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Nicotine & Tobacco Research : Official... Jun 2022Use of snus (moist smokeless tobacco) is widespread in Scandinavia and increasingly popular in the U.S. Snus products vary in terms of product design, portion size, and...
INTRODUCTION
Use of snus (moist smokeless tobacco) is widespread in Scandinavia and increasingly popular in the U.S. Snus products vary in terms of product design, portion size, and nicotine content. The aim of this study was to examine variations in the nicotine content in snus sold on the Norwegian market from 2005 to 2020.
METHODS
We calculated the nicotine content in dry snus in milligram per gram (mg/g) and milligram per serving (mg/s), weighted by the products' market share from data on nicotine content, water content, and portion size (both for portion and loose snus) for the ten most sold snus products from each of the three largest manufacturers in 2005, 2010, 2015, and 2020.
RESULTS
In all snus products combined, the nicotine content per gram snus (mg/g) increased from 16.3 to 24.1, while nicotine per serving (mg/s) was stable around 13.0. In portion snus, the nicotine content increased for both mg/g and mg/s, most notably from 2005 to 2010. In loose snus, mg/g decreased marginally, while mg/s was stable throughout the period.
CONCLUSIONS
In a period with increasing snus use, the nicotine content in snus increased per gram snus, but not per serving. The stability in nicotine per serving is likely due to a decreasing market share of loose snus which accounted for 54% of the snus products in 2005 and 5% in 2020, and which traditionally has a high content of nicotine per serving.
IMPLICATIONS
Use of snus is popular in Scandinavia, most notably in Sweden and Norway, but also increasingly common in Finland, especially among young adults. There are no prior market-based studies of variations in the nicotine content in Swedish snus over time. We found that the average amount of nicotine per gram snus sold on the Norwegian market increased in the period 2005 to 2020, most notably from 2005 to 2010, while the amount of nicotine per serving was stable in the same period, primarily due to a decreasing share of loose snus.
Topics: Humans; Nicotine; Norway; Scandinavian and Nordic Countries; Sweden; Tobacco, Smokeless; Young Adult
PubMed: 35022786
DOI: 10.1093/ntr/ntac006 -
The Journal of Trauma and Acute Care... Aug 2021Surgical stabilization of rib fractures (SSRF) significantly improve the outcomes of patients with rib fractures. Ultrasound is a specific modality for localizing rib...
BACKGROUND
Surgical stabilization of rib fractures (SSRF) significantly improve the outcomes of patients with rib fractures. Ultrasound is a specific modality for localizing rib fractures. We hypothesized that use of perioperative ultrasound localization of fracture sites optimizes surgical approach and clinical outcomes.
METHODS
We performed a retrospective cohort study of adult patients undergoing SSRF and compared those with and without adjunctive perioperative ultrasound fracture localization. Our primary outcome was improved surgical efficiency as measured by incision length and total operative time. Secondary clinical outcomes included numeric pain score on follow-up visit and daily morphine milligram equivalent prescribed within 30 days from discharge.
RESULTS
We performed 49 surgical rib fixations between 2015 and 2020; of which, 13 (26.5%) additionally underwent ultrasound localization (26.5%). There were no significant differences between groups in age, sex, number of ribs repaired, or days till surgery. More patients in the ultrasound group had nonflail chest wall injury (76.9% vs. 27.8%, p = 0.003). Use of perioperative ultrasound was associated with shorter incision length (median, 9 vs. 15.5 cm; p = 0.0001), shorter operative time (median, 120 vs. 174 minutes; p = 0.003), less daily morphine milligram equivalent (25 vs. 68 mg, p = 0.009), and reduced numeric pain score on follow up (median, 4 vs. 7, p = 0.05).
CONCLUSION
Use of perioperative ultrasound localization of rib fractures to optimize surgical approach for SSRF was associated with reduced incision length, operative time, and opioid requirements on patient discharge. We recommend considering routine perioperative localization to improve surgical approach and efficiency during SSRF.
LEVEL OF EVIDENCE
Therapeutic, level IV.
