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Sibiya A, Selvaraj C, Singh SK, Baskaralingam V. Toxicological study on ibuprofen and selenium in freshwater mussel Lamellidens marginalis and exploring the microbial cytochrome through modelling and quantum mechanics approaches for its toxicity degradation in contaminated environment. ENVIRONMENTAL RESEARCH 2024; 257:119331. [PMID: 38851371 DOI: 10.1016/j.envres.2024.119331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/16/2024] [Accepted: 06/01/2024] [Indexed: 06/10/2024]
Abstract
Toxicological stress in aquatic organisms is caused by the discharge of hundreds of toxic pollutants and contaminants among which the current study concentrates on the toxic effect of non-steroidal anti-inflammatory drug ibuprofen (IBF) and the trace element selenium (Se). In this study, IBF and Se toxicity on freshwater mussel Lamellidens marginalis was studied for 14 days, and in silico predictions for their degradation were made using Molecular modelling and Quantum Mechanical approaches. The degrading propensity of cytochrome c oxidase proteins from Trametes verticillatus and Thauera selenatis (Turkey tail fungi and Gram-negative bacteria) is examined into atom level. The results of molecular modelling study indicate that ionic interactions occur in the T. selenatis-HEME bound complex by Se interacting directly with HEME, and in the T. versicolor-HEME bound complex by IBF bound to a nearby region of HEME. Experimental and theoretical findings suggest that, the toxicological effects of Se and IBF pollution can be reduced by bioremediation with special emphasis on T. versicolor, and T. selenatis, which can effectively interact with Se and IBF present in the environment and degrade them. Besides, this is the first time in freshwater mussel L. marginalis that ibuprofen and selenium toxicity have been studied utilizing both experimental and computational methodologies for their bioremediation study.
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Affiliation(s)
- Ashokkumar Sibiya
- Nano Biosciences and Nanopharmacology Division, Biomaterials and Biotechnology in Animal Health Lab, Department of Animal Health and Management, Science Campus 6th Floor, Alagappa University, Karaikudi, 630004, Tamil Nadu, India
| | - Chandrabose Selvaraj
- CsrDD LAB, Center for Global Health Research, Saveetha Medical College, Saveetha Institute of Medical and Technical Sciences, Saveetha Nagar, Thandalam, Chennai, Tamil Nadu 602105, India
| | - Sanjeev Kumar Singh
- CADD and Molecular Modeling Lab, Department of Bioinformatics, Alagappa University, Science Block, Karaikudi, Tamil Nadu, 630004, India
| | - Vaseeharan Baskaralingam
- Nano Biosciences and Nanopharmacology Division, Biomaterials and Biotechnology in Animal Health Lab, Department of Animal Health and Management, Science Campus 6th Floor, Alagappa University, Karaikudi, 630004, Tamil Nadu, India.
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Fink PB, Wheeler AR, Smith WR, Brant-Zawadzki G, Lieberman JR, McIntosh SE, Van Tilburg C, Wedmore IS, Windsor JS, Hofmeyr R, Weber D. Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update. Wilderness Environ Med 2024; 35:198-218. [PMID: 38651342 DOI: 10.1177/10806032241248422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.
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Affiliation(s)
- Patrick B Fink
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | - Albert R Wheeler
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | - William R Smith
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | | | | | - Scott E McIntosh
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | | | - Ian S Wedmore
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Ross Hofmeyr
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - David Weber
- Mountain Rescue Collective, LLC, Park City, UT
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Khankhel N, Friedman BW, Baer J, Lopez L, Feliciano C, Lee S, Irizarry E. Topical Diclofenac Versus Oral Ibuprofen Versus Diclofenac + Ibuprofen for Emergency Department Patients With Acute Low Back Pain: A Randomized Study. Ann Emerg Med 2024; 83:542-551. [PMID: 38441515 PMCID: PMC11141689 DOI: 10.1016/j.annemergmed.2024.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 04/14/2024]
Abstract
STUDY OBJECTIVE Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are useful for a variety of musculoskeletal injuries. It is not known whether topical NSAIDs should be used for patients presenting with acute nonradicular musculoskeletal low back pain. METHODS We conducted a randomized, placebo-controlled double-blind study in which patients 18 to 69 years of age visiting the emergency department (ED) with acute, nontraumatic, nonradicular, musculoskeletal low back pain were randomized at the time of discharge to treatment with 400 mg oral ibuprofen + placebo topical gel, 1% diclofenac topical gel + oral placebo, or 400 mg ibuprofen + 1% diclofenac topical gel. We measured outcomes using the Roland Morris Disability Questionnaire (RMDQ), a 24-item yes/no instrument about the effect of back pain on a respondent's daily activities. The primary outcome was change in RMDQ score between ED discharge and 2 days later. Medication-related adverse events were elicited by asking whether the study medications caused any new symptoms. RESULTS In total, 3,281 patients were screened for participation, and 198 were randomized. Overall, 36% of the population were women, the mean age was 40 years (standard deviation, 13), and the median RMDQ score at baseline was 18 (25th to 75th percentile: 13 to 22), indicating substantial low back-related functional impairment. In total, 183 (92%) participants provided primary outcome data. Two days after the ED visit, the ibuprofen + placebo group had improved by 10.1 (95% confidence interval [CI] 7.5 to 12.7), the diclofenac gel + placebo group by 6.4 (95% CI 4.0 to 8.8), and the ibuprofen + diclofenac gel by 8.7 (95% CI 6.3 to 11.1). The between-group differences were as follows: ibuprofen versus diclofenac, 3.7 (95% CI 0.2 to 7.2); ibuprofen versus both medications 1.4 (95% CI -2.1 to 4.9); and diclofenac versus both medications, 2.3 (95% CI -5.7 to 1.0). Medication-related adverse events were reported by 3/60 (5%) ibuprofen patients, 1/63 (2%) diclofenac patients, and 4/64 (6%) patients who received both. CONCLUSION Among patients with nontraumatic, nonradicular acute musculoskeletal low back pain discharged from an ED, topical diclofenac was probably less efficacious than oral ibuprofen. It demonstrated no additive benefit when coadministered with oral ibuprofen.
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Friedman BW, Chen YT, Campbell C, Nerenberg R, Afrifa F, Schimmrich K, Adewunmi V, Baer J, Irizarry E. A sequential, multiple-assignment, randomized trial of analgesic strategies for acute musculoskeletal Pain. Am J Emerg Med 2024; 82:15-20. [PMID: 38749371 DOI: 10.1016/j.ajem.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/11/2024] [Accepted: 05/06/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND Most methodologically rigorous, ED-based, comparative effectiveness analgesic studies completed in the last two decades failed to find a clinically important difference between the comparators. We believe that many of these comparative effectiveness studies were biased towards the null hypothesis because some ED patients with intense pain will respond to relatively mild interventions. We hypothesized that including a run-in period would alter the results of an acute pain RCT. METHODS We conducted a sequential, multiple-assignment, randomized study. Adults with acute moderate/severe musculoskeletal pain were randomized (3:1 ratio) to run-in period or no run-in. We administered 650 mg acetaminophen to run-in participants. Those run-in patients who reported insufficient relief one-hour later were randomized (1:1 ratio) to ibuprofen 800mg PO or ketorolac 20mg PO as were all participants randomized to no run-in. The primary outcome was achieving a clinically important improvement, defined as improvement ≥1.3 on a 0-10 scale. We built a logistic regression model including run-in/no run-in, ketorolac/ibuprofen, age and sex. RESULTS Of 307 participants who received acetaminophen, 100 (32.6%) reported inadequate relief and were randomized to an NSAID. Of the 100 patients randomized to no run-in, 84/100 (84%) achieved the primary outcome versus 246/287 (86%) run-in participants (95% CI for difference = 2%:-7,10%). Among run-in participants who received an NSAID, 82/99(83%) achieved the primary outcome versus 84/100(84%) no run-in participants (p = 0.82). Among all ibuprofen participants, 44/49(90%) randomized to run-in and 42/50(84%) randomized to no run-in achieved the primary outcome. Among all ketorolac participants, 38/50(76%) randomized to run-in and 42/50 (84%) randomized to no run-in achieved the primary outcome. We observed the following results in a multivariable analysis: OR for ketorolac versus ibuprofen:0.60 (95% CI: 0.28, 1.28); OR for run-in versus no run-in:0.91(95% CI: 0.43, 1.93). CONCLUSIONS Among patients with acute musculoskeletal pain, using an acetaminophen first strategy did not alter pain outcomes.
