There is a substantial preoccupation with different surgical approaches and minimally invasive techniques that may improve clinical outcomes for patients who undergo total hip arthroplasty. This study assessed the impact on hospital-related outcomes of the direct anterior approach (DAA) compared with the posterior approach (PA) performed by a single surgeon in 100 consecutive patients in each cohort. Patient age was similar in the DAA (61 ± 1.1 years) compared with the PA (62 ± 1.3, p = 0.733); however, BMI tended to be lower in DAA patients (29.1 ± 0.8) compared with PA patients (31.3 ± 0.7, p = 0.057). The DAA compared with the PA was associated with significantly less blood loss (285 ± 15 vs. 367 ± 21ml, p = 0.002) and transfusions (18 vs. 39 units, p = 0.009), less narcotic usage on postoperative days 1-3 (101 ± 12 vs. 146 ± 12 morphine equivalent dose, p = 0.010), a quicker hospital discharge (70 ± 3.3 vs. 97 ± 5.5 hours, p < 0.001), and a more favorable disposition (97% vs. 84% discharged home, p = 0.003). Thirty-day readmission rate was significantly higher with the PA (9%) compared with the DAA (1%, p = 0.030). The number of cups in the safe zone (5° to 25° anteversion and 30° to 50° inclination) was significantly higher with the DAA (92%) compared with the PA (75%, p = 0.002), possibly attributed to fluoroscopy used with the DAA. The DAA muscle-preservation technique may have led to the benefits observed in this study compared with the muscle-splitting technique associated with the PA.

Some evidence exist to suggest that women experience more pain and require more medication than men to achieve a similar state of analgesia. However, this was not studied in morbidly obese patients. The study evaluates the effect of gender on postoperative pain and analgesic consumption in the first 24 h in morbidly obese patients who undergo laparoscopic Roux-En-Y gastric bypass surgery (RYNGPB). One hundred thirty obese adult patients who underwent elective RYNGPB were included in the study. Postoperative pain scores were compared using a numeric rating scale, at intervals (0, 15, 30, 45, 60, 90, and 120 min), and following discharge from the postanesthesia care unit (PACU) at 6, 12, and 24 h. Titrated morphine dose during the 2-h PACU stay and pethidine consumption in the subsequent 24 h were measured. One hundred fourteen patients completed the study (59 females and 55 males). Female patients had higher initial pain scores and higher morphine consumption (10.1 ± 3.1 mg) than male patients (7.2 ± 4.5 mg), P = 0.0001. Following PACU discharge, there was no gender difference in pain scores or analgesic consumption. Pethidine consumption in male patients during the first day was 97.8 ± 35.1 versus 98.1 ± 61.6 mg among female patients, P = 0.9729. Female patients had higher initial pain score and morphine consumption than men in the immediate postoperative period, but that difference disappeared after discharge from PACU.

OBJECTIVES:

Morphine causes physical and psychological dependence for individuals after repeated-use. Above all, our previous study showed that acupuncture attenuated reinstatement of morphine-seeking behavior induced by pharmacological cue. In this study, we investigated whether acupuncture could suppress the reinstatement of morphine-seeking behavior induced by the combination of environmental and phamacological cues and the possible neuronal involvement.

MATERIALS AND METHODS:

Male Sprague-Dawley rats were trained to self-administer morphine (1.0 mg/kg) for three weeks. Following the withdrawal phase (seven days), the effects of acupuncture on reinstatement of morphine-seeking behavior were investigated. For the investigation of neuronal involvement, the GABAA receptor antagonist bicuculline and the GABAB receptor antagonist SCH 50911 were pre-treated.

RESULTS:

Morphine-seeking behavior induced by combination of re-exposure to the operant chamber and morphine injection was suppressed perfectly by acupuncture at SI5, but not at the control acupoint LI5 and this effect was blocked by pre-treatment with the GABA receptor antagonists.

CONCLUSIONS:

This study suggests that acupuncture at SI5 can be considered as a predominant therapy for the reinstatement of morphine-seeking behavior in humans.

Neonatal withdrawal syndrome is characterized by non-specific signs and symptoms that occur in infants following in-utero drug exposure. The incidence of neonatal withdrawal syndrome is 16-90% in infants of mothers abusing heroin. Clinical signs of withdrawal syndrome usually occur within the first 48-72 hours after birth. Central nervous system and gastrointestinal system symptoms are the main symptoms. In this case report, two newborns born to the mothers addicted to heroin who suffered neonatal withdrawal syndrome are presented. They were successfully treated with phenobarbital and morphine infusion.

