Improving Postoperative Pain Control After Cesarean Delivery with Enhanced Recovery in Patients on Buprenorphine Therapy

Abstract: Introduction: Prescription drug abuse presents a significant challenge to the management of post operative pain.Pain control amongst the opioid addicted patient can be especially challenging. We aimed to improve pain control after caesarian delivery with enhanced recovery in patients who are on buprenorphine medication-assisted therapy for the treatment of opioid addiction. Materials and Methods: We conducted a pilot study by implementing a protocol using liposomal bupivacaine injected at the time of cesarean delivery. Patients were then given 500mg acetaminophen every 4 hours, 800mg ibuprofen every 8 hours and 0.3mg IV buprenorphine every 6 hours as needed. The patients’ maintenance dosing of buprenorphine was divided into doses throughout the day. In addition, patients were ambulated 4 hours after surgery and had their catheter removed from their bladder as soon as they could safely ambulate. Eleven patients were prospectively recruited and then compared to a retrospective sample of seventeen patients. Results: Patients in the treatment group reported 27% lower pain scores (p Discussion: Our enhanced recovery protocol is an effective alternative to traditional pain control and is associated with a significant reduction in both pain scores and use of breakthrough IV buprenorphine as well as lower charges

Reducing Postoperative Opioids After Minimally Invasive Hysterectomy with Enhanced Recovery

I Introduction: We evaluated the efficacy of various strategies utilized for the control of postoperative pain after minimally invasive hysterectomy. The primary enhanced recovery after surgery (ERAS) protocol of interest utilized premedication (acetaminophen, celecoxib and pregabalin), then intraoperative subcutaneous liposomal bupivacaine followed by scheduled oral acetaminophen and ibuprofen postoperatively. Patients also had tramadol and oxycodone as needed for moderate or severe breakthrough pain, respectively. Materials and Methods: We conducted a retrospective cohort study that included all patients who underwent minimally invasive hysterectomy (total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy) for both benign and oncologic indications over a 2-year period. We then compared six protocols, with 3 being ERAS protocols and 3 as traditional pain control methods. The control group was comprised of the traditional pain control group without intraoperative placement of local analgesia. Patient medical records were evaluated for demographics, surgical characteristics, opioid type and dose, pain scores, length of stay and complications. Opioids were converted to oral morphine dose equivalents. Results: 954 patients were included within the 6 protocols. Median opioid usage was the lowest in the ERAS group with premedication and highest in the control group (22.5mg versus 55.0mg, p Discussion: ERAS protocol with premedication was associated with significant reductions in postoperative opioid use and median pain scores when compared to traditional methods

Self-Reported Tobacco Use and Correlation with Umbilical Cord Blood Cotinine levels at Delivery among Appalachian Gravidas

The detrimental effects of cigarette use during pregnancy are well documented. Studies have shown that cigarette smoking while pregnant is associated with multiple adverse outcomes including: pre-term birth, placental abruption, placenta previa, fetal growth restriction, stillbirth, increased rate of birth defects, and increased risk of sudden infant death syndrome. Cotinine is the primary metabolite of nicotine and allows for measurement of active as well as passive exposure. Cotinine freely cross the placental barrier and maternal concentrations are closely correlated with newborn plasma levels. The aim of this study was to compare maternally reported rates of tobacco use to fetal umbilical cord blood cotinine levels at the time of delivery. A cross-sectional study was conducted on 172 patients. Patients were asked a single yes or no question in regards to their cigarette use during pregnancy. Cord blood was collected at the time of delivery and analyzed for serum concentrations of cotinine. Cotinine levels greater than 3.0 ng/mL were considered consistent with the use of tobacco or tobacco cessation products. Maternal self-reporting of tobacco use indicates a reported tobacco use rate of 27.3% and an actual use rate of 30.2%. The reported tobacco non-use rate was 72.7% and the actual non-use rate was 66.3%. The prevalence of tobacco use during pregnancy in our study was 30.2%, while the overall rate in the United States is reported to be 12.3%. Our findings indicate that self-reported smoking prevalence and verified umbilical cord blood cotinine levels at the time of delivery have excellent correlation (kappa=0.76). Compared to the national average our study group also had nearly double the rate of tobacco use. Due to the deleterious effects of cigarette use during pregnancy continued efforts to educate patients regarding cigarette cessation is of utmost importance as cessation of tobacco products will improve and promote maternal and fetal well-being