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Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Montefiore-Einstein, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Yen Ting Chen
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Caron Campbell
- Department of Emergency Medicine, Montefiore-Einstein, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rebecca Nerenberg
- Department of Emergency Medicine, Montefiore-Einstein, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Freda Afrifa
- Pharmacy Department, Montefiore-Einstein, Bronx, NY, USA
| | - Kristen Schimmrich
- Department of Emergency Medicine, Montefiore-Einstein, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Victoria Adewunmi
- Department of Emergency Medicine, Montefiore-Einstein, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jesse Baer
- Department of Emergency Medicine, Montefiore-Einstein, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eddie Irizarry
- Department of Emergency Medicine, Montefiore-Einstein, Albert Einstein College of Medicine, Bronx, NY, USA
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Hanley AW, Lingard A, Garland EL. A Single-Session, 2-Hour Version of Mindfulness-Oriented Recovery Enhancement (One MORE) Improves Chronic Pain Patients' Pain-Related Outcomes Through 3-Month Follow-Up in a Randomized Controlled Trial. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2024. [PMID: 38588552 DOI: 10.1089/jicm.2023.0501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Introduction: Traditional, 8-week, mindfulness-based interventions can effectively treat chronic pain, but require a time and resource investment too burdensome for many patients and providers. The solution to this logistical challenge may be to distill the core, therapeutic elements of an efficacious 8-week, mindfulness-based intervention, Mindfulness-Oriented Recovery Enhancement (MORE), into a 2-h, single-session intervention. Methods: In this study, the authors conducted a waitlist-controlled, randomized clinical trial to assess the impact of a 2-h, single-session adaptation of MORE (i.e., One MORE) on chronic pain patients' (N = 40) pain-related outcomes through 3-month follow-up. Results: Results indicated that One MORE significantly improved chronic pain patients' pain catastrophizing (i.e., primary outcome; F = 9.97, p = 0.002), pain intensity (F = 26.58, p < 0.001), pain interference (F = 39.43, p < 0.001), physical function (F = 16.29, p < 0.001), sleep (F = 16.66, p < 0.001), anxiety (F = 12.54, p < 0.001), and depression (F = 17.48, p < 0.001). One MORE also significantly increased theoretically indicated therapeutic mechanisms through the 3-month follow-up: mindfulness, positive reappraisal, savoring, self-transcendence. Discussion: Study results are promising, and if replicated, would suggest that One MORE is a highly scalable, low-cost (e.g., sustainable), nonpharmacologic treatment for chronic pain. Clinical Trial Registration: NCT05194241.
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Affiliation(s)
- Adam W Hanley
- Brain Science and Symptom Management Center, College of Nursing, Florida State University, Tallahassee, FL, USA
- Department of Orthopedics, University of Utah, Salt Lake City, UT, USA
| | - Ayaka Lingard
- Center on Mindfulness and Integrative Health Intervention Development (C-MIIND), University of Utah, Salt Lake City, UT, USA
- College of Social Work, University of Utah, Salt Lake City, UT, USA
| | - Eric L Garland
- Center on Mindfulness and Integrative Health Intervention Development (C-MIIND), University of Utah, Salt Lake City, UT, USA
- College of Social Work, University of Utah, Salt Lake City, UT, USA
- Salt Lake City Veterans Affairs Medical Center, Salt Lake City, UT, USA
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Oyler DR, Westgate PM, Walsh SL, Dolly Prothro J, Miller CS, Roberts MF, Freeman PR, Knudsen HK, Lang M, Dominguez-Fernandez E, Rojas-Ramirez MV. Alternatives to dental opioid prescribing after tooth extraction (ADOPT): protocol for a stepped wedge cluster randomized trial. BMC Oral Health 2024; 24:414. [PMID: 38575929 PMCID: PMC10996080 DOI: 10.1186/s12903-024-04201-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Dentists and oral surgeons are leading prescribers of opioids to adolescents and young adults (AYA), who are at high risk for developing problematic opioid use after an initial exposure. Most opioids are prescribed after tooth extraction, but non-opioid analgesics provide similar analgesia and are recommended by multiple professional organizations. METHODS This multi-site stepped wedge cluster-randomized trial will assess whether a multicomponent behavioral intervention can influence opioid prescribing behavior among dentists and oral surgeons compared to usual practice. Across up to 12 clinical practices (clusters), up to 33 dentists/oral surgeons (provider participants) who perform tooth extractions for individuals 12-25 years old will be enrolled. After enrollment, all provider participants will receive the intervention at a time based on the sequence to which their cluster is randomized. The intervention consists of prescriber education via academic detailing plus provision of standardized patient post-extraction instructions and blister packs of acetaminophen and ibuprofen. Provider participants will dispense the blister packs and distribute the patient instructions at their discretion to AYA undergoing tooth extraction, with or without additional analgesics. The primary outcome is a binary, patient-level indicator of electronic post-extraction opioid prescription. Data for the primary outcome will be collected from the provider participant's electronic health records quarterly throughout the study. Provider participants will complete a survey before and approximately 3 months after transitioning into the intervention condition to assess implementation outcomes. AYA patients undergoing tooth extraction will be offered a survey to assess pain control and satisfaction with pain management in the week after their extraction. Primary analyses will use generalized estimating equations to compare the binary patient-level indicator of being prescribed a post-extraction opioid in the intervention condition compared to usual practice. Secondary analyses will assess provider participants' perceptions of feasibility and appropriateness of the intervention, and patient-reported pain control and satisfaction with pain management. Analyses will adjust for patient-level factors (e.g., sex, number of teeth extracted, etc.). DISCUSSION This real-world study will address an important need, providing information on the effectiveness of a multicomponent intervention at modifying dental prescribing behavior and reducing opioid prescriptions to AYA. CLINICALTRIALS GOV: NCT06275191.
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Affiliation(s)
- Douglas R Oyler
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, 760 Press Avenue, Ste. 260, Lexington, KY, 40536, USA.
| | - Philip M Westgate
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Sharon L Walsh
- Department of Behavioral Science and Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Jennifer Dolly Prothro
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, 760 Press Avenue, Ste. 260, Lexington, KY, 40536, USA
| | - Craig S Miller
- Department of Oral Diagnosis, Medicine, and Radiology, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - Monica F Roberts
- Substance Use Priority Research Area, University of Kentucky, Lexington, KY, USA
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, 760 Press Avenue, Ste. 260, Lexington, KY, 40536, USA
| | - Hannah K Knudsen
- Department of Behavioral Science and Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Maggie Lang
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Enif Dominguez-Fernandez
- Department of Oral Health Science, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - Marcia V Rojas-Ramirez
- Department of Oral Diagnosis, Medicine, and Radiology, College of Dentistry, University of Kentucky, Lexington, KY, USA
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Rosi-Schumacher M, Sharma J, Clausen S, Favre N, Powers K, Carr M. Post-tonsillectomy bleeding rate decreases with limitation in maximum post-operative ibuprofen dosage: A quality improvement study. Am J Otolaryngol 2024; 45:104197. [PMID: 38113775 DOI: 10.1016/j.amjoto.2023.104197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/10/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVE The objective of this study is to investigate the effect of a reduction in the prescribed post-operative ibuprofen dosage on frequency of post-tonsillectomy bleeding. METHODS A quality improvement study was conducted at a single tertiary care pediatric hospital with patients weighing >40 kg undergoing tonsillectomy. The intervention was limiting the post-operative ibuprofen dosage to a maximum of 400 mg per dose. Data was collected on all patients returning to the hospital with bleeding after tonsillectomy. The primary outcome was the rate of post-tonsillectomy bleeding. Statistical analysis was conducted using nonparametric comparisons and a run chart. RESULTS A total of 199 tonsillectomy patients >40 kg were included in the study. There were 119 (59.8 %) females and 80 (40.2 %) males total. The pre-intervention group had a total of 56 patients while the post-intervention group had a total of 143 patients. There was no statistical difference in age, weight, or sex between the pre- and post-intervention groups (p > .05). The post-tonsillectomy hemorrhage rate was 11/56 (19.6 %) before the intervention, and 11/143 (7.7 %) after the intervention (p = .016). Children who experienced a bleeding event were significantly older (mean 15.9 years, 95 % CI 14.5-17.3) than those who did not (13.5 years, 95 % CI 12.9-14.1; p = .011). The run chart revealed that the intervention resulted in a nonrandom decrease in rate of post-tonsillectomy bleeding. CONCLUSIONS Post-tonsillectomy bleeding rate decreased with a ceiling post-operative ibuprofen dose of 400 mg/dose in this quality improvement study. Further research is warranted.