Inadequate pain relief after lower limb joint replacement surgery has been a well-recognised limiting factor affecting post-operative mobilisation and length of hospital stay. Multimodal local wound infiltration with local anaesthetics, adrenaline and non-steroidal anti-inflammatory agents can lower the opiate intake, reduce the length of stay and enhance early mobilisation in knee replacement patients. A retrospective review of 64 patients undergoing primary total knee replacement was undertaken. Thirty-two patients (cases) had their wounds infiltrated with ropivacaine, adrenaline and ketorolac by the operating surgeon, intraoperatively. Subsequently, a 19G wound catheter placed into the knee joint. They received two further top-up doses of the same combination at 10 and 20 h post-operatively. This group was compared with a control group of 32 patients who did not receive any local infiltration. Both groups were comparable in terms of BMI and age. Post-operative opiate drug consumption in first 48 h after surgery, length of hospital stays and time taken to mobilise after surgery were recorded. There was significant reduction in opiate consumption in the treatment group with an average consumption of 49.35 mg of morphine compared to 71.48 mg in the control group (p = 0.004). The median length of hospital stay was significantly reduced from 5 days in the control group to 4 days in the treatment group (p = 0.03). The patients in the treatment group mobilised around 19 h earlier (p = 0.001). No major post-operative complications were encountered in either group. Wound infiltration is an effective and safe technique that promotes early rehabilitation and discharge of patients following primary total knee replacement.

Opioid prescribing for chronic noncancer pain is increasing, but there is limited knowledge about longer-term outcomes of people receiving opioids for conditions such as back pain. This study aimed to explore the relationship between prescribed opioids and disability among patients consulting in primary care with back pain. A total of 715 participants from a prospective cohort study, who gave consent for review of medical and prescribing records and completed baseline and 6month follow-up questionnaires, were included. Opioid prescription data were obtained from electronic prescribing records, and morphine equivalent doses were calculated. The primary outcome was disability (Roland-Morris Disability Questionnaire [RMDQ]) at 6months. Multivariable linear regression was used to examine the association between opioid prescription at baseline and RMDQ score at 6months. Analyses were adjusted for potential confounders using propensity scores reflecting the probability of opioid prescription given baseline characteristics. In the baseline period, 234 participants (32.7%) were prescribed opioids. In the final multivariable analysis, opioid prescription at baseline was significantly associated with higher disability at 6-month follow-up (P<.022), but the magnitude of this effect was small, with a mean RMDQ score of 1.18 (95% confidence interval: 0.17 to 2.19) points higher among those prescribed opioids compared to those who were not. Our findings indicate that even after adjusting for a substantial number of potential confounders, opioids were associated with slightly worse functioning in back pain patients at 6-month follow-up. Further research may help us to understand the mechanisms underlying these findings and inform clinical decisions regarding the usefulness of opioids for back pain.

BACKGROUND:

The quantification of pain intensity in vivo is essential for identifying the mechanisms of various types of pain or for evaluating the effects of different analgesics. A variety of behavioral tests for pain measurement have been devised, but many are limited because animals are physically restricted, which affects pain sensation. In this study, pain assessment was attempted with minimal physical restriction, and voluntary movements of unrestrained animals were used to evaluate the intensities of various types of pain.

RESULTS:

The number of times animals reared or total distances traveled was measured using a motion-tracking device and found to be markedly reduced in carrageenan-induced inflammatory, acetic acid-induced visceral, and streptozotocin-induced neuropathic pain tests. These two voluntary movement parameters were found to be highly correlated with paw withdrawal latency from irradiating heat. In addition, these parameters were markedly reversed by morphine and by non-steroidal anti-inflammatory drugs in inflammatory pain models. These parameters were also useful to detect hypoalgesia in TRPV1-/- mice.

CONCLUSIONS:

These results suggest that parameters of voluntary movement, such as, number of rearing and total distance moved, are effective indicators of pain intensity for many types of pain and that they can be used to evaluate degree of pain perception.

PURPOSE:

To investigate interindividual variability in response to pain treatment, we characterized postoperative patients for morphine metabolism and for COMT, OPRM1 and UGT2B7 polymorphisms.

METHODS:

A total of 109 patients treated with morphine were genotyped by DNA sequencing for 12 DNA polymorphisms of the COMT, OPRM1 and UGT2B7 genes. The plasma concentration of morphine and of M3G/M6G metabolites were evaluated by means of reversed phase high-performance liquid chromatography coupled with mass spectrometry.