Topics: Adult; Female; Humans; Male; Middle Aged; Operative Time; Retrospective Studies; Rib Fractures; Thoracic Injuries; Trauma Centers; Treatment Outcome; Ultrasonography
PubMed: 33938512
DOI: 10.1097/TA.0000000000003262 -
International Journal of Gynecological... Dec 2021Opioids are routinely prescribed after minimally invasive gynecologic oncology surgery, with minimal data to inform the ideal dose. The aim of this study was to evaluate...
OBJECTIVES
Opioids are routinely prescribed after minimally invasive gynecologic oncology surgery, with minimal data to inform the ideal dose. The aim of this study was to evaluate the impact of a restrictive opioid prescription protocol on the median morphine milligram equivalents prescribed and pain control in patients undergoing minimally invasive surgery.
METHODS
A restrictive opioid prescription protocol was implemented from January through December 2020 at a single tertiary cancer center in Ontario, Canada. Consecutive patients undergoing minimally invasive hysterectomy for suspected malignancy were included. Simultaneously, we implemented use of multimodal analgesia, patient and provider education, pre-printed standardized prescriptions, and tracking of opioid prescriptions. Total median morphine milligram equivalents prescribed were compared between pre- and post-intervention cohorts. Patients were surveyed regarding opioid use and pain control at 30 days post-surgery.
RESULTS
A total of 101 women in the post-intervention cohort were compared with 92 consecutive pre-intervention controls. Following protocol implementation, median morphine milligram equivalents prescribed decreased from 50 (range 9-100) to 25 (range 8-75) (p<0.001). In the post-intervention cohort, 75% (76/101) used 10 median morphine milligram equivalents or less and 55 patients (54%) used 0 median morphine milligram equivalent. There was no additional increase in opioid refill requests after implementation of our strategy. Overall, patients reported a median pain score of 3/10 at 30 days post-surgery; the highest pain scores and most of the pain occurred in the first week after surgery.
CONCLUSIONS
Implementation of a restrictive opioid prescription protocol led to a significant reduction in opioid use after minimally invasive gynecologic oncology surgery, with over 50% of patients requiring no opioids postoperatively.
Topics: Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Female; Genital Neoplasms, Female; Humans; Hysterectomy; Middle Aged; Minimally Invasive Surgical Procedures; Ontario; Pain Management; Pain, Postoperative; Quality Improvement; Surveys and Questionnaires
PubMed: 34750198
DOI: 10.1136/ijgc-2021-002968 -
Biophysical Reviews Feb 2023Here I will review the development of gene expression systems for production of bovine rhodopsin in the Khorana laboratory with particular focus on stable mammalian cell... (Review)
Review
Here I will review the development of gene expression systems for production of bovine rhodopsin in the Khorana laboratory with particular focus on stable mammalian cell lines made using human embryonic kidney cells (HEK293S). The synthesis of a gene encoding bovine rhodopsin was completed in 1986. This gene was expertly designed with the built-in capacity for DNA duplex cassette replacement mutagenesis which made site-directed mutagenesis relatively straightforward. Intense effort was expended over several years in order to identify a gene expression system capable of producing rhodopsin in milligram amounts as required for biophysical studies. Mammalian expression systems, both transient and stable, were found to be the most favourable based on several criteria including receptor expression levels, correct folding and post translational processing, and capacity for purification of fully functional receptor. Transient expression using COS-1 cells was preferred for routine small-scale production of rhodopsin mutants, while HEK293S stable cell lines were used when milligram amounts of rhodopsin mutants were needed; for example, when conducting NMR studies.
PubMed: 36909956
DOI: 10.1007/s12551-022-01037-2 -
Zhonghua Yu Fang Yi Xue Za Zhi [Chinese... May 2021Food allergy is a global problem. Peanut is one of the most common food allergens that can result in anaphylaxis, even with milligram exposure. Most peanut allergies... (Review)
Review
Food allergy is a global problem. Peanut is one of the most common food allergens that can result in anaphylaxis, even with milligram exposure. Most peanut allergies could persist lifelong. The current standard of care for peanut allergy is strict dietary avoidance and immediate treatment of allergic reaction triggered by accident exposure. Oral immunotherapy (OIT) induces an increased reactivity threshold via modulation of the immune system. In recent years, peanut OIT has been developed to protect peanut-allergic individuals against severe or life-threating allergic reaction. This review discussed the update of the mechanism, efficacy, safety and impact on quality of life of peanut OIT for peanut allergy.