Improving Postoperative Pain Control After Cesarean Delivery with Enhanced Recovery in Patients on Buprenorphine Therapy

Introduction: Prescription drug abuse presents a significant challenge to the management of post operative pain.Pain control amongst the opioid addicted patient can be especially challenging. We aimed to improve pain control after caesarian delivery with enhanced recovery in patients who are on buprenorphine medication-assisted therapy for the treatment of opioid addiction. Materials and Methods: We conducted a pilot study by implementing a protocol using liposomal bupivacaine injected at the time of cesarean delivery. Patients were then given 500mg acetaminophen every 4 hours, 800mg ibuprofen every 8 hours and 0.3mg IV buprenorphine every 6 hours as needed. The patients’ maintenance dosing of buprenorphine was divided into doses throughout the day. In addition, patients were ambulated 4 hours after surgery and had their catheter removed from their bladder as soon as they could safely ambulate. Eleven patients were prospectively recruited and then compared to a retrospective sample of seventeen patients. Results: Patients in the treatment group reported 27% lower pain scores (p Discussion: Our enhanced recovery protocol is an effective alternative to traditional pain control and is associated with a significant reduction in both pain scores and use of breakthrough IV buprenorphine as well as lower charges

Self-Reported Tobacco Use and Correlation with Umbilical Cord Blood Cotinine levels at Delivery among Appalachian Gravidas

The detrimental effects of cigarette use during pregnancy are well documented. Studies have shown that cigarette smoking while pregnant is associated with multiple adverse outcomes including: pre-term birth, placental abruption, placenta previa, fetal growth restriction, stillbirth, increased rate of birth defects, and increased risk of sudden infant death syndrome. Cotinine is the primary metabolite of nicotine and allows for measurement of active as well as passive exposure. Cotinine freely cross the placental barrier and maternal concentrations are closely correlated with newborn plasma levels. The aim of this study was to compare maternally reported rates of tobacco use to fetal umbilical cord blood cotinine levels at the time of delivery. A cross-sectional study was conducted on 172 patients. Patients were asked a single yes or no question in regards to their cigarette use during pregnancy. Cord blood was collected at the time of delivery and analyzed for serum concentrations of cotinine. Cotinine levels greater than 3.0 ng/mL were considered consistent with the use of tobacco or tobacco cessation products. Maternal self-reporting of tobacco use indicates a reported tobacco use rate of 27.3% and an actual use rate of 30.2%. The reported tobacco non-use rate was 72.7% and the actual non-use rate was 66.3%. The prevalence of tobacco use during pregnancy in our study was 30.2%, while the overall rate in the United States is reported to be 12.3%. Our findings indicate that self-reported smoking prevalence and verified umbilical cord blood cotinine levels at the time of delivery have excellent correlation (kappa=0.76). Compared to the national average our study group also had nearly double the rate of tobacco use. Due to the deleterious effects of cigarette use during pregnancy continued efforts to educate patients regarding cigarette cessation is of utmost importance as cessation of tobacco products will improve and promote maternal and fetal well-being

Novel opsin gene variation in large-bodied, diurnal lemurs

Some primate populations include both trichromatic and dichromatic (red-green colour blind) individuals due to allelic variation at the X-linked opsin locus. This polymorphic trichromacy is well described in day-active New World monkeys. Less is known about colour vision in Malagasy lemurs, but, unlike New World monkeys, only some day-active lemurs are polymorphic, while others are dichromatic. The evolutionary pressures underlying these differences in lemurs are unknown, but aspects of species ecology, including variation in activity pattern, are hypothesized to play a role. Limited data on X-linked opsin variation in lemurs make such hypotheses difficult to evaluate. We provide the first detailed examination of X-linked opsin variation across a lemur clade (Indriidae). We sequenced the X-linked opsin in the most strictly diurnal and largest extant lemur, Indri indri, and nine species of smaller, generally diurnal indriids (Propithecus). Although nocturnal Avahi (sister taxon to Propithecus) lacks a polymorphism, at least eight species of diurnal indriids have two or more X-linked opsin alleles. Four rainforest-living taxa-I. indri and the three largest Propithecus species-have alleles not previously documented in lemurs. Moreover, we identified at least three opsin alleles in Indri with peak spectral sensitivities similar to some New World monkeys

