Treating persistent pain in the elderly: how do we proceed?

OBJECTIVE: To describe a performance improvement initiative conducted in accordance with the American Geriatrics Society (AGS) guideline regarding pharmacological management of persistent pain in older adults. SETTINGS: Medical units of a tertiary care teaching hospital. PRACTICE DESCRIPTION: Elderly patients were included if treated for conditions associated with persistent pain. PRACTICE INNOVATION: Using three phases, the pharmacological management of persistent pain in older adults was evaluated before and after health care provider education on the AGS guideline recommendations. Educational seminars, in-service training, and handout materials focused on addressing specific shortfalls identified during the initial evaluation. MAIN OUTCOME MEASUREMENTS: Appropriate use of nonsteroidal anti-inflammatory agents (NSAIDs) and cyclooxygenase-2 selective inhibitors (coxibs), utilization of proper pain assessment tools, types of opioids used, and associated adverse effects. RESULTS: A total of 50 patients with comparable demographics were included in each phase. Following education, there was an improvement in the appropriate use of pain-assessment tools in cognitively impaired older adults. There was a trend toward improvement in the use of NSAIDs and coxibs, but there was no change in practice regarding the frequency of opioid use, combining long- and short-acting opioid preparations, or preventing opioid-induced constipation. CONCLUSION: Although findings from this study aided in recognizing areas for improvement in the management of persistent pain in older adults, further education of health care professionals is needed to ensure the safe and effective management of persistent pain.

Pregnancies after hysteroscopic sterilization: a systematic review.

BACKGROUND: Female sterilization is the second most commonly used form of contraception in the United States. Newer approaches to female sterilization, including hysteroscopic methods, have been approved for use in the United States since 2002. Little is known about the occurrence and timing of pregnancies after these procedures. STUDY DESIGN: The objective of this systematic review was to identify evidence that assesses when and how often pregnancies occur following hysteroscopic sterilization. The PubMed database was searched for all studies published from database inception through March 2012 that reported whether or not pregnancies occurred following hysteroscopic sterilization. RESULTS: Twenty-four original research articles of fair quality met the inclusion criteria: 22 studies of women who underwent Essure® placement and 2 studies of women who underwent Adiana® placement. Eleven articles that documented bilateral tubal occlusion with hysterosalpingogram (HSG) or placement with X-ray or ultrasound following Essure® placement did not report any pregnancies with follow-up ranging from 7 months to 7 years. The remaining 11 articles identified 102 reported pregnancies. Eighteen of these pregnancies occurred prior to the 3-month period required before imaging for contraceptive reliability. Two articles did not report what follow-up imaging was performed among women after Essure® placement; one of these articles reported three pregnancies. Two reports from the same study of women who underwent Adiana® placement reported six pregnancies during the first year of follow-up, three pregnancies during the second year of follow-up and no pregnancies during the third year of follow-up. CONCLUSIONS: Fair-quality evidence suggests that among women who were followed beyond 3 months after hysteroscopic sterilization, pregnancies were rare and generally occurred among women who had no imaging follow-up or had inadequate confirmation of placement or occlusion. Few pregnancies occurred in women with documented bilateral tubal occlusion by HSG or correct placement at 3 months by ultrasound or X-ray. Only one study reported follow-up past 5 years. Further studies are needed to address the long-term effectiveness of hysteroscopic sterilization.