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Lin GC, Friedl HP, Grabner S, Gerhartl A, Neuhaus W. Transport of Non-Steroidal Anti-Inflammatory Drugs across an Oral Mucosa Epithelium In Vitro Model. Pharmaceutics 2024; 16:543. [PMID: 38675204 PMCID: PMC11054638 DOI: 10.3390/pharmaceutics16040543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most prescribed drugs to treat pain or fever. However, oral administration of NSAIDs is frequently associated with adverse effects due to their inhibitory effect on the constitutively expressed cyclooxygenase enzyme 1 (COX-1) in, for instance, the gastrointestinal tract. A systemic delivery, such as a buccal delivery, of NSAIDs would be beneficial and additionally has the advantage of a non-invasive administration route, especially favourable for children or the elderly. To investigate the transport of NSAIDs across the buccal mucosa and determine their potential for buccal therapeutic usage, celecoxib, diclofenac, ibuprofen and piroxicam were tested using an established oral mucosa Transwell® model based on human cell line TR146. Carboxyfluorescein and diazepam were applied as internal paracellular and transcellular marker molecule, respectively. Calculated permeability coefficients revealed a transport ranking of ibuprofen > piroxicam > diclofenac > celecoxib. Transporter protein inhibitor verapamil increased the permeability for ibuprofen, piroxicam and celecoxib, whereas probenecid increased the permeability for all tested NSAIDs. Furthermore, influence of local inflammation of the buccal mucosa on the transport of NSAIDs was mimicked by treating cells with a cytokine mixture of TNF-α, IL-1ß and IFN-γ followed by transport studies with ibuprofen (+ probenecid). Cellular response to pro-inflammatory stimuli was confirmed by upregulation of cytokine targets at the mRNA level, increased secreted cytokine levels and a significant decrease in the paracellular barrier. Permeability of ibuprofen was increased across cell layers treated with cytokines, while addition of probenecid increased permeability of ibuprofen in controls, but not across cell layers treated with cytokines. In summary, the suitability of the in vitro oral mucosa model to measure NSAID transport rankings was demonstrated, and the involvement of transporter proteins was confirmed; an inflammation model was established, and increased NSAID transport upon inflammation was measured.
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Affiliation(s)
- Grace C. Lin
- Competence Unit Molecular Diagnostics, AIT Austrian Institute of Technology GmbH, 1210 Vienna, Austria (A.G.)
| | - Heinz-Peter Friedl
- Competence Unit Molecular Diagnostics, AIT Austrian Institute of Technology GmbH, 1210 Vienna, Austria (A.G.)
| | - Sarah Grabner
- Competence Unit Molecular Diagnostics, AIT Austrian Institute of Technology GmbH, 1210 Vienna, Austria (A.G.)
| | - Anna Gerhartl
- Competence Unit Molecular Diagnostics, AIT Austrian Institute of Technology GmbH, 1210 Vienna, Austria (A.G.)
| | - Winfried Neuhaus
- Competence Unit Molecular Diagnostics, AIT Austrian Institute of Technology GmbH, 1210 Vienna, Austria (A.G.)
- Department of Medicine, Faculty of Medicine and Dentistry, Danube Private University, 3500 Krems, Austria
- Division of Pharmaceutical Technology and Biopharmaceutics, University of Vienna, 1090 Vienna, Austria
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Prezioso D, Piccinocchi G, Abate V, Ancona M, Celia A, De Luca C, Ferrari R, Ferraro PM, Mancon S, Mazzon G, Micali S, Puca G, Rendina D, Saita A, Salvetti A, Spasiano A, Tesè E, Trinchieri A. The role of the general practictioner in the management of urinary calculi. Arch Ital Urol Androl 2023; 95:12155. [PMID: 38193217 DOI: 10.4081/aiua.2023.12155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/19/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND The prevalence of kidney stones tends to increase worldwide due to dietary and climate changes. Disease management involves a high consumption of healthcare system resources which can be reduced with primary prevention measures and prophylaxis of recurrences. In this field, collaboration between general practitioners (GPs) and hospitals is crucial. METHODS a panel composed of general practitioners and academic and hospital clinicians expert in the treatment of urinary stones met with the aim of identifying the activities that require the participation of the GP in the management process of the kidney stone patient. RESULTS Collaboration between GP and hospital was found crucial in the treatment of renal colic and its infectious complications, expulsive treatment of ureteral stones, chemolysis of uric acid stones, long-term follow-up after active treatment of urinary stones, prevention of recurrence and primary prevention in the general population. CONCLUSIONS The role of the GP is crucial in the management and prevention of urinary stones. Community hospitals which are normally led by GPs in liaison with consultants and other health professional can have a role in assisting multidisciplinary working as extended primary care.
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Affiliation(s)
- Domenico Prezioso
- Dipartimento Neuroscienze, Scienze della Riproduzione ed Odontostomatologia Università Federico II, Naples.
| | | | - Veronica Abate
- Department of Clinical Medicine and Surgery, Federico II University, Naples.
| | | | - Antonio Celia
- S.C. Urologia ULSS 7 Pedemontana, Bassano del Grappa (VI).
| | - Ciro De Luca
- Dipartimento Neuroscienze, Scienze della Riproduzione ed Odontostomatologia Università Federico II, Naples.
| | - Riccardo Ferrari
- Department of Urology, University of Modena and Reggio Emilia, Baggiovara (MO).
| | - Pietro Manuel Ferraro
- Sezione di Nefrologia, Dipartimento di Medicina, Università degli Studi di Verona, Verona.
| | - Stefano Mancon
- Department of Urology, IRCCS Humanitas Research Hospital, Rozzano, Milan.
| | - Giorgio Mazzon
- S.C. Urologia ULSS 7 Pedemontana, Bassano del Grappa (VI).
| | - Salvatore Micali
- Department of Urology, University of Modena and Reggio Emilia, Baggiovara (MO).
| | - Giacomo Puca
- Dipartimento Neuroscienze, Scienze della Riproduzione ed Odontostomatologia Università Federico II, Naples.
| | - Domenico Rendina
- Department of Clinical Medicine and Surgery, Federico II University, Naples.
| | - Alberto Saita
- Department of Urology, IRCCS Humanitas Research Hospital, Rozzano, Milan.
| | | | | | - Elisa Tesè
- Società Italiana di Medicina Generale, Florence.
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Alghamdi YA, Morya RE, Bahathiq DM, Bokhari AF, Alaboud AK, Abdulhamid AS, Ghaddaf AA, Jamjoom M. Comparison of acetaminophen, ketamine, or ketorolac versus morphine in the treatment of acute renal colic: A network meta-analysis. Am J Emerg Med 2023; 73:187-196. [PMID: 37679264 DOI: 10.1016/j.ajem.2023.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/13/2023] [Accepted: 08/14/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Renal colic is a disease in which a calculus obstructs the urinary tract, resulting in severe pain do ureteric peristaltic movements. Other symptoms, such as hematuria, nausea, and vomiting, may accompany the pain. This network meta-analysis aimed to compare the efficacy and safety of different analgesic agents for the treatment of acute renal colic. METHODS Medline, Embase, and CENTRAL databases were searched. Randomized controlled trials (RCTs) that compared different analgesic agents, either alone or in combination were included. For the management of acute renal colic, analgesic agents were selected based on the current standard medical practice. The medications included intravenous acetaminophen, ketamine, ketorolac, and morphine. This study sought to evaluate the pain score on the visual analog scale (VAS) at 15, 30, and 60 min; adverse events; and the utilization of rescue therapy. The efficacy of different analgesic agents was explored through a frequentist network meta-analysis using the Netmeta statistical package in R software. All treatments were ranked using the Netrank function, yielding P-scores. RESULTS Twelve RCTs were deemed eligible. As per the P-scores, acetaminophen was the most effective in reducing pain score at 15 min (P-score = 0.74). Ketorolac was the most effective in reducing the pain score at 30 and 60 min (P-score = 0.84) (P-score = 0.99), whereas morphine was the least effective (P-score = 0.07). Moreover, morphine was correlated with the highest odds of adverse events after treatment (P-score = 0.89). Morphine was the most frequently required rescue therapy in cases of suboptimal pain relief (P-score = 0.96). CONCLUSION This network meta-analysis demonstrated that ketorolac and acetaminophen were the most effective analgesic agents according to the pain score. Morphine showed the highest adverse event profile and the highest rate at which rescue therapy was required for the management of acute renal colic.
