European clinical practice recommendations on opioids for chronic noncancer pain - Part 2: Special situations

BACKGROUND

Opioid use for chronic non-cancer pain (CNCP) is under debate. In the absence of pan-European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC).

METHODS

The clinical practice recommendations were developed by eight scientific societies and one patient self-help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence-based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case-series, case-control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment.

RESULTS

The European Clinical Practice Recommendations give guidance for combination with other medications, the management of frequent (e.g. nausea, constipation) and rare (e.g. hyperalgesia) side effects, for special clinical populations (e.g. children and adolescents, pregnancy) and for special situations (e.g. liver cirrhosis).

CONCLUSION

If a trial with opioids for chronic noncancer pain is conducted, detailed knowledge and experience are needed to adapt the opioid treatment to a special patient group and/or clinical situation and to manage side effects effectively.

SIGNIFICANCE

If a trial with opioids for chronic noncancer pain is conducted, detailed knowledge and experience are needed to adapt the opioid treatment to a special patient group and/or clinical situation and to manage side effects effectively. A collaboration of medical specialties and of all health care professionals is needed for some special populations and clinical situations.

Distribution of Fluvoxamine and Identification of the Main Metabolite in a Fatal Intoxication

Fluvoxamine is a selective serotonin reuptake inhibitor, with a half-life of about 30 hours, that is commonly prescribed in the treatment of depression and obsessive and compulsive disorders. Though its more favorable adverse effect profile in comparison to tricyclic antidepressants, overdosages could lead to severe central nervous system depression. We hereby report the case of a 48-year-old woman with psychiatric disorders, who died in the Protected Community where she lived. An autopsy, during which multiorgan congestion and aspiration of gastric content were found, was performed 9 days after the death. Femoral and cardiac blood, urine and bile were collected for toxicological analysis. GC-MS, LC-MS-MS and LC-HRMS screenings were performed on blood samples. The analysis allowed to identify the following drugs: fluvoxamine, clotiapine, 7-aminoclonazepam, propranolol, gabapentin and haloperidol. Quantification of the detected drugs in blood was performed by means of a validated LC-MS-MS analytical procedure, and the following results were achieved: fluvoxamine (2.20 mg/L), gabapentin (41.00 mg/L), 7-aminoclonazepam (0.24 mg/L), clotiapine (0.07 mg/L), haloperidol (<0.01 mg/L) and propranolol (0.24 mg/L). Fluvoxamine concentration in blood exceeded ~10 times the upper limit of therapeutic blood levels (0.23 mg/L). Contributory causes of death, such as due to multiple drug use, however, cannot be excluded. The distribution of fluvoxamine in all biological fluids was evaluated and a postmortem redistribution effect was observed (C/P blood ratio: 1.86). Fluvoxamine acid metabolite was identified in urine, bile and in cardiac blood, through an LC-QTOF analytical procedure.

Urinary retention on an acute geriatric hospitalisation unit: prevalence, risk factors and the role of screening, an observational cohort study

PURPOSE

Urinary retention (UR) is common in older patients. The aim of this observational cohort study was to measure the prevalence of UR in patients aged ≥ 75 years on admission to an acute geriatric hospitalisation unit and to determine which at risk group would benefit from screening.

METHODS

Post-void residual volumes (PVR) were measured within 3 days of admission with an ultrasound bladder scan. Uni- and multivariable analysis were used to determine risk factors associated with PVR ≥ 150 and ≥ 300 millilitres.

RESULTS

Ninety-four patients, mean age 84.6 years, were included. The male/female ratio was 0.7. Patients with PVR ≥ 150 (29.8%) had more urological comorbidities, symptoms of overflow incontinence, voiding difficulties, subtotal voiding, faecal impaction, urinary tract infection (UTI) and were more frequently referred because of urinary symptoms. Patients with PVR ≥ 300 lived less at home, had more urological comorbidities, dysuria, voiding difficulties, subtotal voiding, constipation, faecal impaction, UTI, detrusor relaxants, and were more frequently referred because of urinary symptoms. Voiding difficulties and referral because of urinary symptoms were independently associated with PVR ≥ 150. Not living at home, reporting subtotal voiding, constipation, and referral because of urinary symptoms were independently associated with PVR ≥ 300.

CONCLUSION

Screening for UR on admission to an acute geriatric hospitalisation unit is most indicated in patients with urinary and defaecation problems. However, because the prevalence was high, because UR was also observed in patients without these problems, and history taking may be difficult, the threshold for PVR measurement in acutely ill geriatric patients should be low.

TRIAL REGISTRATION

Clinicaltrials.gov NTC04715971, January 19, 2021 (retrospectively registered).

Urinary retention concomitant with methamphetamine use: a case report

Background

Urinary retention is a condition in which impaired emptying of the bladder results in postvoid residual urine. It can be acute or chronic urinary retention. There have been only scattered case studies that have described urinary retention resulting from methamphetamine use. This case report is aimed at raising awareness about methamphetamine abuse as an important factor in the aetiological considerations when evaluating cases of urinary retention among healthy younger age groups.

Case presentation

We report a patient who had acute urinary retention after brief amphetamine use. A 26-year-old Nigerian man presented at the emergency room on account of an inability to pass urine and lower abdominal pain. Before this incident, the patient reported a recent ingestion of amphetamine to achieve weight reduction and a fit body. A week after use, he started to experience difficulty passing out urine hence necessitating a visit to the emergency department. After a brief assessment, physical examination revealed a man in painful distress with mild suprapubic fullness. He had a successful passage of a urethral catheter for continuous bladder drainage with dramatic improvement in his symptoms. He was subsequently discontinued on methamphetamine use and referred to a urologist for further evaluation.

Conclusion

Most cases of urinary retention are diagnosed clinically and are rarely missed. But because urinary retention is associated with a wide range of aetiological factors, clinicians need to be aware of the effects of certain drugs in the aetiology of urinary retention. In the management of a case of urinary retention in the younger age group, clinicians should enquire about a history of drug use, the drug of particular interest being methamphetamine, and also employ the use of urodynamic studies in the evaluation of such cases.

Postoperative urinary retention: risk factors, bladder filling rate and time to catheterization: an observational study as part of a randomized controlled trial

BACKGROUND

Knowledge of risk factors for postoperative urinary retention may guide appropriate and timely urinary catheterization. We aimed to determine independent risk factors for postoperative urinary catheterization in general surgical patients. In addition, we calculated bladder filling rate and assessed the time to spontaneous voiding or catheterization. We used the patients previously determined individual maximum bladder capacity as threshold for urinary catheterization.

