Clinical outcomes of cardiac arrest patients according to opioid use history

PurposeOpioid analgesics are potent respiratory depressants. The purpose of this study was to describe the effects of opioids administered within 24 hours before cardiac arrest on clinical outcomes.Materials and methodsWe retrospectively collected the cardiac arrest data of noncancer patients who were admitted to the general ward of Asan Medical Center from January 2008 to August 2012. We investigated the proportion of these patients who received opioids within 24 hours of a cardiac arrest event, as well as the cardiac arrest characteristics, survival rates, and opioid administration patterns.ResultsOf the 193 patients identified, 58 (30%) had been administered opioids within the previous 24 hours (the opioid group), whereas the remaining 135 (70%) had not been administered opioids (the nonopioid group). The survival rate did not differ significantly between these 2 groups. In the opioid group, as-needed opioid administration was associated with a lower 24-hour survival rate than regular opioid administration (9 [33.3%] of 27 patients vs 20 [64.5%] of 31 patients; P = .030). In multivariate logistic regression analysis, as-needed opioid administration was negatively associated with 24-hour survival.ConclusionsOpioid administration within 24 hours before cardiac arrest per se was not associated with adverse outcomes. However, administration of opioid analgesics on an as-needed basis was associated with poorer survival outcomes than regular dosing. Greater attention should be paid to patients who receive as-needed opioid administration in the general ward.     

Opioid overdose leading to intensive care unit admission: Epidemiology and outcomes

PurposeThere is a scarcity of studies assessing the patient population admitted to the intensive care unit (ICU) with opioid overdose. We sought to characterize the epidemiologic features and outcomes of this patient population.Materials and methodsThis is a retrospective cohort study of adult patients admitted to the ICU at University of Louisville Hospital for opioid overdose. We reviewed each patient's hospital record for demographic data, comorbidities, opioid used, coingestions, and outcomes.ResultsWe included 178 adult patients, of which 107 (60%) were females. The median age was 41 years (interquartile range [IQR], 23). Oxycodone and hydrocodone were the 2 most commonly abused opioids. Benzodiazepines were the most common drug coingested, followed by amphetamines. Tobacco smoking, chronic pain, and alcoholism were the most frequent comorbidities identified. Mental disorders were also common. Most patients required invasive mechanical ventilation (84.8%). Median ICU length of stay was 3 days. Eighteen patients (10.1%) died in the hospital, whereas 6 patients (3.4%) were discharged to a nursing home. Patients who had any coingestion were significantly more likely to undergo invasive mechanical ventilation (91% vs 77%; P = .014) and had longer ICU length of stay (3 [IQR, 2] vs 2 [IQR, 1.8] days; P = .024).ConclusionOpioid overdose is a common cause of ICU admission and affects a relatively young population. Most have respiratory failure requiring mechanical ventilation. It is associated with a relatively high inhospital mortality. Coingestions appear to have an impact on outcomes.     

Intrapartum and postpartum analgesia for women maintained on buprenorphine during pregnancy

ObjectiveTo determine whether buprenorphine maintenance alters intrapartum or postpartum pain or medication requirements.MethodsSixty three patients treated with buprenorphine for opioid dependence during pregnancy (vaginal n = 44; cesarean n = 19) were matched retrospectively to control women. Analgesic medication and pain scores (0–10) were extracted from the medical record. Primary endpoint: opioid utilization postpartum (oxycodone equivalents). Secondary endpoints: pain scores and intrapartum analgesia.ResultsThere were no differences in intrapartum pain or analgesia. Following vaginal birth, buprenorphine maintained women had increased pain (buprenorphine 2.7 (1.7, 4.0); control 2.1 (1.2, 3.0), p = 0.006) but no increase in opioid utilization (buprenorphine: 11.8 ± 24.8; control 5.4 ± 10.4 mg/24 h, p = 0.10); following cesarean delivery both pain (buprenorphine: 5.1 (4.1, 6.1); control: 3.3 (2.5, 4.1), p = 0.009) and opioid utilization (buprenorphine: 89.3 ± 38.0, control: 60.9 ± 13.1 mg/24 h, p = 0.004) were increased.ConclusionBuprenorphine maintained women have similar intrapartum pain and analgesic needs during labor, but experience more postpartum pain and require 47% more opioid analgesic following cesarean delivery.     

