Developing Opioid Prescription Guidelines After Anorectal Surgery: Do Patient-Reported Outcomes and Risk Factors Influence Consumption?

BACKGROUND: Opioids prescribed to address postoperative pain drive opioid-related deaths in the United States. Prescribing guidelines have been developed for many general surgical procedures, which have decreased opioid prescription and consumption. The literature on opioids after anorectal surgery is lacking. OBJECTIVE: We analyzed our data on opioid prescription and consumption to create opioid-prescribing guidelines for anorectal procedures. DESIGN: We designed a prospectively collected postoperative survey given to consecutive patients undergoing anorectal surgery by colorectal surgeons. SETTINGS: Patients had surgery at 2 academic, university-affiliated hospitals. PATIENTS: Patients undergoing anorectal surgery from May 3, 2018, to December 18, 2019, were included in the study. Patients were excluded if they were <18 years of age, had a concurrent abdominopelvic surgery, consumed opioids in the week before their operation, or were without follow-up at 3 months postoperatively. MAIN OUTCOME MEASURES: The primary outcome of this study was the number of opioid pills needed to fulfill consumption of 80% of patients. Secondary outcome measures were patient, operative, and postoperative factors associated with increasing pill consumption. RESULTS: Eighteen 5-mg oxycodone tablets were needed to fulfill the needs of 80% of patients. An overall median of 8 pills was consumed. Pill prescription was independently predictive of increased consumption. The only patient factor associated with increased consumption was race; no other patient or operative factors were predictive of consumption. LIMITATIONS: Limitations of this study include its partially retrospective nature, use of self-reported data, and lack of racial diversity among our cohort. CONCLUSIONS: Without any clinical factors predictive of increased consumption, prescription guidelines can be standardized to ≤18 5-mg oxycodone tablets across anorectal surgery patients. As prescription is correlated with consumption, further work is needed to determine whether lesser quantities of opioids prescribed offer similar postoperative pain relief for patients undergoing anorectal surgery. See Video Abstract at http://links.lww.com/DCR/B821 .DESARROLLO DE PAUTAS PARA LA PRESCRIPCIÓN DE OPIOIDES DESPUÉS DE CIRUGÍA ANORRECTAL: ¿INFLUYEN EN EL CONSUMO LOS RESULTADOS INFORMADOS POR EL PACIENTE Y LOS FACTORES DE RIESGO? ANTECEDENTES: Los opioides recetados para tratar el dolor posoperatorio provocan muertes relacionadas con los opioides en los Estados Unidos. Se han desarrollado pautas de prescripción para muchos procedimientos quirúrgicos generales y estas han conducido a una disminución de la prescripción y el consumo de opioides. Hay una carencia de literatura sobre el uso de opioides después de cirugía anorrectal. OBJETIVO: Analizamos nuestros datos sobre prescripción y consumo de opioides para crear pautas de prescripción de opioides para procedimientos anorrectales. DISEO: Diseñamos una encuesta postoperatoria recopilada prospectivamente que se administró a pacientes consecutivos sometidos a cirugía anorrectal por cirujanos colorrectales. AJUSTES: Los pacientes fueron operados en dos hospitales académicos afiliados a la universidad. PACIENTES: Se incluyeron en el estudio pacientes sometidos a cirugía anorrectal desde el 3/05/2018 hasta el 18/12/2019. Se excluyó a los pacientes que tenían menos de 18 años, a los que se sometieron a cirugía abdominopélvica concurrente, a los que consumieron opioides en la semana anterior a la operación, o si no tenían seguimiento a los 3 meses del postoperatorio. PRINCIPALES MEDIDAS DE DESENLACE: El desenlace principal de este estudio fue el número de píldoras de opioides necesarias para satisfacer el consumo del 80% de los pacientes. Las medidas de desenlace secundarias fueron los factores del paciente, operatorios y posoperatorios asociados con el aumento del consumo de píldoras. RESULTADOS: Fueron necesarios dieciocho comprimidos de oxicodona de 5 mg para cubrir las necesidades del 80% de los pacientes. Se consumió una mediana general de 8 píldoras. La prescripción de la píldora fue un predictor independiente de un mayor consumo. El único factor del paciente asociado con un mayor consumo fue la raza; ningún otro paciente o factores operativos fueron predictivos del consumo. LIMITACIONES: Las limitaciones de este estudio incluyen su naturaleza parcialmente retrospectiva, el uso de datos autoinformados y la falta de diversidad racial entre nuestra cohorte. CONCLUSIONES: Sin ningún factor clínico que prediga un aumento del consumo, las pautas de prescripción se pueden estandarizar a dieciocho o menos comprimidos de oxicodona de 5 mg en pacientes sometidos a cirugía anorrectal. Como la prescripción se correlaciona con el consumo, se necesita más trabajo para determinar si cantidades menores de opioides prescritos ofrecen un alivio del dolor posoperatorio similar para los pacientes sometidos a cirugía anorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B821 . (Traducción-Juan Carlos Reyes ).

