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Diving and Hyperbaric Medicine Jun 2024Blood alcohol concentrations above defined levels are detrimental to cognitive performance. Empirical and published evidence suggest that nitrogen narcosis is analogous...
Blood alcohol concentrations above defined levels are detrimental to cognitive performance. Empirical and published evidence suggest that nitrogen narcosis is analogous to alcohol intoxication with both impairing prefrontal cortex function. Nitrogen narcosis is also known to have been a factor in fatal accidents. To examine the effects of nitrogen narcosis, a recent publication used the Iowa Gambling Task tool, to simulate dynamic real-life risky decision-making behaviour. If the reported outcomes are corroborated in larger rigorously designed studies it is likely to provide further evidence that divers may well experience the negative effects of a 'narcotic agent', even at relatively shallow depths. These deleterious effects may occur regardless of diving experience, aptitude or professional status. In 1872, English law made it an offence to be 'drunk' whilst in charge of horses, carriages, cattle and steam engines. Understanding the danger was easy, establishing who is 'drunk' in the eyes of the court required a legal definition. Driving above a 'legal limit' for alcohol was made illegal in the United Kingdom in 1967. The limit was set at 80 milligrams of alcohol per 100 millilitres of blood. It took just short of one hundred years to get from first introducing a restriction to specific activities, whilst under the influence of alcohol, to having a clear and well-defined enforceable law. The question surely is whether our modern society will tolerate another century before legally defining safe parameters for nitrogen narcosis?
Topics: Humans; Diving; Inert Gas Narcosis; Driving Under the Influence; United Kingdom; Alcoholic Intoxication; Blood Alcohol Content
PubMed: 38870957
DOI: 10.28920/dhm54.2.137-139 -
JTCVS Open Dec 2022Enhanced Recovery After Surgery protocols are relatively new in cardiac surgery. Enhanced Recovery After Surgery addresses perioperative analgesia by implementing...
OBJECTIVE
Enhanced Recovery After Surgery protocols are relatively new in cardiac surgery. Enhanced Recovery After Surgery addresses perioperative analgesia by implementing multimodal pain control regimens that include both opioid and nonopioid components. We investigated the effects of an Enhanced Recovery After Surgery protocol at our institution on postoperative outcomes with particular focus on analgesia.
METHODS
Single-center retrospective study comparing perioperative opioid use before and after implementation of an Enhanced Recovery After Surgery protocol at our institution. Subjects were divided into 2 cohorts: Enhanced Recovery After Surgery (study group from year 2020) and pre-Enhanced Recovery After Surgery (control group from year 2018). Baseline and perioperative variables including total opioid use from the day of surgery to postoperative day 5 were collected. Opioid use was calculated as morphine milligram equivalents and compared between the 2 cohorts.
RESULTS
A total of 466 patients were included: 250 in the Enhanced Recovery After Surgery group and 216 in the pre-Enhanced Recovery After Surgery group. Both groups had similar baseline characteristics, but the Enhanced Recovery After Surgery group had significantly more subjects with intravenous drug use history ( < .0001), endocarditis ( < .0001), and liver disease ( = .007) compared with the pre-Enhanced Recovery After Surgery group. Every day from the day of surgery to postoperative day 5, the Enhanced Recovery After Surgery group had significant reduction (57%) in opioid use compared with the pre-Enhanced Recovery After Surgery group. Total opioid use for the entire length of stay was 259 morphine milligram equivalents in the Enhanced Recovery After Surgery group versus 452 morphine milligram equivalents in the pre-Enhanced Recovery After Surgery group ( < .0001). Subgroup analysis of subjects with intravenous drug use history did not demonstrate a significant reduction in opioid use.
CONCLUSIONS
Enhanced Recovery After Surgery protocols with an emphasis on multimodal pain management throughout perioperative care are associated with a significant reduction in the postoperative use of opioid analgesics.
PubMed: 36590721
DOI: 10.1016/j.xjon.2022.08.008 -
American Journal of Preventive Medicine May 2022Increases in opioid prescribing contributed to the opioid epidemic in the U.S. Subsequent efforts to promote safer use of opioids for treating pain included augmenting...