METHODS

Risk factors for urinary catheterization were prospectively determined in 936 general surgical patients. Patients were at least 18 years of age and operated under general or spinal anesthesia without the need for an indwelling urinary catheter. Patients measured their maximum bladder capacity preoperatively at home, by voiding in a calibrated bowl after a strong urge that could no longer be ignored. Postoperatively, bladder volumes were assessed hourly with ultrasound. When patients reached their maximum bladder capacity and were unable to void, they were catheterized by the nursing staff. Bladder filling rate and time to catheterization were determined.

RESULTS

Spinal anesthesia was the main independent modifiable risk factor for urinary catheterization (hyperbaric bupivacaine, relative risk 8.1, articaine RR 3.1). Unmodifiable risk factors were a maximum bladder capacity < 500 mL (RR 6.7), duration of surgery ≥ 60 min (RR 5.5), first scanned bladder volume at the Post Anesthesia Care Unit ≥250mL (RR 2.1), and age ≥ 60 years (RR 2.0). Urine production varied from 100 to 200 mL/h. Catheterization or spontaneous voiding took place approximately 4 h postoperatively.

CONCLUSION

Spinal anesthesia, longer surgery time, and older age are the main risk factors for urinary retention catheterization. Awareness of these risk factors, regularly bladder volume scanning (at least every 3 h) and using the individual maximum bladder capacity as volume threshold for urinary catheterization may avoid unnecessary urinary catheterization and will prevent bladder overdistention with the attendant risk of lower urinary tract injury.

TRIAL REGISTRATION

Dutch Central Committee for Human Studies registered trial database: NL 21058.099.07. Current Controlled Trials database: Preventing Bladder Catheterization after an Operation under General or Spinal Anesthesia by Using the Patient's Own Maximum Bladder Capacity as a Limit for Maximum Bladder Volume. ISRCTN97786497 . Registered 18 July 2011 -Retrospectively registered. The original study started 19 May 2008, and ended 30 April 2009, when the last patient was included.

Monitoring of micturition and bladder volumes can replace routine indwelling urinary catheters in children receiving intravenous opioids: a prospective cohort study

In this prospective observational study, the incidence, risk factors and the time to event of urinary retention in children receiving intravenous opioids were evaluated. Urinary retention was confirmed by ultrasound following the inability to void for 8 h or earlier in patients experiencing discomfort. In total, 207 opioid episodes were evaluated, of which 199 (96.1%) concerned morphine, in 187 children admitted to the pediatric ward or pediatric intensive care unit. The median age was 7.6 years (IQR 0.9-13.8), and 123 (59.4%) were male. The incidence of urinary retention was 31/207 (15.0%) opioid episodes, in which 14/32 (43.8%) patients received continuous sedation for mechanical ventilation and 17/175 (9.7%) received no sedation. Multivariable logistic regression analysis showed a significant association with continuous sedation (OR 6.8, 95% CI 2.7-17.4, p 0.001) and highest daily fluid intake (OR 0.8 per 10% deviation of normal intake, 95% CI 0.7-0.9, p 0.01). Opioid dosage, age and gender were not significantly associated. Most events (28/31, 90.3%) occurred within 24 h.Conclusion: The incidence of urinary retention in children receiving intravenous opioids is low, indicating that placement of urinary catheters is not routinely necessary in these patients. However, micturition and bladder volumes must be monitored, especially in sedated children and during the first 24 h of opioid administration. What is Known: • Great variation exists in the routine placement of urinary catheters in children receiving IV opioids. What is New: • Confirmed by ultrasound, the incidence of urinary retention in children receiving intravenous opioids in this study was 15%, indicating that placement of urinary catheters is not routinely necessary in these patients. • Children receiving continuous sedation for invasive mechanical ventilation showed a sevenfold greater risk of developing urinary retention than non-sedated patients.

Inhibitory Effects of Antipsychotics on the Contractile Response to Acetylcholine in Rat Urinary Bladder Smooth Muscles

The clinical applications of antipsychotics for symptoms unrelated to schizophrenia, such as behavioral and psychological symptoms, in patients with Alzheimer's disease, and the likelihood of doctors prescribing antipsychotics for elderly people are increasing. In elderly people, drug-induced and aging-associated urinary disorders are likely to occur. The most significant factor causing drug-induced urinary disorders is a decrease in urinary bladder smooth muscle (UBSM) contraction induced by the anticholinergic action of therapeutics. However, the anticholinergic action-associated inhibitory effects of antipsychotics on UBSM contraction have not been sufficiently assessed. In this study, we examined 26 clinically available antipsychotics to determine the extent to which they inhibit acetylcholine (ACh)-induced contraction in rat UBSM to predict the drugs that should not be used by elderly people to avoid urinary disorders. Of the 26 antipsychotics, six (chlorpromazine, levomepromazine (phenothiazines), zotepine (a thiepine), olanzapine, quetiapine, clozapine (multi-acting receptor targeted antipsychotics (MARTAs))) competitively inhibited ACh-induced contractions at concentrations corresponding to clinically significant doses. Further, 11 antipsychotics (perphenazine, fluphenazine, prochlorperazine (phenothiazines), haloperidol, bromperidol, timiperone, spiperone (butyrophenones), pimozide (a diphenylbutylpiperidine), perospirone, blonanserin (serotonin-dopamine antagonists; SDAs), and asenapine (a MARTA)) significantly suppressed ACh-induced contraction; however, suppression occurred at concentrations substantially exceeding clinically achievable blood levels. The remaining nine antipsychotics (pipamperone (a butyrophenone), sulpiride, sultopride, tiapride, nemonapride (benzamides), risperidone, paliperidone (SDAs), aripiprazole, and brexpiprazole (dopamine partial agonists)) did not inhibit ACh-induced contractions at concentrations up to 10-5 M. These findings suggest that chlorpromazine, levomepromazine, zotepine, olanzapine, quetiapine, and clozapine should be avoided by elderly people with urinary disorders.

Clinical Protocol for Identifying and Managing Bladder Dysfunction during Acute Care after Traumatic Spinal Cord Injury

Bladder dysfunction is widespread following traumatic spinal cord injury (TSCI). Early diagnosis of bladder dysfunction is crucial in preventing complications, determining prognosis, and planning rehabilitation. We aim to suggest the first clinical protocol specifically designed to evaluate and manage bladder dysfunction in TSCI patients during acute care. A retrospective cohort study was conducted on 101 patients admitted for an acute TSCI between C1 and T12. Following spinal surgery, presence of voluntary anal contraction (VAC) was used as a criterion for removal of indwelling catheter and initiating trial of void (TOV). Absence of bladder dysfunction was determined from three consecutive post-void bladder scan residuals ≤200 mL without incontinence. All patients were reassessed 3 months post-injury using the Spinal Cord Independence Measure (SCIM). A total of 74.3% were diagnosed with bladder dysfunction during acute care, while 57.4% had a motor-complete TSCI. Three months later, 94.7% of them reported impaired bladder function. None of the patients discharged from acute care after a functional bladder was diagnosed reported impaired bladder function at the 3-month follow-up. A total of 95.7% patients without VAC had persisting impaired bladder function at follow-up. The proposed protocol is specifically adapted to the dynamic nature of neurogenic bladder function following TSCI. The assessment of VAC into the protocol provides major insight on the potential for reaching adequate bladder function during the subacute phase. Conducting TOV using bladder scan residuals in patients with VAC is a non-invasive and easy method to discriminate between a functional and an impaired bladder following acute TSCI.