Effects of safinamide on REM sleep behavior disorder in Parkinson disease: A randomized, longitudinal, cross-over pilot study.

BACKGROUND: Rapid Eye Movement sleep behavior disorder (RBD) is characterized by dream enactment and loss of muscle atonia during REM-sleep. RBD as a premotor feature occurred souvent in patients who develop Parkinson's disease. The glutamatergic, glycinergic, and GABA-ergic systems appear to play a crucial role in the pathogenesis of RBD. METHODS: The present exploratory longitudinal cross-over study aimed to observe the effect of safinamide on RBD symptoms. Thirty patients with PD and RBD were randomized into two groups (15 subjects each), those that received for a period of 3-months safinamide (50 mg/die) in addition (Group A + ) or in absence (Group B - ) to the usual antiparkinsonian therapy. Patients exploring the clinical and video-polysomnographic changes occurred during this pharmacological therapy. RESULTS: Twenty-two of 30 patients reported clear improvement in symptoms during safinamide treatment, and 16 were absolutely free from clinical RBD-symptoms at the end of the treatment. Eight patients reported slight improvement in RBD-symptoms. In 6/30 patients no substantial improvement was recorded about clinical RBD-symptoms had frightening dreams or from the bed after 1-week of treatment. In addition, after safinamide, the mean UPDRS-II and III scores decreased, while PDSS-2 score indicating an improvement in both motor symptoms and nocturnal sleep features. A significant reduction of sleep behavior disorder by questionnaire-Hong Kong-score (RBDQ-HS), mainly for two individual RBDQ-HK-items (dream related movements and failing out of bed) was registered. CONCLUSIONS: This pilot study indicated that safinamide is well tolerated and improves RBD-symptom in parkinsonian.

Role of impaired glucose metabolism in the postherpetic neuralgia.

BACKGROUND: Postherpetic neuralgia (PHN) is one of the most common and debilitating sequela of herpes zoster. The etiology of PHN is not completely understood. Several studies showed that diabetes mellitus may increase the risk of infectious diseases, including herpes zoster. Instead, the relationship between PHN and prediabetes has never been described. OBJECTIVE: To evaluate glucose metabolism abnormalities in patients with PHN. METHODS: We studied 87 consecutive patients with PHN and normal fasting glycemia and 108 pain-free controls. In both groups we evaluated glucose and insulin levels after a 2-hour oral glucose tolerance test and insulin resistance. In addition, in all patients we performed skin thoracic biopsy to exclude a small fiber neuropathy. RESULTS: After a 2-hour oral glucose tolerance test, the prevalence of glucose metabolism abnormalities was significantly higher in patients than in controls (P<0.001): impaired glucose tolerance was found in 36 (38%) patients and in 16 (15%) controls, whereas a newly diagnosed diabetes mellitus was found in 9 (9%) patients and in 6 (5%) controls. The insulin resistance showed no significant differences between patients and controls. CONCLUSIONS: Our study suggests that PHN may be a marker for impaired glucose tolerance. A glucose tolerance test should be considered in patients presenting with PHN.

