Opioide bei chronischem Arthroseschmerz

Background

The efficacy, tolerability and safety of opioid therapy in chronic osteoarthritis (OA) pain is under debate. We updated a Cochrane systematic review on the efficacy and safety of opioids in chronic OA pain published in 2009.

Methods

We screened MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) up until October 2013, as well as reference sections of original studies and systematic reviews of randomized controlled trials (RCTs) of opioids in chronic osteoarthritis (OA) pain. We included double-blind randomized placebo-controlled studies lasting ≥?4 weeks. Using a random effects model, absolute risk differences (RD) were calculated for categorical data and standardized mean differences (SMD) for continuous variables.

Results

We included 20 RCTs with 33 treatment arms and 8545 participants. Median study duration was 12 (4–24) weeks. Oxycodone and tramadol were each tested in six studies; buprenorphine, hydromorphone, morphine and tapentadol each in two studies and codeine, fentanyl and oxymorphone in one study each. Results are reported with 95?% confidence intervals (CIs). Opioids were superior to placebo in reducing pain intensity (SMD ??0.22 [??0.28, ??0.17], p?<?0.00001; 16 studies with 6743 participants). Opioids were not superior to placebo in 50?% pain reduction (RD ??0.00 [??0.07, 0.07], p?=?0.96; two studies with 2684 participants). Opioids were superior to placebo in terms of reports of much or very much global improvement (RD 0.13 [0.05, 0.21], p?=?0.002; three studies with 2251 participants). Opioids were superior to placebo in improving physical functioning (SMD ??0.22 [??0.28, ??0.17], p?<?0.00001; 14 studies with 5887 participants). Patients dropped out more frequently with opioids than with placebo (RD 0.17 [0.14, 0.21], p?<?0.00001; 15 studies with 6834 participants; number needed to harm 5 [4–6]. There was no significant difference between opioids and placebo in the frequency of serious adverse events (SAE) or deaths over the respective observation periods.

Conclusion

Opioids were superior to placebo in terms of efficacy and inferior in terms of tolerability. The effect sizes of average reduction in pain intensity and physical disability were small. Opioids and placebo did not differ in terms of safety. The conclusion on the safety of opioids compared to placebo is limited by the low number of SAE and deaths. Short-term opioid therapy may be considered in selected chronic OA pain patients. No current evidence-based guideline recommends opioids as first-line treatment option for chronic OA pain. To provide superior evidence for future treatment guidelines, RCTs must directly compare existing pharmacological and nonpharmacological therapies and administer these in various combinations and sequences.The English full-text version of this article is freely available at SpringerLink (under “Supplemental”).

     

Randomized controlled trial comparing Moviprep® and Phosphoral® as bowel cleansing agents in patients undergoing colonoscopy

Background

Introducing colonoscopy as part of colorectal cancer screening on a national level, we aimed at evaluating the efficacy of the two most common bowel cleansing agents, Moviprep^® and Phosphoral^®. Secondly, we evaluated the benefit for the patient and society in terms of sick leave and discomfort.

Methods

In a single-blinded randomized equivalence trial, Phosphoral^® (NaP) was compared with Moviprep^® (2 l polyethylene glycol + ascorbic acid) in patients undergoing colonoscopy due to suspicion of cancer. Patients filled out questionnaires concerning stool consistency, discomfort and number of sick days due to bowel cleansing. Blinded colonoscopists estimated the efficiency of the cleansing using the validated Harefield Cleansing Scale.

Results

Two hundred and sixty-six patients were included 250 of whom underwent full colonoscopy. There was no difference in the percentage of acceptable bowel cleansings in the two groups; however, a significantly higher number of A scores were observed in the Moviprep^® group (p = 0.028). We found no correlation between stool consistency and outcome of the cleansing and no difference in subjective discomfort during cleansing. Vomiting during cleansing occurred more often in the Phosphoral^® group (p = 0.002). There was a trend toward a smaller number of sick days in patients who used Moviprep^® compared with Phosphoral^®.

Conclusions

Moviprep^® and Phosphoral^® provided equally efficient bowel cleansing in 90 % of patients, but Moviprep^® provided a higher quality of cleansings graded as successful. The two agents were equally tolerated, and no difference was found in the related number of sick days.     

Non-fluoroscopic catheter visualization using MediGuide™ technology: experience from the first 600 procedures

A novel cardiovascular navigation system known as MediGuide? (MG) which allows non-fluoroscopic catheter tracking over a background of pre-recorded cine loops was recently introduced. This system allows significant reduction of fluoroscopy exposure which is one of the potentially harmful aspects of today's electrophysiological procedures such as ablations or device implantations. We provide a summary of recently published studies related to this new technological platform and describe our experience from the first 600 MG procedures at our institution. After reviewing the currently available publications in the field of MG-supported EP procedures, we describe the workflows for (1) ablation of supraventricular tachycardia (SVT), atrial fibrillation (AF), and ventricular tachycardia using MG-enabled diagnostic and ablation catheters, as well as (2) implant of cardiac resynchronization therapy (CRT) devices using sensor-equipped delivery tools including sheaths, sub-selectors, and guidewires. As shown in several studies [5–9], MG procedures resulted in similar efficacy as conventional cases but with a significant reduction in fluoroscopy time and dose. In particular, for SVT ablations, the median fluoroscopy time using the MG technology was 0.5?±?1.4 min compared to 10.2?±?9.6 min in conventional fluoroscopic settings. Similar reductions were demonstrated for AF ablation procedures from 25 min in conventional settings with electroanatomical mapping systems and live x-ray to 4.6 min with the addition of the MG technology. Recently, it was demonstrated that the application of MG for CRT device implants could successfully result in a median fluoroscopy time of 2.6 min for LV lead deployment. In summary, the first measurable clinical impact of the MG technology on a daily clinical routine is the reduction of fluoroscopy time and radiation exposure for various EP indications. These beneficial effects were achieved without negative consequences on procedural efficacy, complications, or time in more than 600 EP procedures.     

