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Multimodal analgesia reduces opioid requirements in trauma patients with rib fractures
BackgroundRib fractures are common in trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is essential to avoid the complications associated with rib fractures. Opioids are frequently used for analgesia in these patients. This study compared the effect of a multimodal pain regimen (MMPR) on inpatient opioid use and outpatient opioid prescribing practices in adult trauma patients with rib fractures.Study designA pre-post cohort study of adult trauma patients with rib fractures was conducted at a Level I trauma center before (PRE) and after (POST) implementation of an MMPR. Patients on long-acting opioids before admission and those on continuous opioid infusions were excluded. Primary outcomes were oral opioid administration during the first 5 days of hospitalization and opioids prescribed at discharge. Opioid data were converted to morphine milligram equivalents (MMEs).ResultsSix hundred fifty-three patients met inclusion criteria (323 PRE, 330 POST). There was a significant reduction in the daily MME during the second through fifth days of hospitalization; and the average inpatient MME over the first five inpatient days (23 MME PRE vs. 17 MME POST, p = 0.0087). There was a significant reduction in the total outpatient MME prescribed upon discharge (322 MME PRE vs. 225 MME POST, p = 0.006).ConclusionThe implementation of an MMPR in patients with rib fractures resulted in significant reduction in inpatient opioid consumption and was associated with a reduction in the quantity of opiates prescribed at discharge.Level of evidenceTherapeutic/Care Management; level IV
Motor alterations associated with exposure to manganese in the environment in Mexico
Overexposure to manganese (Mn) causes neurotoxicity (a Parkinson-like syndrome) or psychiatric damage (âmanganese
madnessâ). Several studies have shown alterations to motor and neural behavior associated with exposure to Mn in the
workplace. However, there are few studies on the effects of environmental exposure of whole populations. We studied the risk
of motor alterations in people living in a mining district in Mexico. We studied 288 individual people (168 women and 120
men) from eight communities at various distances from manganese extraction or processing facilities in the district of
Molango. We measured manganese concentrations in airborne particles, water, soil and crops and evaluated the possible routes
of Mn exposure. We also took samples of people's blood and determined their concentrations of Mn and lead (Pb). We used
âEsquema de DiagnĂłstico NeuropsicolĂłgicoâ Ardila and Ostrosky-SolĂs's neuropsychological battery to evaluate motor
functions. Concentrations of Mn in drinking water and maize grain were less than detection limits at most sampling sites.
Manganese extractable by DTPA in soils ranged between 6 and 280 mg kgâ1 and means were largest close to Mn extraction
or processing facilities. Air Mn concentration ranged between 0.003 and 5.86 ÎŒg/m3; the mean value was 0.42 ÎŒg/m3 and
median was 0.10 ÎŒg/m3, the average value (geometric mean) resulted to be 0.13 ÎŒg/m3. Mean blood manganese concentration
was 10.16 ÎŒg/l, and geometric mean 9.44 ÎŒg/l, ranged between 5.0 and 31.0 ÎŒg/l. We found no association between
concentrations of Mn in blood and motor tests. There was a statistically significant association between Mn concentrations in
air and motor tests that assessed the coordination of two movements (OR 3.69; 95% CI 0.9, 15.13) and position changes in
hand movements (OR 3.09; CI 95% 1.07, 8.92). An association with tests evaluating conflictive reactions (task that explores
verbal regulations of movements) was also found (OR 2.30; CI 95% 1.00, 5.28). It seems from our results that people living close to the manganese mines and processing plants suffer from an incipient motor deficit, as a result of their inhaling
manganese-rich dust