Do clowns attenuate pain and anxiety undergoing botulinum toxin injections in children?

ObjectiveBotulinum toxin injection (BTI) is the primary treatment for spasticity in children. Anxiety and pain are important concerns to address to attenuate the discomfort of BTI. The aim of this study was to compare the effectiveness of medical clowns and usual distractions, both added to nitrous oxide (N₂O) and analgesic cream, on pain and anxiety during BTI sessions in children.MethodsThe primary outcome was pain evaluated by the Face, Legs, Activity, Cry, Consolability (FLACC) scale. Secondary criteria were pain rated on a Visual Analog Scale (VAS) by the child and parent, anxiety rated on a VAS before and during BTIs by the child and parent(s), rating of the success of the sessions on a 4-point Likert scale by the physician and parent(s), and rating of the benefits of the distraction by the parent(s). Non-parametric tests were used for between-group comparisons.ResultsBaseline group characteristics of the clown and control groups did not differ. During 88 BTI sessions (40 with clown distraction and 48 with control distraction) in 59 children (35 boys; 52 with cerebral palsy, 12 with moderate to severe cognitive disorders), median maximal FLACC score was 2.5 (interquartile range [IQR]: 1–4) in the clown group and 3 (IQR: 1–4.3) in the control group. VAS self-reported pain score was 2.5 (IQR: 0–5) and 3 (IQR: 1–6.3) in the clown and control groups (P = 0.56), and VAS proxy-reported pain score was 2.5 (IQR: 0.3–3.4) and 3 (IQR: 1–4.5) (P = 0.25). After BTI sessions, the 2 groups did not differ in VAS self- and proxy-reported anxiety (P = 0.83 and P = 0.81). Physician and parent ratings of the success of sessions were similar between the groups (P = 0.89 and P = 0.11). Parent ratings of the perceived benefits of distraction were higher in the clown than control group (P = 0.004).ConclusionsAlthough clown distraction was particularly appreciated by parents, it did not significantly reduce pain or anxiety in children as compared with usual distraction.Trial registrationClinicalTrials.gov ID: NCT03149263.     

Real-time feedback improves accuracy of manually applied forces during cervical spine mobilisation

PurposeTo determine if real-time feedback enables students to apply mobilisation forces to the cervical spine that are similar to an expert physiotherapist.MethodsAn instrumented treatment table collected mobilisation force data with feedback about forces displayed on a computer screen. An expert physiotherapist performed posteroanterior mobilisation of C7 on 21 asymptomatic subjects while forces were recorded. These data were used as force targets for 51 students who mobilised one of the asymptomatic subjects on two occasions. Students' forces were recorded before and after practice either with (experimental group) or without real-time feedback (control group). Improved performance was defined as a smaller difference between expert and student forces, comparing groups with non-parametric statistics.ResultsStudents receiving feedback applied more accurate forces than controls (median difference between student and expert forces in the experimental group, 4.0 N, inter-quartile range (IQR) 1.9–7.7; in controls, 14.3 N, IQR 6.2–26.2, difference between groups p < 0.001). One week later, these students still applied forces that more closely matched the expert's compared to controls (p < 0.01), but the differences between the students' and expert's forces were greater (6.4 N, IQR 3.1–14.7).ConclusionPractice with real-time objective feedback enables students to apply forces similar to an expert, supporting its use in manual therapy training.     