Increasing Age Predicts Increasing Residual Urine Volume

OBJECTIVES

To determine reference values for postvoid residual (PVR) volume for patients referred to a tertiary urogynecology center.

METHODS

After Institutional Review Board approval, we performed a retrospective chart review of all new patients presenting to our referral center. We assessed associations between PVR and patient demographics, pelvic floor symptoms, and physical examination by Wilcoxon rank sum or Kruskal-Wallis tests as appropriate. A multivariable logistic regression model was used to calculate odds ratios for patient characteristics associated with PVR in the top age range-specific decile.

RESULTS

Three hundred sixty-one patients were included in the analysis. The median PVR was 20 mL (interquartile range, 1st, 3rd quartiles, 10, 50). Older age was associated with higher PVR (P < 0.001). The median PVR in participants younger than 40 years was 10 mL, ages 40 to 49 years was 18 mL, 50 to 69 years was 20 mL, 70 to 79 years was 38 mL and in women older than 79 years was 50 mL. A multivariable analysis showed that prolapse stage (odds ratio [OR], 3.46 with prolapse stage 2-4 vs stage 0-1; P = 0.001), history of stroke (OR, 7.62; [95% CI 2.17-26.77, P = 0.002]), narcotic use (OR, 2.45; [95% CI 1.01-5.92; P = 0.047]), and urinary frequency (OR, 2.61; [95% CI, 1.14-5.98; P = 0.024]) were risk factors for increased PVR (as defined at >90%ile for age), independent of the age-related elevation.

CONCLUSIONS

The majority of patients presenting for urogynecologic evaluation had a low PVR with a median of 20 mL. Postvoid residual was higher for older age groups but nearly all volumes were less than 100 mL. The utility of a PVR measurement is highest for patients with pelvic organ prolapse, urinary frequency, narcotic use, or history of stroke.

Association between anticholinergic burden and anticholinergic adverse outcomes in the elderly: Pharmacological basis of their predictive value for adverse outcomes

The use of anticholinergic drugs and other drugs with anticholinergic activity is highly prevalent in older people. Cumulative anticholinergic effects, known as anticholinergic burden, are associated with important peripheral and central adverse effects and outcomes. Several methods have been developed to quantify anticholinergic burden and to estimate the risk of adverse anticholinergic effects. Serum anticholinergic activity (SAA) and anticholinergic burden scoring systems are the most commonly used methods to predict the occurrence of important negative outcomes. These tools could guide clinicians in making more rational prescriptions to enhance patient safety, especially in older people. However, the literature has reported conflicting results about the predictive ability of these tools. The majority of these instruments ignore relevant pharmacologic aspects such as the doses used, differential muscarinic receptor subtype affinities, and blood-brain barrier permeability. To increase the clinical relevance of these tools, mechanistic and clinical pharmacology should collaborate. This narrative review describes the rational and pharmacological basis of anticholinergic burden tools and provides insight about their predictive value for adverse outcomes.

Scan-Negative Cauda Equina Syndrome: A Prospective Cohort Study

OBJECTIVE

To describe clinical features relevant to diagnosis, mechanism, and etiology in patients with "scan-negative" cauda equina syndrome (CES).

METHODS

We carried out a prospective study of consecutive patients presenting with the clinical features of CES to a regional neurosurgery center comprising semi-structured interview and questionnaires investigating presenting symptoms, neurologic examination, psychiatric and functional disorder comorbidity, bladder/bowel/sexual function, distress, and disability.

RESULTS

A total of 198 patients presented consecutively over 28 months. A total of 47 were diagnosed with scan-positive CES (mean age 48 years, 43% female). A total of 76 mixed category patients had nerve root compression/displacement without CES compression (mean age 46 years, 71% female) and 61 patients had scan-negative CES (mean age 40 years, 77% female). An alternative neurologic cause of CES emerged in 14/198 patients during admission and 4/151 patients with mean duration 25 months follow-up. Patients with scan-negative CES had more positive clinical signs of a functional neurologic disorder (11% scan-positive CES vs 34% mixed and 68% scan-negative, p < 0.0001), were more likely to describe their current back pain as worst ever (41% vs 46% and 70%, p = 0.005), and were more likely to have symptoms of a panic attack at onset (37% vs 57% and 70%, p = 0.001). Patients with scan-positive CES were more likely to have reduced/absent bilateral ankle jerks (78% vs 30% and 12%, p < 0.0001). There was no significant difference between groups in the frequency of reduced anal tone and urinary retention.

CONCLUSION

The first well-phenotyped, prospective study of scan-negative CES supports a model in which acute pain, medication, and mechanisms overlapping with functional neurologic disorders may be relevant.

Three-dimensional bladder ultrasound for estimation of urine volume in dogs compared with traditional 2-dimensional ultrasound methods

Background

Although point‐of‐care volumetric assessments of the urinary bladder are not routinely performed in dogs, urine volume quantification can provide important clinical information including noninvasive urine output estimation.

Hypothesis/Objective

Use of 3‐dimensional (3D) ultrasound for determination of urinary bladder volume (UBV) in dogs will be accurate for different bladder volumes and will decrease the need for operator skill in measuring UBV compared to 2‐dimensional (2D) ultrasound evaluation.

Animals

Ten laboratory‐bred Beagle dogs.

Methods

Prospective, experimental study. Urinary bladders were infused with a calculated amount of sterile saline to represent small, medium, and large volumes. Each UBV was estimated and calculated by a board‐certified veterinary radiologist using 3 different 2D ultrasound formulas followed by use of a 3D ultrasound device by a novice. Measured UBVs were compared to the instilled UBV for both 2D and 3D ultrasound methods. Time from start to end of examination was recorded for both ultrasound methods in a subset of dogs.

Results

The 3D ultrasound device underestimated UBV with a mean difference of −9.8 mL compared with 2D ultrasound that overestimated UBV with a difference of +4.2 to 20.3 mL dependent on the 2D formula used. The 3D ultrasound method took less time to measure UBV (mean of 80 seconds per measurement) compared to the 2D method (165 seconds per measurement; P = .02).