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Affiliation(s)
- Mattie Rosi-Schumacher
- Department of Otolaryngology-Head and Neck Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14209, United States of America
| | - Jyoti Sharma
- Department of Otolaryngology-Head and Neck Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14209, United States of America
| | - Sean Clausen
- Department of Otolaryngology-Head and Neck Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14209, United States of America
| | - Nicole Favre
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY 14209, United States of America
| | - Kristina Powers
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY 14209, United States of America
| | - Michele Carr
- Department of Otolaryngology-Head and Neck Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14209, United States of America.
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Andre A, Benichou M, Dym H. Post-Procedure Analgesic Management. Dent Clin North Am 2024; 68:213-225. [PMID: 37951635 DOI: 10.1016/j.cden.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
During the development of multimodal pain management protocols, practitioners need to consider the potential risks each treatment modality inherently carries in order to prevent or diminish harmful outcomes. As an example, the part dentists played in the early stages of the opioid epidemic in the United States of America should serve as a cautionary account. By understanding the roots of this crisis, as practitioners we are better equipped to implement the novel analgesic agents available today to optimize post-operative pain control while minimizing any risk of addiction and harm to our communities. It is therefore critical that our colleagues understand the variety of accessible options for pain management to assure that our profession is able to seek adequate and sustainable relief for our post-operative patients. This article will go in depth to explain the analgesic tools practitioners can implement for an effective low-risk protocol, including a combination of NSAIDS and acetaminophen approach, using long-acting local anesthetics such as Exparel, pregabalin, gabapentin, ketamine, dexmedetomidine, and corticosteroids, and enhanced recovery after surgery protocols.
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Affiliation(s)
- Amanda Andre
- The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA.
| | - Michael Benichou
- The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA
| | - Harry Dym
- The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA
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9
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Murphy PB, Kasotakis G, Haut ER, Miller A, Harvey E, Hasenboehler E, Higgins T, Hoegler J, Mir H, Cantrell S, Obremskey WT, Wally M, Attum B, Seymour R, Patel N, Ricci W, Freeman JJ, Haines KL, Yorkgitis BK, Padilla-Jones BB. Efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association. Trauma Surg Acute Care Open 2023; 8:e001056. [PMID: 36844371 PMCID: PMC9945020 DOI: 10.1136/tsaco-2022-001056] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/09/2023] [Indexed: 02/25/2023] Open
Abstract
Objectives Fracture is a common injury after a traumatic event. The efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) to treat acute pain related to fractures is not well established. Methods Clinically relevant questions were determined regarding NSAID use in the setting of trauma-induced fractures with clearly defined patient populations, interventions, comparisons and appropriately selected outcomes (PICO). These questions centered around efficacy (pain control, reduction in opioid use) and safety (non-union, kidney injury). A systematic review including literature search and meta-analysis was performed, and the quality of evidence was graded per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The working group reached consensus on the final evidence-based recommendations. Results A total of 19 studies were identified for analysis. Not all outcomes identified as critically important were reported in all studies, and the outcome of pain control was too heterogenous to perform a meta-analysis. Nine studies reported on non-union (three randomized control trials), six of which reported no association with NSAIDs. The overall incidence of non-union in patients receiving NSAIDs compared with patients not receiving NSAIDs was 2.99% and 2.19% (p=0.04), respectively. Of studies reporting on pain control and reduction of opioids, the use of NSAIDs reduced pain and the need for opioids after traumatic fracture. One study reported on the outcome of acute kidney injury and found no association with NSAID use. Conclusions In patients with traumatic fractures, NSAIDs appear to reduce post-trauma pain, reduce the need for opioids and have a small effect on non-union. We conditionally recommend the use of NSAIDs in patients suffering from traumatic fractures as the benefit appears to outweigh the small potential risks.
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Affiliation(s)
- Patrick B Murphy
- Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - George Kasotakis
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins Univ, Baltimore, Maryland, USA
| | - Anna Miller
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Edward Harvey
- Department of Surgery, McGill University, Montreal, Québec, Canada
| | - Eric Hasenboehler
- Holy Spirit Hospital Penn State Health, Camp Hill, Pennsylvania, USA
| | - Thomas Higgins
- Department of Orthopaedics, University of Utah Health, Salt Lake City, Utah, USA
| | - Joseph Hoegler
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Hassan Mir
- Department of Orthopaedic Surgery, University of South Florida, Tampa, Florida, USA
| | - Sarah Cantrell
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - William T Obremskey
- The Vanderbilt Orthopaedic Institute Center for Health Policy, Nashville, Tennessee, USA
| | - Meghan Wally
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Basem Attum
- Institute Center for Health Policy, Nashville, Tennessee, USA
| | - Rachel Seymour
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nimitt Patel
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - William Ricci
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Jennifer J Freeman
- Department of Surgery, TCU and UNTHSC School of Medicine, Fort Worth, Texas, USA
| | - Krista L Haines
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Brian K Yorkgitis
- Department of Surgery, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida, USA
| | - Brandy B Padilla-Jones
- Department of General Surgery, Sunrise Hospital and Medical Center, Las Vegas, Nevada, USA
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Ghirardo S, Trevisan M, Ronfani L, Zanon D, Maestro A, Barbieri F, De Nardi L, Amaddeo A, Barbi E, Cozzi G. Oral ibuprofen versus oral ketorolac for children with moderate and severe acute traumatic pain: a randomized comparative study. Eur J Pediatr 2023; 182:929-935. [PMID: 36526794 PMCID: PMC9758024 DOI: 10.1007/s00431-022-04759-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/28/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
This study is to compare ibuprofen and ketorolac for children with trauma-related acute pain. We conducted a multicentre randomized, double-blind, controlled trial in the Paediatric Emergency Department setting. We enrolled patients aged 8 to 17 who accessed the emergency department for pain related to a limb trauma that occurred in the previous 48 h. At the admission, patients were classified based on numeric rating scale-11 (NRS-11) in moderate (NRS 4-6) and severe (NRS 7-10) pain groups. Each patient was randomized to receive either ibuprofen (10 mg/kg) or ketorolac (0.5 mg/kg) and the placebo of the not given drug in a double dummies design. NRS-11 was asked every 30 min until 2 h after drug and placebo administration. The primary outcome was NRS-11 reduction at 60 min. Among 125 patients with severe pain, NRS-11 reduction after 60 min from drug administration was 2.0 (IQR 1.0-4.0) for ibuprofen and 1.0 (IQR 1.0-3.0) for ketorolac (p = 0.36). Ibuprofen was significantly better, considering secondary outcomes, at 90 min with a lower median of NRS-11 (p 0.008), more patients with NRS-11 less than 4 (p 0.01) and a reduction of pain score of more than 3 NRS-11 points (p 0.01). Among 87 patients with moderate pain, the NRS-11 reduction after 60 min from drug administration was 1.63 (± 1.8) for ibuprofen and 1.8 (± 1.6) for ketorolac, with no statistically significant difference.Conclusions: Oral ibuprofen and ketorolac are similarly effective in children and adolescents with acute traumatic musculoskeletal pain.Trial registration: ClinicalTrial.gov registration number: NCT04133623.
