Analgesic effects of methadone and magnesium following posterior spinal fusion for idiopathic scoliosis in adolescents: a randomized controlled trial

Abstract

Purpose

To provide optimal conditions for neurophysiological monitoring and rapid awakening, remifentanil is commonly used during pediatric spinal surgery. However, remifentanil may induce hyperalgesia and increase postoperative opioid requirements. We evaluated the potential of methadone or magnesium to prevent remifentanil-induced hyperalgesia.

Methods

Using a prospective, randomized, blinded design, adolescents presenting for posterior spinal fusion to treat idiopathic scoliosis were assigned to receive desflurane with remifentanil alone (REMI), remifentanil + methadone (MET) (0.1 mg/kg IV over 15 min), or remifentanil + magnesium (MAG) (50 mg/kg bolus over 30 min followed by 10 mg/kg/h). Primary outcomes were opioid requirements and postoperative pain scores. Secondary outcomes included intraoperative anesthetic requirements, neurophysiological monitoring conditions, and emergence times.

Results

Data analysis included 60 patients. Total opioid requirement (hydromorphone) in the REMI group (received perioperatively and on the inpatient ward) was 0.34 ± 0.11 mg/kg compared to 0.26 ± 0.10 mg/kg in the MET group (95% confidence interval (CI) of difference: − 0.14, − 0.01; p = 0.035). The difference in opioid requirements between the REMI and MET group was related to intraoperative dosing (0.04 ± 0.02 mg/kg vs. 0.02 ± 0.01 mg/kg; 95% CI of difference: − 0.01, − 0.02; p = 0.003). No difference was noted in pain scores, and no differences were noted when comparing the REMI and MAG groups.

Conclusion

With the dosing regimens in the current study, the only benefit noted with methadone was a decrease in perioperative opioid requirements. However, given the potential for hyperalgesia with the intraoperative use of remifentanil, adjunctive use of methadone appears warranted.

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Neonatal Abstinence Syndrome (NAS) in Southwestern Border States: Examining Trends, Population Correlates, and Implications for Policy

Abstract

Introduction Neonatal abstinence syndrome (NAS) is withdrawal syndrome in newborns following birth and is primarily caused by maternal drug use during pregnancy. This study examines trends, population correlates, and policy implications of NAS in two Southwest border states. Materials and Methods A cross-sectional analysis of Hospital Inpatient Discharge Data (HIDD) was utilized to examine the incidence of NAS in the Southwest border states of Arizona (AZ) and New Mexico (NM). All inpatient hospital births in AZ and NM from January 1, 2008 through December 31, 2013 with ICD9-CM codes for NAS (779.5), cocaine (760.72), or narcotics (760.75) were extracted. Results During 2008–2013 there were 1472 NAS cases in AZ and 888 in NM. The overall NAS rate during this period was 2.83 per 1000 births (95% CI 2.68–2.97) in AZ and 5.31 (95% CI 4.96–5.66) in NM. NAS rates increased 157% in AZ and 174% in NM. NAS newborns were more likely to have low birth weight, have respiratory distress, more likely to have feeding difficulties, and more likely to be on state Medicaid insurance. AZ border region (border with Mexico) had NAS rates significantly higher than the state rate (4.06 per 1000 births [95% CI 3.68–4.44] vs. 2.83 [95% CI 2.68–2.97], respectively). In NM, the border region rate (2.09 per 1000 births [95% CI 1.48–2.69]) was significantly lower than the state rate (5.31 [95% CI 4.96–5.66]). Conclusions Despite a dramatic increase in the incidence of NAS in the U.S. and, in particular, the Southwest border states of AZ and NM, there is still scant research on the overall incidence of NAS, its assessment in the southwest border, and associated long-term outcomes. The Healthy Border (HB) 2020 binational initiative of the U.S.-Mexico Border Health Commission is an initiative that addresses several public health priorities that not only include chronic and degenerative diseases, infectious diseases, injury prevention, maternal and child health but also mental health and addiction. The growing opioid epidemic and rise in NAS cases in the Southwest border, as partially shown in this study, provides another opportunity to track health illnesses and outcomes in the Southwest border, especially because there are targeted resources through High Intensity Drug Trafficking Areas (HIDTA) funding.

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The Acute Metabolic and Vascular Impact of Interrupting Prolonged Sitting: A Systematic Review and Meta-Analysis

Abstract

Objective

The aim was to conduct a systematic review and meta-analysis analyzing the impact of up to 24 h of prolonged sitting on postprandial glucose, insulin and triglyceride responses, blood pressure and vascular function, in comparison to sitting interrupted with light- to moderate-intensity physical activity.

Methods

To be included, studies had to examine the impact of prolonged sitting lasting < 24 h in apparently healthy males or females of any age. Studies were identified from searches of the MEDLINE, CINAHL and SportDISCUS databases on July 6, 2016. Study quality was assessed using the Downs and Black Checklist; publication bias was assessed via funnel plot.