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Affiliation(s)
- Yasir A Alghamdi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia; King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia.
| | - Roaa E Morya
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia; King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia
| | - Dena M Bahathiq
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia; King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia
| | - Abdullah F Bokhari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia; King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia
| | - Ahmad K Alaboud
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia; King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia
| | - Ahmed S Abdulhamid
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia; King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia
| | - Abdullah A Ghaddaf
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia; King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia
| | - Maan Jamjoom
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia; King Abdullah International Medical Research Center, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia; Department of Emergency Medicine, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah 21423, Saudi Arabia
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Corvino A, Magli E, Minale M, Autelitano A, Valente V, Pierantoni GM. Phloroglucinol-Derived Medications are Effective in Reducing Pain and Spasms of Urinary and Biliary Tracts: Results of Phase 3 Multicentre, Open-Label, Randomized, Comparative Studies of Clinical Effectiveness and Safety. Adv Ther 2023; 40:619-640. [PMID: 36443585 PMCID: PMC9898402 DOI: 10.1007/s12325-022-02347-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/04/2022] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Pain and spasms of urinary and biliary tracts are conditions causing poor quality of life. Treatment with analgesic drugs such as non-steroidal anti-inflammatory drugs and modulators of the parasympathetic system are not always tolerated, and often additional therapeutic options are necessary. The present analysis aimed to evaluate the pharmacokinetics and effectiveness of oral and parenteral preparations based on phloroglucinol in reducing pain and spasms associated with renal or biliary colic in phase 3, multicentre, open-label, randomized, comparative studies on clinical effectiveness and safety. METHODS Pharmacokinetic and pharmacodynamic studies were carried out. Four phase 3 multicentre, open-label, randomized, comparative studies were conducted to evaluate the clinical effectiveness and safety in patients with pain and spasms of urinary or biliary tracts. Eligible patients randomly received either phloroglucinol orally or via intramuscular (IM)/intravenous (IV) administration and reference drug, dexketoprofen for urinary spasms and pain, the non-steroidal anti-inflammatory drug metamizole or scopolamine-based reference drug for biliary colic. The primary outcomes were symptoms and observed frequency of spasms, while the secondary outcome was the duration of improvement or the time between the drug administration and the recurrence of symptoms. Comparison of groups by quantitative characteristics was performed using the T-test for independent samples or the Mann-Whitney test. Intragroup comparisons were performed using the Wilcoxon test, or the T-test for linked samples. Qualitative signs were analysed using the Pearson's χ2 test and Fisher's exact test. RESULTS The pharmacokinetic studies showed that (i) most of the phloroglucinol (> 80% for IV and per os formulations) was eliminated in the first 6 h after dosing, (ii) the drug was eliminated in urine as unchanged phloroglucinol (1,3,5-trihydroxybenzene) in a small proportion (< 3% of the dose) and (iii) a considerable amount of the drug was detected after enzymatic deconjugation with β-glucoronidase/arylsulfatase from Helix pomatia. As for the pharmacokinetic study, a total of 364 patients were enrolled, divided in four studies: two designed to test the effectiveness of oral and IM/IV preparations in biliary colic and two in urinary colic. Baseline characteristics between groups were similar. Phloroglucinol oral or IV/IM showed an effectiveness comparable to the reference drug in reducing pain and spasms associated with both urinary and biliary colic. There was no difference between all groups by survival analysis. CONCLUSION Oral and parenteral preparations based on phloroglucinol are as effective in reducing pain and spasms associated with renal or biliary colic as current therapeutic options. Therefore, phloroglucinol may be considered as useful to treat pain and spasms associated with urinary and biliary colic.
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Affiliation(s)
- Angela Corvino
- grid.4691.a0000 0001 0790 385XDepartment of Pharmacy, University of Naples “Federico II”, Naples, Italy
| | - Elisa Magli
- grid.4691.a0000 0001 0790 385XDepartment of Pharmacy, University of Naples “Federico II”, Naples, Italy
| | | | | | - Valeria Valente
- grid.4691.a0000 0001 0790 385XDepartment of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, Naples, Italy
| | - Giovanna Maria Pierantoni
- Department of Molecular Medicine and Medical Biotechnology, University of Naples "Federico II", Naples, Italy.
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Johnson G, Tabner A, Fakis A, Sherman R, Chester V, Bedford E, Jackson R, Ratan H, Mason S. Salbutamol for analgesia in renal colic: study protocol for a prospective, randomised, placebo-controlled phase II trial (SARC). Trials 2022; 23:352. [PMID: 35468847 PMCID: PMC9036510 DOI: 10.1186/s13063-022-06225-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Renal colic is the pain experienced by a patient when a renal calculus (kidney stone) causes partial or complete obstruction of part of the renal outflow tract. The standard analgesic regimes for renal colic are often ineffective; in some studies, less than half of patients achieve complete pain relief, and a large proportion of patients require rescue analgesia within 4 h. Current analgesic regimes are also associated with significant side effects including nausea, vomiting, drowsiness and respiratory depression. It has been hypothesised that beta adrenoreceptor agonists, such as salbutamol, may reduce the pain of renal colic. They have been shown to impact a number of factors that target the physiological causes of pain in renal colic (ureteric spasm and increased peristalsis, increased pressure at the renal pelvis and prostaglandin release with inflammation). There is biological plausibility and a body of evidence sufficient to suggest that this novel treatment for the pain of renal colic should be taken to a phase II clinical trial. The aim of this trial is to test whether salbutamol is an efficacious analgesic adjunct when added to the standard analgesic regime for patients presenting to the ED with subsequently confirmed renal colic. METHODS A phase II, randomised, placebo-controlled trial will be performed in an acute NHS Trust in the East Midlands. Patients presenting to the emergency department with pain requiring IV analgesia and working diagnosis of renal colic will be randomised to receive standard analgesia ± a single intravenous injection of Salbutamol. Secondary study objectives will explore the feasibility of conducting a larger, phase III trial. DISCUSSION The trial will provide important information about the efficacy of salbutamol as an analgesic adjunct in renal colic. It will also guide the development of a definitive phase III trial to test the cost and clinical effectiveness of salbutamol as an analgesic adjunct in renal colic. Salbutamol benefits from widespread use across the health service for multiple indications, extensive staff familiarity and a good side effect profile; therefore, its potential use for pain relief may have significant benefits for patient care. TRIAL REGISTRATION ISRCTN Registry ISRCTN14552440 . Registered on 22 July 2019.
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Affiliation(s)
- Graham Johnson
- Emergency Department, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK. .,University of Nottingham, Nottingham, NG7 2RD, UK.
| | - Andrew Tabner
- Emergency Department, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Apostolos Fakis
- Derby Clinical Trials Support Unit, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Rachelle Sherman
- Derby Clinical Trials Support Unit, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Victoria Chester
- Derby Clinical Trials Support Unit, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | | | - Richard Jackson
- Liverpool CR-UK Centre Cancer Research UK, Liverpool Cancer Trials Unit 1st Floor, C Block, Waterhouse Building, 3 Brownlow Street, Liverpool, L69 3GL, UK
| | - Hari Ratan
- Nottingham University Hospitals, Hucknall Rd., Nottingham, NG5 1PB, UK
| | - Suzanne Mason
- CURE group, School of Health and Related Research, University of Sheffield, Sheffield, UK
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Gulacti U, Algin A, Turgut K, Yavuz E, Aydin I, Buyukaslan H, Lok U, Arslan E, Gonel A. Transcutaneous electrical nerve stimulation (TENS) for the treatment of renal colic in the emergency department: A randomized, double-blind, placebo-controlled trial. Am J Emerg Med 2022; 56:127-132. [PMID: 35397352 DOI: 10.1016/j.ajem.2022.02.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/14/2022] [Accepted: 02/21/2022] [Indexed: 11/16/2022] Open
Abstract
STUDY OBJECTIVE To determine the analgesic efficacy of TENS treatment in patients with renal colic in the emergency department (ED). METHODS This double-blind, randomized controlled trial was conducted in a tertiary care ED. Patients with a definitive diagnosis of renal colic were assigned (1:1) as randomized to receive the real TENS with frequency 100 Hz, pulse width 200 microseconds, voltage 2 mA, or placebo with sham TENS. Pain intensity was measured using visual analog scales (VAS) at baseline, after 15 and 30th minutes. RESULTS A total of 100 patients were included in the final analysis: 50 patients treated with real TENS and 50 patients treated with sham TENS. VAS scores in both groups were similar at baseline. The mean reduction in VAS score at 15 min was 33.3 ± 17.6 (95% Confidence interval (CI): 28.3 to 38.3) for the real TENS group and 14.9 ± 11.6 (95% CI 11.6 to 18.2) for the sham TENS group (mean difference: 18.4 (95% CI: 12.5 to 24.4, P < 0.0001). The mean reduction in VAS score at 30 min was 63.7 ± 21.1 (95% CI: 57.7 to 69.7) for the real TENS group and 14.9 ± 16.2 (95% CI: 19.5 to 10.3) for the sham TENS group (mean difference: 48.8, 95% CI: 41.4 to 56.3, P < 0.0001). Four patients (8%) in the real TENS group and 24 patients (48%) in the sham TENS group required the rescue medication after 30th minutes. CONCLUSIONS TENS is effective for acute pain treatment in renal colic patients in the ED. TENS therapy could be a treatment option for renal colic.