Conclusions and Clinical Importance

The tested 3D ultrasound device was found to be an accurate and rapid point‐of‐care tool for measuring UBV in dogs, providing a noninvasive method to estimate bladder volume in real time.

Bladder Care in Palliative Care Inpatients: A Prospective Dual Site Cohort Study

Background: Urinary catheterization is often undertaken to relieve distressing bladder symptoms in palliative care.

Objective: The primary aim of this study was to determine the incidence of, and clinical indications that predispose patients admitted to palliative care units to, urinary catheterization. The secondary aims were to determine causal factors, including the type of malignancy, antecedent medications, and duration of admission in these patients.

Methods: This was a prospective observational dual site cohort study in palliative care inpatients. Univariate categorical chi-square analysis was performed to compare patients with and without urinary catheterization, and to identify risk factors associated with urinary catheter use.

Results: The incidence of catheterization in this cohort was 41% (43/104) and urinary retention (63%) was the most common cause. Agitation (47%) and urinary incontinence (70%) were common symptoms in those catheterized. Medications that were significantly associated with the need for urinary catheterization were benzodiazepines (p < 0.01) and antipsychotics (p = 0.01). All measures that define poor functional status were found to be significant (p < 0.01). Patients with prolonged hospitalization of greater than three weeks were catheterized more frequently (p = 0.017). The majority of patients catheterized (79%) were admitted for terminal care.

Conclusions: The high incidence of urinary catheterization highlights the need for good bladder care for all patients in the palliative care setting. Patients with risk factors include the use of antipsychotics and benzodiazepines, declining functional status and prolonged hospital admission are more likely to be catheterized.

Urinary Retention in a Patient With an Artificial Urinary Sphincter: A Case Report of a Rare Cause of Urinary Retention

Urinary retention is the inability to spontaneously void with lower abdominal or suprapubic pain caused by infection, trauma, obstruction, medications, or neurological etiologies. Acute urinary retention (AUR) is a urological emergency often seen in males presenting to the emergency department (ED). AUR is frequently seen in men over the age of 60 and approximately one-third of men over the age of 80. A 61-year-old Spanish-speaking male, with a history of prostate cancer and prostatectomy with the recent insertion of an artificial urethral sphincter two months prior, presented to the ED with urinary retention, complaining of malfunction in his artificial sphincter with worsening abdominal pain, distention, urinary urgency, and nausea. A bladder scan demonstrated 450 ml of urine. Bedside ultrasound (US) showed moderate bilateral hydronephrosis and hydroureter. After consultation with urology, they revealed that the patient did not understand how to properly use his implanted device. Urology experts have recommended minimal urethral instrumentation in patients with artificial urinary sphincters due to the risk of complications. Although we present a rare cause of urinary retention, emergency physicians should avoid catheterization in these patients. Bedside renal ultrasound is useful for the diagnosis of hydronephrosis and hydroureter and confirmation of pump and balloon placement. We recommend a prompt urology consultation. This case is an important example of appropriate postoperative education and close-ended communication. Certified interpreters should be used to avoid communication barriers and complications.

Chronic opioid use is associated with increased postoperative urinary retention, length of stay and non-routine discharge following lumbar fusion surgery

BACKGROUND

The incidence of chronic opioid use (COU) is increasing with health related complications impacting both patients and healthcare services.

OBJECTIVE

The aim of this study was to identify the impact of COU on postoperative urinary retention (PUR) in patients following lumbar fusion surgery as well as its impact on length of stay (LOS) and non-routine discharges (NRD).

MATERIALS & METHODS

The State Inpatient Databases were utilised to identify patients undergoing elective lumbar fusion procedures. Patients with and without COU were separated into groups and matched using 3:1 propensity score matching. PUR, LOS in the upper quartile and discharge to a location other than home were the outcomes of interest. Multivariable logistic regression was used to examine the impact of COU on the above outcomes and Wald chi-square tests were used to determine the factors with the most significant associations.

RESULTS

COU was significant for PUR (p = 0.037), prolonged LOS (p < 0.001), and NRD (p < 0.001). Factors most significantly associated with PUR were Elixhauser Mortality Index and COU both with p < 0.05. Factors associated with prolonged LOS and NRD were Elixhauser Mortality Index, COU, and insurance status.

CONCLUSION

COU has a notable impact on PUR, LOS, and NRD. The Elixhauser Mortality Index and insurance status of patients also showed predictive utility for these outcomes. This knowledge enables us to identify sources of pressure for health services and approach them strategically through increased awareness.

A Review of Urologic Conditions in Remote and Austere Environments: Presentation, Evaluation, and Management

The objective of this review is to provide recommendations on the evaluation and management of urologic conditions in a resource-poor or austere setting from the perspective of the urological literature. The material was synthesized predominantly from urologic society guidelines and journals to bring additional urology-focused insight to the topic to complement the currently available literature, which is largely based on recommendations from nonurologic specialties. We sought to provide a reference guide from a urology-based framework that encourages a collaborative multidisciplinary approach to the development of a resource that serves those in a wilderness, austere, or resource-poor setting.

Assessment of patients with lower urinary tract symptoms where an undiagnosed neurological disease is suspected: A report from an International Continence Society consensus working group

AIM

Lower urinary tract symptoms (LUTS) are a common urological referral, which sometimes can have a neurological basis in a patient with no formally diagnosed neurological disease ("occult neurology"). Early identification and specialist input is needed to avoid bad LUTS outcomes, and to initiate suitable neurological management.

METHODS

The International Continence Society established a neurological working group to consider: Which neurological conditions may include LUTS as an early feature? What diagnostic evaluations should be undertaken in the LUTS clinic? A shortlist of conditions was drawn up by expert consensus and discussed at the annual congress of the International Neurourology Society. A multidisciplinary working group then generated recommendations for identifying clinical features and management.

RESULTS

The relevant conditions are multiple sclerosis, multiple system atrophy, normal pressure hydrocephalus, early dementia, Parkinsonian syndromes (including early Parkinson's Disease and Multiple System Atrophy) and spinal cord disorders (including spina bifida occulta with tethered cord, and spinal stenosis). In LUTS clinics, the need is to identify additional atypical features; new onset severe LUTS (excluding infection), unusual aspects (eg, enuresis without chronic retention) or "suspicious" symptoms (eg, numbness, weakness, speech disturbance, gait disturbance, memory loss/cognitive impairment, and autonomic symptoms). Where occult neurology is suspected, healthcare professionals need to undertake early appropriate referral; central nervous system imaging booked from LUTS clinic is not recommended.

CONCLUSIONS

Occult neurology is an uncommon underlying cause of LUTS, but it is essential to intervene promptly if suspected, and to establish suitable management pathways.