INTRODUCTION
Increases in opioid prescribing contributed to the opioid epidemic in the U.S. Subsequent efforts to promote safer use of opioids for treating pain included augmenting prescription drug monitoring programs and prescribing guidelines. The purpose of this study is to characterize the distribution of opioids dispensed in the U.S. by specialty.
METHODS
Data from the IQVIA National Prescription Audit were analyzed (in 2019). Prescriptions were standardized to morphine milligram equivalents using the 2018 Centers for Disease Control and Prevention conversion file. The annual number of prescriptions and total dose (morphine milligram equivalents) of opioids dispensed, overall and by specialty (provider type or physician specialty), were calculated for 2012-2017.
RESULTS
The number of prescriptions for opioids dispensed declined by 26.6% overall from 2012 to 2017. However, the number of prescriptions dispensed increased for pain medicine (8.8%) and advanced practice providers (nurse practitioners: 34.8%, physician assistants: 5.4%). Similarly, total morphine milligram equivalents for opioids dispensed declined by 28.6% from 2012 to 2017. Despite an increase in the number of prescriptions, total morphine milligram equivalents of opioids dispensed declined by nearly 20% in pain medicine. Higher total morphine milligram equivalents of dispensed opioids were observed in 2017 than in 2012 for advanced practice providers (nurse practitioners: 19.1%, physician assistants: 1.8%), although a decline in morphine milligram equivalents was observed from 2016 to 2017.
CONCLUSIONS
During a period in which prescribing interventions were expanded, opioid prescribing declined overall, although not uniformly by specialty.
Topics: Analgesics, Opioid; Drug Prescriptions; Humans; Morphine; Pain; Practice Patterns, Physicians'; Prescription Drug Monitoring Programs
PubMed: 35151524
DOI: 10.1016/j.amepre.2021.10.022 -
American Journal of Preventive Medicine Oct 2021This study assesses the associations between the recent implementation of robust features of state Prescription Drug Monitoring Programs and the abrupt discontinuation...
INTRODUCTION
This study assesses the associations between the recent implementation of robust features of state Prescription Drug Monitoring Programs and the abrupt discontinuation of long-term opioid therapies.
METHODS
Data were from a national commercial insurance database and included privately insured adults aged 18-64 years and Medicare Advantage enrollees aged ≥65 years who initiated a long-term opioid therapy episode between Quarter 2 of 2011 and Quarter 2 of 2017. State Prescription Drug Monitoring Programs were characterized as nonrobust, robust, and strongly robust. Abrupt discontinuation was measured on the basis of high daily morphine milligram equivalents over the last 30 days of a long-term opioid therapy episode or no sign of tapering before discontinuation. Difference-in-differences models were estimated in 2019‒2020 to assess the association between robust Prescription Drug Monitoring Programs and abrupt discontinuation.
RESULTS
Among nonelderly privately insured adults, robust Prescription Drug Monitoring Programs were associated with an increase from 14.8% to 15.4% (4% relative increase, p=0.02) in the rate of ending long-term opioid therapy with ≥60 daily morphine milligram equivalents. For older Medicare Advantage enrollees, strongly robust Prescription Drug Monitoring Programs were associated with a reduction from 4.8% to 4.3% (10.4%, p=0.01) and from 3.0% to 2.4% (17.3%, p=0.001) in the rate of ending long-term opioid therapy with ≥90 and 120 daily morphine milligram equivalents, respectively. Prescription Drug Monitoring Programs robustness was not associated with clinically meaningful changes in the rate of discontinuing long-term opioid therapy without tapering.
CONCLUSIONS
Discontinuation without tapering was the norm for long-term opioid therapies in the samples throughout the study years. Findings do not support the notion that policies aimed at enhancing Prescription Drug Monitoring Program use were associated with substantial increases in abrupt long-term opioid therapy discontinuation.
Topics: Aged; Analgesics, Opioid; Humans; Medicare; Policy; Prescription Drug Monitoring Programs; United States
PubMed: 34233856
DOI: 10.1016/j.amepre.2021.04.019 -
Biophysical Journal Aug 2021The crowdedness of living cells, hundreds of milligrams per milliliter of macromolecules, may affect protein folding, function, and misfolding. Still, such processes are...