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Affiliation(s)
- Umut Gulacti
- Department of Emergency Medicine, Adiyaman University Medical Faculty, Adiyaman, Turkey.
| | - Abdullah Algin
- Department of Emergency Medicine, SBU Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Kasim Turgut
- Department of Emergency Medicine, Adiyaman University Medical Faculty, Adiyaman, Turkey
| | - Erdal Yavuz
- Department of Emergency Medicine, Adiyaman University Medical Faculty, Adiyaman, Turkey
| | - Irfan Aydin
- Department of Emergency Medicine, Adiyaman University Medical Faculty, Adiyaman, Turkey
| | - Hasan Buyukaslan
- Department of Emergency Medicine, Harran University Medical Faculty, Sanliurfa, Turkey
| | - Ugur Lok
- Department of Emergency Medicine, Sutcu imam University Medical Faculty, K.Maras, Turkey
| | - Ebru Arslan
- Department of Emergency Medicine, Adiyaman University Medical Faculty, Adiyaman, Turkey
| | - Ataman Gonel
- Department of Biochemistry, Medical Park Hospital, Gaziantep, Turkey
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Lee GG, Park JS, Kim HS, Yoon DS, Lim JH. Clinical effect of preoperative intravenous non-steroidal anti-inflammatory drugs on relief of postoperative pain in patients after laparoscopic cholecystectomy: Intravenous ibuprofen vs. intravenous ketorolac. Ann Hepatobiliary Pancreat Surg 2022; 26:251-256. [PMID: 35264467 PMCID: PMC9428437 DOI: 10.14701/ahbps.21-151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims Postoperative pain management is a key to enhanced recovery after surgery. The aim of this study was to evaluate clinical effect of preoperative intravenous (IV) non-steroidal anti-inflammatory drugs (NSAIDs) on relief of postoperative pain in patients after laparoscopic cholecystectomy. Methods This single center, retrospective study was conducted between September 2019 and May 2020. A total of 163 patients were divided into two groups: Ibuprofen group (preoperative IV ibuprofen, n = 77) and Ketorolac group (preoperative IV ketorolac, n = 86). The primary outcome was postoperative pain score measured immediately in the recovery room. Results There was no difference in demographic characteristics between the two groups of patients. Postoperative pain score measured immediately in the recovery room was significantly higher in the Ibuprofen group than in the Ketorolac group (mean value: 5.09 vs. 4.61; p = 0.027). The number of patients who needed analgesics immediately in the recovery room was also higher in the Ibuprofen group than in the Ketorolac group (28 [36.4%] vs. 18 [20.9%]; p = 0.036). Conclusions In this study, preoperative IV injection with ketorolac reduced postoperative pain and analgesic requirement in the recovery room more effectively than that with ibuprofen. However, both showed similar effects on peak pain and pain at discharge. Numbers of patients requiring additional analgesics were also similar between the two groups.
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Affiliation(s)
- Gyeong Geon Lee
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Seong Park
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung Sun Kim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Sup Yoon
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Hong Lim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Raskolnikov D, Hall MK, Ngo SD, Dighe M, Kanal KM, Harper JD, Gore JL. Strategies to Optimize Nephrolithiasis Emergency Care (STONE): Prospective Evaluation of an Emergency Department Clinical Pathway. Urology 2021; 160:60-68. [PMID: 34757049 DOI: 10.1016/j.urology.2021.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/16/2021] [Accepted: 09/08/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To convene a multi-disciplinary panel to develop a pathway for Emergency Department (ED) patients with suspected nephrolithiasis and then prospectively evaluate its effect on patient care. MATERIALS AND METHODS The STONE Pathway was developed and linked to order sets within our Electronic Health Record in April 2019. Records were prospectively reviewed for ED patients who underwent ultrasound or Computerized Tomography (CT) to evaluate suspected nephrolithiasis between January 2019 and August 2019 within our institution. The primary outcome measure was the proportion of patients whose ED CT was low dose (<4 mSv). Secondary outcome measures included receipt of pathway-concordant pain medications and urine strainers. Order set utilization was evaluated as a process measure. Balance measures assessed included repeat ED visits, imaging, hospitalizations, and a urologic clinic visit or surgery within 30 days of discharge. RESULTS 441 patients underwent ED imaging, of whom 261 (59%) were evaluated for suspected nephrolithiasis. The STONE Pathway was used in 50 (30%) eligible patients. Patients treated with the Pathway were more likely to undergo low-dose CTs (49% vs. 23%, p<0.001), and receive guideline-concordant pain medications such as NSAIDs (90% vs. 62%, p<0.001), and were less likely to return to the ED within 30 days (13% vs. 2%, p=0.01). These measures demonstrated special cause variation following Pathway release. CONCLUSIONS Clinical pathways increase compliance with evidence-based practices for pain control and imaging in nephrolithiasis emergency care and may improve the delivery of value-based care.
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Affiliation(s)
| | - M Kennedy Hall
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Steven D Ngo
- School of Medicine, University of Washington, Seattle, WA
| | - Manjiri Dighe
- Department of Radiology, University of Washington, Seattle, WA
| | - Kalpana M Kanal
- Department of Radiology, University of Washington, Seattle, WA
| | | | - John L Gore
- Department of Urology, University of Washington, Seattle, WA
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Opioid Analgesics and Persistent Pain After an Acute Pain Emergency Department Visit: Evidence from a Cohort of Suspected Urolithiasis Patients. J Emerg Med 2021; 61:637-648. [PMID: 34690022 DOI: 10.1016/j.jemermed.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/19/2021] [Accepted: 09/11/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Severe acute pain is still commonly treated with opioid analgesics in the United States, but this practice could prolong the duration of pain. OBJECTIVES Estimate the risk of experiencing persistent pain after opioid analgesic use after emergency department (ED) discharge among patients with suspected urolithiasis. METHODS We analyzed data collected for a longitudinal, multicenter clinical trial of ED patients with suspected urolithiasis. We constructed multilevel models to estimate the odds ratios (ORs) of reporting pain at 3, 7, 30, or 90 days after ED discharge, using multiple imputation to account for missing outcome data. We controlled for clinical, demographic, and institutional factors and used weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge. RESULTS Among 2413 adult ED patients with suspected urolithiasis, 62% reported persistent pain 3 days after discharge. Participants prescribed an opioid analgesic at discharge were OR 2.51 (95% confidence interval [CI] 1.82-3.46) more likely to report persistent pain than those without a prescription. Those who reported using opioid analgesics 3 days after discharge were OR 2.24 (95% CI 1.77-2.84) more likely to report pain at day 7 than those not using opioid analgesics at day 3, and those using opioid analgesics at day 30 had OR 3.25 (95% CI 1.96-5.40) greater odds of pain at day 90. CONCLUSIONS Opioid analgesic prescription doubled the odds of persistent pain among ED patients with suspected urolithiasis. Limiting opioid analgesic prescribing at ED discharge for these patients might prevent persistent pain in addition to limiting access to these medications.
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Konservatives Management. Urolithiasis 2021. [DOI: 10.1007/978-3-662-62454-8_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Subramaniyam S, Yang S, Diallo BN, Fanshu X, Lei L, Li C, Tastan Bishop Ö, Bhattacharyya S. Oral Phyto-thymol ameliorates the stress induced IBS symptoms. Sci Rep 2020; 10:13900. [PMID: 32807797 PMCID: PMC7431530 DOI: 10.1038/s41598-020-70420-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 07/29/2020] [Indexed: 12/14/2022] Open
Abstract
Physical stressors play a crucial role in the progression of irritable bowel syndrome (IBS). Here we report a heterogeneous physical stress induced IBS rat model which shows depression and subsequent modulation of IBS by oral treatment of thymol. Oral administration of Thymol reduces the stress induced IBS significantly altering the stress induced gastrointestinal hypermotility, prolonged the whole gut transit time, and increased abdominal withdrawal reflex suggesting gastrointestinal hypermotility and visceral discomfort caused the onset of depression. Immunohistochemical analysis in small intestine and colon of rats shows the decreased 5-HT3AR expression level while thymol treatment normalized the 5-HT3AR expression in the stressed rats. Molecular docking studies showed that thymol competes with endogenous serotonin and an antagonist, Tropisetron and all have similar binding energies to 5-HT3AR. Molecular dynamics simulations revealed that thymol and tropisetron might have similar effects on 5-HT3AR. Our study suggest that thymol improves IBS symptoms through 5-HT3AR, could be useful for the treatment of IBS.