Apolipoprotein M promoter polymorphisms alter promoter activity and confer the susceptibility to the development of type 1 diabetes

ObjectivesApolipoprotein M plays an important role in the formation of preβ-HDL and cholesterol efflux to HDL. In the present study, we investigate the potential association between the ApoM promoter polymorphisms and type 1 diabetes.Design and methodsThe study was conducted in Peking Union Medical College, Beijing, China and Karolinska Institutet, Stockholm, Sweden. Two populations, including 493 Han Chinese subjects (177 T1D patients/316 controls) and 225 Swedish (124/101), are enrolled in the present study. Three single nucleotide polymorphisms (SNP) C-1065A, T-855C and T-778C in the promoter region of the ApoM gene are genotyped using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) protocol. Promoter activity was measured by reporter gene assay.ResultsSNP T-778C was strongly associated with T1D in both Han Chinese (p = 0.002, OR = 2.188, CI 95% = 1.338–3.581) and Swedish (p = 0.021, OR = 2.865, CI 95% = 1.128–7.278) populations. The luciferase activity of ?778C promoter was 1.41 times as high as that of ?778T promoter (9.90 ± 1.92 vs. 7.04 ± 0.76, p = 0.001).ConclusionsAllele C of SNP T-778C may increase promoter activity and confer the risk susceptibility to the development of T1D.     

“Rolling Refreshers”: A novel approach to maintain CPR psychomotor skill competence

ObjectivesHigh quality CPR skill retention is poor. We hypothesized that “just-in-time” and “just-in-place” training programs would be effective and well-accepted to maintain CPR skills among PICU staff.Methods“Rolling Refreshers”, a portable manikin/defibrillator system with chest compression sensor providing automated corrective feedback to optimize CPR skills, were conducted daily in the PICU with multidisciplinary healthcare providers. Providers practiced CPR until skill success was attained, prospectively defined as <3 corrective prompts within 30 s targeting chest compression (CC) rate 90–120/min, CC depth >38 mm during continuous CPR. Providers completing ≥2 refreshers/month (Frequent Refreshers [FR]) were compared to providers completing <2 refreshers/month (Infrequent Refreshers [IR]) for time to achieve CPR skill success. Univariate analysis performed using non-parametric methods. Following actual cardiac arrests, CPR providers were surveyed for subjective feedback on training approach efficacy (5-point Likert scale; 1 = poor to 5 = excellent).ResultsOver 15 weeks, 420 PICU staff were “refreshed”: 340 nurses, 34 physicians, 46 respiratory therapists. A consecutive sample of 20 PICU staff was assessed before subsequent refresher sessions (FREQ n = 10, INFREQ n = 10). Time to achieve CPR skill success was significantly less in FREQ (median 21 s, IQR: 15.75–30 s) than in INFREQ (median 67 s, IQR: 41.5–84 s; p < 0.001). Following actual resuscitations, CPR providers (n = 9) rated “Rolling Refresher” training as effective (mean = 4.2; Likert scale 1–5; standard deviation 0.67).ConclusionsA novel “Rolling Refresher” CPR skill training approach using “just-in-time” and “just-in-place” simulation is effective and well received by PICU staff. More frequent refreshers resulted in significantly shorter times to achieve proficient CPR skills.     

A meta-analysis of the bradykinin B2 receptor gene − 58C/T polymorphism with hypertension

Background and objectiveNumerous studies have attempted to associate ? 58C/T polymorphism of bradykinin B2 receptor gene (BDKRB2) with hypertension, whereas results were often irreproducible. We performed a meta-analysis aiming to provide a comprehensive evaluation of this polymorphism and hypertension.MethodsCase-control reports published in English were searched totaling four studies with six populations (823 cases and 916 controls). Random-effects model was applied irrespective of between-study heterogeneity, and study quality was assessed in duplicate.ResultsCompared with ? 58C allele carriers, those with ? 58T allele had a lower yet nonsignificant risk for hypertension (OR = 0.86; 95% CI: 0.68–1.09; P = 0.21). Lack of significance persisted after combining those with genotypes ? 58TC and ? 58TT together (OR = 0.87; 95% CI: 0.67–1.09; P = 0.21) or with ? 58TC and ? 58CC together (OR = 0.75; 95% CI: 0.48–1.18; P = 0.22) in association with hypertension. Sensitivity analyses by race indicated that comparison of ? 58T versus ? 58C generated a protective effect for hypertension in Asians (OR = 0.77; 95% CI: 0.58–1.02; P = 0.07) and African-Americans (OR = 0.65; 95% CI: 0.43–0.98; P = 0.04), but a risk effect in Caucasians (OR = 1.22; 95% CI: 0.92–1.61; P = 0.17). No publication bias was observed.ConclusionsOur results suggested that ? 58T allele exhibited a protective effect on hypertension in Asians and African-Americans, yet a risk effect in Caucasians.     

