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Urology Practice Jul 2024Gabapentin has been used in enhanced recovery after surgery (ERAS) pathways for pain control for patients undergoing ambulatory uro-oncologic surgery; however, it may...
INTRODUCTION
Gabapentin has been used in enhanced recovery after surgery (ERAS) pathways for pain control for patients undergoing ambulatory uro-oncologic surgery; however, it may cause undesirable side effects. We studied the causal association between gabapentin and rapidity of recovery and perioperative pain management after minimally invasive uro-oncologic surgery.
METHODS
We identified 2397 patients ≤ 65 years undergoing prostatectomies or nephrectomies between 2018 and 2022; 131 (5.5%) did not receive gabapentin. We tested the effect of gabapentin use on time of discharge and perioperative opioid consumption, respectively, using multivariable linear regression adjusting for potential confounders including age, gender, BMI, American Society of Anesthesiologists score, and surgery type.
RESULTS
On adjusted analysis, we found no evidence of a difference in discharge time among those who did vs did not receive gabapentin (adjusted difference 0.07 hours shorter on gabapentin; 95% CI -0.17, 0.31; = .6). There was no evidence of a difference in intraoperative opioid consumption by gabapentin receipt (adjusted difference -1.5 morphine milligram equivalents; 95% CI -4.2, 1.1; = .3) or probability of being in the top quartile of postoperative opioid consumption within 24 hours (adjusted difference 4.2%; 95% CI -4.8%, 13%; = .4). We saw no important differences in confounders by gabapentin receipt suggesting causal conclusions are justified.
CONCLUSIONS
Our confidence intervals did not include clinically meaningful benefits from gabapentin, when used with an ERAS protocol, in terms of length of stay or perioperative opioid use. These results support the omission of gabapentin from ERAS protocols for minimally invasive uro-oncologic surgeries.
Topics: Humans; Gabapentin; Male; Middle Aged; Female; Pain, Postoperative; Analgesics; Ambulatory Surgical Procedures; Prostatectomy; Minimally Invasive Surgical Procedures; Nephrectomy; Retrospective Studies; Analgesics, Opioid; Time Factors
PubMed: 38899668
DOI: 10.1097/UPJ.0000000000000570 -
Preventive Medicine Jun 2024Understanding the clinical and demographic profile of patients on gabapentinoids can highlight areas of prescribing disparities, inform clinical practice, and guide...
OBJECTIVE
Understanding the clinical and demographic profile of patients on gabapentinoids can highlight areas of prescribing disparities, inform clinical practice, and guide future research to optimize effectiveness and safety of gabapentinoids for pain management. We used a national sample of Medicare beneficiaries to examine trends, patterns, and patient-level predictors of gabapentinoid use among long-term opioid users.
METHODS
Using a national Medicare sample between 2014 and 2020, we examined factors associated with gabapentinoid use among long-term opioid users. We included Medicare eligible long-term opioid users with no prior gabapentinoid use. The primary outcome was gabapentinoid use after the long-term opioid use episode. Logistic regression was used to test the association with gabapentinoid use for year, age, sex, race/ethnicity, region, Medicare entitlement, low-income status, frailty, pain locations, anxiety, depression, opioid use disorder, and opioid morphine milligrams equivalent.
RESULTS
Gabapentinoid use among long-term opioid users increased from 12.6% in 2014 to 16.8% in 2019 (p < .0001). Factors associated with increased gabapentinoid use were Hispanic ethnicity, back pain, nerve pain, and moderate or high opioid usage. Factors associated with decreased gabapentinoid use were older age and Medicare entitlement due to old age.
CONCLUSIONS
Variation of gabapentinoid use by socio-demographics and insurance status indicates opportunities to improve pain management and a need for shared therapeutic decision making informed by discussion between pain patients and providers regarding safety and effectiveness of pain therapies. Our findings underscore the need for future research into the comparative effectiveness and safety of gabapentinoids for non-cancer chronic pain in various subpopulations.
PubMed: 38897356
DOI: 10.1016/j.ypmed.2024.108046 -
The Journal of Pediatrics Jun 2024To determine whether an enteral, clonidine-based sedation strategy (CLON) during therapeutic hypothermia (TH) for hypoxic-ischemic encephalopathy (HIE) would decrease...