Results

Forty-four studies met the inclusion criteria for the systematic review; of these, 20 were included in the meta-analysis, which compared prolonged sitting to the effects of interrupting sitting with regular activity breaks on postprandial glucose, insulin and triglycerides. When compared to prolonged sitting, regular activity breaks lowered postprandial glucose (d = − 0.36, 95% confidence interval [CI] − 0.50 to − 0.21) and insulin (d = − 0.37, 95% CI − 0.53 to − 0.20), but not triglyceride responses (d = 0.06, 95% CI − 0.15 to 0.26). Subgroup analyses indicated reductions in postprandial triglyceride responses only occurred 12–16 h after the intervention. The magnitude of the reductions in glucose, insulin or triglyceride response was not modified by the intensity of the activity breaks, the macronutrient composition of the test meal, or the age or body mass index of participants.

Conclusion

Prolonged sitting results in moderate elevations in postprandial glucose and insulin responses when compared to sitting interrupted with activity breaks.

PROSPERO ID

CRD42015020907.

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SpyCatcher: Use of a Novel Cholangioscopic Snare for Capture and Retrieval of a Proximally Migrated Biliary Stent

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Can Specialized Pro-resolving Mediators Deliver Benefit Originally Expected from Fish Oil?

Abstract

Purpose of the Review

Fish oil (FO) supplementation has historically been used by individuals suffering from cardiovascular disease and other inflammatory processes. However, a meta-analysis of several large randomized control trials (RCTs) suggested FO conferred no benefit in reducing cardiovascular risk. Skeptics surmised that the lack of benefit was related to FO dose or drug interactions; therefore, the widely accepted practice of FO consumption was brought into question.

Recent Findings

Thereafter, Serhan et al. identified specialized pro-resolving mediators (SPMs) to be one of the bioactive components and mechanisms of action of FO. SPMs are thought to enhance resolution of inflammation, as opposed to classic anti-inflammatory agents which inhibit inflammatory pathways. Numerous diseases, including persistent Inflammation, immunosuppression, and catabolic syndrome (PICS), are rooted in a burden of chronic inflammation. SPMs are gaining traction as potential therapeutic agents used to resolve inflammation in cardiovascular disorders, inflammatory bowel disease, sepsis, pancreatitis, and acute respiratory distress syndrome (ARDS).

Summary

This narrative reviews the history of FO and the various studies that made the health benefits of FO inconclusive, as well as an overview of SPMs and their use in specific disease states.

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Evolution of Clinical Trials in Inflammatory Bowel Diseases

Abstract

Purpose of Review

Since the first clinical trial of cortisone in ulcerative colitis in 1955, remarkable progress has been made in the design and conduct of clinical trials in inflammatory bowel diseases (IBD). In this review article, we will discuss evolution of clinical trials in IBD over the last 3–5 years.

Recent Findings

Recognizing limitations intrinsic to clinical disease activity indices in IBD, regulatory authorities have recommended evaluating co-primary endpoints of patient-reported outcomes and endoscopic disease activity in clinical trials. Biomarker-enriched trial enrolment and central endoscopy reading have emerged as critical events in trial recruitment and outcome assessment and have driven placebo response rates down. While trials of novel biologic therapies and advanced small molecules continue at an accelerated pace, pragmatic comparative efficacy trials of treatment strategy aimed at optimizing current therapies (such as early combined immunosuppression [REACT], tight disease control [CALM], therapeutic drug monitoring [TAXIT, TAILORIX]) have directly informed clinical practice. With emphasis on value-based care and population health management, multi-pronged remote monitoring, self-management, and telemedicine approaches in the era of smartphones have re-emerged with promise. Non-conventional therapies such as fecal microbiota transplantation, though still experimental, have provided insight into disease pathogenesis and offered hope for microbial manipulation strategies for treating these complex diseases.

Summary

Clinical trials have rapidly evolved over the last 5 years not only focusing on novel therapies but also optimizing existing treatment approaches and population health management. Over the next decade, these trials will continue to advance the field, and be readily translatable into clinical practice.

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Intensive Pharmacy Care Improves Outcomes of Hepatitis C Treatment in a Vulnerable Patient Population at a Safety-Net Hospital

Abstract

Background

Treatment of hepatitis C virus (HCV) with direct-acting antiviral (DAA) regimens has resulted in high rates of sustained virologic response (SVR). Treatment of vulnerable populations may be improved by incorporating an on-site intensive specialty pharmacy (ON-ISP).

Aims

To describe outcomes of HCV treatment at a safety-net hospital and proportion of subjects achieving SVR for those using the ON-ISP compared to an off-site pharmacy (OFF-SP).

Methods

A retrospective cohort study of 219 subjects treated for HCV with DAA at Boston Medical Center was conducted. Subject characteristics, virologic response, and pharmacy services used were recorded. We used multivariable logistic regression to test the association between ON-ISP and SVR after adjusting for covariates.

Results

SVR occurred in 71% of subjects by intention-to-treat (73% among ON-ISP users vs 57% among OFF-SP users) and 95% completing treatment per-protocol (96% among ON-ISP users vs 87% among OFF-SP users). Adjustment for age, sex, ethnicity, insurance, fibrosis, prior treatment, and MELD revealed an increased likelihood of SVR among users of ON-ISP: OR 6.0 (95% CI 1.18–31.0). No significant difference in treatment delay or adverse events was seen among users of either pharmacy type.

Conclusions

HCV treatment with DAA was well tolerated, but the rate of SVR was low (71%) compared to trials. This was due to loss to follow-up, as the per-protocol rate of SVR was much higher (95%). Use of ON-ISP was associated with an increase in SVR and may be valuable for improving care for vulnerable populations.

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