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Affiliation(s)
- Sergio Ghirardo
- Department of Medicine, Surgery and Health Science, University of Trieste, Trieste, Italy.
| | - Matteo Trevisan
- Department of Medicine, Surgery and Health Science, University of Trieste, Trieste, Italy
| | - Luca Ronfani
- Department Servizio di Epidemiologia e Biostatistica, Institute for Maternal, Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Davide Zanon
- Department of Pharmacy and Clinical Pharmacology Unit, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Alessandra Maestro
- Department of Pharmacy and Clinical Pharmacology Unit, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Francesca Barbieri
- Department: Pediatria e Neonatologia, AAS 5 Ospedale di Santa Maria degli Angeli di Pordenone, Pordenone, Italy
| | - Laura De Nardi
- Department of Medicine, Surgery and Health Science, University of Trieste, Trieste, Italy
| | - Alessandro Amaddeo
- Pediatric Emergency Department, Institute for Maternal, Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Egidio Barbi
- Department of Medicine, Surgery and Health Science, University of Trieste, Trieste, Italy ,Department of Pediatrics, Institute for Maternal, Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Giorgio Cozzi
- Pediatric Emergency Department, Institute for Maternal, Child Health IRCCS Burlo Garofolo, Trieste, Italy
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Cikcikoglu Yildirim N, Serdar O, Basaran S. The use of Gammarus pulex as a model organism for ecotoxicological assessment of ibuprofen and propranolol at environmental relevant concentrations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2022; 32:2385-2395. [PMID: 34404301 DOI: 10.1080/09603123.2021.1967888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/10/2021] [Indexed: 06/13/2023]
Abstract
The aim of this study is to assess the toxicity of ibuprofen (IBU) and propranolol (PRO) drugs usingGammarus pulex as a model organism. Firstly, the 96 h LC50 values of IBU and PRO were determined and then three sublethal concentrations of the drugs were exposed to G. pulex. The activities of superoxide dismutase (SOD), catalase (CAT) and acetylcholinesterase (AChE) were evaluated. SOD activity decreased in G. pulex exposed to IBU and PRO compared to control. In all groups exposed to IBU, CAT activity increased at different concentrations at 24 and 96 h. In the groups exposed to different PRO concentrations, CAT activities increased after 24 h compared to the control group (p < 0.05). AChE activities increased in all application groups exposed to IBU for 96 hours (p < 0.05). In conclusion, exposure to IBU and PRO resulted in increased oxidative damage. PRO has been found to cause neurotoxicity.
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Affiliation(s)
- Nuran Cikcikoglu Yildirim
- Pertek Sakine Genç Vocational School/Department of Veterinary Medicine/Laboratorian and Veterinarian Health Programme
| | - Osman Serdar
- Munzur University, Fisheries Faculty, Tunceli, Turkey
| | - Senay Basaran
- Munzur University, Department of Environmental Engineering, Tunceli, Turkey
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Farkouh A, Hemetsberger M, Noe CR, Baumgärtel C. Interpreting the Benefit and Risk Data in Between-Drug Comparisons: Illustration of the Challenges Using the Example of Mefenamic Acid versus Ibuprofen. Pharmaceutics 2022; 14:pharmaceutics14102240. [PMID: 36297674 PMCID: PMC9609416 DOI: 10.3390/pharmaceutics14102240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 12/02/2022] Open
Abstract
Evidence-based pain therapy should rely on precisely defined and personalized criteria. This includes balancing the benefits and risks not only of single drugs but often requires complex between-drug comparisons. Non-steroidal anti-inflammatory drugs (NSAIDs) have been available for several decades and their use is described in an abundance of guidelines. Most of these guidelines recommend that ‘the selection of a particular NSAID should be based on the benefit-risk balance for each patient’. However, head-to-head studies are often lacking or of poor quality, reflecting the lower standards for clinical research and regulatory approval at the time. The inconsistency of approved indications between countries due to national applications adds to the complexity. Finally, a fading research interest once drugs become generic points to a general deficit in the post-marketing evaluation of medicines. Far from claiming completeness, this narrative review aimed to illustrate the challenges that physicians encounter when trying to balance benefits and risks in a situation of incomplete and inconsistent data on longstanding treatment concepts. Ibuprofen and mefenamic acid, the most frequently sold NSAIDs in Austria, serve as examples. The illustrated principles are, however, not specific to these drugs and are generalizable to any comparison of older drugs in daily clinical practice.
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Affiliation(s)
- André Farkouh
- Department of Pharmaceutical Sciences, University of Vienna, 1090 Vienna, Austria
- Correspondence: ; Tel.: +43-664-3029922
| | | | - Christian R. Noe
- Department of Medicinal Chemistry, University of Vienna, 1090 Vienna, Austria
| | - Christoph Baumgärtel
- AGES Austrian Medicines and Medical Devices Agency, Austrian Federal Office for Safety in Health Care, 1200 Vienna, Austria
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Davis A, Fassassi C, Dove D, Drapkin J, Likourezos A, Gohel A, Favale P, Hossain R, Butt M, Gerges L, Motov S. Analgesic Efficacy of Oral Aspirin/Ketamine Combination for Management of Acute Musculoskeletal Pain in the Emergency Department - A Proof of Concept Pilot Study. J Emerg Med 2022; 62:750-759. [PMID: 35624056 DOI: 10.1016/j.jemermed.2022.01.029] [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: 12/02/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Musculoskeletal pain (MSK) affects one out of three adults and is the most common source of significant long-term pain, physical disability, and under-treatment in the emergency department (ED). OBJECTIVE We aimed to assess the analgesic efficacy of a combination of oral VTS-Aspirin® (Vitalis Analgesics, New York, NY) and ketamine in managing acute MSK pain in adult ED patients. METHODS This was a prospective, proof-of-concept, single-arm, pilot study evaluating the analgesic efficacy of a single dose of oral combination of VTS-Aspirin and ketamine in adult ED patients with acute moderate-to-severe MSK pain. The primary outcome included the difference in pain scores on an 11-point numeric pain rating scale at 60 min. Secondary outcomes included the need for rescue analgesia, the occurrence of adverse events at 60 min, and a change in pain scores at 120 min. RESULTS We enrolled 25 subjects in the study. The mean baseline pain score was 8.6 and the mean pain score at 60 min decreased to 4.8. The oral ketamine dose ranged from 24 mg to 50 mg, with a mean dose of 37.8 mg. No clinically concerning changes in vital signs were noted. No serious adverse events occurred in any of the subjects. Majority of adverse effects were transient and weak in intensity. CONCLUSION We demonstrated that administration of an oral combination of VTS-Aspirin and ketamine to adult ED patients with acute MSK pain resulted in clinically significant pain relief in 80% of enrolled subjects.
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Affiliation(s)
- Ashley Davis
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Catsim Fassassi
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Daniel Dove
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Jefferson Drapkin
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Antonios Likourezos
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Ankit Gohel
- Department of Pharmacy, Maimonides Medical Center, Brooklyn, New York
| | - Patrizia Favale
- Department of Pharmacy, Maimonides Medical Center, Brooklyn, New York
| | - Rukhsana Hossain
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Mahlaqa Butt
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Louis Gerges
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
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Rech MA, Griggs C, Lovett S, Motov S. Acute pain management in the Emergency Department: Use of multimodal and non-opioid analgesic treatment strategies. Am J Emerg Med 2022; 58:57-65. [DOI: 10.1016/j.ajem.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/05/2022] [Accepted: 05/14/2022] [Indexed: 12/01/2022] Open
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Bennemla M, Bouafia-Chergui S, Amrane A, Chabani M. The photocatalytic degradation kinetics of the anti-inflammatory drug ibuprofen in aqueous solution under UV/TiO 2 system and neural networks modeling. INTERNATIONAL JOURNAL OF CHEMICAL REACTOR ENGINEERING 2022. [DOI: 10.1515/ijcre-2021-0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
In this study, the kinetic degradation of the anti-inflammatory drug Ibuprofen in aqueous solution by heterogeneous TiO2 photocatalytic was investigated. The data obtained were used for training an artificial neural network. Preliminary experiments of photolysis and adsorption were carried out to assess their contribution to the photocatalytic degradation. Both, direct photolysis and adsorption of Ibuprofen are very low-efficient processes (15,83% and 23,88%, respectively). The degradation efficiency was significantly elevated with the addition of TiO2 Catalyst (>94%). The photocatalytic degradation followed a pseudo-first-order reaction according to the L-H model. The hydroxyl radicals and photo-hole (h+) were found to contribute to the Ibuprofen removal. The higher the initial concentration of Ibuprofen resulted in the lower percentage of degradation. This can be credited to the fact that the created photon and radicals were constant. The higher the initial concentration of Ibuprofen the fewer radicals were shared for each Ibuprofen molecular and so the lower percentage of degradation. The maximum photoactivity from the available light is accomplished when the concentration of catalyst reaches to 1 g/L (0.8 g), which was adopted as the optimal amounts. Compared to the removal of ibuprofen, the mineralization was relatively lower. This decrease is due to the organic content of the treated solution, which is mainly composed of recalcitrant intermediate products. The network was planned as a Levenberg-Marquardt algorithm with three layer, four neurons in the input layer, fourteen neurons in the hidden layer and one neuron in the output layer (4:14:1). The artificial neural network was trained until the MSE value between the simulated data and the experimental results was 10−5. The best results (R
2 = 0.999 and MSE = 1.5 × 10−4) were obtained with a log sigmoid transfer function at hidden layer and a linear transfer function at output layer.