The crowdedness of living cells, hundreds of milligrams per milliliter of macromolecules, may affect protein folding, function, and misfolding. Still, such processes are most often studied in dilute solutions in vitro. To assess consequences of the in vivo milieu, we here investigated the effects of macromolecular crowding on the amyloid fiber formation reaction of α-synuclein, the amyloidogenic protein in Parkinson's disease. For this, we performed spectroscopic experiments probing individual steps of the reaction as a function of the macromolecular crowding agent Ficoll70, which is an inert sucrose-based polymer that provides excluded-volume effects. The experiments were performed at neutral pH at quiescent conditions to avoid artifacts due to shaking and glass beads (typical conditions for α-synuclein), using amyloid fiber seeds to initiate reactions. We find that both primary nucleation and fiber elongation steps during α-synuclein amyloid formation are accelerated by the presence of 140 and 280 mg/mL Ficoll70. Moreover, in the presence of Ficoll70 at neutral pH, secondary nucleation appears favored, resulting in faster overall α-synuclein amyloid formation. In contrast, sucrose, a small-molecule osmolyte and building block of Ficoll70, slowed down α-synuclein amyloid formation. The ability of cell environments to modulate reaction kinetics to a large extent, such as severalfold faster individual steps in α-synuclein amyloid formation, is an important consideration for biochemical reactions in living systems.
Topics: Amyloid; Humans; Kinetics; Parkinson Disease; Protein Folding; alpha-Synuclein
PubMed: 34242594
DOI: 10.1016/j.bpj.2021.06.032 -
Surgery Aug 2022Adherence to opioid prescribing protocols after operations remains challenging despite published guidelines. Integration of these guidelines with the electronic health...
BACKGROUND
Adherence to opioid prescribing protocols after operations remains challenging despite published guidelines. Integration of these guidelines with the electronic health record could potentially improve their adoption. We hypothesize that implementing an electronic health record order set containing prepopulated tablet quantities tailored to surgical procedures based on published guidelines will decrease postoperative opioid prescription.
METHODS
We conducted a 12-month prepost intervention study on adult patients who underwent appendectomy, cholecystectomy, inguinal or umbilical hernia repair, thyroidectomy, or parathyroidectomy at a single institution. An electronic health record order set was developed with prepopulated opioid tablet quantities reflecting the upper limit of published recommendations. The primary endpoint was change in morphine milligram equivalent prescribed postintervention and was analyzed using linear regression adjusting for age, race, procedure, and prescriber training level. Secondary endpoints were emergency department visits for pain-related issues and opioid refill rates.
RESULTS
We identified 524 patients (mean age = 53, 51% male) in our baseline cohort and 433 patients (mean age = 52, 58% male) in our postintervention group. The mean morphine milligram equivalent prescribed was 62.6 and 50.4 for the preintervention and postintervention cohorts, respectively (P = .049). Thyroidectomies and parathyroidectomies achieved the largest decrease after intervention, which decreased to 42.6 morphine milligram equivalent from 79.7 morphine milligram equivalent preintervention (P < .001). Refill rate was 1.6% postintervention compared to 3.1% preintervention (P = .20), and emergency department visit for pain control rate was 0.2% post intervention and 2.5% preintervention (P = .005).
CONCLUSION
An electronic health record tailored order set based on prescription guidelines is a safe, effective, and scalable intervention for decreasing opioid prescriptions after operations.
Topics: Adult; Analgesics, Opioid; Drug Prescriptions; Electronic Health Records; Female; Humans; Male; Middle Aged; Morphine Derivatives; Pain, Postoperative; Practice Patterns, Physicians'; Retrospective Studies; Tablets
PubMed: 35430051
DOI: 10.1016/j.surg.2022.03.018 -
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 -
Female Pelvic Medicine & Reconstructive... May 2021The objective of this study was to determine total postoperative opioid consumption by women 60 years and older during the first week after pelvic organ prolapse...
OBJECTIVES
The objective of this study was to determine total postoperative opioid consumption by women 60 years and older during the first week after pelvic organ prolapse surgery. We secondarily aimed to describe opioid prescribing patterns in this cohort.
METHODS
This is a secondary analysis of a prospective cohort study assessing changes in cognition in women 60 years and older undergoing prolapse surgery. Postoperative opioid use at home during the first week was collected through daily self-reported diary entries. Total postoperative opioid consumption was calculated by adding opioid administration in the postoperative anesthesia recovery unit, inpatient setting, and home opioid use (as documented in diary). Regression models were used to identify demographic and clinical factors associated with total postoperative opioid consumption in the top quartile of this cohort and home opioid use.