Postoperative Urinary Retention in Patients Undergoing Lung Resection: Incidence and Risk Factors

BACKGROUND

The purpose of this study was to (1) determine the incidence of postoperative urinary retention (POUR) in patients undergoing lung resection at our institution, (2) identify differences in potential risk factors between patients with and without POUR, and (3) describe patient outcomes across POUR status.

METHODS

The medical records of 225 patients between 2016 and 2017 were reviewed, and 191 met criteria for inclusion. The institution's catheterization removal protocol was followed in all patients. Recatheterization was defined as requiring in-and-out catheterization or Foley catheter placement. Fisher exact and Wilcoxon tests were used for analysis.

RESULTS

POUR developed in 35 patients (18%). Patients with POUR were older (P = .01), had increased baseline creatinine (P = .04), and a higher prevalence of benign prostatic hyperplasia (P = .007). POUR patients were also less likely to get a Foley catheter intraoperatively (P = .0002). Other intraoperative factors, such as surgical approach and extent of resection, were not significantly different between patients with and without POUR. Postoperative factors (epidural use or days with chest tube) were similar. Although patients with POUR were more likely to be discharged with a Foley catheter (13% vs 0%, P = .002), no difference in length of stay, incidences of urinary tract infections, or 30-day readmission were observed.

CONCLUSIONS

POUR develops in approximately 1 in 5 patients undergoing lung resection. Patients with POUR were more likely to not have a Foley catheter placed intraoperatively. However, patients who had POUR did not have worsened patient outcomes (urinary tract infections, length of stay, or 30-day readmission).

Incidence and risk factors of non-device-associated urinary tract infections in an acute-care hospital

OBJECTIVE

To update current estimates of non-device-associated urinary tract infection (ND-UTI) rates and their frequency relative to catheter-associated UTIs (CA-UTIs) and to identify risk factors for ND-UTIs.

DESIGN

Cohort study.

SETTING

Academic teaching hospital.

PATIENTS

All adult hospitalizations between 2013 and 2017 were included. UTIs (device and non-device associated) were captured through comprehensive, hospital-wide active surveillance using Centers for Disease Control and Prevention case definitions and methodology.

RESULTS

From 2013 to 2017 there were 163,386 hospitalizations (97,485 unique patients) and 1,273 UTIs (715 ND-UTIs and 558 CA-UTIs). The rate of ND-UTIs remained stable, decreasing slightly from 6.14 to 5.57 ND-UTIs per 10,000 hospitalization days during the study period (P = .15). However, the proportion of UTIs that were non-device related increased from 52% to 72% (P < .0001). Female sex (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.50-2.50) and increasing age were associated with increased ND-UTI risk. Additionally, the following conditions were associated with increased risk: peptic ulcer disease (HR, 2.25; 95% CI, 1.04-4.86), immunosuppression (HR, 1.48; 95% CI, 1.15-1.91), trauma admissions (HR, 1.36; 95% CI, 1.02-1.81), total parenteral nutrition (HR, 1.99; 95% CI, 1.35-2.94) and opioid use (HR, 1.62; 95% CI, 1.10-2.32). Urinary retention (HR, 1.41; 95% CI, 0.96-2.07), suprapubic catheterization (HR, 2.28; 95% CI, 0.88-5.91), and nephrostomy tubes (HR, 2.02; 95% CI, 0.83-4.93) may also increase risk, but estimates were imprecise.

CONCLUSION

Greater than 70% of UTIs are now non-device associated. Current targeted surveillance practices should be reconsidered in light of this changing landscape. We identified several modifiable risk factors for ND-UTIs, and future research should explore the impact of prevention strategies that target these factors.

[Treatment of benign prostatic hyperplasia in geriatric patients-use and limitations of existing guidelines]

The demographic developments of western society and the resulting increase in the number of very old patients in urology represents a challenge for the design of clinical studies and, consequently, recommendations of guidelines. While in internal medicine there is already a subspecialization with a focus on the treatment of elderly and multimorbid patients, in urology there is hardly any subspecialization into the problems of geriatric patients. Thus, using a case study as an example, the treatment decisions for benign prostatic hyperplasia (BPH) in geriatric patients are discussed. In addition the available evidence from the literature and guidelines are presented in order to assiste in daily management of geriatric patients with lower urinary tract symptoms and to critically discuss potential fields of application and limitations of the existing guidelines. In this context, we also examine the challenges when choosing a drug therapy and in deciding which of the many surgical options should be used.

Relative Risk of Adverse Events and Treatment Discontinuations Between Older and Non-Older Adults Treated with Antimuscarinics for Overactive Bladder: A Systematic Review and Meta-Analysis

INTRODUCTION

Overactive bladder (OAB) affects adults of all ages. The risk for medication-related adverse events (AEs) may differ between age groups, given age-related changes in pharmacokinetics and pharmacodynamics. No previous study has differentiated the risk of AEs between older and non-older adults with OAB.

OBJECTIVE

Our objective was to assess the risk of AEs and treatment discontinuations between older and non-older adults with OAB initiated on an antimuscarinic.

METHODS

We searched MEDLINE (PubMed interface), Embase, SCOPUS, and Cochrane Central Register for Controlled Trials in a previous analysis in February 2015 and repeated the search in August 2018, with no additional studies identified. Studies that delineated AEs or treatment discontinuations between the older and non-older (age <65 years) subjects were included.

RESULTS

Six studies that made nine comparisons between older and non-older subjects met the inclusion criteria. The AEs of dry mouth (46.7%), constipation (10.3%), and headache (7.7%) were most frequently reported. Older subjects were more likely to experience dry mouth (relative risk [RR] 1.09; 95% confidence interval [CI] 1.00-1.19), constipation (RR 1.92; 95% CI 1.52-2.43), dizziness (RR 2.37; 95% CI 1.21-4.62), and urinary retention (RR 4.17; 95% CI 1.76-9.89) than were non-older subjects. Headache was less likely to occur in older subjects (RR 0.58; 95% CI 0.40-0.86). Treatment discontinuations due to AEs were more likely to occur in the older subjects (RR 1.59; 95% CI 1.20-2.11).

CONCLUSION

Treatment of OAB with antimuscarinics in the older population resulted in significantly higher rates of AEs, barring headache, when compared with non-older subjects.

MDCT Imaging of Acute Bladder Pathology

In this review, we will discuss and illustrate the pathophysiology, presentation, and multidetector computed tomography findings associated with emergent bladder conditions, limiting our discussion to traumatic, infectious, and obstructive etiologies. After reviewing computed tomography cystographic technique, the commonly utilized classification systems for bladder trauma will be presented with illustrative examples of associated typical and more infrequent secondary injuries and complications. Next, the pathogenesis and imaging appearance of both mechanical and neurogenic acute urinary retention will be addressed, including less common though potentially pathognomonic obstructive etiologies including urethral calculi and ectopic ureteroceles. Finally, we will review and illustrate the imaging features of both inflammatory and infectious cystitis, including hemorrhagic and emphysematous variants, as well as the potentially encountered secondary complications.