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Affiliation(s)
- M. Bennemla
- Laboratoire Génie de la réaction, Equipe Procédés durables de dépollution, Faculté de Génie des Procédés et Génie Mécanique , U.S.T.H.B. BP 32 , El Allia , Babezzouar , Algeria
| | - S. Bouafia-Chergui
- Laboratoire Génie de la réaction, Equipe Procédés durables de dépollution, Faculté de Génie des Procédés et Génie Mécanique , U.S.T.H.B. BP 32 , El Allia , Babezzouar , Algeria
| | - A. Amrane
- Ecole Nationale Supérieure de Chimie de Rennes, CNRS , UMR 6226 , 11 allée de Beaulieu , CS 50837 , 35708 , Rennes , France
- Université Européenne de Bretagne , 5 boulevard Laënnec , 35000 , Rennes , France
| | - M. Chabani
- Laboratoire Génie de la réaction, Equipe Procédés durables de dépollution, Faculté de Génie des Procédés et Génie Mécanique , U.S.T.H.B. BP 32 , El Allia , Babezzouar , Algeria
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Friedman BW. Peripheral Nerve Blocks for Headache: A Precise Approach to Pain Management in the Emergency Department. Ann Emerg Med 2021; 79:262-264. [PMID: 34952731 DOI: 10.1016/j.annemergmed.2021.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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ANALGESIC EFFICACY OF TRAMADOL/DEXKETOPROFEN VS IBUPROFEN AFTER IMPACTED LOWER THIRD MOLAR EXTRACTION: A RANDOMIZED CONTROLLED CLINICAL TRIAL. J Evid Based Dent Pract 2021; 21:101618. [PMID: 34922724 DOI: 10.1016/j.jebdp.2021.101618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/29/2021] [Accepted: 07/15/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Impacted third molar extraction is associated with acute moderate-to-severe pain for up to 48 hours post-surgery. This trial was designed to compare the analgesic effectiveness, swelling, and adverse events after impacted third molar surgery following multimodal therapy with 75 mg tramadol hydrochloride plus 25 mg dexketoprofen or monotherapy with 400 mg ibuprofen. METHODS Seventy-two patients were randomly assigned to receiving ibuprofen (n = 36) or tramadol-dexketoprofen (n = 36). Postoperative pain intensity and swelling were measured using a visual analog scale (VAS); pain relief experienced was reported using a 4-point verbal rating scale; the rescue medication requirement, adverse effects, and global impression of the medication were recorded. RESULTS No statistically significant between-group difference in pain intensity was observed at any time point; however, pain relief was significantly higher in the tramadol-dexketoprofen treated-group at 6 and 36 hours. Self-reported verbal rating scale assessments showed significantly lower swelling in the tramadol-dexketoprofen group at 24 hours post-surgery but not at 48 or 72 hours, and VAS-swelling scores showed no significant between-group difference. The frequency of postoperative nausea and dizziness was significantly higher in the tramadol-dexketoprofen group. CONCLUSIONS Multimodal therapy proved more effective to manage moderate-severe pain after impacted third molar surgery in comparison to monotherapy. However, the improvement in relief must be balanced against the increased risk of adverse effects when considering this multimodal approach.
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Irizarry E, Restivo A, Salama M, Davitt M, Feliciano C, Cortijo‐Brown A, Friedman BW. A randomized controlled trial of ibuprofen versus ketorolac versus diclofenac for acute, nonradicular low back pain. Acad Emerg Med 2021; 28:1228-1235. [PMID: 34133820 DOI: 10.1111/acem.14321] [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: 04/26/2021] [Revised: 05/26/2021] [Accepted: 06/08/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line medication for acute low back pain (LBP). It is unclear if the choice of NSAID impacts outcomes. We compared ibuprofen, ketorolac, and diclofenac for the treatment of acute, nonradicular LBP. METHODS This was a three-armed, double-blind, comparative effectiveness study, in which we enrolled patients at the conclusion of an ED visit for musculoskeletal LBP and determined outcomes by telephone 5 days later. Patients were randomized to receive a 5-day supply of 600 mg of ibuprofen, 10 mg of ketorolac, or 50 mg of diclofenac, each to be used every 8 h as needed. Every participant also received LBP education. The primary outcome was improvement in Roland-Morris Disability Questionnaire (RMDQ), a 24-item instrument on which lower scores indicate better LBP functional outcomes, between ED visit and day 5. Secondary outcomes included pain intensity, measured using the descriptors none, mild, moderate, and severe, and the presence of stomach irritation. RESULTS A total of 868 patients were screened and 66 patients were enrolled in each of the three arms. Baseline characteristics were similar. Improvements in RMDQ by day 5 were as follows: ibuprofen 9.4, ketorolac 11.9, and diclofenac 10.9 (p = 0.34). Mild or no pain on day 5 was as follows: ibuprofen 38 of 61 (62%), ketorolac 47 of 59 (80%), and diclofenac 45 of 62 (71%; 95% CI for rounded mean difference of 17% between ibuprofen and ketorolac = 1, 33%, p = 0.04, number needed to treat = 6 [95% CI = 3-69]). Stomach irritation was reported by 16 of 62 (26%) ibuprofen patients versus three of 61 (5%) in the ketorolac arm and six of 64 (9%) in the diclofenac arm (p < 0.01). CONCLUSION There were no important differences between groups with regard to the primary outcome. These data do not rule out that possibility that ketorolac results in better pain relief and less stomach irritation than ibuprofen.