Use of latent growth curve models for assessing the effects of darbepoetin alfa on hemoglobin and fatigue

Background:The relationship between darbepoetin alfa and fatigue in chemotherapy-induced anemia (CIA) patients is complex because of patients receiving transfusions and the mediating effect of hemoglobin. Latent growth models (LGMs) were used to examine simultaneously relationships among drug exposure, fatigue outcomes, covariates, and mediating factors.Methods:Data from four CIA studies (AMG 20010145: small cell lung cancer, n = 547; AMG 980297: lung cancer, n = 288; AMG 20000161: lymphoproliferative malignancies, n = 339; AMG 20030232: non-myeloid malignancies, n = 320) were analyzed separately. Patients reported fatigue using the FACT-Fatigue. The effect of darbepoetin alfa on FACT-F changes mediated through hemoglobin changes was examined with LGMs controlling for transfusions, age, sex, baseline ECOG performance status, and health status (EQ-5D VAS). Model fit was assessed using multiple indices including the comparative fit index (CFI).Results:Darbepoetin alfa increased hemoglobin levels which were associated with decreases in fatigue. Increases in hemoglobin were statistically significantly (p < 0.05) related to decreases in fatigue in the studies (AMG 20030145: β? = 0.28; AMG 980297: β? = 0.46; AMG 20000161: β? = 0.59; and AMG 20030232: β? = 0.39). Darbepoetin alfa statistically significantly increased hemoglobin (AMG 20010145:β? = 0.50, AMG 980297:β? = 0.53, AMG 20000161:β? = 0.47, and AMG 20030232:β? = 0.30) while controlling for covariates. Model fit was acceptable (CFI ≥ 0.89) in all studies.Conclusions:Results indicate LGMs may be a valuable statistical method for modeling complex relationships among clinical and patient reported outcomes. A statistically significant effect of darbepoetin alfa on fatigue change through hemoglobin change occurred across four studies, after modeling the effects of transfusions, age, sex, EQ-5D VAS and ECOG.     

Identification of a novel IRGM promoter single nucleotide polymorphism associated with tuberculosis

BackgroundHuman immunity-related GTPase M (IRGM) is found to play an important role in defense against intracellular pathogen Mycobacterium tuberculosis in vitro by regulating autophagy. To verify whether single nucleotide polymorphisms (SNPs) in the promoter region of IRGM gene are associated with tuberculosis (TB) 1.7 kb IRGM promoter region was sequenced and SNP analysis was conducted in TB patients and healthy controls.MethodsA simple and rapid procedure for extracting DNA from clotted-blood was developed in this study. A 1.7 kb IRGM promoter region was amplified and sequenced for nucleotide polymorphism search. Then, 3 SNPs were selected and analyzed in 216 TB patients and 275 healthy subjects by ligase detection reaction technique.ResultsDNA extracted by our method was of high quality and suitable for PCR, sequencing, and genotyping. We identified 29 polymorphisms in the 1.7 kb IRGM promoter region, including 11 novel polymorphisms not yet reported. Large population analysis showed that frequencies of ? 1208A allele (P = 0.031), ? 1208AA genotype (P = 0.042), and ? 1208A/?1161C/?947C (P = 0.035) and ? 1208G/?1161C/?947C (P = 0.030) haplotypes in cases were significantly different from those in controls.ConclusionsIn 1.7 kb IRGM promoter region, only ? 1208A/G polymorphism is associated with susceptibility to TB.     