Animal models of major depressive disorder and the implications for drug discovery and development

INTRODUCTION

Depression is a highly debilitating psychiatric disorder that affects the global population and causes severe disabilities and suicide. Depression pathogenesis remains poorly understood, and the disorder is often treatment-resistant and recurrent, necessitating the development of novel therapies, models and concepts in this field. Areas covered: Animal models are indispensable for translational biological psychiatry, and markedly advance the study of depression. Novel approaches continuously emerge that may help untangle the disorder heterogeneity and unclear categories of disease classification systems. Some of these approaches include widening the spectrum of model species used for translational research, using a broader range of test paradigms, exploring new pathogenic pathways and biomarkers, and focusing more closely on processes beyond neural cells (e.g. glial, inflammatory and metabolic deficits). Expert opinion: Dividing the core symptoms into easily translatable, evolutionarily conserved phenotypes is an effective way to reevaluate current depression modeling. Conceptually novel approaches based on the endophenotype paradigm, cross-species trait genetics and 'domain interplay concept', as well as using a wider spectrum of model organisms and target systems will enhance experimental modeling of depression and antidepressant drug discovery.

Antipsychotic Use and the Risk of Initiating Medication for Benign Prostate Hyperplasia in Persons With Alzheimer Disease: A Matched Cohort Study

BACKGROUND

Antipsychotics (APs) are known to exacerbate symptoms of benign prostate hyperplasia (BPH) and may even cause urinary retention. The anticholinergic effects of APs and their dopamine D2- and α-receptor blockade may lead to voiding dysfunction of BPH patients. The objective of our study was to investigate whether the use of APs is associated with an increased risk of initiating medication for BPH in men with Alzheimer disease (AD).

METHODS

Data from the nationwide MEDALZ (MEDication use and ALZheimer's disease) cohort, including all community-dwelling persons diagnosed with AD in Finland, were utilized. Register-based data included medication dispensing, comorbidities, and hospital discharge diagnoses. Men who initiated APs (n = 4579) were 1:1 matched with men who did not initiate APs (n = 4579), according to time since AD diagnoses and age. The risk of starting BPH medication was investigated with Cox regression.

RESULTS

Among AP users, BPH medication was initiated to 345 persons (7.5%). Antipsychotic use was not associated with risk of initiating BPH medication (comorbidity-adjusted hazard ratio, 0.92; 95% confidence interval, 0.74-1.15) compared with no use of APs. In addition, no risk was found when AP drug substances were analyzed separately.

CONCLUSIONS

Use of APs did not increase the risk of initiating medication for BPH in men with AD.

Electroacupuncture for Postoperative Urinary Retention: A Systematic Review and Meta-Analysis

Background

This systematic review aimed at summarizing and evaluating the evidence from randomized controlled trials (RCTs) which used electroacupuncture (EA) to treat postoperative urinary retention (PUR).

Methods

We searched thirteen databases electronically through April 2018 without language restrictions. We included RCTs of women with PUR; other types of urinary retention or not-RCTs were excluded. Two independent reviewers extracted studies' characteristics, and disagreements were resolved by consensus. Data were pooled and expressed as standard mean difference (SMD) for continuous outcomes and odds ratio (OR) for dichotomous outcomes, with 95% confidence interval (CI).

Results

We found very low to moderate level of evidence that effects of less than or equal to a week were statistically significant: therapeutic effect improved (OR=4.21; 95%CI [3.04, 5.83]; P<0.00001), residual urine volume decreased (SMD=-13.24; 95%CI [-15.70, -10.78]; P<0.00001), bladder capacity increased (SMD=0.56; 95%CI [0.30, 0.83]; P<0.0001), and urinary flow rate improved (SMD=0.91; 95%CI [0.64, 1.18]; P<0.00001). Effect over a week was statistically significant as well. Therapeutic effect improved (OR=8.29; 95%CI [2.91, 24.25]; P<0.0001), residual urine volume decreased (SMD=-1.78; 95%CI [-2.66, -0.89]; P<0.0001), bladder capacity (SMD=0.92; 95%CI [0.61, 1.23]; P<0.00001) and urinary flow rate (SMD=1.69; 95%CI [0.59, 2.79]; P=0.003) increased, and first urination after surgery was earlier (SMD=-0.92; 95%CI [-1.37, -0.46]; P<0.0001), compared with physical exercise, medication, or no treatment.

Conclusion

The efficacy and safety of EA on key outcomes in women with PUR are statistically significant, but the level of most evidence was very low or low. More large-scale, long-term RCTs with rigorous methodological quality are needed.

Association between urinary incontinence and physical frailty in Korea

OBJECTIVE

The purpose of this study was to investigate the associations between urinary incontinence (UI) and physical frailty (PF).

METHODS

The study participants (n = 404) who visited the geriatric clinic were divided into two groups according to the presence or absence of UI based on questionnaire results. We analysed the relationship between each factor associated with PF and the risk of UI according to the number of factors associated with PF.

RESULTS

Urinary incontinence was associated with grip strength and history of falls (P = 0.01, 0.02, respectively). The risk of UI increased as the patients' number of PF-related factors increased (P for trend = 0.04).

CONCLUSIONS

The risk of UI increased as the severity of PF increased. Strength and the experiences of falls were associated with UI.

Elevated clozapine levels associated with infection: A systematic review

Clozapine is the most effective anti-psychotic medication for treatment refractory schizophrenia. A growing number of case reports have linked infection to high clozapine levels and associated adverse outcomes. We present a systematic review of published cases to clarify the relationship between infection and elevated clozapine levels. The case reports were located through PubMed and Embase. In addition, 8 new cases from two Australian states were included. Demographics, psychiatric diagnoses and medical morbidities, medications, clinical symptoms, clozapine levels, inflammatory markers and final clinical outcome were extracted. 40 cases were identified in 23 publications that demonstrated elevated clozapine levels associated with infection. Infections were commonly respiratory in origin. Adverse events, typically sedation, were associated with raised clozapine levels during infection. In many cases the signs of infection such as fever and white blood cell count were reduced. Severe adverse effects were uncommon, with one case each of seizure, myocarditis and neutropenia. The relationship between infection, clozapine levels and adverse events is complex and multi-factorial. Monitoring of clozapine levels is essential during hospitalisation for infection and consideration should be given to gradual dose reduction to minimise dose related side effects.