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MESH Headings
- Administration, Oral
- Animals
- Behavior, Animal
- Chronic Disease
- Gastrointestinal Transit/drug effects
- Intestine, Small/drug effects
- Intestine, Small/pathology
- Irritable Bowel Syndrome/drug therapy
- Irritable Bowel Syndrome/etiology
- Irritable Bowel Syndrome/physiopathology
- Male
- Models, Biological
- Molecular Docking Simulation
- Rats, Sprague-Dawley
- Receptors, Serotonin, 5-HT3/chemistry
- Receptors, Serotonin, 5-HT3/metabolism
- Stress, Psychological/complications
- Thymol/administration & dosage
- Thymol/chemistry
- Thymol/therapeutic use
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Affiliation(s)
- Selvaraj Subramaniyam
- Department of Pharmaceutical Science and Chinese Traditional Medicine, Southwest University, Beibei, Chongqing, 400715, China
| | - Shuyou Yang
- Department of Pharmaceutical Science and Chinese Traditional Medicine, Southwest University, Beibei, Chongqing, 400715, China
| | - Bakary N'tji Diallo
- Research Unit in Bioinformatics (RUBi), Department of Biochemistry and Microbiology, Rhodes University, P.O. Box 94, Grahamstown, 6140, South Africa
| | - Xu Fanshu
- Department of Pharmaceutical Science and Chinese Traditional Medicine, Southwest University, Beibei, Chongqing, 400715, China
| | - Luo Lei
- Department of Pharmaceutical Science and Chinese Traditional Medicine, Southwest University, Beibei, Chongqing, 400715, China
| | - Chong Li
- Department of Pharmaceutical Science and Chinese Traditional Medicine, Southwest University, Beibei, Chongqing, 400715, China
| | - Özlem Tastan Bishop
- Research Unit in Bioinformatics (RUBi), Department of Biochemistry and Microbiology, Rhodes University, P.O. Box 94, Grahamstown, 6140, South Africa.
| | - Sanjib Bhattacharyya
- Department of Pharmaceutical Science and Chinese Traditional Medicine, Southwest University, Beibei, Chongqing, 400715, China.
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12
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Gu HY, Luo J, Wu JY, Yao QS, Niu YM, Zhang C. Increasing Nonsteroidal Anti-inflammatory Drugs and Reducing Opioids or Paracetamol in the Management of Acute Renal Colic: Based on Three-Stage Study Design of Network Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2019; 10:96. [PMID: 30853910 PMCID: PMC6395447 DOI: 10.3389/fphar.2019.00096] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 01/24/2019] [Indexed: 12/28/2022] Open
Abstract
Background: Currently, although non-steroidal anti-inflammatory drugs (NSAIDs) were recommended for acute renal colic in the 2018 European Association of Urology guidelines, there are no specific NSAIDs and no specific routes of administration in this guideline. The clinical practice of advocating intravenous opioids as the initial analgesia is still common out of the fear of adverse events from NSAIDs. Objectives: To comprehensively assess the efficacy and safety of NSAIDs, opioids, paracetamol, and combination therapy for acute renal colic. Methods: Ovid MEDLINE, Ovid EMbase, the Cochrane Library, Clinical Trials Registry Platform for Clinicaltrials.gov, and WHO International Clinical Trials Registry Platform were searched through February 2, 2018. Two reviewers selected all randomized controlled trails (RCTs) regarding NSAIDs, opioids, paracetamol, combination therapy, and placebo were identified for analysis. We designed a three-stage strategy based on classification and pharmacological mechanisms in the first stage, routes of administration in the second stage, and specific drug branches with different routes in the third stage using network meta-analysis. The pain variance at 30 min was seen as the primary outcome. Results: 65 RCTs with 8633 participants were involved. Comparing different classification and pharmacological mechanisms, combination therapy with more adverse events was more efficient than NSAIDs for the primary outcomes. Opioids gave rise to more nonspecific adverse events and vomiting events. NSAIDs were superior to opioids, paracetamol, and combination therapy after a full consideration of all outcomes. Comparing different routes of administration, NSAIDs with IV or IM route ranked first from efficacy and safety perspective. Comparing different specific drug branches with different routes, ibuprofen via IV route, ketorolac via IV route and diclofenac via IM route were superior for the management of acute renal colic. The results from diclofenac using IM route were more than those from ibuprofen used with IV route and ketorolac with IV route. Conclusions: In patients with adequate renal function, diclofenac via the IM route is recommended for patients without risks of cardiovascular events. Ibuprofen and ketorolac with IV route potentially superior to diclofenac via IM route remain to be investigated. Combination therapy is an alternative choice for uncontrolled pain after the use of NSAIDs.
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Affiliation(s)
- Hui-Yun Gu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Jie Luo
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Jun-Yi Wu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Qi-Sheng Yao
- Department of Emergency, Taihe Hospital, Hubei University of Medicine, Shiyan, China.,Department of Urology, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Yu-Ming Niu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China.,Department of Emergency, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
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Forouzanfar MM, Mohammadi K, Hashemi B, Safari S. Comparison of Intravenous Ibuprofen with Intravenous Ketorolac in Renal Colic Pain Management; A Clinical Trial. Anesth Pain Med 2019; 9:e86963. [PMID: 30881914 PMCID: PMC6412918 DOI: 10.5812/aapm.86963] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 01/01/2019] [Accepted: 01/18/2019] [Indexed: 01/20/2023] Open
Abstract
Background Choosing a proper medication for pain management of patients with acute renal colic has been a challenge for physicians treating these patients. Objectives The present study was performed with the aim of comparing intravenous (IV) ibuprofen and IV ketorolac in pain management of these patients. Methods In the present double-blind clinical trial study, patients suspected with renal colic presented to the emergency department were randomly divided into 2 groups receiving IV ibuprofen or IV ketorolac and were compared regarding effectiveness (pain reduction 15, 30, and 60 minutes after injection), treatment success, and possible side effects. Results In total, 240 patients suspected with renal colic with the mean age of 27.38 ± 12.32 years were randomly divided into 2 groups of 120 individuals treated with IV ketorolac or ibuprofen (66.4% male). The two groups were in a similar condition regarding age (P = 0.56), sex (P = 0.78) history of kidney stone (P = 0.40), vital signs (P > 0.05), stone size (P = 0.73), stone location (P = 0.13), and pain severity on admission (P = 0.32). 15, 30, and 60 minutes after drug injection, pain severity in the ketorolac group was significantly higher than the group receiving ibuprofen (P < 0.0001 for all comparisons), yet these differences were not clinically significant. Fifteen minutes after the injection, the rate of treatment success was significantly higher in the group receiving IV ibuprofen (P < 0.0001). After 60 minutes, the number of completely relieved cases reached 37 (30.8%) patients in the ketorolac group and 83 (69.1%) patients in the ibuprofen group. No significant difference was seen in side effects between the two groups (P = 0.35). Conclusions The findings of the present study show that ibuprofen is a more rapid acting drug compared to ketorolac in controlling pain caused by renal colic. In addition, its rate of complete relief from pain was twice as much as that of ketorolac. Since the side effects observed for ibuprofen in the present study were very mild, it is suggested to use this drug in treatment and pain control of renal colic patients.
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Affiliation(s)
- Mohammad Mehdi Forouzanfar
- Emergency Department, Shoahadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Khaghan Mohammadi
- Emergency Department, Shoahadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Behrouz Hashemi
- Emergency Department, Shoahadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeed Safari
- Emergency Department, Shoahadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding Author: Emergency Department, Shoahadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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14
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Jennings CA, Khan Z, Sidhu P, Navarrete O, Palladino A, Rutland E, Villa JAC, Gonzalez LJ, Kalantari H, Hassen GW. Management and outcome of obstructive ureteral stones in the emergency department: Emphasis on urine tests and antibiotics usage. Am J Emerg Med 2019; 37:1855-1859. [PMID: 30686535 DOI: 10.1016/j.ajem.2018.12.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/15/2018] [Accepted: 12/23/2018] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Kidney stone related complaints in the Emergency Department (ED) are common. Current guidelines recommend antibiotic therapy for infected obstructive stones and stone removal in a timely fashion, but there is no clear recommendation for prophylactic antibiotic use for bacteriuria or pyuria in the setting of obstructive ureteral stones. OBJECTIVES The aim of this study is to evaluate the current management of patients with obstructive ureteral stones in a single ED with emphasis on urine tests and antibiotics use. METHODS The picture archiving and communication system (PACS) was used to filter the list of patients who received a computed tomography (CT) scan of the abdomen and pelvis that positively identified obstructive ureteral stones. Demographics and clinical data were also recorded and analyzed. RESULTS Of the patients discharged, 278 patients did not receive antibiotics in the ED or a prescription. Of these, 8 patients had positive culture, 4 patients followed up, and one developed and was treated for a urinary-tract infection. One hundred ninety two patients were not given antibiotics in the ED but received an antibiotics prescription, and 4 patients had positive cultures grow. Two followed up and had no infection-related complications. Fourteen patients were discharged without a prescription after receiving a single dose of antibiotics in the ED, with no positive urine cultures and 9 patients following up without complication. CONCLUSION Antibiotics were given at the discretion of the provider without clear pattern. A high rate of infectious complication did not occur in the followed up patient group.
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Affiliation(s)
| | - Zoya Khan
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, New York, NY, United States of America
| | - Pardeep Sidhu
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, New York, NY, United States of America
| | - Oralia Navarrete
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, New York, NY, United States of America
| | - Ann Palladino
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, New York, NY, United States of America
| | - Emily Rutland
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, New York, NY, United States of America
| | | | - Leidy Johanna Gonzalez
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, New York, NY, United States of America
| | - Hossein Kalantari
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, New York, NY, United States of America
| | - Getaw Worku Hassen
- NYMC, Metropolitan Hospital Center, Department of Emergency Medicine, New York, NY, United States of America.