OBJECTIVE
To determine whether an enteral, clonidine-based sedation strategy (CLON) during therapeutic hypothermia (TH) for hypoxic-ischemic encephalopathy (HIE) would decrease opiate use, while maintaining similar short-term safety and efficacy profiles to a morphine-based strategy (MOR).
STUDY DESIGN
This was a single-center, observational study conducted at a level IV neonatal intensive care unit from January 1, 2017, to October 1, 2021. From April 13, 2020, to August 13, 2020, MOR was transitioning to CLON. Thus, patients receiving TH for HIE were grouped to MOR (before April 13, 2020) and CLON (after August 13, 2020). We calculated the total and rescue morphine milligram equivalent (MME)/ kg (primary outcome) and frequency of hemodynamic changes (secondary outcome) for both groups.
RESULTS
MOR and CLON groups (74 and 25 neonates, respectively) had similar baseline characteristics and need for rescue sedative intravenous infusion (21.6% MOR and 20% CLON). Both, MME/ kg and need for rescue opiates (combined bolus and infusions) were higher in MOR than CLON (p < 0.001). As days in TH advanced, a lower percentage of CLON patients needed rescue opiates (92% on day 1 to 68% on day 3). MOR patients received a higher cumulative dose of dopamine and more frequently required a second inotrope and hydrocortisone for hypotension. MOR had a lower respiratory rate during TH (p=0.01 vs. CLON).
CONCLUSIONS
Our CLON protocol is non-inferior to MOR, maintaining perceived effectiveness and hemodynamic safety, with an apparently reduced need for opiates and inotropes.
PubMed: 38889855
DOI: 10.1016/j.jpeds.2024.114158 -
JBJS Reviews Jun 2024The effectiveness of tranexamic acid (TXA) as an antifibrinolytic agent in total shoulder arthroplasty (TSA) is well documented; however, there remains considerable... (Review)
Review
BACKGROUND
The effectiveness of tranexamic acid (TXA) as an antifibrinolytic agent in total shoulder arthroplasty (TSA) is well documented; however, there remains considerable practice variability concerning the optimal route of administration and dosing protocols concerning the medication's use. Our aim was to conduct a scoping review of the literature regarding the efficacy of various methods of TXA administration in TSA and to identify knowledge gaps that may be addressed.
METHODS
A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. The PubMed and MEDLINE electronic databases were searched to identify all articles published before March 2023 investigating the administration of TXA in TSA. Randomized controlled trials and cohort studies were included, and data were extracted to capture information regarding intervention details and related outcomes such as blood loss, transfusion needs, and complication rates.
RESULTS
A total of 15 studies were included in this review. All selected studies used either intravenous (IV) or topical TXA, with 1 study also including a combined approach of both topical and IV TXA. Of the studies that used an IV approach, the most commonly reported favorable outcomes were a reduction in blood volume loss, reduction in hemoglobin or hematocrit change, and decreased drain output. Dosing varied significantly between all identified studies because some used a standard dosing amount in grams or milligrams for all treatment group participants, whereas others used weight-based dosing amounts. All studies that used a weight-based dosing regimen as well as studies using a standard dosing amount between 1,000 and 5,000 mg reported favorable outcomes for postoperative blood loss.
CONCLUSION
Both IV and topical TXA clearly demonstrate favorable perioperative hematologic profiles in TSA. Although both approaches have demonstrated a successful association with decreased blood loss and transfusion requirements, there is no definitive benefit to choosing one over the other. Furthermore, the use of oral TXA either in combination or isolation warrants further study in TSA because of its comparable efficacy profiles and significantly lower associated costs of application.
Topics: Tranexamic Acid; Humans; Arthroplasty, Replacement, Shoulder; Antifibrinolytic Agents; Blood Loss, Surgical
PubMed: 38889236
DOI: 10.2106/JBJS.RVW.24.00035 -
Environmental Science and Pollution... Jun 2024Livestock excrement is used around the world as natural fertilizers or, after processing, as organic fertilizers for crops and grasslands. But due to the presence of...