Topics: Administration, Oral; Allergens; Arachis; Desensitization, Immunologic; Humans; Immunotherapy; Peanut Hypersensitivity; Quality of Life
PubMed: 34034398
DOI: 10.3760/cma.j.cn112150-20210308-00226 -
The Clinical Journal of Pain Sep 2021The aim was to evaluate the safety of intravenous lidocaine for postoperative pain and the impact on opioid requirements and pain scores.
OBJECTIVES
The aim was to evaluate the safety of intravenous lidocaine for postoperative pain and the impact on opioid requirements and pain scores.
MATERIALS AND METHODS
This was a single-center, retrospective, single-arm analysis of adult patients who received intravenous lidocaine for postoperative pain from January 2016 to December 2019. Patients were excluded if they received lidocaine for any indication other than pain or if lidocaine was only given intraoperatively. The primary outcome of this analysis was to determine the incidence of adverse effects (AEs) and the reason for discontinuation of lidocaine. Secondary outcomes included median daily pain scores (visual analog scale and Critical-Care Pain Observation Tool) and opioid consumption (daily morphine milligram equivalents) 24 hours before infusion and during day 1.
RESULTS
A total of 452 patients were evaluated of which 298 (65.9%) patients met inclusion criteria. Of the 154 patients excluded, 153 did not receive lidocaine postoperatively. The median duration of infusion was 34 [20:48] hours with a median initial and maintenance rate of 1 mg/kg/h dosed on ideal body weight. In our analysis, 174 (58.4%) patients had a documented AE during infusion and 38 (12.8%) had lidocaine discontinued because of an AE. The most common AE was nausea in 62 (20.8%) patients and the most common reason for discontinuation was confusion in 8 (2.7%) patients. Daily morphine milligram equivalents (P<0.001) and visual analog scale (P<0.001) significantly decreased when comparing 24 hours before infusion and day 1.
CONCLUSION
Although a majority of patients receiving lidocaine for postoperative pain experienced an AE, this did not result in discontinuation in most patients.
Topics: Adult; Analgesics, Opioid; Anesthetics, Local; Double-Blind Method; Humans; Infusions, Intravenous; Lidocaine; Pain Measurement; Pain, Postoperative; Retrospective Studies
PubMed: 34265786
DOI: 10.1097/AJP.0000000000000960 -
Hospital Pediatrics Jan 2020Multimodal analgesia (MMA) may reduce opioid use among children who are hospitalized, and may contribute toward enhanced recovery after selective dorsal rhizotomy (SDR)...
OBJECTIVES
Multimodal analgesia (MMA) may reduce opioid use among children who are hospitalized, and may contribute toward enhanced recovery after selective dorsal rhizotomy (SDR) for patients with spasticity in pediatric cerebral palsy. In this retrospective cohort study, we assess an MMA protocol consisting of scheduled nonsteroidal antiinflammatory drug doses (ketorolac or ibuprofen), alternating with scheduled acetaminophen and diazepam doses, with as-needed opioids. It was hypothesized that protocol use would be associated with reductions in opioid requirements and other clinical improvements.
METHODS
Data were obtained for 52 patients undergoing SDR at an academic tertiary care pediatric hospital (2012-2017, with the protocol implemented in 2014). Using a retrospective cohort design, we compared outcomes between protocol and nonprotocol patients, employing both univariate test and Wilcoxon rank test comparisons as well as multivariable regression methods. The primary outcome was total as-needed opioid requirements over postoperative days (PODs) 0 to 2, measured in oral morphine milligram equivalents per kilogram. Additional outcomes included antiemetic medication doses, discharge opioid prescriptions, total direct cost, and length of stay.