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Affiliation(s)
- Eddie Irizarry
- Department of Emergency Medicine Montefiore Medical CenterAlbert Einstein College of Medicine Bronx NY USA
| | - Andrew Restivo
- Department of Emergency Medicine Montefiore Medical CenterAlbert Einstein College of Medicine Bronx NY USA
| | - Maha Salama
- Department of Emergency Medicine Montefiore Medical CenterAlbert Einstein College of Medicine Bronx NY USA
| | - Michelle Davitt
- Department of Emergency Medicine Montefiore Medical CenterAlbert Einstein College of Medicine Bronx NY USA
| | - Carmen Feliciano
- Department of Emergency Medicine Montefiore Medical CenterAlbert Einstein College of Medicine Bronx NY USA
| | - Alexis Cortijo‐Brown
- Department of Emergency Medicine Montefiore Medical CenterAlbert Einstein College of Medicine Bronx NY USA
| | - Benjamin W. Friedman
- Department of Emergency Medicine Montefiore Medical CenterAlbert Einstein College of Medicine Bronx NY USA
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Lyngstad G, Skjelbred P, Swanson DM, Skoglund LA. Analgesic effect of oral ibuprofen 400, 600, and 800 mg; paracetamol 500 and 1000 mg; and paracetamol 1000 mg plus 60 mg codeine in acute postoperative pain: a single-dose, randomized, placebo-controlled, and double-blind study. Eur J Clin Pharmacol 2021; 77:1843-1852. [PMID: 34655316 PMCID: PMC8585829 DOI: 10.1007/s00228-021-03231-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/08/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Effect size estimates of analgesic drugs can be misleading. Ibuprofen (400 mg, 600 mg, 800 mg), paracetamol (1000 mg, 500 mg), paracetamol 1000 mg/codeine 60 mg, and placebo were investigated to establish the multidimensional pharmacodynamic profiles of each drug on acute pain with calculated effect size estimates. METHODS A randomized, double-blind, single-dose, placebo-controlled, parallel-group, single-centre, outpatient, and single-dose study used 350 patients (mean age 25 year, range 18 to 30 years) of homogenous ethnicity after third molar surgery. Primary outcome was sum pain intensity over 6 h. Secondary outcomes were time to analgesic onset, duration of analgesia, time to rescue drug intake, number of patients taking rescue drug, sum pain intensity difference, maximum pain intensity difference, time to maximum pain intensity difference, number needed to treat values, adverse effects, overall drug assessment as patient-reported outcome measure (PROM), and the effect size estimates NNT and NNTp. RESULTS Ibuprofen doses above 400 mg do not significantly increase analgesic effect. Paracetamol has a very flat analgesic dose-response profile. Paracetamol 1000/codeine 60 mg gives similar analgesia as ibuprofen from 400 mg, but has a shorter time to analgesic onset. Active drugs show no significant difference in maximal analgesic effect. Other secondary outcomes support these findings. The frequencies of adverse effects were low, mild to moderate in all active groups. NNT and NTTp values did not coincide well with PROMs. CONCLUSION Ibuprofen doses above 400 mg for acute pain offer limited analgesic gain. Paracetamol 1000 mg/codeine 60 mg is comparable to ibuprofen doses from 400 mg. Calculated effect size estimates and PROM in our study seem not to relate well as clinical analgesic efficacy estimators. TRIAL REGISTRATION NCT00699114.
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Affiliation(s)
- Gaute Lyngstad
- Section of Dental Pharmacology and Pharmacotherapy, Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo, Blindern, P. O. Box 1119, N-0317 Nydalen Oslo, Norway
| | - Per Skjelbred
- Department of Maxillofacial Surgery, Oslo University Hospital, P. O. Box 4950, Nydalen N-0424 Oslo, Norway
| | - David M. Swanson
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Blindern, P.O. Box 1122, N-0317 Oslo, Norway
| | - Lasse A. Skoglund
- Section of Dental Pharmacology and Pharmacotherapy, Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo, Blindern, P. O. Box 1119, N-0317 Nydalen Oslo, Norway
- Department of Maxillofacial Surgery, Oslo University Hospital, P. O. Box 4950, Nydalen N-0424 Oslo, Norway
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Friedman BW, Irizarry E, Feliciano C, Izzo AJ, Borrayes L, Restivo A, Costa V, Bijur PE. A randomized controlled trial of oxycodone/acetaminophen versus acetaminophen alone for emergency department patients with musculoskeletal pain refractory to ibuprofen. Acad Emerg Med 2021; 28:859-865. [PMID: 33576545 DOI: 10.1111/acem.14231] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/07/2021] [Accepted: 02/09/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Use of oral opioids does not result in more pain relief than nonopioid alternatives when administered to patients as first-line treatment for acute musculoskeletal pain. This study compared the efficacy of oxycodone/acetaminophen to that of acetaminophen alone as second-line treatment for patients with acute musculoskeletal pain who were administered prescription-strength ibuprofen and reported insufficient relief 1 h later. METHODS A randomized, double-blind study was conducted in two urban emergency departments. Opioid-naïve patients ≥ 18 years with an acute musculoskeletal injury were administered ibuprofen 600 mg as part of the study protocol. Those who reported insufficient relief 1 h later were randomized (1:1 ratio) to oxycodone 10 mg/acetaminophen 650 mg or acetaminophen 650 mg. The primary outcome was improvement in 0 to 10 pain scale between randomization and 2 h later. We also assessed medication-associated adverse events. A sample size calculation, built around a minimum clinically important difference of 1.3 units, determined the need for 154 patients. RESULTS We screened 924 patients and enrolled 393. All 393 received ibuprofen. A total of 159 (40%) patients reported inadequate relief after 1 h had elapsed. A total of 154 of these were randomized, 77 to oxycodone/acetaminophen and 77 to acetaminophen. Baseline characteristics were comparable. Among patients randomized to oxycodone/acetaminophen, mean (±SD) improvement in 0 to 10 pain scale was 4.0 (±2.6) versus 2.9 (±2.4) in the acetaminophen arm. The 95% confidence interval (CI) for the mean difference of 1.1 was 0.3 to 1.9. Among patients who received oxycodone/acetaminophen, 26 of 76 (34%) reported any medication-related adverse event versus seven of 74 (9%) participants who received acetaminophen. The 95% CI for the between-group difference of 25% was 12% to 37%). CONCLUSION Among patients with acute musculoskeletal pain refractory to oral ibuprofen, oxycodone/acetaminophen resulted in slightly greater pain relief than acetaminophen, but this was associated with more medication-related adverse events.
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Affiliation(s)
- Benjamin W. Friedman
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Eddie Irizarry
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Carmen Feliciano
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Albert J. Izzo
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Lester Borrayes
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Andrew Restivo
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Vincent Costa
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Polly E. Bijur
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
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Pergolizzi JV, Magnusson P, LeQuang JA, Breve F, Taylor R, Wollmuth C, Varrassi G. Can NSAIDs and Acetaminophen Effectively Replace Opioid Treatment Options for Acute Pain? Expert Opin Pharmacother 2021; 22:1119-1126. [PMID: 33689517 DOI: 10.1080/14656566.2021.1901885] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Opioid analgesia for acute painful conditions has come under increasing scrutiny with the public health crisis of opioid overdose, leading clinicians to seek nonopioid alternatives, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (paracetamol). AREAS COVERED This perspective evaluates recent clinical trials of nonopioids, opioids, and combination therapy for use in acute pain. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) often provide adequate analgesia, although these agents are not without risks. Combination therapy using a small amount of opioid together with a nonopioid pain reliever has been shown effective and reduces opioid consumption. EXPERT OPINION The short-term use of opioids under close clinical supervision, such as in-hospital use of opioid analgesics for postoperative pain, may be appropriate, but even here, combination therapy or nonopioid therapy may be preferred. The use of opioids even for acute pain of short duration has been questioned. The ideal analgesic has yet to be developed, but effective pain control pharmacological regimens for acute pain are available.
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Affiliation(s)
| | - Peter Magnusson
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden.,Cardiology Research Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | | | - Frank Breve
- Department of Pharmacy, Temple University, Philadelphia, Pennsylvania, USA
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22
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Machado GC, Abdel-Shaheed C, Underwood M, Day RO. Non-steroidal anti-inflammatory drugs (NSAIDs) for musculoskeletal pain. BMJ 2021; 372:n104. [PMID: 33514562 DOI: 10.1136/bmj.n104] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Gustavo C Machado
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Christina Abdel-Shaheed
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
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23
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Abstract
PURPOSE OF REVIEW Acute pain management in the surgical ICU is imperative. Effective acute pain management hastens a patient's return to normal function and avoid the negative sequelae of untreated acute pain. Traditionally, opioids have been the mainstay of acute pain management strategies in the surgical ICU, but alternative medications and management strategies are increasingly being utilized. RECENT FINDINGS Extrapolating from lessons learned from enhanced recovery after surgery protocols, surgical intensivists are increasingly utilizing multimodal pain regimens (MMPRs) in critically ill surgical patients recovering from major surgical procedures and injuries. MMPRs incorporate both oral medications from several drug classes and regional blocks when feasible. In addition, although MMPRs may include opioids as needed, they are able to achieve effective pain control while minimizing opioid exposure. SUMMARY Even after major elective surgery or significant injury, opioid-minimizing MMPRs can effectively treat acute pain.