RESULTS
Data from 80 women were analyzed. Mean ± SD age was 71.78 ± 6.14 years (range, 60-88 years). Fifty women (62.5%) underwent vaginal surgery, and 30 (7.5%) underwent laparoscopic/robotic surgery, with concomitant hysterectomy in 47 (58.8%). The median (interquartile range) total morphine milligram equivalents used during the first week after surgery was 30 (7.5-65.75). The median (interquartile range) total morphine milligram equivalents prescribed was 225 (150-225).
CONCLUSIONS
Opioid consumption after prolapse surgery in older women is very modest and equates to a median (interquartile range) of 4 (1-9) oxycodone (5 mg) tablets. Opioid prescribing patterns should be adjusted accordingly.
Topics: Aged; Aged, 80 and over; Analgesics, Opioid; Drug Utilization; Female; Humans; Middle Aged; Pain, Postoperative; Pelvic Organ Prolapse; Postoperative Period; Prospective Studies
PubMed: 32032130
DOI: 10.1097/SPV.0000000000000844 -
Chemistry (Weinheim An Der Bergstrasse,... Nov 2022A sterically encumbered aminoborane sensor is introduced and used for quantitative stereochemical analysis of monoalcohols, diols and amino alcohols. The small-molecule...
A sterically encumbered aminoborane sensor is introduced and used for quantitative stereochemical analysis of monoalcohols, diols and amino alcohols. The small-molecule probe exhibits a rigid ortho-substituted arene scaffold with a proximate boron binding site and a triarylamine circular dichroism (CD) reporter unit which proved to be crucial for the observed chiroptical signal induction. Coordination of the chiral target molecule produces strong Cotton effects and UV changes that are readily correlated to its absolute configuration, enantiomeric composition and concentration to achieve comprehensive stereochemical analysis within a 5 % absolute error margin. The sensing method was successfully applied in the chromatography-free analysis of less than one milligram of a crude asymmetric reaction mixture and the advantages of this chiroptical sensing approach, which is amenable to high-throughput experimentation equipment and automation, over traditional methods is discussed.
Topics: Stereoisomerism; Amino Alcohols; Circular Dichroism; Indicators and Reagents; Boron
PubMed: 35796635
DOI: 10.1002/chem.202202028 -
American Journal of Physical Medicine &... Apr 2023The aim of the study is to evaluate opioid analgesic utilization and predictors for adverse events during hospitalization and discharge disposition among patients...
OBJECTIVE
The aim of the study is to evaluate opioid analgesic utilization and predictors for adverse events during hospitalization and discharge disposition among patients admitted with osteoarthritis or spine disorders.
DESIGN
This is a retrospective study of 12,747 adult patients admitted to six private community hospitals from 2017 to 2020. Opioid use during hospitalization and risk factors for hospital-acquired adverse events and nonhome discharge were investigated.
RESULTS
The total number of patients using opioids decreased; however, the daily morphine milligram equivalent use for patients on opioids increased from 2017 to 2020. Increased odds of nonhome discharge were associated with older age, Medicaid, Medicare insurance, and increased lengths of stay, increased body mass index, daily morphine milligram equivalent, and electrolyte replacement in the osteoarthritis group. In the spine group, older age, Black race, Medicaid, Medicare, no insurance, increased Charlson Comorbidity Index, lengths of stay, polypharmacy, and heparin use were associated with nonhome discharge. Adverse events were associated with increased age, lengths of stay, Medicare, polypharmacy, antiemetic, and benzodiazepine use in the osteoarthritis group and increased Charlson Comorbidity Index, lengths of stay, and electrolyte replacement in the spine group.
CONCLUSIONS
Despite the decreasing number of patients using opioids over the years, patients on opioids had an increased daily morphine milligram equivalent over the same period.
Topics: Adult; Humans; Aged; United States; Analgesics, Opioid; Retrospective Studies; Inpatients; Medicare; Hospitalization; Hospitals; Osteoarthritis; Electrolytes; Morphine Derivatives
PubMed: 36095159
DOI: 10.1097/PHM.0000000000002101