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15
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Uribe AA, Arbona FL, Flanigan DC, Kaeding CC, Palettas M, Bergese SD. Comparing the Efficacy of IV Ibuprofen and Ketorolac in the Management of Postoperative Pain Following Arthroscopic Knee Surgery. A Randomized Double-Blind Active Comparator Pilot Study. Front Surg 2018; 5:59. [PMID: 30338261 PMCID: PMC6178884 DOI: 10.3389/fsurg.2018.00059] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 09/06/2018] [Indexed: 01/01/2023] Open
Abstract
Introduction: Acute postoperative pain following knee arthroscopy is common in orthopedic surgeries. Managing pain postoperatively combines usage of opioids and non-steroidal anti-inflammatory drugs. The aim of this clinical study was to assess the efficacy of two different analgesic treatment regimens: intravenous (IV) ibuprofen and IV ketorolac for the treatment of postoperative pain pertaining to arthroscopic knee surgery. Methods: This was a single center, randomized, double-blind, parallel, active comparator clinical pilot study. Subjects were randomized to receive either IV ibuprofen, administered as two 800 mg doses or IV ketorolac, administered as a single 30 mg dose. Subjects in the ibuprofen group received 800 mg of IV ibuprofen within 2 h prior to surgery and a repeated second dose 4 h after the initial dose if they had not been discharged. Subjects in the ketorolac group received IV ketorolac 30 mg at the end of surgery, as per the manufacturer's recommendations. Pain assessments and opioid consumption data were collected up to 24 h postoperatively. Results: Of 53 randomized subjects, 51 completed the study. There were 20 subjects in the ibuprofen group and 31 subjects in the ketorolac group. The median (IQR) visual analog scale (VAS) pain score at resting upon post-anesthesia care unit (PACU) arrival was 33 (12, 52) vs. 9 (2, 25) (p = 0.0064) for the ketorolac and ibuprofen group, respectively. The median (IQR) visual analog scale (VAS) pain score at movement upon PACU arrival was 38 (20, 61) vs. 15 (6, 31) (p = 0.0018) for the ketorolac and ibuprofen group, respectively. Median VAS pain scores during movement taken at subsequent 30 min intervals in the ibuprofen group were less than half that of those reported in the ketorolac group for up to 90 min after arriving in PACU. The median VAS pain scores at rest and movement in the course of 120 min-24 h after PACU arrival was not statistically significant in both groups. Rescue opioid medication during PACU stay was required in 55.0% (N = 11) and 83.9% (N = 26), with a mean amount of narcotic consumption (oral morphine conversion) of 5.53 ± 5.89 mg vs. 19.92 ± 15.63 mg for the ibuprofen and ketorolac group, respectively (P < 0.001). However, opioid consumption during the first 24 h after PACU discharge was not statistically significant (p-value = 0.637). The mean time to first rescue medication was 77.62 ± 33.03 and 55.78 ± 35.37 for the ibuprofen and ketorolac group, respectively (p-value = 0.0456). There were no significant differences in patient satisfaction and documented adverse events during the first 24 h. Conclusion: This pilot study showed that the use of preemptive IV ibuprofen 800 mg could be considered to reduce postoperative pain and opioid consumption. Future prospective clinical trials using similar regimens should be conducted in order to gain a better understanding of how to best provide perioperative analgesic regimens. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT01650519.
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Affiliation(s)
- Alberto A Uribe
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Fernando L Arbona
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - David C Flanigan
- Department of Orthopedics, Jameson Crane Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Christopher C Kaeding
- Department of Orthopedics, Jameson Crane Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Marilly Palettas
- Center of Biostatistics, The Ohio State University, Columbus, OH, United States
| | - Sergio D Bergese
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States.,Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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16
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Herzig SJ, Mosher HJ, Calcaterra SL, Nuckols TK. Reply to "In Reference to 'Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement from the Society of Hospital Medicine'". J Hosp Med 2018; 13:728. [PMID: 30261091 PMCID: PMC7556321 DOI: 10.12788/jhm.3058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Shoshana J Herzig
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
- Harvard Medical School, Boston, Massachusetts, USA
| | - Hilary J Mosher
- The Comprehensive Access and Delivery Research and Evaluation Center at the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Susan L Calcaterra
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
- Department of Medicine, Division of General Internal Medicine, University of Colorado, Aurora, Colorado, USA
| | - Teryl K Nuckols
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
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17
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Herzig SJ, Mosher HJ, Calcaterra SL, Jena AB, Nuckols TK. Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement From the Society of Hospital Medicine. J Hosp Med 2018; 13:263-271. [PMID: 29624189 PMCID: PMC6278928 DOI: 10.12788/jhm.2980] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hospital-based clinicians frequently treat acute, noncancer pain. Although opioids may be beneficial in this setting, the benefits must be balanced with the risks of adverse events, including inadvertent overdose and prolonged opioid use, physical dependence, or development of opioid use disorder. In an era of epidemic opioid use and related harms, the Society of Hospital Medicine (SHM) convened a working group to develop a consensus statement on opioid use for adults hospitalized with acute, noncancer pain, outside of the palliative, end-of-life, and intensive care settings. The guidance is intended for clinicians practicing medicine in the inpatient setting (eg, hospitalists, primary care physicians, family physicians, nurse practitioners, and physician assistants). To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines, composed a draft Statement based on extracted recommendations, and obtained feedback from external experts in hospital-based opioid prescribing, SHM members, the SHM Patient-Family Advisory Council, other professional societies, and peer-reviewers. The iterative development process resulted in a final Consensus Statement consisting of 16 recommendations covering 1) whether to use opioids in the hospital, 2) how to improve the safety of opioid use during hospitalization, and 3) how to improve the safety of opioid prescribing at hospital discharge. As most guideline recommendations from which the Consensus Statement was derived were based on expert opinion alone, the working group identified key issues for future research to support evidence-based practice.
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Affiliation(s)
- Shoshana J Herzig
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Hilary J Mosher
- The Comprehensive Access and Delivery Research and Evaluation Center at the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Susan L Calcaterra
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
- Department of Medicine, Division of General Internal Medicine, University of Colorado, Aurora, Colorado, USA
| | - Anupam B Jena
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Teryl K Nuckols
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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18
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Beltaief K, Grissa MH, Msolli MA, Bzeouich N, Fredj N, Sakma A, Boubaker H, Bouida W, Boukef R, Nouira S. Acupuncture versus titrated morphine in acute renal colic: a randomized controlled trial. J Pain Res 2018; 11:335-341. [PMID: 29483783 PMCID: PMC5815470 DOI: 10.2147/jpr.s136299] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objective The objective of this study was to compare the analgesic effect and tolerance profile of acupuncture versus intravenous (IV) titrated morphine in patients presenting to the emergency department (ED) with renal colic. Materials and methods A total of 115 patients were randomized into two groups. Patients in the IV titrated-morphine group (n=61) received 0.1 mg/kg morphine every 5 minutes until pain score dropped by at least 50% of its baseline value. Patients in the acupuncture group (n=54) received an acupuncture session of 30 minutes following a prespecified protocol. The visual analog scale (VAS) was used to assess pain intensity at baseline and at 10, 20, 30, 45, and 60 minutes following the start of the treatment protocol. Possible treatment side effects were also recorded. Results No significant differences were found between the two groups concerning age, sex, or baseline VAS score. From the 10th minute until the end of the intervention, acupuncture was associated with a deeper analgesic effect than titrated morphine (P<0.05 from the 10th minute and over). Analgesia was also faster in the acupuncture group, with time to obtain 50% reduction of baseline VAS of 14 minutes in the acupuncture group versus 28 minutes in the IV titrated-morphine group (P<0.001). Only three patients in the acupuncture group experienced minor side effects versus 42 in the morphine group (P<0.001). No major side effects were observed in this study. Conclusion In ED patients with renal colic, acupuncture was associated with a much faster and deeper analgesic effect and a better tolerance profile in comparison with titrated IV morphine.