RESULTS
Twelve patients received the MMA protocol, and 40 patients did not. POD-0 MMA initiation was independently associated with a reduction of 0.14 morphine milligram equivalents per kilogram in mean opioid requirements over PODs 0 to 2 in the multiple regression analysis (95% confidence interval 0.01 to 0.28; = .04). No statistically significant differences were demonstrated in doses of antiemetic medications, discharge opioid prescriptions, total direct cost, and length of stay.
CONCLUSIONS
This MMA protocol may help reduce opioid use after SDR. Improving protocol implementation in a prospective, multisite study will help elucidate further MMA effects on pain, costs, and recovery.
Topics: Analgesia; Analgesics, Opioid; Anti-Inflammatory Agents, Non-Steroidal; Child; Humans; Pain, Postoperative; Retrospective Studies; Rhizotomy
PubMed: 31862854
DOI: 10.1542/hpeds.2019-0016 -
Trials Apr 2022Opioids and benzodiazepines (BZDs) are some of the most commonly prescribed medications that contribute to falls in older adults. These medications are challenging to...
BACKGROUND
Opioids and benzodiazepines (BZDs) are some of the most commonly prescribed medications that contribute to falls in older adults. These medications are challenging to appropriately prescribe and monitor, with little guidance on safe prescribing of these medications for older patients. Only a handful of small studies have evaluated whether reducing opioid and BZD use through deprescribing has a positive impact on outcomes. Leveraging the strengths of a large health system, we evaluated the impact of a targeted consultant pharmacist intervention to deprescribe opioids and BZDs for older adults seen in primary care practices in North Carolina.
METHODS
We developed a toolkit and process for deprescribing opioids and BZDs in older adults based on a literature review and guidance from an interprofessional team of pharmacists, geriatricians, and investigators. A total of fifteen primary care practices have been randomized to receive the targeted consultant pharmacist service (n = 8) or usual care (n = 7). The intervention consists of several components: (1) weekly automated reports to identify chronic users of opioids and BZDs, (2) clinical pharmacist medication review, and (3) recommendations for deprescribing and/or alternate therapies routed to prescribers through the electronic health record. We will collect data for all patients presenting one of the primary care clinics who meet the criteria for chronic use of opioids and/or BZDs, based on their prescription order history. We will use the year prior to evaluate baseline medication exposures using morphine milligram equivalents (MMEs) and diazepam milligram equivalents (DMEs). In the year following the intervention, we will evaluate changes in medication exposures and medication discontinuations between control and intervention clinics. Incident falls will be evaluated as a secondary outcome. To date, the study has enrolled 914 chronic opioid users and 1048 chronic BZD users. We anticipate that we will have 80% power to detect a 30% reduction in MMEs or DMEs.
DISCUSSION
This clinic randomized pragmatic trial will contribute valuable evidence regarding the impact of pharmacist interventions to reduce falls in older adults through deprescribing of opioids and BZDs in primary care settings.
TRIAL REGISTRATION
Clinicaltrials.gov NCT04272671 . Registered on February 17, 2020.
Topics: Accidental Falls; Aged; Analgesics, Opioid; Benzodiazepines; Clinical Trials as Topic; Deprescriptions; Humans; Pharmacists
PubMed: 35379307
DOI: 10.1186/s13063-022-06164-5 -
Spine Nov 2023Retrospective cohort study.
Evidence for a Multimodal Pain Management Regimen in Reduction of Postoperative Opioid Use in Pediatric Patients Receiving Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.
STUDY DESIGN
Retrospective cohort study.
OBJECTIVE
This project aims to evaluate the relationship between increased use of intraoperative nonopioid analgesics, muscle relaxers, and anesthetics and postoperative outcomes, including opioid utilization, time until ambulation, and hospital length of stay.
SUMMARY OF BACKGROUND DATA
Adolescent idiopathic scoliosis (AIS) is a structural deformity of the spine that occurs in otherwise healthy adolescents, occurring with a frequency of 1% to 3%. Up to 60% of patients receiving spinal surgeries, particularly posterior spinal fusion (PSF), experience at least 1 day of moderate-to-severe pain after surgery.