Exploring the impact of mindfulness meditation training in pre-licensure and post graduate nurses

The complex, high stress, technologically laden healthcare environment compromises providers' ability to be fully present in the moment; especially during patient interactions. This “pulling away” of attention (mindlessness) from the present moment creates an environment where decision making can take place in the absence of thoughtful, deliberate engagement in the task at hand. Mindfulness, can be cultivated through a variety of mindfulness practices. Few schools of nursing or hospitals offer mindfulness training, despite study findings supporting its effectiveness in improving levels of mindfulness, and perceived connections with patients and families.MethodsA mindfulness program developed for this study and tailored to nursing was used to provide the mindfulness training. Pre and post training assessments were completed and included administration of the Freiburg Mindfulness Inventory (FMI) and the Defining Issues Test (DIT) of moral judgment version 2.ResultsA statistically significant improvement in the FMI scores p = 0.003 was found. The pre-licensure group did not show a statistically significant improvement in their FMI scores pre to post training (p = 0.281), however the post graduate group did (p = 0.004). Statistically significant pre - post scores were found in two schemas of the DIT-2 (P [Post conventional] score, p = 0.039 and N2 [Maintaining norms] score, p = 0.032).ConclusionsMindfulness training improves mindfulness and some aspects of ethical decision making in the groups studied as part of this project. The findings of this study are promising and further demonstrate the merits of a mindfulness practice, however aspects of mindfulness training would need to be addressed prior to launching a full scale attempt to incorporate this into a work life or some other quality improvement program.     

Reduced serum vaspin concentrations in obese children following short-term intensive lifestyle modification

BackgroundRecently, visceral adipose tissue-derived serpin (vaspin) was identified as a potential insulin sensitizing adipokine, however, the factors determining the levels of circulating vaspin levels have not been fully understood. We investigated the association between adiposity, insulin resistance, lipid profiles and inflammatory markers including vaspin levels, and the effects of short-term intensive lifestyle modification on circulating vaspin levels in overweight or obese children.MethodsA total of 50 (25 boys, 25 girls) overweight or obese children aged 11 to 13 years (average age: 12.0 ± 0.9 y, BMI: 25.35 ± 86 kg/m²) who complied with inclusion criteria participated in our study. To determine the association between adiposity, insulin resistance, lipid profiles and inflammatory markers including vaspin levels, cross-sectional analyses were performed. Thereafter, subjects underwent a tightly controlled seven-day intensive lifestyle modification including physical activity, dietary modification, and behavioral modification education in residence of a local university dormitory.ResultsThere was a negative correlation between vaspin concentration and fasting insulin (r = ?.325, p < 0.05) and homeostasis model assessment of insulin resistance (HOMA-IR) (r = ?.331, p < 0.05) when percent body fat was controlled. Multivariate linear regression analysis found serum vaspin level to be an independent predictor of insulin and HOMA-IR. Short-term intensive lifestyle modification significantly decreased vaspin levels by 39.28% (pre: .84 ± 1.0, post: .51 ± 1.0 ng/ml, p < 0.001) while adiponectin levels increased by 11.2% (pre: 6.50 ± 2.89, post: 7.28 ± 2.98 ng/ml, p < 0.01). In addition, short-term lifestyle modification significantly improved HOMA-IR (pre: 3.58 ± 1.93, post 1.30 ± 1.9, p < 0.001) and lipid profiles.ConclusionsSerum vaspin level is one of the predictors for insulin resistance and was significantly reduced following short-term lifestyle modification.     

VEGF-A gene promoter polymorphisms and microvascular complications in patients with essential hypertension

ObjectivesWe investigated the possible involvement of vascular endothelial growth factor (VEGF-A) gene promoter polymorphisms in essential hypertension (EH).Design and methods1225 bp of the VEGF-A gene promoter were screened for polymorphisms using PCR amplification and direct DNA sequence analysis in 62 EH and 62 normotensive (HS) individuals. Circulating VEGF-A levels were determined by immunoassay.Results?152G/A (p = 0.009) and ?116G/A (p = 0.016) polymorphisms were correlated to hypertension (p < 0.05). Median platelet VEGF-A load in EH was 2.10 fg/plt. Patients with microvascular complications (MC) had higher platelet VEGF-A load than those without (p = 0.005). Multivariate analyses showed that ?116 A allele was an independent predictor of microalbuminuria (p = 0.014) and increased platelet VEGF-A load (p = 0.009) in EH. Platelet VEGF-A load independently predicted MC (p = 0.049) in addition to ?116G/A polymorphism (p = 0.035).ConclusionsAbnormal regulation of VEGF-A due to polymorphism at position ?116 might represent a genetic factor for increased VEGF-A production and MC in EH.     