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Affiliation(s)
- Kaouthar Beltaief
- Emergency Department, Fattouma Bourguiba University Hospital.,Research Laboratory LR12SP18, University of Monastir, Monastir
| | - Mohamed Habib Grissa
- Emergency Department, Fattouma Bourguiba University Hospital.,Research Laboratory LR12SP18, University of Monastir, Monastir
| | - Mohamed Amine Msolli
- Emergency Department, Fattouma Bourguiba University Hospital.,Research Laboratory LR12SP18, University of Monastir, Monastir
| | - Nasri Bzeouich
- Emergency Department, Fattouma Bourguiba University Hospital.,Research Laboratory LR12SP18, University of Monastir, Monastir
| | - Nizar Fredj
- Emergency Department, Fattouma Bourguiba University Hospital.,Research Laboratory LR12SP18, University of Monastir, Monastir
| | - Adel Sakma
- Emergency Department, Fattouma Bourguiba University Hospital.,Research Laboratory LR12SP18, University of Monastir, Monastir
| | - Hamdi Boubaker
- Emergency Department, Fattouma Bourguiba University Hospital.,Research Laboratory LR12SP18, University of Monastir, Monastir
| | - Wahid Bouida
- Emergency Department, Fattouma Bourguiba University Hospital.,Research Laboratory LR12SP18, University of Monastir, Monastir
| | - Riadh Boukef
- Emergency Department, Fattouma Bourguiba University Hospital.,Emergency Department, Sahloul University Hospital, Sousse, Tunisia
| | - Semir Nouira
- Emergency Department, Fattouma Bourguiba University Hospital.,Research Laboratory LR12SP18, University of Monastir, Monastir
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19
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Sciatic nerve injury following analgesic drug injection in rats: A histopathological examination. North Clin Istanb 2017; 5:176-185. [PMID: 30688928 PMCID: PMC6323560 DOI: 10.14744/nci.2017.28190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 11/05/2017] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE: Sciatic nerve neuropathy can be observed following intramuscular gluteal injections. The histopathological examination of sciatic nerve damage following intramuscular injection in the gluteal region for acute pain treatment is not feasible in humans due to the inability to dissect and examine the nerve tissue. To overcome this issue, we used a rat model for demonstrating damage to the sciatic nerve tissue after the application of commonly used drug injections. METHODS: We investigated possible damage following the intramuscular injection of diclofenac, lornoxicam, morphine, and pethidine in a rat model based on histopathological characteristics such as myelin degeneration, axon degeneration, epineurium degeneration, fibrosis, epineurium thickening, perineurium thickening, lymphocyte infiltration, vacuolization, and edema. RESULTS: All the analgesic drugs used in our study induced histopathological changes in the sciatic nerve. Anti-S100 positivity, showing nerve damage, was found to be the lowest in the group treated with diclofenac. Neurotoxic effects of diclofenac on the sciatic nerve were greater than those of the other drugs used in the study. Lornoxicam induced the least histopathological changes in the nerve. CONCLUSION: Diclofenac induced severe nerve damage not only after direct injection in the sciatic nerve but also after injection in the area around the nerve. Thus, we recommend restricting the use of intramuscular gluteal injections of diclofenac. Intramuscular use of morphine and pethidine should also be overviewed.
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20
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Tabner AJ, Johnson GD, Fakis A, Surtees J, Lennon RI. β-Adrenoreceptor agonists in the management of pain associated with renal colic: a systematic review. BMJ Open 2016; 6:e011315. [PMID: 27324714 PMCID: PMC4916590 DOI: 10.1136/bmjopen-2016-011315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To determine whether β-adrenoreceptor agonists are effective analgesics for patients with renal colic through a systematic review of the literature. SETTING Adult emergency departments or acute assessment units. PARTICIPANTS Human participants with proven or suspected renal colic. INTERVENTIONS β-adrenoreceptor agonists. OUTCOME MEASURES Primary: level of pain at 30 min following administration of the β-agonist. Secondary: level of pain at various time points following β-agonist administration; length of hospital stay; analgesic requirement; stone presence, size and position; degree of hydronephrosis. RESULTS 256 records were screened and 4 identified for full-text review. No articles met the inclusion criteria. CONCLUSIONS AND IMPLICATIONS There is no evidence to support or refute the proposed use of β-agonists for analgesia in patients with renal colic. Given the biological plausibility and existing literature base, clinical trials investigating the use of β-adrenoreceptor agonists in the acute setting for treatment of the pain associated with renal colic are recommended. TRIAL REGISTRATION NUMBER CRD42015016266.
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Affiliation(s)
| | | | - Apostolos Fakis
- Research and Development Department, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - Jane Surtees
- Research and Development Department, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
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Abstract
BACKGROUND Kidney stones are a common and increasing problem worldwide. Nephrolithiasis is frequently a chronic disease given the risk of recurrence following passage of a first stone. OBJECTIVES In the present article, an update on the diagnosis and treatment of kidney stones relevant for internal medicine physicians is provided. METHODS This review is based on a selective literature search and our own work. RESULTS AND CONCLUSION The diagnosis of kidney stones is based on the clinical history and physical examination. Confirmatory radiologic tests include noncontrast computerized tomography or ultrasonography with both techniques having recently been shown to have equivalent overall outcomes. The therapy of kidney stones is based on the clinical presentation and diagnostic findings (e.g., fever, response to pain management, and demonstration of relevant obstruction) as well as location, size, and composition of the stone. If invasive treatment is being considered, the urology department should be consulted. Given the high risk of recurrence, stone analysis must be performed as well as the concentration of lithogenic and litholytic substances measured in a 24-h urine collection. The newly established recurrence of kidney stone nomogram (ROKS nomogram) identifies kidney stone formers at greatest risk for a second symptomatic episode who may benefit from medical intervention.
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Abstract
At December 2014, this review has been withdrawn from the Cochrane Library. This review is out of date, although it is correct at the date of publication. The review may be misleading as new studies could alter the original conclusions. All previous versions of the review can be found in the ‘Other versions’ tab. We are seeking additional authors to support the updating of this review. For further information, please contact PaPaS Managing Editor, Anna Hobson [Contact Person]. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Joseph F Standing
- Pharmaceutical Biosciences, Uppsala Universitet, Division of Pharmacokinetics and Drug Therapy, Uppsala Universistet BMC Box 591, Uppsala, Sweden, 75124
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Moloney RD, O'Mahony SM, Dinan TG, Cryan JF. Stress-induced visceral pain: toward animal models of irritable-bowel syndrome and associated comorbidities. Front Psychiatry 2015; 6:15. [PMID: 25762939 PMCID: PMC4329736 DOI: 10.3389/fpsyt.2015.00015] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 01/28/2015] [Indexed: 12/12/2022] Open
Abstract
Visceral pain is a global term used to describe pain originating from the internal organs, which is distinct from somatic pain. It is a hallmark of functional gastrointestinal disorders such as irritable-bowel syndrome (IBS). Currently, the treatment strategies targeting visceral pain are unsatisfactory, with development of novel therapeutics hindered by a lack of detailed knowledge of the underlying mechanisms. Stress has long been implicated in the pathophysiology of visceral pain in both preclinical and clinical studies. Here, we discuss the complex etiology of visceral pain reviewing our current understanding in the context of the role of stress, gender, gut microbiota alterations, and immune functioning. Furthermore, we review the role of glutamate, GABA, and epigenetic mechanisms as possible therapeutic strategies for the treatment of visceral pain for which there is an unmet medical need. Moreover, we discuss the most widely described rodent models used to model visceral pain in the preclinical setting. The theory behind, and application of, animal models is key for both the understanding of underlying mechanisms and design of future therapeutic interventions. Taken together, it is apparent that stress-induced visceral pain and its psychiatric comorbidities, as typified by IBS, has a multifaceted etiology. Moreover, treatment strategies still lag far behind when compared to other pain modalities. The development of novel, effective, and specific therapeutics for the treatment of visceral pain has never been more pertinent.
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Affiliation(s)
- Rachel D Moloney
- Laboratory of Neurogastroenterology, Alimentary Pharmabiotic Centre, Biosciences Institute, University College Cork , Cork , Ireland
| | - Siobhain M O'Mahony
- Laboratory of Neurogastroenterology, Alimentary Pharmabiotic Centre, Biosciences Institute, University College Cork , Cork , Ireland ; Department of Anatomy and Neuroscience, University College Cork , Cork , Ireland
| | - Timothy G Dinan
- Laboratory of Neurogastroenterology, Alimentary Pharmabiotic Centre, Biosciences Institute, University College Cork , Cork , Ireland ; Department of Psychiatry, University College Cork , Cork , Ireland
| | - John F Cryan
- Laboratory of Neurogastroenterology, Alimentary Pharmabiotic Centre, Biosciences Institute, University College Cork , Cork , Ireland ; Department of Anatomy and Neuroscience, University College Cork , Cork , Ireland
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Golzari SEJ, Soleimanpour H, Rahmani F, Zamani Mehr N, Safari S, Heshmat Y, Ebrahimi Bakhtavar H. Therapeutic approaches for renal colic in the emergency department: a review article. Anesth Pain Med 2014; 4:e16222. [PMID: 24701420 PMCID: PMC3961032 DOI: 10.5812/aapm.16222] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Revised: 12/08/2013] [Accepted: 12/16/2013] [Indexed: 12/21/2022] Open
Abstract
Context: Renal colic is frequently described as the worst pain ever experienced, and management of this intense pain is necessary. The object of our review was to discuss different approaches of pain control for patients with acute renal colic in the emergency department. Evidence Acquisition: Studies that discussed the treatment of renal colic pain were included in this review. We collected articles from reputable internet databases. Results: Our study showed that some new treatment approaches, such as the use of lidocaine or nerve blocks, can be used to control the severe and persistent pain of renal colic. Conclusions: Some new approaches are discussed and their impact on renal colic pain control was compared with traditional therapies. The effectiveness of the new approaches in this review is similar or even better than in traditional treatments.
