Patient-controlled epidural analgesia (PCEA) for postoperative pain control after lumbar spine surgery

Spine surgery remains one of the most common procedures for patients with a wide variety of spine disorders. Postoperative pain after major spine surgery is moderate to severe. We retrospectively reviewed 245 medical records of adult patients undergoing major spine surgery who received either patient-controlled epidural analgesia based on local anesthetics and opioids or patient-controlled intravenous analgesia as postoperative pain management. Several outcomes were analyzed including pain intensity, opioid consumption, time to endotracheal extubation, the incidence of deep venous thrombosis, and length of stay in the hospital. We found that the use of patient-controlled epidural analgesia provided better postoperative analgesia [median (quartiles) verbal analog scale score of 4 (3, 5) vs. 5 (3, 6)] and decreased the amount of opioid consumption postoperatively [median of 0 mg (0, 3) vs. 35 mg (0, 150)] compared with patient-controlled intravenous analgesia. Also, a substantially higher number of patients in the patient-controlled intravenous group required opioids as rescue analgesia. Incidences of deep venous thrombosis, operating room extubation, and length of stay in the hospital were not associated with the analgesic technique. The results of this study suggest that the use of neuroaxial analgesia for the management of postoperative pain associated with major spine surgery may have some beneficial properties over intravenous analgesia. The use of a reduced amount of opioids by patients with epidural analgesia may be relevant because of potential fewer side effects mainly in elderly patients. Several limitations related to the retrospective nature of the study are described. Prospective randomized-controlled trials are needed to understand and elucidate the optimum regimen of postoperative pain management after major spine surgery.     

Confirm Rx insertable cardiac monitor for primary atrial fibrillation detection in high-risk heart failure patients (Confirm-AF trial)

Background

Patients with heart failure (HF) represent a large population of patients who are at high risk for complications related to undiagnosed atrial fibrillation (AF). However, currently there are limited modalities available for early AF detection in this high-risk population. An implantable cardiac monitor (ICM) is inserted subcutaneously and can provide long-term arrhythmia information via remote monitoring.

Methods and Results

Confirm-AF is a prospective randomized, nonblinded, two arm, multicenter clinical trial to be performed in the United States, enrolling 477 patients with a history of HF hospitalization and left ventricular ejection fraction >35% from 30 medical sites. Patients will be randomized in a 2:1 fashion to undergo ICM implant with remote monitoring and symptom-triggered mobile app transmissions versus (vs.) Non-ICM management and follow-up. The primary objective of this trial is to compare the time to first detection of AF lasting > 5 min using an Abbott ICM compared to non-ICM monitoring in symptomatic HF patients. This article describes the design and analytic plan for the Confirm-AF trial.

Conclusions

The Confirm-AF trial seeks to accurately define the burden of AF in high-risk HF patients with LVEF > 35% using an Abbott ICM. A finding showing significantly higher incidence of AF along with improved clinical outcomes with ICM monitoring is expected to have substantial clinical implications and may change the method of monitoring high-risk HF patients.     

Impact of a clinical pharmacist on medication safety in mental health Hospital-in-the-Home: a retrospective analysis

Background

Integration of clinical pharmacists into multidisciplinary Mental Health Hospital-in-the-Home teams is increasing but little is known about the medication safety contribution these pharmacists make.

Aim

To evaluate whether clinical pharmacist involvement in a Mental Health Hospital-in-the-Home service improved medication safety key performance indicators.

Method

Medical records were retrospectively reviewed of all patients admitted to 2 Western Australian Mental Health Hospital-in-the-Home services from September to November 2015.

Site 1

was a 16-bed service incorporating a clinical pharmacist as part of its multidisciplinary team.

Site 2

was a similarly structured 18-bed service but without clinical pharmacist involvement. The primary outcome measure was completion of medication safety key performance indicators obtained from the Western Australian Government Pharmaceutical Review Policy and mental health-specific best practice guidelines.

Results

Key performance indicators from Site 1 (n?=?75 records), which incorporated a clinical pharmacist, demonstrated significantly (p?<?0.001) higher rates of completion of medication reconciliation [65 (87%) versus 17 (29%)], accurate adverse drug reaction list [73 (97%) versus 34 (58%)], accurate discharge medication list [51 (74%) versus 18 (45%)], accurate medication profile [74 (99%) versus 40 (68%)] and medication chart review [74 (99%) versus 0 (0%)] than Site 2 (n?=?59).

Conclusion

Integrating a clinical pharmacist into a Mental Health Hospital-in-the-Home program significantly improved achievement of medication safety key performance indicators.

     

Laser bladder perforation from photoselective vaporization of prostate resulting in rhabdomyolysis induced acute renal failure

Hyponatremia and its related comorbidities remain a concern after traditional transurethral resection of the prostrate (TURP). Photoselective vaporization of the prostate (PVP) laser coagulation therapy is a new, relatively bloodless procedure for treatment of benign prostatic hyperplasia (BPH). Perceived benefits with PVP laser TURP include excellent visualization of the operative field during urethral prostatic tissue vaporization and the reduced incidence of laser penetration through the prostatic capsular fibers once the capsule is reached. Theoretically, this would provide a low risk method of perforation during laser TURP. After literature review, we report this as the first case of laser bladder perforation as a complication arising from PVP therapy. This case report discusses the management of acute hyponatremic induced rhabdomyolysis with acute renal failure (ARF) and the recommendation to use sodium chloride vs. sterile water for bladder irrigation during PVP TURP procedures.     

Phase II trial of temsirolimus in patients with relapsed or refractory multiple myeloma

In a phase II trial, 16 patients with relapsed refractory multiple myeloma received temsirolimus 25 mg I.V. weekly until progression. One partial response and 5 minor responses were observed for a total response rate of 38%. The median time to progression was 138 days. Grade 3–4 toxicity included fatigue (n = 3), neutropenia (n = 2), thrombocytopenia (n = 2), interstitial pneumonitis (n = 1), stomatitis (n = 1) and diarrhea (n = 1). Clinical activity was associated with a higher area under the curve (AUC) and maximal reduction in phosphorylated p70^S6K and 4EBP1 in peripheral blood mononuclear cells. At the dose and schedule used, temsirolimus had low single agent activity. Investigation of alternate dosing schedules and use in combinations is indicated.