Early experience with a newly developed electrospun polycarbonate-urethane vascular graft for hemodialysis access.

PURPOSE: In this pilot study, we tested a newly developed electrospun multilayered, self-sealing graft, AVflo™, specifically designed for early hemodialysis access. 
 METHODS: Ten eligible consenting patients had a polycarbonate-urethane graft (AVflo™) implanted and were followed up prospectively for at least six months. Performance measures included graft patency, complications and time to first cannulation. Mean age of the patients was 66.7 ± 10 years. Chronic glomerulonephritis was the most common cause of renal failure. A total of 70% of the patients had a history of previous vascular access and 40% history of minimally invasive radiologic procedures for patency maintenance. In 40% of the cases the need for AV graft implantation was because of recurrent infections from permanent catheter for dialysis. Seven grafts were placed in the upper arm and three in the thigh. Mean follow up was 230 ± 75 days. 
 RESULTS: There were no systemic or local reactions to the graft and we did not report any graft infections. Two grafts thrombosed because of severe bleeding post-cannulation due to an incorrect needle puncture. Both grafts were successfully thrombectomized. Primary and secondary patency rates at six months were 60% and 78%, respectively. These patency rates were comparable to those reported for other polyether-urethane and ePTFE grafts. Median time to first cannulation was seven days (3-21) and all puncture sites sealed in less than five minutes.

Insulin resistance increases risk of carpal tunnel syndrome: a case-control study.

Carpal tunnel syndrome (CTS) is one of the most common upper limb compression neuropathies. In only 50% of cases it is possible to identify a cause. Our objective was to determine the role of glucose metabolism abnormalities in idiopathic CTS. We identified 117 patients with idiopathic moderate or severe CTS and 128 controls. In all we evaluated glucose and insulin levels at fasting and after 2-h oral glucose tolerance test (2h-OGTT). In addition we determined insulin resistance (IR). Following OGTT the prevalence of glucose metabolism abnormalities was significantly higher in the CTS group (p = 0.001). IR was documented in 80% of patients, of whom 45% had impaired glucose tolerance, 14% newly diagnosed diabetes mellitus, and 20% IR only. Waist circumference and body mass index were also significantly increased in the CTS group. In this study, we focused on evidence that pre-diabetes may represent a risk factor for CTS. We proposed to determine IR as a rule in all patients with idiopathic CTS.

Role of the Oral Glucose Tolerance Test (OGTT) in the idiopathic restless legs syndrome.

BACKGROUND: Restless legs syndrome (RLS) is a sensorimotor disorder characterised by a distressing urge to move the legs. Several clinical conditions have been associated with RLS, such as iron deficiency, uraemia, pregnancy, polyneuropathy and Diabetes Mellitus (DM). However the causes remain unknown in about 70-80% of cases. OBJECTIVE: To evaluate the role of glucose metabolism abnormalities in idiopathic RLS. METHODS: We enrolled 132 consecutive patients with idiopathic RLS associated with normal fasting glycaemia and 128 control subjects. We evaluated glucose and insulin levels after a 2-h oral glucose tolerance test (2h-OGTT) in patients and control subjects. In addition we determined Insulin Resistance (IR) by Homa-Index. RESULTS: After 2h-OGTT, the prevalence of glucose metabolism abnormalities was significantly higher in patients with RLS than in controls (P=.002). Impaired Glucose Tolerance (IGT) was found in 54 (41%) patients and in 23 (18%) controls, while a new-diagnosed DM (NDDM) was found in 25 (19%) patients and in 8 (6%) controls. The IR showed no significant differences between patients and controls. CONCLUSIONS: Our study suggests that IGT (prediabetes) is frequently associated with idiopathic RLS. We propose to perform a 2h-OGTT in idiopathic RLS patients with normal fasting glycaemia.