Urinary Retention and Medication Utilization on a Palliative Care Unit: A Retrospective Observational Study

Urinary retention is a common problem at end-of-life that may be a result of medications used to control other symptoms. To determine whether use of retention-causing drugs was associated with catheterization for urinary retention among palliative care unit (PCU) patients, the authors reviewed charts of 91 consecutively admitted patients to a hospital-based PCU. Utilization of eight classes of retention-causing medications (opioids, antidopaminergics, benzodiazepines, anticholinergics, antidepressants, calcium channel antagonists, nonsteroidal anti-inflammatory drugs [NSAIDs], and H1 histamine antagonists) was compared between those catheterized for urinary retention (n = 34) and those never catheterized (n = 31). All patients used medication from more than one class of retention-causing medication. A statistically significant association with urinary retention occurred for antidopaminergic medications, but not other drug classes. The total number of classes of retention-causing medications was not associated with catheterization. These findings question whether urinary retention need hinder medication use for symptom management at end-of-life. Tapering of antidopaminergic medications, compared with other drug classes studied, may be more likely to resolve retention.

Prevalence of pain and pharmacological pain treatment among old people in nursing homes in 2007 and 2013

PURPOSE

Many elderly people living in nursing homes experience pain and take analgesic medication. The aim of this study was to analyze the prevalence of pain and pharmacological pain treatment among people living in nursing homes in Sweden, in two large, comparable, samples from 2007 to 2013.

METHODS

Cross-sectional surveys were performed in 2007 and 2013, including all residents in nursing homes in the county of Västerbotten, Sweden. A total of 4933 residents (2814 and 2119 respectively) with a mean age of 84.6 and 85.0 years participated. Of these, 71.1 and 72.4% respectively were cognitively impaired. The survey was completed by the staff members who knew the residents best.

RESULTS

The prescription of opioids became significantly more common while the use of tramadol decreased significantly. The staff reported that 63.4% in 2007 and 62.3% in 2013 had experienced pain. Of those in pain, 20.2% in 2007 and 16.8% in 2013 received no treatment and 73.4 and 75.0% respectively of those with pain, but no pharmacological treatment, were incorrectly described by the staff as being treated for pain.

CONCLUSIONS

There has been a change in the pharmacological analgesic treatment between 2007 and 2013 with less prescribing of tramadol and a greater proportion taking opioids. Nevertheless, undertreatment of pain still occurs and in many cases, staff members believed that the residents were prescribed analgesic treatment when this was not the case.

Inappropriate anticholinergic drugs prescriptions in older patients: analysing a hospital database

Background Although many anticholinergics are inappropriate in older patients, the prescription of these drugs in a hospital setting has not been extensively studied. Objective To describe prescriptions of anticholinergic drugs in terms of frequency, at risk situations and constipation in hospitalized, older adults. Setting Using a database from a French general hospital (period 2009-2013), we extracted information on 14,090 hospital stays by patients aged 75 and over. Methods Anticholinergic drug prescriptions were automatically detected, with a focus on prescriptions in three well-known at-risk situations: falls, dementia, and benign prostatic hyperplasia. Cases of constipation that might have been causally related to the administration of anticholinergic drugs were screened for and reviewed. Main outcome measure Prescriptions with a high associated risk of anticholinergic related adverse reactions. Results Administration of an anticholinergic drug was detected in 1412 (10.0%) of the hospital stays by older patients. At-risk situations were identified in 413 (36.5%) of these stays: 137 (9.7%) for falls, 243 (17.2%) for dementia, and 114 (8.1%) for benign prostatic hyperplasia; 78 (18.9%) of these 413 stays featured a combination of two or three at-risk situations. Cases of constipation induced by anticholinergic drug administration were identified in 188 (13.3%) patient stays by using validated adjudication rules for adverse drug reactions: 85 and 103 cases were respectively evaluated as "possible" or "probable" adverse drug reactions. Conclusions Anticholinergic drugs prescription was found in 10.0% of hospitalized, older patients. More than one third of these prescriptions occurred in at-risk situations and more than one in ten prescriptions induced constipation.

Treating Overactive Bladder in Older Patients with a Combination of Mirabegron and Solifenacin: A Prespecified Analysis from the BESIDE Study

BACKGROUND

The BESIDE study demonstrated that combination therapy (mirabegron and solifenacin 5mg) improved overactive bladder symptoms versus solifenacin 5mg or 10mg, and was well tolerated.

OBJECTIVE

To ensure efficacy and safety is maintained in older patients (>65 yr), who usually experience greater symptom severity and comorbidities, a prespecified subanalysis stratified by age group was conducted.

DESIGN, SETTING, AND PARTICIPANTS

Patients remaining incontinent (≥1 episode during 3-d diary) following 4-wk single-blind daily solifenacin 5mg were randomized 1:1:1 to a daily double-blind combination (solifenacin 5mg and mirabegron 25mg, increased to 50mg at wk 4), solifenacin 5mg or 10mg for 12 wk. Four cohorts stratified by age (<65 yr, ≥65 yr and < 75 yr, ≥75 yr) were investigated.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Efficacy assessments: change from baseline to end of treatment in average daily incontinence (primary) and micturition frequency (key secondary), number of incontinence episodes during the 3-d diary (key secondary), and change from baseline in average daily urgency and urgency incontinence episodes. Safety included treatment-emergent adverse events and vital signs.

RESULTS AND LIMITATIONS

Full analysis set included 2110 patients: 30.9% aged ≥65 yr and 8.9% aged ≥75 yr. At the end of treatment, daily, and 3-d incontinence daily micturitions, urgency, and urgency incontinence, were improved in each treatment group and age group; the largest reductions were observed with combination in each age cohort. There were no notable differences in vital signs or the incidence of treatment-emergent adverse events between treatment and age groups, with the exception of dry mouth, which was highest with solifenacin 10mg.

CONCLUSIONS

Efficacy and safety in the overall population is maintained in older (≥65 yr) and elderly (≥75 yr) patients treated with a combination of solifenacin and mirabegron, or solifenacin monotherapy; irrespective of age, combination was associated with the greatest improvement in overactive bladder symptoms.

PATIENT SUMMARY

This study investigated the effectiveness and safety of a combination of two different treatments (mirabegron 50mg and solifenacin 5mg) or solifenacin (5mg or 10mg) alone in patients aged <65 yr or ≥65 yr, and <75 yr or ≥75 yr with overactive bladder. Symptoms of overactive bladder, such as the urgent need to visit the toilet, incontinence, and frequent urination, were improved with all treatments regardless of the patient's age, but combination treatment demonstrated the greatest benefit, and was well tolerated.

Bilateral Breast Reduction Without Opioid Analgesics: A Comparative Study

BACKGROUND

Breast reduction has traditionally been performed under general anesthesia with adjunct opioid use. However, opioids are associated with a wide variety of adverse effects, including nausea, vomiting, constipation, postoperative sedation, dizziness, and addiction.

