
SETTING
Cleveland Clinic Akron General Hospital.
PARTICIPANTS
Patients ≥18 years of age who underwent CABG surgery and received perioperative pain management pre- and post-C-ERAS protocol implementation at admission to Cleveland Clinic Akron General Hospital.
INTERVENTIONS
A hospital C-ERAS protocol that included a multimodal analgesia approach to postoperative pain management.
MEASUREMENTS AND MAIN RESULTS
The primary outcome was the amount of opioid used measured in morphine milligram equivalents (MME) within 96 hours postoperatively. A total of 146 charts were reviewed, with 133 included (66 pre-C-ERAS and 67 post-C-ERAS). There was a significant reduction in median MMEs 96 hours postoperatively post-C-ERAS (98 [52-135] v 211 [130-290], p < 0.001). Additionally, a significant reduction in median MMEs was observed post-C-ERAS before (65 [43-100] v 129 [95-165], p < 0.001) and after (10 [0-40] v 68 [21-141], p < 0.001) chest tube removal and for the entire prescription at discharge (0 [0-109] v 90 [0-210], p = 0.005).
CONCLUSIONS
Implementing a C-ERAS protocol within a CABG surgery patient population reduced the amount of MME.
Topics: Humans; Enhanced Recovery After Surgery; Retrospective Studies; Pain, Postoperative; Analgesics, Opioid; Length of Stay
PubMed: 37127522
DOI: 10.1053/j.jvca.2023.03.043 -
Achieving opioid-free discharge following robotic thoracic surgery: A single-institution experience.JTCVS Open Sep 2023Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control and have been associated with decreased opioid requirements....
OBJECTIVES
Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control and have been associated with decreased opioid requirements. We investigated the impact of continual ERATS refinement on the incidence of opioid-free discharge.
METHODS
We retrospectively analyzed our prospectively maintained institutional database for elective, opioid-naive robotic thoracoscopic procedures. Demographics, operative outcomes, postoperative opioid dispensed (morphine milligram equivalent), and opioid discharge status were collected. Our primary outcome of interest was factors associated with opioid-free discharge; our secondary objective was to determine the incidence of new persistent opioid users.
RESULTS
In total, 466 patients from our optimized ERATS protocol were included; 309 (66%) were discharged without opioids. However, 34 (11%) of patients discharged without opioids required a prescription postdischarge. Conversely, 7 of 157 patients (11%), never filled their opioid prescriptions given at discharge. Factors associated with opioid-free discharges were nonanatomic resections, mediastinal procedures, minimal pain, and lack of opioid usage on the day of discharge. More importantly, 3.2% of opioid-free discharge patients became new persistent opioid users versus 10.8% of patients filling opioid prescriptions after discharges ( = .0013). Finally, only 2.3% of opioid-naive patients of the entire cohort became chronic opioid users; there was no difference in the incidence of chronic use by opioid discharge status.
CONCLUSIONS
Optimized opioid-sparing ERATS protocols are highly effective in reducing opioid prescription on the day of discharge. We observed a very low rate of new persistent or chronic opioid use in our cohort, further highlighting the role ERATS protocols in combating the opioid epidemic.
PubMed: 37808010
DOI: 10.1016/j.xjon.2023.06.017 -
International Journal of Spine Surgery Oct 2023Circumferential lumbar spine fusions are extensive procedures that involve accessing the lumbar spine from multiple approaches. These surgeries often make postoperative...
BACKGROUND
Circumferential lumbar spine fusions are extensive procedures that involve accessing the lumbar spine from multiple approaches. These surgeries often make postoperative pain control challenging, and efforts have been made to find alternative methods of analgesia that do not rely solely on opioids. The use of erector spinae plane (ESP) blocks has been found to be effective in controlling pain while decreasing narcotic requirements in patients undergoing thoracolumbar spine surgery. The purpose of this study is to evaluate the efficacy of ESP blocks for postoperative pain control and its effect on opioid consumption in patients undergoing circumferential lumbar spinal fusion.
METHODS
A retrospective review was performed on patients undergoing 1- or 2-level elective anterior lumbar interbody fusion with open posterior decompression and posterolateral fusion. An analysis was performed to determine the effect of ESP blocks on hospital length of stay (LOS), pain scores using the visual analog scale, and opioid consumption using morphine milligram equivalents.
RESULTS
144 patients were included in the cohort analysis, of whom 36 patients received a preoperative ESP block and 108 did not. Demographic data, comorbidities, and number of levels fused were equally distributed between groups. Patients who received an ESP block had shorter LOS (3.0 vs 4.0 days, = 0.005) and lower cumulative morphine milligram equivalent in the first 48 hours after surgery (123.7 vs 141.2, = 0.05). Visual analog scale scores did not significantly differ between patients group except for on postoperative day 4 and at 12-month follow-up.
CONCLUSIONS
The use of ESP blocks for patients undergoing 1- or 2-level circumferential fusion via an anterior lumbar interbody fusion with concomitant posterior open procedures was associated with decreased postoperative inpatient opioid requirements and LOS. This cohort study supports the growing body of evidence that ESP blocks are a useful adjunct for multimodal pain control.
LEVEL OF EVIDENCE
3 CLINICAL RELEVANCE: The data and results of this study provide clinical evidence supporting the use of ESP blocks in patients undergoing circumferential lumbar spine fusion procedures.
PubMed: 37625857
DOI: 10.14444/8528 -
Journal of Nursing Care QualityComplementary pain management strategies are effective at reducing pain in postsurgical patients.
BACKGROUND
Complementary pain management strategies are effective at reducing pain in postsurgical patients.
LOCAL PROBLEM
Cardiac nurses at a large academic hospital reported inconsistent awareness of patient opioid utilization and poor implementation of complementary pain management strategies.
METHODS
A pre/post-quality improvement project was conducted on 2 inpatient cardiac units. Outcomes included nursing staff's perceived knowledge, confidence, and use of complementary pain management strategies and knowledge of patient postsurgical opioid utilization through calculation of morphine milligram equivalence (MME).
INTERVENTIONS
A comprehensive education program was implemented that included increased patient access to pain management resources, nurse education about complementary pain management strategies, and nurse education and access to MME calculations using a custom electronic health record application.
RESULTS
Nursing staff's perceived knowledge, confidence, and use of complementary pain techniques increased. Patient opioid utilization findings were inconclusive.
CONCLUSIONS
Educational programs about complementary pain management offer promise to improve cardiac postsurgical patient care.
Topics: Humans; Pain Management; Analgesics, Opioid; Pain; Cardiac Surgical Procedures
PubMed: 37026869
DOI: 10.1097/NCQ.0000000000000712