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24
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Muñiz-González AB. Ibuprofen as an emerging pollutant on non-target aquatic invertebrates: Effects on Chironomus riparius. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2021; 81:103537. [PMID: 33157253 DOI: 10.1016/j.etap.2020.103537] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/19/2020] [Accepted: 10/24/2020] [Indexed: 06/11/2023]
Abstract
The concern about pharmaceuticals has been increased over the last decade due to their burgeoning consumption. Ibuprofen has an extensive presence in surface water with risks for the aquatic biota. This study focuses on the effects of ibuprofen at environmental concentrations on the survival, transcriptional level, and enzymatic activity for 24, 96 h on Chironomus riparius. Ibuprofen developed a substantial effect on survival by all the conditions. mRNA levels of EcR, Dronc, and Met (endocrine system), hsp70, hsp24, and hsp27 (stress response), and Proph and Def (immune system) were modified, joined to increased GST and PO activity. The results confirmed alterations on the development of C. riparius, as well as two essential mechanisms, involved in protection against external toxicological challenge. Ibuprofen poses an incipient risk to C. riparius and could at an organismal level by compromising their survival, development, and ability to respond to adverse conditions on the future populations.
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Affiliation(s)
- Ana-Belén Muñiz-González
- Environmental Toxicology and Biology Group, Department of Mathematics and Fluid Physics, UNED, Spain.
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25
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Do early non-steroidal anti-inflammatory drugs for analgesia worsen acute kidney injury in critically ill trauma patients? An inverse probability of treatment weighted analysis. J Trauma Acute Care Surg 2020; 89:673-678. [PMID: 32649618 DOI: 10.1097/ta.0000000000002875] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Administration of nonsteroidal anti-inflammatory drugs (NSAIDs) for acute posttraumatic analgesia is increasing in popularity as an alternative to opioids despite reservations regarding its potential impact on the development of acute kidney injury (AKI). We hypothesized that early NSAID administration for analgesia would be associated with worsened renal function in severely injured trauma patients. METHODS A retrospective cohort study of severely injured adult (≥16 years) patients admitted to the intensive care unit with ≥1 rib fracture between 2010 and 2017 was performed. The early NSAID group was defined by receipt of one or more doses of NSAID within the first 48 hours of hospitalization. Acute kidney injury diagnosis and staging were defined by the Kidney Disease Improving Global Outcomes Guidelines. The primary outcome was a composite measure of two outcomes within the first week of hospitalization: (1) AKI progression (increase in AKI stage from arrival) or (2) death. Secondary outcomes included AKI progression, AKI improvement, AKI duration, and mortality. Inverse propensity of treatment weights were generated using clinically sound covariates suspected to be associated with the decision to give early NSAIDs and the primary or secondary outcomes. Multivariable analyses were performed adjusting for inverse propensity of treatment weights, covariates, and length of stay. RESULTS Of 2,340 patients, 268 (11%) were administered early NSAIDs. When compared with the control group, patients who received early NSAIDs were less severely injured. Renal outcomes were worse in the control group. Standardized mean differences were minimal after weighting. On multivariable analysis, administration of early NSAIDs was not associated with worsened renal outcomes or increased mortality. CONCLUSION Although only 11% of patients received early NSAIDs after trauma for analgesia, early NSAID exposure was not associated with increased AKI progression, decreased AKI improvement, prolonged duration, or increased mortality. Given the lack of evidence showing harm, early NSAIDs for analgesia may be underused for severely injured patients. LEVEL OF EVIDENCE Prognostic, level III, Therapeutic, level IV.
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26
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Bijur PE, Friedman BW, Irizarry E, Chang AK, Gallagher EJ. A Randomized Trial Comparing the Efficacy of Five Oral Analgesics for Treatment of Acute Musculoskeletal Extremity Pain in the Emergency Department. Ann Emerg Med 2020; 77:345-356. [PMID: 33358232 DOI: 10.1016/j.annemergmed.2020.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE We compare the efficacy and adverse effects of 5 oral analgesics in emergency department (ED) patients aged 21 to 64 years with acute musculoskeletal pain. METHODS This was a randomized clinical trial conducted in 2 urban EDs. Patients received 400 mg ibuprofen/1,000 mg acetaminophen, 800 mg ibuprofen/1,000 mg acetaminophen, 30 mg codeine/300 mg acetaminophen, 5 mg hydrocodone/300 mg acetaminophen, or 5 mg oxycodone/325 mg acetaminophen. The primary outcome was change in pain before administration of medication (baseline) to 1 hour postbaseline. A numeric rating scale was used, varying from 0="no pain" to 10="worst imaginable pain." Secondary outcomes included receipt of rescue medication and adverse effects at 1 and 2 hours postbaseline. ANOVA was used to test differences in the primary outcome between treatment groups. RESULTS Six hundred participants, predominantly men and Latino, were enrolled. Change in pain from baseline to 60 minutes did not differ by treatment (P=.69). The mean change in pain in numeric rating scale units was 400 mg ibuprofen/1,000 mg acetaminophen 3.0 (95% confidence interval [CI] 2.6 to 3.5); 800 mg ibuprofen/1,000 mg acetaminophen 3.0 (95% CI 2.5 to 3.5), 30 mg codeine/300 mg acetaminophen 3.4 (95% CI 2.9 to 3.9), 5 mg hydrocodone/300 mg acetaminophen 3.1 (95% CI 2.7 to 3.5), and 5 mg oxycodone/325 mg acetaminophen 3.3 (95% CI 2.8 to 3.7). Rescue medication was received before 1 hour had elapsed by 2 patients receiving 400 mg ibuprofen/1,000 mg acetaminophen (1.7%), 3 patients receiving 800 mg ibuprofen/1,000 mg acetaminophen (2.5%), zero patients receiving 30 mg codeine/300 mg acetaminophen (0.0%), 3 patients receiving 5 mg hydrocodone/300 mg acetaminophen (2.5%), and zero patients receiving 5 mg oxycodone/325 mg acetaminophen (0.0%) (P=.21). More patients who received opioids were nauseated or vomited compared with those who did not: 6.7% versus 1.7% (5.0% difference; 95% CI 1.7% to 8.2%). The findings at 2 hours were similar. CONCLUSION No analgesic was more efficacious than others 1 or 2 hours after baseline. There was significantly more nausea and vomiting among patients treated with opioids.
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Affiliation(s)
- Polly E Bijur
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY.
| | - Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Eddie Irizarry
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Andrew K Chang
- Department of Emergency Medicine, Albany Medical Center, Albany, NY
| | - E John Gallagher
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY
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27
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Aches and Pain in the Geriatric Trauma Patient. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00202-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Yalçınlı S, Kıyan GS, Can Ö. Comparison of intravenous ibuprofen and paracetamol efficiency in soft tissue injuries: A randomized, double-blind study. Am J Emerg Med 2020; 38:2014-2018. [DOI: 10.1016/j.ajem.2020.06.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/22/2020] [Indexed: 11/26/2022] Open
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29
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Kim HS, Courtney DM, McCarthy DM, Cella D. Patient-reported Outcome Measures in Emergency Care Research: A Primer for Researchers, Peer Reviewers, and Readers. Acad Emerg Med 2020; 27:403-418. [PMID: 31945245 DOI: 10.1111/acem.13918] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/04/2020] [Accepted: 01/06/2020] [Indexed: 01/07/2023]
Abstract
Patient-reported outcomes (PROs) are of increasing importance in clinical research because they capture patients' experience with well-being, illness, and their interactions with health care. Because PROs tend to focus on specific symptoms (e.g., pain, anxiety) or general assessments of patient functioning and quality of life that offer unique advantages compared to traditional clinical outcomes (e.g., mortality, emergency department revisits), emergency care researchers may benefit from incorporation of PRO measures into their research design as a primary or secondary outcome. Patients may also benefit from the ability of PROs to inform clinical practice and facilitate patient decision making, as PROs are obtained directly from the lived experience of other patients with similar conditions or health status. This review article introduces and defines key terminology relating to PROs, discusses reasons for utilizing PROs in clinical research, outlines basic psychometric and practical assessments that can be used to select a specific PRO measure, and highlights examples of commonly utilized PRO measures in emergency care research.