Livestock excrement is used around the world as natural fertilizers or, after processing, as organic fertilizers for crops and grasslands. But due to the presence of veterinary antibiotics in them, they may pose a threat not only to the natural environment, mainly to soil microorganisms, but also to human and animal health. This article describes a method for detecting 21 antibacterial substances in solid natural and organic fertilizers. Antibiotics from fertilizers were extracted with a mixture of acetonitrile and McIlvain-NaEDTA buffer, twice. The extracts were purified by solid phase extraction technique on Strata-X cartridges and analyzed with the use UHPLC-MS/MS technique. The method was validated in accordance with EU Commission Implementing Regulation 2021/808; the obtained recovery ranged from 93.6 to 116.6% (depending on the analytes), and the linearity ranged from 50 to 1000 µg/kg. The developed method was used to analyze 73 samples of solid natural and organic fertilizers. Our research has shown that over 38% of natural fertilizers were contaminated with antibiotics, mainly doxycycline in concentrations reaching several dozen milligrams per kilogram of fertilizers. In the case of processed organic fertilizers, the presence of antibiotics was found in over 37% of the analyzed samples. The research results showed that the developed and validated analytical method may be useful for assessing the presence and content of antibacterial substances in solid natural and organic fertilizers.
PubMed: 38886273
DOI: 10.1007/s11356-024-33956-w -
The Oncologist Jun 2024Immune checkpoint inhibitors (ICIs) have revolutionized cancer care with incredible reductions in mortality. One of the most devastating complications of treatment is...
BACKGROUND
Immune checkpoint inhibitors (ICIs) have revolutionized cancer care with incredible reductions in mortality. One of the most devastating complications of treatment is ICI-related pneumonitis (ICI-p). Despite this, little is known regarding risk factors for severe pneumonitis and treatment effectiveness of various therapeutic options for steroid-refractory disease. To address this, we conducted a retrospective study on patients with cancer who developed ICI-p.
METHODS
We examined consecutive patients who received ICIs and developed ICI-p. Risk factors of interest for severe disease and steroid-refractory ICI-p, including pre-treatment pulmonary function tests (PFTs) and chest imaging, were compared between patients with severe (grades 3-5) and mild (grades 1-2) pneumonitis. The clinical and treatment courses for patients with steroid-refractory ICI-p were recorded.
RESULTS
A total of 132 patients developed ICI-p, with 60 patients having mild and 72 with severe disease. We found that lower forced vital capacity percent predicted (66.24 vs 85.05, P = .05), lower total lung capacity percent predicted (85.23 vs 99.71, P = .13), and specific radiographic patterns on pre-treatment chest imaging were predictors of severe disease. Initial corticosteroid dose of less than 1 milligram per kilogram prednisone equivalent (P = .14) was correlated with partially steroid-responsive or steroid-refractory ICI-p. Ten patients had steroid refractory ICI-p, and those who received IVIG alone as the immune suppressant beyond corticosteroids had improved survival (P = 05).
CONCLUSIONS
We are the first to identify pre-treatment PFTs and chest imaging abnormalities as risk factors for severe ICI-p. We also found that lower corticosteroid doses were associated with partially steroid-responsive and steroid-refractory ICI-p. Larger, prospective studies are needed to validate our results.
PubMed: 38886156
DOI: 10.1093/oncolo/oyae147 -
Spine Jun 2024Prospective cohort using routinely-collected health data.
STUDY DESIGN
Prospective cohort using routinely-collected health data.
OBJECTIVE
To compare opioid use based on surgery intensity (low or high).
SUMMARY OF BACKGROUND DATA
Many factors influence an individual's experience of pain. The extent to which post-surgical opioid use is influenced by the severity of spine surgery is unknown.
METHODS
The participants were individuals undergoing spine surgery in a large military hospital. Procedures were categorized as low-intensity (e.g., microdiscectomy and laminectomy) and high-intensity (e.g., fusion and arthroplasty). The Surgical Scheduling System and Military Health System Data Repository were queried for healthcare utilization the 1 year before and after surgery. We compared opioid use after surgery between groups, adjusting for prior opioid use and surgical complications.