PATIENTS AND METHODS
This is a retrospective chart review of pediatric patients aged 10 to 17 having received PSF with >5 levels fused for AIS at a dedicated children's hospital and a regional tertiary referral center with a dedicated pediatric spine program between January 2018 and September 2022. A linear regression model was used to evaluate the influence of baseline characteristics and intraoperative medications on the total amount of postoperative morphine milligram equivalents received.
RESULTS
There were no significant differences in the background characteristics of the two patient populations. Patients receiving PSF at the tertiary referral center received equivalent or greater amounts of all nonopioid pain medications and demonstrated decreased time until ambulation (19.3 vs . 22.3 h), postoperative opioid use (56.1 vs . 70.1 MME), and postoperative hospital length of stay (35.9 vs . 58.3 h). Hospital location was not individually associated with a difference in postoperative opioid use. There was not a significant difference in postoperative pain ratings. When accounting for all other variables, liposomal bupivacaine had the greatest contribution to the decrease in postoperative opioid use.
CONCLUSION
Patients receiving greater amounts of nonopioid intraoperative medications utilized 20% fewer postoperative morphine milligram equivalents, were discharged 22.3 hours earlier and had earlier recorded evidence of mobility. Postoperatively, nonopioid analgesics were as effective as opioids in the reduction of subjective pain ratings. This study further demonstrates the efficacy of multimodal pain management regimens in pediatric patients receiving PSF for AIS.
Topics: Humans; Adolescent; Child; Analgesics, Opioid; Pain Management; Retrospective Studies; Analgesics, Non-Narcotic; Scoliosis; Spinal Fusion; Pain, Postoperative; Opioid-Related Disorders; Morphine Derivatives
PubMed: 37294836
DOI: 10.1097/BRS.0000000000004747 -
A Multidisciplinary and a Comprehensive Approach to Reducing Fragility Fractures in Preterm Infants.Current Pediatric Reviews Dec 2022With advances in neonatal care, bone fractures prior to discharge from the hospital in preterm infants receiving contemporary neonatal care, are rare. Nevertheless, such...
With advances in neonatal care, bone fractures prior to discharge from the hospital in preterm infants receiving contemporary neonatal care, are rare. Nevertheless, such fractures do occur in very low birth weight and extremely low birth weight infants who go on to develop metabolic bone disease of prematurity (MBDP), with or without secondary hyperparathyroidism. MBDP is a multifactorial disorder arising from the disruption of bone mass accrual due to premature birth, postnatal immobilisation, and loss of placental oestrogen resulting in bone loss, inadequate provision of bone minerals from enteral and parenteral nutrition, and medications that leach out bone minerals from the skeleton. All of these factors lead to skeletal demineralisation and a decrease in bone strength and an increased risk of fractures of the long bones and ribs. Secondary hyperparathyroidism resulting from phosphate supplements, or enteral/parenteral feeds with a calcium-to-phosphate ratio of < 1.3:1.0 leads to subperiosteal bone resorption, cortical thinning, and further skeletal weakening. Such fractures may occur from routine handling and procedures such as cannulation. Most fractures are asymptomatic and often come to light incidentally on radiographs performed for other indications. In 2015, we instituted a comprehensive and multidisciplinary Neonatal Bone Health Programme (NBHP), the purpose of which was to reduce fragility fractures in high-risk neonates, by optimising enteral and parenteral nutrition, including maintaining calcium-to-phosphate ratio ≥1.3:1, milligram to milligram, biochemical monitoring of MBDP, safe-handling of at-risk neonates, without compromising passive physiotherapy and skin-to-skin contact with parents. The at-risk infants in the programme had radiographs of the torso and limbs at 4 weeks and after 8 weeks from enrolment into the program or before discharge. Following the introduction of the NBHP, the bone fracture incidence reduced from 12.5% to zero over an 18-month period.
PubMed: 36545738
DOI: 10.2174/1573396319666221221122013