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Affiliation(s)
- Howard S. Kim
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL
- Center for Health Services & Outcomes Research Northwestern University Feinberg School of Medicine Chicago IL
| | - D. Mark Courtney
- Department of Emergency Medicine University of Texas Southwestern Medical School Dallas TX
| | - Danielle M. McCarthy
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL
- Center for Health Services & Outcomes Research Northwestern University Feinberg School of Medicine Chicago IL
| | - David Cella
- Department of Medical Social Sciences Northwestern University Feinberg School of Medicine Chicago IL
- Center for Patient‐Centered Outcomes Northwestern University Feinberg School of Medicine Chicago IL
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30
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Gutiérrez-Noya VM, Gómez-Oliván LM, Ramírez-Montero MDC, Islas-Flores H, Galar-Martínez M, Dublán-García O, Romero R. Ibuprofen at environmentally relevant concentrations alters embryonic development, induces teratogenesis and oxidative stress in Cyprinus carpio. THE SCIENCE OF THE TOTAL ENVIRONMENT 2020; 710:136327. [PMID: 31923683 DOI: 10.1016/j.scitotenv.2019.136327] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/22/2019] [Accepted: 12/23/2019] [Indexed: 06/10/2023]
Abstract
Ibuprofen (IBU) is a non-steroidal anti-inflammatory (NSAIDs) that is used in various conditions. The prescriptions and the global consumption of this drug are very high and its annual production oscillates in millions of tons, this generates that the IBU is present in many waterbodies because it is discharged through the municipal, hospital and industrial effluents. For the above, the purpose of this work was to determine if IBU at environmentally relevant concentrations was capable of inducing alterations to embryonic development, teratogenic effects and oxidative stress in oocytes and embryos of Cyprinus carpio. Oocytes of common carp were exposed to IBU concentrations between 1.5 and 11.5 μg L-1 (environmentally relevant). LC50 and EC50 of malformations were determined to calculate the teratogenic index (TI). Also, main alterations to embryonic development and teratogenic effects were evaluated. Oxidative stress was evaluated by determining biomarkers of cellular oxidation and antioxidation using the same concentrations at 72 and 96 hpf in embryos of Cyprinus carpio. The results showed a LC50 of 4.17 μg L-1, EC50 of 1.39 μg L-1 and TI of 3.0. The main embryonic development disorders and teratogenic effects were delayed hatching, hypopigmentation, pericardial edema, yolk deformation, and developmental delay. Biomarkers of cellular oxidation and antioxidants were increased with respect to the control in a concentration-dependent manner. The results of the study allow us to conclude that IBU at environmentally relevant concentrations is capable of inducing embryotoxicity and teratogenicity in a fish of commercial interest like Cyprinus carpio.
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Affiliation(s)
- Verónica Margarita Gutiérrez-Noya
- Laboratorio de Toxicología Ambiental, Facultad de Química, Universidad Autónoma del Estado de México, Paseo Colón intersección Paseo Tollocan, Colonia Residencial Colón, CP 50120 Toluca, Estado de México, Mexico
| | - Leobardo Manuel Gómez-Oliván
- Laboratorio de Toxicología Ambiental, Facultad de Química, Universidad Autónoma del Estado de México, Paseo Colón intersección Paseo Tollocan, Colonia Residencial Colón, CP 50120 Toluca, Estado de México, Mexico.
| | - María Del Carmen Ramírez-Montero
- Laboratorio de Toxicología Ambiental, Facultad de Química, Universidad Autónoma del Estado de México, Paseo Colón intersección Paseo Tollocan, Colonia Residencial Colón, CP 50120 Toluca, Estado de México, Mexico
| | - Hariz Islas-Flores
- Laboratorio de Toxicología Ambiental, Facultad de Química, Universidad Autónoma del Estado de México, Paseo Colón intersección Paseo Tollocan, Colonia Residencial Colón, CP 50120 Toluca, Estado de México, Mexico
| | - Marcela Galar-Martínez
- Laboratorio de Toxicología Acuática, Departamento de Farmacia, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Unidad Profesional Adolfo López Mateos, Av. Wilfrido Massieu s/n y cerrada Manuel Stampa, Col. Industrial Vallejo, Ciudad de México CP 07700, Mexico
| | - Octavio Dublán-García
- Laboratorio de Toxicología Ambiental, Facultad de Química, Universidad Autónoma del Estado de México, Paseo Colón intersección Paseo Tollocan, Colonia Residencial Colón, CP 50120 Toluca, Estado de México, Mexico
| | - Rubi Romero
- Centro Conjunto de Investigación en Química Sustentable, UAEM-UNAM, Universidad Autónoma del Estado de México, Km 14.5 Carretera Toluca-Atlacomulco, CP 50200 Toluca, Mexico
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31
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Collins D. Ibuprofen for acute pain relief in the emergency department. BMJ Evid Based Med 2020; 26:bmjebm-2019-111312. [PMID: 32127374 DOI: 10.1136/bmjebm-2019-111312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Dylan Collins
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
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32
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Smith BC, Vigotsky AD, Apkarian AV, Schnitzer TJ. Temporal Factors Associated With Opioid Prescriptions for Patients With Pain Conditions in an Urban Emergency Department. JAMA Netw Open 2020; 3:e200802. [PMID: 32211867 PMCID: PMC7097712 DOI: 10.1001/jamanetworkopen.2020.0802] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Opioid prescriptions for treatment of pain in emergency departments (EDs) are associated with long-term opioid use. The temporal pattern of opioid prescribing in the context of the opioid epidemic remains unknown. OBJECTIVE To examine the temporal pattern of opioid prescribing within an ED for varying pain conditions between 2009 and 2018. DESIGN, SETTING, AND PARTICIPANTS A population-based, cross-sectional study was conducted at the ED of an urban academic medical center. All patients treated within that ED between January 1, 2009, and December 31, 2018, were included. MAIN OUTCOMES AND MEASURES The proportion of patients prescribed an opioid for treatment of pain in the ED temporally by condition, condition type, patient demographics, and physician prescriber. RESULTS Between 2009 and 2018, 556 176 patient encounters took place in the ED, with 70 218 unique opioid prescriptions ordered. A total of 316 632 patients (55.9%) were female, 45 070 (42.6%) were of white race, and 43 412 (40.6%) were privately insured; the median age group was 41 to 45 years. Yearly opioid prescriptions decreased by 66.3% (from 16.3 to 5.5 opioids per 100 encounters) between 2013 and 2018, with a yearly adjusted odds ratio (aOR) of 0.808 (95% CI, 0.802-0.814) compared with the prior year. In patients with musculoskeletal pain (back, joint, limb, and neck pain), opioid prescribing decreased by 71.1% (from 36.7 to 10.6 opioids per 100 encounters between 2013 and 2018; aOR, 0.758; 95% CI, 0.744-0.773). In patients with musculoskeletal trauma (fracture, sprain, contusion, and injury), opioid prescribing decreased by 58.0% (from 34.2 to 14.8 opioids per 100 encounters; aOR, 0.811; 95% CI, 0.797-0.824). In patients with nonmusculoskeletal pain (abdominal pain, kidney stone, respiratory distress, and pharyngitis) opioid prescribing decreased by 53.7% (from 20.1 to 9.3 opioids per 100 encounters; aOR, 0.850; 95% CI, 0.834-0.868). Between 2009 and 2018, patients who were black (aOR, 0.760; 95% CI, 0.741-0.779) and those who were Asian (aOR, 0.714; 95% CI, 0.665-0.764) had the lowest odds of receiving an opioid compared with other racial/ethnic groups. CONCLUSIONS AND RELEVANCE There was a substantial temporal decrease in the number of opioid prescriptions within this ED during the study period. This decrease was associated with substantial relative reductions in opioid prescribing for treatment of musculoskeletal pain compared with fractures and kidney stones.
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Affiliation(s)
- Ben C. Smith
- Medical Student, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Andrew D. Vigotsky
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois
- Department of Statistics, Northwestern University, Evanston, Illinois
| | - A. Vania Apkarian
- Center for Translational Pain Research, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Thomas J. Schnitzer
- Anesthesiology and Medicine (Rheumatology), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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