OBJECTIVES

This study compares bilateral breast reduction using a multimodal opioid-free pain management regimen vs traditional general anesthesia with adjunct opioids.

METHODS

A total of 83 female patients were enrolled in this study. Group 1 includes a retrospective series of 39 patients that underwent breast reduction via general anesthesia with adjunct opioid use. This series was compared to 2 prospective groups of patients who did not receive opioids either preoperatively or intraoperatively. In group 2, twenty-six patients underwent surgery under intravenous sedation and local anesthesia. In group 3, eighteen patients underwent surgery with general anesthesia. All patients in groups 2 and 3 received preoperative gabapentin and celecoxib along with infiltration of local anesthetics during the operation and prior to discharge to the Post-Anesthesia Care Unit (PACU). Primary outcome measures included the duration of surgery, time from end of operation to discharge home, postoperative opioid and antiemetic use, and unplanned postoperative hospitalizations.

RESULTS

When compared to group 1, groups 2 and 3 experienced a shorter time from end of operation to discharge home (P < 0.05), fewer unplanned hospital admissions (P < 0.05), and highly significant decrease in postoperative opioid use (P < 0.001).

CONCLUSIONS

This multimodal approach allows patients to safely undergo opioid-free bilateral breast reduction either under local or general anesthesia as an outpatient. This method resulted in significantly less morbidity, use of opioids postoperatively, as well as unplanned hospital admissions compared to "traditional" breast reduction under general anesthesia with the use of opioids.

LEVEL OF EVIDENCE

3.

The Safety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature

Newer generation antidepressant drugs (ADs) are widely used as the first line of treatment for major depressive disorders and are considered to be safer than tricyclic agents. In this critical review, we evaluated the literature on adverse events, tolerability and safety of selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, bupropion, mirtazapine, trazodone, agomelatine, vilazodone, levomilnacipran and vortioxetine. Several side effects are transient and may disappear after a few weeks following treatment initiation, but potentially serious adverse events may persist or ensue later. They encompass gastrointestinal symptoms (nausea, diarrhea, gastric bleeding, dyspepsia), hepatotoxicity, weight gain and metabolic abnormalities, cardiovascular disturbances (heart rate, QT interval prolongation, hypertension, orthostatic hypotension), genitourinary symptoms (urinary retention, incontinence), sexual dysfunction, hyponatremia, osteoporosis and risk of fractures, bleeding, central nervous system disturbances (lowering of seizure threshold, extrapyramidal side effects, cognitive disturbances), sweating, sleep disturbances, affective disturbances (apathy, switches, paradoxical effects), ophthalmic manifestations (glaucoma, cataract) and hyperprolactinemia. At times, such adverse events may persist after drug discontinuation, yielding iatrogenic comorbidity. Other areas of concern involve suicidality, safety in overdose, discontinuation syndromes, risks during pregnancy and breast feeding, as well as risk of malignancies. Thus, the rational selection of ADs should consider the potential benefits and risks, likelihood of responsiveness to the treatment option and vulnerability to adverse events. The findings of this review should alert the physician to carefully review the appropriateness of AD prescription on an individual basis and to consider alternative treatments if available.

Safety, tolerability, and risks associated with first- and second-generation antipsychotics: a state-of-the-art clinical review

Since the discovery of chlorpromazine (CPZ) in 1952, first-generation antipsychotics (FGAs) have revolutionized psychiatric care in terms of facilitating discharge from hospital and enabling large numbers of patients with severe mental illness (SMI) to be treated in the community. Second-generation antipsychotics (SGAs) ushered in a progressive shift from the paternalistic management of SMI symptoms to a patient-centered approach, which emphasized targets important to patients - psychosocial functioning, quality of life, and recovery. These drugs are no longer limited to specific Diagnostic and Statistical Manual of Mental Disorders (DSM) categories. Evidence indicates that SGAs show an improved safety and tolerability profile compared with FGAs. The incidence of treatment-emergent extrapyramidal side effects is lower, and there is less impairment of cognitive function and treatment-related negative symptoms. However, treatment with SGAs has been associated with a wide range of untoward effects, among which treatment-emergent weight gain and metabolic abnormalities are of notable concern. The present clinical review aims to summarize the safety and tolerability profile of selected FGAs and SGAs and to link treatment-related adverse effects to the pharmacodynamic profile of each drug. Evidence, predominantly derived from systematic reviews, meta-analyses, and clinical trials of the drugs amisulpride, aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, sertindole, ziprasidone, CPZ, haloperidol, loxapine, and perphenazine, is summarized. In addition, the safety and tolerability profiles of antipsychotics are discussed in the context of the "behavioral toxicity" conceptual framework, which considers the longitudinal course and the clinical and therapeutic consequences of treatment-emergent side effects. In SMI, SGAs with safer metabolic profiles should ideally be prescribed first. However, alongside with safety, efficacy should also be considered on a patient-tailored basis.

The Basic Pharmacology of Opioids Informs the Opioid Discourse about Misuse and Abuse: A Review

Morphine and other opioids are widely used to manage moderate to severe acute pain syndromes, such as pain associated with trauma or postoperative pain, and they have been used to manage chronic pain, even chronic nonmalignant pain. However, recent years have seen a renewed recognition of the potential for overuse, misuse, and abuse of opioids. Therefore, prescribing opioids is challenging for healthcare providers in that clinical effectiveness must be balanced against negative outcomes-with the possibility that neither are achieved perfectly. The current discourse about the dual 'epidemics' of under-treatment of legitimate pain and the over-prescription of opioids is clouded by inadequate or inaccurate understanding of opioid drugs and the endogenous pain pathways with which they interact. An understanding of the basic pharmacology of opioids helps inform the clinician and other stakeholders about these simultaneously under- and over-used agents.

High Risk of Postoperative Urinary Retention in 1-Year-Old Cleft Palate Patients: An Observational Study

PURPOSE

Estimate the frequency of urinary catheterizations in a high-risk population of children.

DESIGN

It was a descriptive, observational study.

METHODS

Incidence of postoperative urinary retention was recorded for one-year-old cleft palate surgery patients admitted to the postanaesthesia care unit or pediatric intensive care unit at Rikshospitalet, Oslo University Hospital, Norway.

FINDING

Forty-five out of 70 patients (64%) were catheterized once or several times during the perioperative period. Furthermore, a total of 40 out of 54 patients (74%) had a bladder volume 60 mL or more measured by ultrasound scanner; 10 of these measured volumes exceeded twice the bladder capacity.

CONCLUSIONS

Postoperative urinary retention was discovered in 64% of patients; some of them were catheterized more than once during the perioperative period. Based on these data and the departmental procedure for postoperative care of these patients, the results indicated the need for an indwelling catheter.