A randomized controlled trial of pretransplant antiviral therapy to prevent recurrence of hepatitis C after liver transplantation

Hepatitis C virus (HCV) infection recurs in liver recipients who are viremic at transplantation. We conducted a randomized, controlled trial to test the efficacy and safety of pretransplant pegylated interferon alpha‐2b plus ribavirin (Peg‐IFN‐α2b/RBV) for prevention of post‐transplant HCV recurrence. Enrollees had HCV and were listed for liver transplantation, with either potential living donors or Model for End‐Stage Liver Disease upgrade for hepatocellular carcinoma. Patients with HCV genotypes (G) 1/4/6 (n = 44/2/1) were randomized 2:1 to treatment (n = 31) or untreated control (n = 16); HCV G2/3 (n=32) were assigned to treatment. Overall, 59 were treated and 20 were not. Peg‐IFN‐α2b, starting at 0.75 μg/kg/week, and RBV, starting at 600 mg/day, were escalated as tolerated. Patients assigned to treatment versus control had similar baseline characteristics. Combined virologic response (CVR) included pretransplant sustained virologic response and post‐transplant virologic response (pTVR), defined as undetectable HCV RNA 12 weeks after end of treatment or transplant, respectively. In intent‐to‐treat analyses, 12 (19%) assigned to treatment and 1 (6%) assigned to control achieved CVR ( P = 0.29); per‐protocol values were 13 (22%) and 0 (0%) ( P = 0.03). Among treated G1/4/6 patients, 23 of 30 received transplant, of whom 22% had pTVR; among treated G2/3 patients 21 of 29 received transplant, of whom 29% had pTVR. pTVR was 0%, 18%, and 50% in patients treated for 16 weeks, respectively ( P = 0.01). Serious adverse events (SAEs) occurred with similar frequency in treated versus untreated patients (68% versus 55%; P = 0.30), but the number of SAEs per patient was higher in the treated group (2.7 versus 1.3; P = 0.003). Conclusion : Pretransplant treatment with Peg‐IFN‐α2b/RBV prevents post‐transplant recurrence of HCV in selected patients. Efficacy is higher with >16 weeks of treatment, but treatment is associated with increased risk of potentially serious complications. (H EPATOLOGY 2013)Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/97469/1/25976_ftp.pd

Early symptoms in symptomatic and preclinical genetic frontotemporal lobar degeneration

Funder: UK Medical Research CouncilFunder: The Bluefield ProjectFunder: NIHR Cambridge Biomedical Research CentreFunder: Weston Brain InstituteFunder: Swedish Brain FoundationFunder: StratNeuro, Swedish DemensfondenFunder: NIHR Queen Square Dementia Biomedical Research Unit, the NIHR UCL/H Biomedical Research Centre and the Leonard Wolfson Experimental Neurology Centre (LWENC) Clinical Research FacilityFunder: The Canadian Institutes of Health Research as part of a Centres of Excellence in Neurodegeneration grantFunder: Karolinska Institutet Doctoral FundingFunder: Stockholm County Council ALFFunder: Swedish Alzheimer FoundationObjectives: The clinical heterogeneity of frontotemporal dementia (FTD) complicates identification of biomarkers for clinical trials that may be sensitive during the prediagnostic stage. It is not known whether cognitive or behavioural changes during the preclinical period are predictive of genetic status or conversion to clinical FTD. The first objective was to evaluate the most frequent initial symptoms in patients with genetic FTD. The second objective was to evaluate whether preclinical mutation carriers demonstrate unique FTD-related symptoms relative to familial mutation non-carriers. Methods: The current study used data from the Genetic Frontotemporal Dementia Initiative multicentre cohort study collected between 2012 and 2018. Participants included symptomatic carriers (n=185) of a pathogenic mutation in chromosome 9 open reading frame 72 (C9orf72), progranulin (GRN) or microtubule-associated protein tau (MAPT) and their first-degree biological family members (n=588). Symptom endorsement was documented using informant and clinician-rated scales. Results: The most frequently endorsed initial symptoms among symptomatic patients were apathy (23%), disinhibition (18%), memory impairments (12%), decreased fluency (8%) and impaired articulation (5%). Predominant first symptoms were usually discordant between family members. Relative to biologically related non-carriers, preclinical MAPT carriers endorsed worse mood and sleep symptoms, and C9orf72 carriers endorsed marginally greater abnormal behaviours. Preclinical GRN carriers endorsed less mood symptoms compared with non-carriers, and worse everyday skills. Conclusion: Preclinical mutation carriers exhibited neuropsychiatric symptoms compared with non-carriers that may be considered as future clinical trial outcomes. Given the heterogeneity in symptoms, the detection of clinical transition to symptomatic FTD may be best captured by composite indices integrating the most common initial symptoms for each genetic group