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Affiliation(s)
- Samad EJ Golzari
- Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hassan Soleimanpour
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding author: Hassan Soleimanpour, Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. Tel: +989141164134, Fax: +984113352078, E-mail:
| | - Farzad Rahmani
- Emergency Medicine Department, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nahid Zamani Mehr
- Students Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saeid Safari
- Anesthesiology and Critical Care Department, Iran University of Medical Sciences, Tehran, Iran
| | - Yaghoub Heshmat
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Park CH, Ha JY, Park CH, Kim CI, Kim KS, Kim BH. Relationship Between Spontaneous Passage Rates of Ureteral Stones Less Than 8 mm and Serum C-Reactive Protein Levels and Neutrophil Percentages. Korean J Urol 2013; 54:615-8. [PMID: 24044096 PMCID: PMC3773592 DOI: 10.4111/kju.2013.54.9.615] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 07/02/2013] [Indexed: 11/18/2022] Open
Abstract
PURPOSE A ureter obstruction caused by a ureteral stone results in inflammatory changes in the proximal submucosal layer and prevents the spontaneous passage of the ureteral stone. Accordingly, we analyzed the relationship between the spontaneous passage rates of ureteral stones less than 8 mm in size and serum C-reactive protein (CRP) levels and neutrophil percentages. MATERIALS AND METHODS A total of 187 patients who were diagnosed with ureteral stones less than 8 mm in size and were managed consecutively at Keimyung University Dongsan Medical Center from January 2001 to January 2011 were retrospectively analyzed. Ureteral stone removal was defined as no ureteral stone shown in an imaging test without any treatment for 8 weeks after diagnosis. The patients were divided into three groups according to the levels of serum CRP and into two groups according to neutrophil percentage. The associations between these factors and ureteral stone passage rates were then examined. RESULTS The ureteral stone passage rates of the low serum CRP level group, the medium serum CRP level group, and the high serum CRP level group were 94.1% (159/169), 70% (7/10), and 50.0% (4/8), respectively. The passage rates of ureteral stones in the group with a normal neutrophil percentage and in the group with a higher neutrophil percentage were 94.5% (121/128) and 83.1% (49/59), respectively (p=0.011). CONCLUSIONS Measuring serum CRP levels and neutrophil percentages in patients with small ureteral stones of less than 8 mm is useful in predicting whether the stone will be spontaneously passed. When the serum CRP level and neutrophil percentage of a patient are high, aggressive treatment such as extracorporeal shock wave lithotripsy should be considered.
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Affiliation(s)
- Chang Hyun Park
- Department of Urology, Keimyung University School of Medicine, Daegu, Korea
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Lipp C, Dhaliwal R, Lang E. Analgesia in the emergency department: a GRADE-based evaluation of research evidence and recommendations for practice. Crit Care 2013; 17:212. [PMID: 23510305 PMCID: PMC3672477 DOI: 10.1186/cc12521] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Chris Lipp
- University of Calgary, Faculty of Medicine, Alberta Health Services, Calgary, Canada
| | - Raj Dhaliwal
- University of Calgary, Faculty of Medicine, Alberta Health Services, Calgary, Canada
| | - Eddy Lang
- University of Calgary, Faculty of Medicine, Alberta Health Services, Calgary, Canada
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Davis MP. Drug management of visceral pain: concepts from basic research. PAIN RESEARCH AND TREATMENT 2012; 2012:265605. [PMID: 22619712 PMCID: PMC3348642 DOI: 10.1155/2012/265605] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 02/13/2012] [Indexed: 12/24/2022]
Abstract
Visceral pain is experienced by 40% of the population, and 28% of cancer patients suffer from pain arising from intra- abdominal metastasis or from treatment. Neuroanatomy of visceral nociception and neurotransmitters, receptors, and ion channels that modulate visceral pain are qualitatively or quantitatively different from those that modulate somatic and neuropathic pain. Visceral pain should be recognized as distinct pain phenotype. TRPV1, Na 1.8, and ASIC3 ion channels and peripheral kappa opioid receptors are important mediators of visceral pain. Mu agonists, gabapentinoids, and GABAB agonists reduce pain by binding to central receptors and channels. Combinations of analgesics and adjuvants in animal models have supra-additive antinociception and should be considered in clinical trials. This paper will discuss the neuroanatomy, receptors, ion channels, and neurotransmitters important to visceral pain and provide a basic science rationale for analgesic trials and management.
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Affiliation(s)
- Mellar P. Davis
- Cleveland Clinic Lerner School of Medicine, Case Western Reserve University, Cleveland, OH 44195, USA
- Solid Tumor Division, Harry R. Horvitz Center for Palliative Medicine, Taussig Cancer Institute, USA
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Standing JF, Savage I, Pritchard D, Waddington M. Cochrane Review: Diclofenac for acute pain in children. ACTA ACUST UNITED AC 2011. [DOI: 10.1002/ebch.666] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Abstract
BACKGROUND Diclofenac is commonly used for acute pain in children, but is not licensed for this indication in all age groups. OBJECTIVES 1) Assess the efficacy of diclofenac for acute pain in children. 2) Assess the safety of diclofenac for short-term use in children. 3) Identify gaps in the evidence to direct future research. SEARCH STRATEGY Seventeen databases indexing clinical trial reports were searched in February 2005 (with an update search as part of this first review in May 2008). A hand search of Paediatric Anaesthesia was undertaken and summaries obtained of adverse reaction reports from the UK Yellow Card Scheme and World Health Organization (WHO) Monitoring Centre. The reference lists of included studies were also searched. SELECTION CRITERIA Any published report, in any language, involving the administration of diclofenac to a patient aged 18 years or younger for acute pain and detailing either monitoring of efficacy or safety. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study quality and extracted the data. Authors were contacted where necessary. Review Manager version 5 was used for analysis. MAIN RESULTS 1) EFFICACY: randomised controlled trials (RCTs) comparing diclofenac with placebo/any other treatment by using pain scores (assessed or reported), or need for rescue analgesia.2) SAFETY: any type of study seeking adverse events (regardless of cause). An adverse event was defined as any reported adverse or untoward happening to a patient being treated with diclofenac for acute pain.Seven publications on diclofenac efficacy and 79 on safety (74 studies plus five case reports) were included in the final analysis. Compared with placebo/no treatment, diclofenac significantly reduced need for post-operative rescue analgesia (relative risk [RR] 0.6; number needed to treat to benefit [NNT] 3.6; 95% confidence interval [CI] 2.5 to 6.3).Compared with any other non-NSAID, patients receiving diclofenac suffered less nausea or vomiting, or both (RR 0.6; NNT 7.7 [5.3 to 14.3]). There appeared to be no increase in bleeding requiring surgical intervention in patients receiving diclofenac in the peri-operative period. Serious diclofenac adverse reactions occurred in fewer than 0.24% of children treated for acute pain. The types of serious adverse reactions were similar to those reported in adults. AUTHORS' CONCLUSIONS Diclofenac is an effective analgesic for perioperative acute pain in children. It causes similar types of serious adverse reactions in children as in adults, but these are rare. More research on optimum dosing and safety in asthmatic children is required.
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Affiliation(s)
- Joseph F Standing
- Pharmaceutical Biosciences, Uppsala Universitet, Division of Pharmacokinetics and Drug Therapy, Uppsala Universistet BMC Box 591, Uppsala, Sweden, 75124
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Intravenous Paracetamol or Morphine for the Treatment of Renal Colic: A Randomized, Placebo-Controlled Trial. Ann Emerg Med 2009; 54:568-74. [DOI: 10.1016/j.annemergmed.2009.06.501] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 05/16/2009] [Accepted: 06/18/2009] [Indexed: 11/30/2022]
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Abstract
The diagnostic approach to ureteric colic has changed due to the introduction of new radiological imaging such as non-contrast CT. The role of intravenous urography, which is regarded as the gold standard for the diagnosis of ureteric colic, is being challenged by CT, which has become the first-line investigation in a number of centres. The management of ureteric colic has also changed. The role of medical treatment has expanded beyond symptomatic control to attempt to target some of the factors in stone retention and thereby improve the likelihood of spontaneous stone expulsion.
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Affiliation(s)
- M Masarani
- Department of Urology, Imperial College London, Chelsea & Westminster Teaching Hospital, London, UK.