RESULTS
342 individuals met the inclusion criteria, mean age 45.4 years (SD 10.9), 33.0% female. Of these, 221(64.6%) underwent a low-intensity procedure and 121(35.4%) underwent a high-intensity procedure. Mean postoperative opioid prescription fills were greater in the high- versus low-intensity group (9.0 vs. 5.7;P<0.001), as were the mean total days' supply (158.9 vs. 81.8;P<0.001). Median morphine milligram equivalents were not significantly different (MME; 40.2 vs. 42.7;P=0.287). 26.3% of the cohort were chronic opioid users after surgery. Adjusted rates of long-term opioid use were not different between groups when only accounting for prior opioid use, but significantly higher for the high-intensity group when adjusting for surgical complications (OR=2.08;95CI 1.09,3.97). 52.5% of the entire cohort was still filling opioid prescriptions after six months.
CONCLUSION
Higher-intensity procedures were associated with greater postoperative opioid use than lower-intensity procedures. Chronic opioid use was not significantly different between surgical intensity groups when considering only prior opioid use. Chronic opioid use was significantly higher among higher intensity procedures when accounting for surgical complications. The prresence of surgical complications is a stronger predictor of post-surgical long-term opioid use in high intensity surgeries than history of opioid use alone.
PubMed: 38881243
DOI: 10.1097/BRS.0000000000005069 -
The Spine Journal : Official Journal of... Jun 2024Prolonged opioid therapy following spine surgery is an ongoing postoperative concern. While prior studies have investigated postoperative opioid use patterns in the...
BACKGROUND CONTEXT
Prolonged opioid therapy following spine surgery is an ongoing postoperative concern. While prior studies have investigated postoperative opioid use patterns in the elective cervical surgery patient population, to our knowledge, opioid use patterns in patients undergoing surgery for traumatic cervical spine injuries have not been elucidated.
PURPOSE
The purpose of this study was to compare opioid use and prescription patterns in the postoperative pain management of patients undergoing traumatic and elective cervical spine fusion surgery.
STUDY DESIGN
Retrospective cohort study PATIENT SAMPLE: Adult patients with traumatic cervical injuries who underwent primary anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) during their initial hospital admission. The propensity matched, control group consisted of adult elective cervical fusion patients who underwent primary ACDF or PCDF.
OUTCOME MEASURES
Demographic data, surgical characteristics, spinal disease diagnosis, location of cervical injury, procedure type, operative levels fused, and Prescription Drug Monitoring Program (PDMP) data. PDMP data included the number of opioid prescriptions filled, preoperative opioid use, postoperative opioid use, and use of perioperative benzodiazepines, muscle relaxants, or gabapentin. Opioid consumption data was collected in morphine milligram equivalents (MME) and standardized per day.
METHODS
A 1:1 propensity match was performed to match traumatic injury patients undergoing cervical fusion surgery with elective cervical fusion patients. Traumatic injury patients were matched based on age, sex, CCI, procedure type, and cervical levels fused. Pre- and postoperative opioid, benzodiazepine, muscle relaxant, and gabapentin use were assessed for the traumatic injury and elective patients. T- or Mann-Whitney U tests were used to compare continuous data and Chi-Squared or Fisher's Exact were used to compare categorical data. Multivariate stepwise regression using MME per day 0 - 30 days following surgery as the dependent outcome was performed to further evaluate associations with postoperative opioid use.
RESULTS
A total of 48 patients underwent fusion surgery for a traumatic cervical spine injury and 48 elective cervical fusion with complete PDMP data were assessed. Elective patients were found to fill more prescriptions (3.19 vs. 0.65, p=0.023) and take more morphine milligram equivalents (MME) per day (0.60 vs. 0.04, p=0.014) within one year prior to surgery in comparison to traumatic patients. Elective patients were also more likely to use opioids (29.2% vs. 10.4%, p=0.040) and take more MMEs per day (0.70 vs. 0.05, p=0.004) within 30 days prior to surgery. Within 30 days postoperatively, elective patients used opioids more frequently (89.6% vs. 52.1%, p<0.001) and took more MMEs per day (3.73 vs. 1.71, p<0.001) than traumatic injury patients. Multivariate stepwise regression demonstrated preoperative opioid use (Estimate: 1.87, p=0.013) to be correlated with higher postoperative MME per day within 30 days of surgery. Surgery after traumatic injury was correlated with lower postoperative MME use per day within 30 days of surgery (Estimate:-1.63 p=0.022).