RESULTS:

An association between average morphine consumption during the first 24 postoperative hours by patient-controlled analgesia (PCA) and COMT haplotypes was found. Specifically, patients with the diplotype for average pain intensity (APS/APS) required the lowest morphine doses compared to the other subjects (p = 0.011). The APS haplotype contains an adenine corresponding to methionine, instead of valine, at position 158 of the COMT protein. Met/Met homozygous patients consumed significantly lower morphine doses than other subjects (p = 0.014); accordingly, Val158Met genotyping alone might be used in the clinical setting to predict PCA morphine need. Considering both COMT Val158Met and OPRM1 A118G polymorphisms, carriers of both the Met/Met and AA genotypes required less morphine than other subjects, although the difference was not significant. The analysis of UGT2B7 revealed the occurrence of two common haplotypes (G_C_C_A_C and A_T_T_G_T) that did not prove to be related with plasma morphine and M3G/M6G concentration.

CONCLUSIONS:

By considering COMT, OPRM1, and UGT2B7 genotypes, as well as pharmacokinetic results, only COMT polymorphisms appear to be predictive of morphine need in postoperative pain therapy.

The anticonvulsant effects of agmatine, an endogenous polyamine and a metabolite of l-arginine, have been shown in various experimental seizure models. Agmatine also potentiates the anti-seizure activity of morphine. The present study aimed to investigate a possible involvement of nitric oxide (NO) pathway in the protection by agmatine and morphine co-administration against pentylenetetrazole (PTZ) -induced seizure in male mice. To this end, the thresholds for the clonic seizures induced by the intravenous administration of PTZ, a GABA antagonist, were assessed. Intraperitoneal administration of morphine at lower dose (1mg/kg) increased the seizure threshold. Also intraperitoneal administration of agmatine (5 and 10mg/kg) increased the seizure threshold significantly. Combination of subeffective doses of morphine and agmatine led to potent anticonvulsant effects. Non-effective doses of morphine (0.1 and 0.5mg/kg) were able to induce anticonvulsant effects in mice pretreated with agmatine (3mg/kg). Concomitant administration of either the non-selective nitric oxide synthase (NOS) inhibitor L-NAME (1, 5mg/kg, i.p.) or the selective NOS inhibitor 7-NI (15, 30mg/kg, i.p.), with an ineffective combination of morphine (0.1mg/kg) plus agmatine (1mg/kg) produced significant anticonvulsant impacts. Moreover, the NO precursor, l-arginine (30, 60mg/kg, i.p.), inhibited the anticonvulsant action of agmatine (3mg/kg) plus morphine (0.5mg/kg) co-administration. Our results indicate that pretreatment of animals with agmatine enhances the anticonvulsant effects of morphine via a mechanism which may involve the NO pathway.

STUDY OBJECTIVE:

To determine the risk factors of perioperative complications and the impact of intrathecal morphine (ITM) in major vascular surgery.

DESIGN:

Retrospective analysis of a prospective cohort. SETTINGS: Operating room, intensive care unit, and Postanesthesia Care Unit of a university hospital.

MEASUREMENTS:

Data from 595 consecutive patients who underwent open abdominal aortic surgery between January 1997 and December 2011 were reviewed. Data were stratified into three groups based on the analgesia technique delivered: systemic analgesia (Goup SA), thoracic epidural analgesia (Group TEA), and intrathecal morphine (Group ITM). Preoperative patient characteristics, perioperative anesthetic and medical interventions, and major nonsurgical complications were recorded.

MAIN RESULTS:

Patients managed with ITM (n=248) and those given thoracic epidural analgesia (n=70) required lower doses of intravenous (IV) sufentanil intraoperatively and were extubated sooner than those who received systemic analgesia (n=270). Total inhospital mortality was 2.9%, and 24.4% of patients experienced at least one major complication during their hospital stay. Intrathecal morphine was associated with a lower risk of postoperative morbidity (OR 0.51, 95% CI 0.28 - 0.89), particularly pulmonary complications (OR 0.54, 95% CI 0.31 - 0.93) and renal dysfunction (OR 0.52, 95% CI 0.29 - 0.97). Other predictors of nonsurgical complications were ASA physical status 3 and 4 (OR 1.94, 95% CI 1.07 - 3.52), preoperative renal dysfunction (OR 1.61, 95% CI 1.01 - 2.58), prolonged surgical time (OR 1.78, 95% CI 1.16 - 2.78), and the need for blood transfusion (OR 1.77, 95% CI 1.05 - 2.99).

CONCLUSION:

This single-center study showed a decreased risk of major nonsurgical complications in patients who received neuraxial analgesia after abdominal aortic surgery.