Perioperative management of patients with cancer pain treated with opioids: a retrospective study

Abstract

Purpose

We retrospectively studied perioperative management of patients receiving opioid treatment for cancer pain to facilitate establishing a standard policy for our institute.

Methods

Subjects were patients who had been administered strong opioids for cancer pain and had undergone surgery with general anesthesia. We divided the patients into groups C and D. Group C was comprised of patients who had been administered their baseline opioids continuously during the perioperative period, and group D of those who had discontinued baseline opioid use during this period.

Results

We identified 70 evaluable patients, 36 in group C and 34 in group D. The intraoperative anesthesia courses were similar, being uneventful, in all cases. With respect to postoperative adverse effects within 24 h after awakening from anesthesia, severe adverse effects (additional administration of more than four analgesics and intense agitation) were significantly more frequent in group D than in group C (12 vs 1, respectively. p = 0.004). Univariate analysis revealed that baseline opioid discontinuation was the only factor associated with severe adverse effects [odds ratio 12.6, 95% confidence interval (1.49–105.8), p = 0.01].

Conclusion

Discontinuation of baseline opioid increased adverse effects in the early postoperative period, which were attributed to exacerbation of early postoperative pain.

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A Cyclin E Centered Genetic Network Contributes to Alcohol-Induced Variation in Drosophila Development

Prenatal exposure to ethanol causes a wide range of adverse physiological, behavioral and cognitive consequences. However, identifying allelic variants and genetic networks associated with variation in susceptibility to prenatal alcohol exposure is challenging in human populations, since time and frequency of exposure and effective dose cannot be determined quantitatively and phenotypic manifestations are diverse. Here, we harnessed the power of natural variation in the Drosophila melanogaster Genetic Reference Panel (DGRP) to identify genes and genetic networks associated with variation in sensitivity to developmental alcohol exposure. We measured development time from egg to adult and viability of 201 DGRP lines reared on regular or ethanol- supplemented medium and identified polymorphisms associated with variation in susceptibility to developmental ethanol exposure. We also documented genotype-dependent variation in sensorimotor behavior after developmental exposure to ethanol using the startle response assay in a subset of 39 DGRP lines. Genes associated with development, including development of the nervous system, featured prominently among genes that harbored variants associated with differential sensitivity to developmental ethanol exposure. Many of them have human orthologs and mutational analyses and RNAi targeting functionally validated a high percentage of candidate genes. Analysis of genetic interaction networks identified Cyclin E (CycE) as a central, highly interconnected hub gene. Cyclin E encodes a protein kinase associated with cell cycle regulation and is prominently expressed in ovaries. Thus, exposure to ethanol during development of Drosophila melanogaster might serve as a genetic model for translational studies on fetal alcohol spectrum disorder.

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ECT: a new look at an old friend

Purpose of review Electroconvulsive therapy (ECT) as a treatment option in psychiatry is advancing day by day. This review discusses new advancements in ECT with regards to anesthetic variables, stimulus, and response variables along with their impact on clinical outcomes. Recent findings Anesthetic variables influence clinical efficacy and patient tolerance of ECT. Although etomidate or a ketamine–propofol combination may be the first choice for many clinicians, the search for ideal induction agent continues. Dexmedetomidine, remifentanil, or ketamine may aid in augmentation of ECT; however, they are not recommended routinely. A systematic procedure for hyperventilation of the patient has been shown to have clinical repercussions. Optimizing anesthesia-ECT time interval (ASTI) has a significant impact on the success of the procedure. BIS monitoring alone cannot be relied upon for timing stimulus. High-dose brief pulse right unilateral ECT represents an acceptable first-line form of treatment, though there is currently no 'gold standard'. Other stimulus variations such as focal electrically administered seizure therapy, individualized low-amplitude seizure therapy, magnetic seizure therapy, left unilateral and left anterior right temporal electrode placements are explored to reduce memory effects. EEG ictal indices may be relied upon for seizure adequacy, and therefore may be used to both guide treatment and predict the outcome of the procedure. Summary Modern ECT is streamlined by augmentation with drugs, hyperventilation, optimizing anesthesia-ECT time interval, and various stimulus parameters guided by seizure adequacy markers. Correspondence to Pavan Kumar Kadiyala, Assistant Professor, Department of Psychiatry, ASR Academy of Medical Sciences, Eluru, AP 534005, India. Tel: +919980731234; e-mail: drkadiyala2@gmail.com Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Do we really need an anesthesiologist for routine colonoscopy in American Society of Anesthesiologist 1 and 2 patients?

Purpose of review In an era where healthcare costs are being heavily scrutinized, every expenditure is reviewed for medical necessity. Multiple national gastroenterology societies have issued statements regarding whether an anesthesiologist is necessary for routine colonoscopies in American Society of Anesthesiologist (ASA) 1 and 2 patients. Recent findings A large percentage of patients are undergoing screening colonoscopy without any sedation at all, which would not require an independent practitioner to administer medications. Advances in technique and technology are making colonoscopies less stimulating. Advantages to administering sedation, including propofol, have been seen even when not administered under the direction of an anesthesiologist and complications seem to be rare. The additional cost of having monitored anesthesia care appears to be a driving factor in whether a patient receives it or not. Summary A large multiinstitutional randomized control trial would be necessary to rule out potential confounders and to determine whether there is a safety benefit or detriment to having anesthesiologist-directed care in the setting of routine colonoscopies in ASA 1 and 2 patients. Further discussion would be necessary regarding what the monetary value of that effect is if a small difference were to be detected. Correspondence to Jeffrey D. White, MD, Department of Anesthesiology, University of Florida College of Medicine, 1600 SW Archer Road, PO Box 100254, Gainesville, FL 32610, USA. Tel: +1 352 273 6575; e-mail: jwhite@anest.ufl.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Association between non-variceal spontaneous portosystemic shunt and outcomes after TIPS in cirrhosis

Whether pre-existing nonvariceal spontaneous portosystemic shunts (SPSSs) in cirrhotic patients affect outcomes after transjugular intrahepatic portosystemic shunt (TIPS) and whether they need to be closed remains unclear.

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Incidence of HCV infection amongst HIV positive men who had sex with men and prevalence data from patients followed at the Infectious Diseases Clinic of Modena, Italy

Men who had sex with men (MSM) living with HIV are at higher risk of developing sexual transmitted diseases. This study reports two years incidence rate and prevalence of HCV in a cohort of HIV positive MSM.

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Narrative Medicine in Amyotrophic Lateral Sclerosis and a rehabilitation project based on International Classification of Functioning, Disability and Health (ICF)

Objective To systematize the disability condition related to Amyotrophic Lateral Sclerosis (ALS) patients using the International Classification of Functioning, Disability and Health (ICF) and Narrative Medicine approach as a common tool to identify a patient's functional problems. Once identified, this can be used as the basis for an individual rehabilitation project. Design An observational study on patients residing in a central region of Italy with a diagnosis of ALS. The narrative approach involved listening to the patients' stories while guiding them with a semi-structured questionnaire of 19 ICF items taken from the WHO-DAS II. A score from 0-4 for capacity (C) and performance (P) was adopted to evaluate each patient's functioning in their daily living activities. Results The ICF questionnaire was able to discriminate among responders (p

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