Association of − 765G>C polymorphism of the COX-2 gene with recurrent embryo implantation failure in Southern Chilean women

BackgroundEmbryo implantation failure is considered an important cause of infertility in women undergoing assisted reproductive protocols. Recent studies demonstrated that the cyclooxygenase-2 (COX-2) enzyme is implicated in biosynthesis of prostaglandins and play an important role in the molecular implantation mechanisms. According to this evidence, we evaluated the potential association between the ? 765G>C (rs20417) polymorphism at the COX-2 gene and the implantation failure susceptibility in a sample of Chilean women.MethodsA total of 186 unrelated women matched by age were included in the present study, 106 patients (aged 31.9 ± 4.17 y) with no history of successful pregnancy and a diagnosis of infertility undergoing assisted reproductive protocols and 80 healthy controls (aged 31.4 ± 4.05 y). The COX-2 ? 765G>C gene polymorphism was analyzed by PCR-RFLP.ResultsGenotype distribution and allelic frequencies for ? 765G>C polymorphism of COX-2 gene were significantly different between patients and controls (P = 0.004 and P = 0.002, respectively). The odds ratio for implantation failure associated to the ? 765C allelic variant was 2.14 (95% C.I., 1.35–3.39, P = 0.00071).ConclusionOur data suggest, by the first time, that the COX-2 ? 765G>C polymorphism is associated with recurrent implantation failure in Chilean women and may constituted a novel molecular biomarker of reproductive failure.     

The nitric oxide synthase 3 gene polymorphisms and their association with deep vein thrombosis in Asian Indian patients

BackgroundEndothelium derived nitric oxide is formed from l-arginine by endothelial nitric oxide synthase encoded by the nitric oxide synthase 3 (NOS3) gene. Nitric oxide possesses a variety of protective effects on endothelial cells and therefore NOS3 is a logical candidate gene to be investigated for the susceptibility of deep vein thrombosis (DVT).MethodsOne hundred consecutive patients (M: F = 56:44) with idiopathic deep vein thrombosis and an equal number of age and sex matched healthy controls were the study subjects. All study subjects were typed for five NOS3 polymorphisms (? 786C/T, ? 922A/G, 894G/T, Intron 4 VNTR, and Intron 23 G10T).ResultsTwo polymorphisms (? 922A/G and 894G/T) are showing their association with DVT. ? 922A/G shows both genotypic (P = 0.0218; χ² = 5.25; O.R = 1.94) as well as allelic association (P = 0.0014; χ² = 10.19; O.R = 2.0) while 894G/T shows only allelic (P = 0.04; χ² = 3.93; O.R = 3.93) association with DVT.ConclusionSusceptibility to DVT in North Indian Asian patients may be associated with some variants of NOS3 gene.     

Neuropeptide Y polymorphisms and ischemic stroke in Chinese population

BackgroundStroke is the second most common cause of death in developed countries and a major cause of adult disability and mortality worldwide. New data strongly suggest that neuropeptide Y (NPY) may be a candidate gene for ischemic stroke.MethodsWe investigated 450 ischemic stroke patients and 423 healthy controls matched for sex and age in a Han Chinese population. Three functional polymorphisms (? 883TGins/del, ? 602G/T and ? 399 T/C) located in NPY gene promoter were genotyped using DNA sequencing methods.ResultsOf 3 NPY polymorphisms investigated in our study, the ? 399CC genotype (OR: 1.699, 95% CI: 1.124–2.567, P = 0.011) and the ? 399C allele (OR: 1.254, 95% CI: 1.031–1.524, P = 0.023) were more frequent among ischemic stroke patients than in controls, especially in the small vessel disease (SVD) subtype patients. The similar results were observed in multivariable logistic regression analysis. Haplotype analysis revealed that the ? 883ins/?399C haplotype was a risk marker for ischemic stroke (P = 0.008).ConclusionsThe C allele of ? 399 T/C polymorphism in the promoter regions of NPY is an independent risk factor for ischemic stroke, suggesting that NYP system may involve in the mechanisms of stroke pathology.