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Affiliation(s)
- Nicole L Miller
- Methodist Hospital Institute for Kidney Stone Disease, Indiana University School of Medicine, and International Kidney Stone Institute, Indianapolis, IN 46202, USA
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Safdar B, Degutis LC, Landry K, Vedere SR, Moscovitz HC, D'Onofrio G. Intravenous Morphine Plus Ketorolac Is Superior to Either Drug Alone for Treatment of Acute Renal Colic. Ann Emerg Med 2006; 48:173-81, 181.e1. [PMID: 16953530 DOI: 10.1016/j.annemergmed.2006.03.013] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To study the efficacy of intravenous ketorolac, morphine, and both drugs in combination in reducing pain in acute renal colic. METHODS We conducted a prospective, double-blinded, randomized controlled trial in an urban, teaching emergency department. Patients aged 18 to 55 years and with a clinical diagnosis of acute renal colic and a pain rating greater than 5 on a 10-cm visual analogue scale or at least "moderate pain" on a 4-category verbal pain scale were eligible for inclusion. Exclusion criteria were contraindication to nonsteroidal anti-inflammatory drugs or opiates, a history of drug dependence, presence of peritonitis, or analgesics within 6 hours of presentation. Patients received either morphine 5 mg at time zero and 5 mg at 20 minutes, ketorolac 15 mg at time zero and 15 mg at 20 minutes, or a combination of both. Primary outcomes were pain reduction and the need for rescue analgesia at 40 minutes. RESULTS Of the 555 consecutive patients screened, 158 patients met inclusion criteria and 130 patients were randomized during 6 months. Mean difference in change in pain score (visual analog scale 40 minutes minus visual analog scale 0 minutes) between combination group and morphine group was 1.8 cm (95% confidence interval [CI] -3.3 to -0.1) and, compared to the ketorolac group, was 2.2 cm (95% CI -3.7 to -0.5); P<.003. Patients with combination therapy were less likely to require rescue morphine compared to the morphine group (odds ratio 0.2; 95% CI 0.1 to 0.7; P=.007). CONCLUSION A combination of morphine and ketorolac offered pain relief superior to either drug alone and was associated with a decreased requirement for rescue analgesia.
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Affiliation(s)
- Basmah Safdar
- Section of Emergency Medicine, Yale University School of Medicine, New Haven, CT 06519, USA.
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Afshar K, MacNeily AE, Marks AJ, Jafari S. Nonsteroidal anti-inflammatory drugs (NSAIDs) and non-opioids for acute renal colic. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2006. [DOI: 10.1002/14651858.cd006027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
A short cut review was carried out to establish whether intravenous non-steroidal anti-inflammatory drugs are better than opioids at reducing pain in renal colic. 230 papers were found, of which five presented the best evidence to answer the clinical question, these have been meta-analysed by the Cochrane collaboration. The results of the meta-analysis are presented here. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. The clinical bottom line is that intravenous NSAID's should be the first-line treatment for patients presenting to the ED with acute renal colic.
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Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane Database Syst Rev 2005; 2004:CD004137. [PMID: 15846699 PMCID: PMC6986698 DOI: 10.1002/14651858.cd004137.pub3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Renal colic is a common cause of acute severe pain. Both opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for treatment, but the relative efficacy of these drugs is uncertain. OBJECTIVES To examine the benefits and disadvantages of NSAIDs and opioids for the management of pain in acute renal colic. SEARCH STRATEGY We searched the Cochrane Renal Group's specialised register (May 2003), the Cochrane Central Register of Randomised Controlled Trials (CENTRAL - The Cochrane Library issue 2, 2003), MEDLINE (1966 - 31 January 2003), EMBASE (1980 - 31 January 2003) and handsearched reference lists of retrieved articles. Most recent search date: January 2005 SELECTION CRITERIA Randomised controlled trials (RCTs) comparing any opioid with any NSAID, regardless of dose or route of administration were included. DATA COLLECTION AND ANALYSIS Data was extracted and quality assessed independently by two reviewers, with differences resolved by discussion. Dichotomous outcomes are reported as relative risk (RR) and measurements on continuous scales are reported as weighted mean differences (WMD) with 95% confidence intervals. Subgroup analysis by study quality, drug type and drug route have been performed where possible to explore reasons for heterogeneity. MAIN RESULTS Twenty trials from nine countries with a total of 1613 participants were identified. Both NSAIDs and opioids lead to clinically significant falls in patient-reported pain scores. Due to unexplained heterogeneity these results could not be pooled although 10/13 studies reported lower pain scores in patients receiving NSAIDs. Patients treated with NSAIDs were significantly less likely to require rescue medication (RR 0.75, 95% CI 0.61 to 0.93, P = 0.007), though most of these trials used pethidine. The majority of trials showed a higher incidence of adverse events in patients treated with opioids, but there was significant heterogeneity between studies so the results could not be pooled. There was significantly less vomiting in patients treated with NSAIDs (RR 0.35, 95% CI 0.23 to 0.53, P < 0.00001). In particular, patients receiving pethidine had a much higher rate of vomiting compared with patients receiving NSAIDs. Gastrointestinal bleeding and renal impairment were not reported. AUTHORS' CONCLUSIONS Both NSAIDs and opioids can provide effective analgesia in acute renal colic. Opioids are associated with a higher incidence of adverse events, particularly vomiting. Given the high rate of vomiting associated with the use of opioids, particularly pethidine, and the greater likelihood of requiring further analgesia, we recommend that if an opioid is to be used it should not be pethidine.
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Affiliation(s)
- A Holdgate
- Department of Emergency Medicine, St George Hospital, Kogarah, NSW, Australia, 2217.
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Lasoye TA, Sedgwick PM, Patel N, Skinner C, Nayeem N. Management of acute renal colic in the UK: a questionnaire survey. BMC Emerg Med 2004; 4:5. [PMID: 15585056 PMCID: PMC539300 DOI: 10.1186/1471-227x-4-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2004] [Accepted: 12/07/2004] [Indexed: 11/10/2022] Open
Abstract
Background There is great variation in the Accident and Emergency workload and location of Urology services in UK hospitals. This study investigated the relationship of the initial management of acute renal colic with the department workload plus local facilities including location of X-ray and urology services in UK Accident and Emergency (A&E) departments. Methods A&E departments in each of the 11 UK Deanery regions were stratified based on departmental workload, namely <30,000 (small); 30,000 to 50,000 (medium); 50,000 to 80,000 (large) and >80,000 (very large) patients per year. One third of departments were selected in each group leading to a sample size of 106. A questionnaire was administered. Associations between categorical variables were investigated using the chi-squared test and when not valid, Fisher's Exact test was employed. Differences between groups in ordinal variables were investigated using the Mann-Whitney test. Results All questionnaires were returned. Twenty-nine units (27.4%) did not perform any radiological investigation on renal colic patients. The number of radiological investigations that were available to departments was associated with workload (P = 0.003); with 57.1% of the small departments performing none and at least 82.8% of units in the other categories performing at least one. Of those departments with X-ray facilities in or adjacent to the department, 63% performed an intravenous urography (IVU) compared to 25% of those departments without (P = 0.026). Of those departments with on-site urology services, 86% performed at least one radiological investigation compared to 52% of units without such services (P = 0.001). Department workload was associated with the first choice analgesia (NSAIDs or parenteral opiates) (P = 0.011). Of the small departments, 64.3% used NSAIDs, 21.4% used parenteral opiates and 14.3% used neither. In comparison, NSAIDS were used by at least 87%, and opiates by at most 12.5% of units in each of the other three categories of department workload. Conclusions Over a quarter of UK A&E departments did not perform any radiological investigations and some departments do not even offer renal colic patients any analgesia. Patient management was associated with departmental workload, location of X-ray and Urology services. National guidelines are needed to ensure optimum care for all patients.
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Affiliation(s)
- Tunji A Lasoye
- Accident and Emergency Department, King's College Hospital, London, England, UK
| | - Philip M Sedgwick
- Department of Community Health Sciences, St George's Hospital Medical School, London, England, UK
| | - Nilay Patel
- Department of Urology, Churchill Hospital, Oxford, England, UK
| | - Chas Skinner
- Department of Psychology, University of Southampton, Southampton, England, UK
| | - Nadeem Nayeem
- Accident and Emergency Department, University Hospital Lewisham, London, England, UK
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Holdgate A, Pollock T. Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic. BMJ 2004; 328:1401. [PMID: 15178585 PMCID: PMC421776 DOI: 10.1136/bmj.38119.581991.55] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine the relative benefits and disadvantages of non-steroidal anti-inflammatory drugs (NSAIDs) and opioids for the management of acute renal colic. DATA SOURCES Cochrane Renal Group's specialised register, Cochrane central register of controlled trials, Medline, Embase, and reference lists of retrieved articles. REVIEW METHODS Randomised controlled trials comparing any opioid with any NSAID in acute renal colic if they reported any of the following outcomes: patient rated pain, time to pain relief, need for rescue analgesia, rate of recurrence of pain, and adverse events. RESULTS 20 trials totalling 1613 participants were identified. Both NSAIDs and opioids led to clinically important reductions in patient reported pain scores. Pooled analysis of six trials showed a greater reduction in pain scores for patients treated with NSAIDs than with opioids. Patients treated with NSAIDs were significantly less likely to require rescue analgesia (relative risk 0.75, 95% confidence interval 0.61 to 0.93). Most trials showed a higher incidence of adverse events in patients treated with opioids. Compared with patients treated with opioids, those treated with NSAIDs had significantly less vomiting (0.35, 0.23 to 0.53). Pethidine was associated with a higher rate of vomiting. CONCLUSIONS Patients receiving NSAIDs achieve greater reductions in pain scores and are less likely to require further analgesia in the short term than those receiving opioids. Opioids, particularly pethidine, are associated with a higher rate of vomiting.
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Affiliation(s)
- Anna Holdgate
- Department of Emergency Medicine, St George Hospital, Gray St, Kogarah, NSW 2217, Australia.
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