CONCLUSION
Cervical fusion patients with a history of traumatic spine injury consume fewer opioids in the early postoperative period in comparison to elective cervical fusion patients, however both cohorts consumed a similar amount after the initial 30-day postoperative period. Preoperative opioid use was also a risk factor for higher consumption in the short-term postoperative period. These results may aid physicians in further understanding patients' postoperative care needs based on presenting injury characteristics and highlights the need for enhanced follow-up care for traumatic cervical spine injury patients after fusion surgery.
PubMed: 38880487
DOI: 10.1016/j.spinee.2024.06.006 -
Journal of Pain and Symptom Management Jun 2024Opioid use prior to cancer diagnosis increases the likelihood of long-term use during survivorship, however, patterns of use before and after diagnosis are not...
BACKGROUND
Opioid use prior to cancer diagnosis increases the likelihood of long-term use during survivorship, however, patterns of use before and after diagnosis are not understood.
METHODS
We used population-based dispensing data linked with cancer and death notifications to identify two cohorts of adults residing in New South Wales initiating opioids within 24 months prior to a first cancer diagnosed between 2014 and 2016: 'survivors' (alive 24 months following diagnosis) and 'decedents' (died within 24 months). We used group-based trajectory modelling to identify trajectories of monthly opioid dispensings and dispensed oral morphine equivalent milligrams (OMEmg) during the 24 months before/after cancer diagnosis.
RESULTS
There were 21,843 survivors with four prediagnosis opioid dispensing trajectories: infrequent (58% of the cohort), late increasing (26%), moderate (10%), and sustained dispensing (6%). We observed an overall increase in dispensed OMEmg of 83 OMEmg (95% CI: 76-91) during the month of diagnosis, with strong opioid formulations comprising most treatment postdiagnosis. Within each prediagnosis opioid trajectory group, we observed five to six postdiagnosis trajectory groups, including no opioid dispensing. Moderate and sustained prediagnosis groups had large proportions of people continuing or increasing opioid dispensing after diagnosis, while small proportions discontinued opioid treatment. We observed similar trajectories in the decedent cohort.
CONCLUSIONS
There is considerable heterogeneity in opioid use before and after cancer diagnosis. Our findings suggest noncancer factors drive a significant proportion of postdiagnosis opioid use, but use increased significantly from the month of cancer diagnosis and never returned to prediagnosis levels.
PubMed: 38878910
DOI: 10.1016/j.jpainsymman.2024.06.006 -
Plant Methods Jun 2024There is a growing demand for fast and reliable plant biomolecular analyses. DNA extraction is the major bottleneck in plant nucleic acid-based applications especially...
BACKGROUND
There is a growing demand for fast and reliable plant biomolecular analyses. DNA extraction is the major bottleneck in plant nucleic acid-based applications especially due to the complexity of tissues in different plant species. Conventional methods for plant cell lysis and DNA extraction typically require extensive sample preparation processes and large quantities of sample and chemicals, elevated temperatures, and multiple sample transfer steps which pose challenges for high throughput applications.
RESULTS
In a prior investigation, an ionic liquid (IL)-based modified vortex-assisted matrix solid phase dispersion approach was developed using the model plant, Arabidopsis thaliana (L.) Heynh. Building upon this foundational study, the present study established a simple, rapid and efficient protocol for DNA extraction from milligram fragments of plant tissue representing a diverse range of taxa from the plant Tree of Life including 13 dicots and 4 monocots. Notably, the approach was successful in extracting DNA from a century old herbarium sample. The isolated DNA was of sufficient quality and quantity for sensitive molecular analyses such as qPCR. Two plant DNA barcoding markers, the plastid rbcL and nuclear ribosomal internal transcribed spacer (nrITS) regions were selected for DNA amplification and Sanger sequencing was conducted on PCR products of a representative dicot and monocot species. Successful qPCR amplification of the extracted DNA up to 3 weeks demonstrated that the DNA extracted using this approach remains stable at room temperature for an extended time period prior to downstream analysis.
CONCLUSIONS
The method presented here is a rapid and simple approach enabling cell lysis and DNA extraction from 1.5 mg of plant tissue across a broad range of plant taxa. Additional purification prior to DNA amplification is not required due to the compatibility of the extraction solvents with qPCR. The method has tremendous potential for applications in plant biology that require DNA, including barcoding methods for agriculture, conservation, ecology, evolution, and forensics.
PubMed: 38877523
DOI: 10.1186/s13007-024-01217-z