Combination of a reduced dose of an intrathecal local anesthetic with a small dose of an opioid: A meta-analysis of randomized trials

We tested whether the combination of a reduced dose of a local anesthetic (LA) with an opioid compared with a standard dose of the same LA alone guaranteed adequate intraoperative anesthesia and postoperative analgesia and decreased LA-related adverse effects. We systematically searched (to November 2012) for randomized comparisons of combinations of a reduced dose of an LA with a concomitant opioid (experimental) with a standard dose of the LA alone (control) in adults undergoing surgery with single-injection intrathecal anesthesia without general anesthesia. We included 28 trials (1393 patients). In experimental groups, the median decrease in LA doses was 40% (range, 12%–70%). There was no difference between experimental and control groups in the need for intraoperative opioids or general anesthesia for failed block or in the duration of postoperative analgesia. With experimental interventions, there was evidence of a reduction in the duration of motor blockade postoperatively (average, −50 minutes), time to discharge from hospital or PACU (−33 minutes), time to ambulation (−28 minutes), and time to urination (−14 minutes). There was also evidence of a decrease in the risk of shivering (risk ratio [RR]: 0.26; 95% confidence interval [CI]: 0.12–0.56), nausea (RR: 0.45; 95% CI: 0.31–0.66), and arterial hypotension (RR: 0.52; 95% CI: 0.35–0.78). The risk of pruritus was increased (RR: 11.7; 95% CI: 6.2–21.9). Adding an opioid to a reduced dose of an intrathecal LA can decrease LA-related adverse effects and improve recovery from the spinal block without compromising intraoperative anesthesia or duration of postoperative analgesia.     

Energy expenditure during physiotherapist-assisted and self-treatment in cystic fibrosis

Cystic fibrosis (CF) results in increased energy requirements at rest. However, the energy expended during physiotherapy management is unknown. The aim of this study, therefore, is to examine the energy expended during two commonly used forms of chest physiotherapy in CF subjects. Twenty-six CF subjects completed a randomised crossover trial with 48 hours between treatments. Two regimens of treatment were conducted: therapist-assisted treatment (active cycle of breathing, ACBT, with percussion, vibration), and independent treatment (ACBT alone, under the supervision of a physiotherapist). Subjects completed pulmonary function tests before and after either treatment. Indirect calorimetry and oximetry parameters were recorded at rest, during, and following treatment. Treatment groups were compared using ANOVA and two-sample crossover t-tests. When compared to resting values, physiotherapy treatment resulted in significant increases in VO₂, VCO₂ and respiratory exchange ratio. No difference was evident between treatment regimens for the change in VO₂ between baseline and treatment. The increase in ventilation (baseline to treatment) was significantly greater for the therapist-assisted treatment. The therapist-assisted ACBT was associated with a significant carryover effect for forced expiratory flow at 50% of vital capacity (FEF₅₀). Oxygen requirements for the two treatments were similar. However, the assisted regimen resulted in greater changes in minute ventilation during treatment and improved 48-hour post-treatment pulmonary function after only one treatment session. These findings suggest that the inclusion of percussion and vibration within the ACBT may influence respiratory muscle activity during treatment and result in improved pulmonary function.     

People and Places: some factors in the alcohol-violence link

The possible association between heavy drinking and intoxication with aggression and violence has been debated for centuries. A select and concise review of some of the evidence on this topic will be presented. This seeks to draw some general conclusions from an extensive, flawed and often contradictory literature. The main focus of this review is on social and contextual factors. Experimental evidence suggests that alcohol consumption probably does increase the propensity for aggression in men, but less so for women. The effects of drinking depend upon the alcohol consumed, the drinker and the setting in which consumption occurs. Most drinking occasions do not result in aggression or violence, and drinking is neither necessary nor sufficient to cause violence. Heavy and inappropriate drinking is associated with both violent and nonviolent crimes; heavy and problem drinkers are at risk of being violent or of being the victims of violence. Experience of violence (including sexual abuse) in childhood or later in life are associated with the development of heavy or problem drinking. The risk of exposure to violence is influenced by a host of demographic, lifestyle and contextual factors. Responses to alcohol-related violence at the societal level involve a number of harm minimization strategies. At an individual level it has been shown that treatment for problem drinking can lead to reduced risk levels (for both perpetrators and victims of violence).