Is dignity therapy feasible to enhance the end of life experience for people with motor neurone disease and their family carers?

Background: Development of interventions that address psychosocial and existential distress in people with motor neurone disease (MND) or that alleviate caregiver burden in MND family carers have often been suggested in the research literature. Dignity therapy, which was developed to reduce psychosocial and existential distress at the end of life, has been shown to benefit people dying of cancer and their families. These results may not be transferable to people with MND. The objectives of this study are to assess the feasibility, acceptability and potential effectiveness of dignity therapy to enhance the end of life experience for people with motor neurone disease and their family carers. Methods/design: This is a cross-sectional study utilizing a single treatment group and a pre/post test design. The study population will comprise fifty people diagnosed with MND and their nominated family carers. Primarily quantitative outcomes will be gathered through measures assessed at baseline and at approximately one week after the intervention. Outcomes for participants include hopefulness, spirituality and dignity. Outcomes for family carers include perceived caregiver burden, hopefulness and anxiety/depression. Feedback and satisfaction with the intervention will be gathered through a questionnaire. Discussion: This detailed research will explore if dignity therapy has the potential to enhance the end of life experience for people with MND and their family carers, and fill a gap for professionals who are called on to address the spiritual, existential and psychosocial needs of their MND patients and families

Acute Cardiovascular and Metabolic Responses to Three Modes of Treadmill Exercise in Older Adults with Parkinson’s Disease

Parkinson’s disease (PD) is a neurodegenerative condition characterized by muscle tremors, rigidity and dyskinesis leading to balance and gait abnormalities that could alter physiologic responses during exercise. Locomotion on an aquatic treadmill (ATM) or anti-gravity treadmill (AGTM) may be a safe alternative to exercise on a traditional land treadmill (LTM) in those with PD. PUPROSE: To determine the acute cardiovascular and metabolic responses to three different modes of treadmill exercise in older adults diagnosed with Parkinson’s disease. METHODS: Eight adults diagnosed with PD (68 ± 3 years of age) completed one exercise session on an LTM, one session on an ATM, and one session on an AGTM at 50% body weight. Participants walked from 1 to 3 mph in 0.5 mph increments at 0% grade during each exercise session. Heart rate (HR), energy expenditure (EE), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were measured at rest and during steady-state exercise at each speed on each treadmill. Rate of perceived exertion was also measured during steady-state exercise. Rate pressure product (RPP) was calculated. RESULTS: All variables, with the exception of DBP, increased as speed increased across all treadmill modes (p \u3c 0.001). Between treadmill modes across all speeds, EE was statistically different (p = 0.025). There was a significant interaction effect for mode and speed for HR (p \u3c 0.001) and RPP (p = 0.003). At all speeds except 1.5 mph, HR was higher on the LTM versus the AGTM (p \u3c 0.05). CONCLUSION: Exercising on an ATM or an AGTM elicits similar physiologic responses to exercise on an LTM in adults with P