Motivation for and adherence to growth hormone replacement therapy in adults with hypopituitarism: the patients‘ perspective

Pituitary - While reasons for non-adherence in children requiring growth hormone (GH) replacement (GH-Rx) are well researched, few studies have investigated adherence in adult GH deficient...     

Functional short- and long-term effects of nasal CPAP with and without humidification on the ciliary function of the nasal respiratory epithelium

Purpose

Continuous positive airway pressure (CPAP) is the gold standard in the treatment of obstructive sleep apnea (OSA), but its impact on ciliary function is unclear to date. Furthermore, CPAP is associated with numerous side effects related to the nose and upper airway. Humidified CPAP is used to relieve these symptoms, but again, little is known regarding its effect on ciliary function of the nasal respiratory epithelium.

Methods

In this prospective, randomized, crossover trial, 31 patients with OSA (AHI >15/h) were randomized to two treatment arms: nasal continuous positive airway pressure (nCPAP) with humidification or nCPAP without humidification for one night in each modality to assess short-term effects of ciliary beat frequency (CBF) and mucus transport time (MTT) and consecutively for 8 weeks in each modality to assess long-term effects in a crossover fashion.

Results

The baseline CBF was 4.8?±?0.6 Hz, and baseline MTT was 540?±?221 s. After one night of CPAP with and without humidification, ciliary function increased moderately yet with statistical significance (p <0.05). The short-term groups with and without humidification did not differ statistically significant. Regarding long-term effects of CPAP, a statistically significant increase in ciliary function above the baseline level and above the short-term level was shown without humidification (7.2?±?0.4 Hz; 402?±?176 s; p <0.01). The increase above baseline level was even more pronounced with humidification (9.3?±?0.7 Hz; 313?±?95 s; p <0.01). There was a statistically significant difference between both groups at long-term assessment with regard to CBF (p <0.01).

Conclusions

Independent of airway humidification, nCPAP has moderate effects on short-term ciliary function of the nasal respiratory epithelium. However, a significant increase in ciliary function—both in terms of an increased CBF and a decreased MTT—was detected after long-term use. The effect was more pronounced when humidification was used during nCPAP.     

Selfish supernumerary chromosome reveals its origin as a mosaic of host genome and organellar sequences

Supernumerary B chromosomes are optional additions to the basic set of A chromosomes, and occur in all eukaryotic groups. They differ from the basic complement in morphology, pairing behavior, and inheritance and are not required for normal growth and development. The current view is that B chromosomes are parasitic elements comparable to selfish DNA, like transposons. In contrast to transposons, they are autonomously inherited independent of the host genome and have their own mechanisms of mitotic or meiotic drive. Although B chromosomes were first described a century ago, little is known about their origin and molecular makeup. The widely accepted view is that they are derived from fragments of A chromosomes and/or generated in response to interspecific hybridization. Through next-generation sequencing of sorted A and B chromosomes, we show that B chromosomes of rye are rich in gene-derived sequences, allowing us to trace their origin to fragments of A chromosomes, with the largest parts corresponding to rye chromosomes 3R and 7R. Compared with A chromosomes, B chromosomes were also found to accumulate large amounts of specific repeats and insertions of organellar DNA. The origin of rye B chromosomes occurred an estimated ～1.1-1.3 Mya, overlapping in time with the onset of the genus Secale (1.7 Mya). We propose a comprehensive model of B chromosome evolution, including its origin by recombination of several A chromosomes followed by capturing of additional A-derived and organellar sequences and amplification of B-specific repeats.     

The Push-Turn-Taptap Task Outperforms Measures of Executive Functioning in Predicting Declines in Functionality: Evidence-Based Approach to Test Validation

Performance on the Push-Turn-Taptap (PTT) task has been shown to be a strong predictor of concurrent everyday functioning. This study utilized a prospective, longitudinal design to evaluate the PTT task for predicting future performance on a behavioral assessment of everyday functioning. The PTT task was compared to other measures of executive functioning as well as general cognition in terms of administration time and ability to identify participants who evidenced functional decline. A total of 50 community-dwelling older adults (ages 58–87) completed the PTT task, Mattis Dementia Rating Scale, Geriatric Depression Scale, Behavioral Dyscontrol Scale, Delis-Kaplan Executive Function System, and Timed Instrumental Activities of Daily Living. Baseline PTT performance (a) was highly correlated with an objective measure of everyday functioning after approximately one year (r?=??.497, p?<?.001), (b) was associated with changes in follow-up functioning, F(3, 46)?=?3.15, p?=?.03, (c) was a better predictor of future functional status than a longer battery of EF, and (d) reliably identified individuals with the greatest magnitude of functional decline. The PTT tasks may provide a particularly advantageous method of predicting future changes in everyday functioning in older adults.