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Eucker SA, Glass O, Knisely MR, O'Regan A, Gordee A, Li C, Klasson CL, TumSuden O, Pauley A, Chen HJ, Tupetz A, Staton CA, Kuchibhatla M, Chow SC. An Adaptive Pragmatic Randomized Controlled Trial of Emergency Department Acupuncture for Acute Musculoskeletal Pain Management. Ann Emerg Med 2024; 84:337-350. [PMID: 38795078 DOI: 10.1016/j.annemergmed.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 03/01/2024] [Accepted: 03/13/2024] [Indexed: 05/27/2024]
Abstract
STUDY OBJECTIVE Acute musculoskeletal pain in emergency department (ED) patients is frequently severe and challenging to treat with medications alone. The purpose of this study was to determine the feasibility, acceptability, and effectiveness of adding ED acupuncture to treat acute episodes of musculoskeletal pain in the neck, back, and extremities. METHODS In this pragmatic 2-stage adaptive open-label randomized clinical trial, Stage 1 identified whether auricular acupuncture (AA; based on the battlefield acupuncture protocol) or peripheral acupuncture (PA; needles in head, neck, and extremities only), when added to usual care was more feasible, acceptable, and efficacious in the ED. Stage 2 assessed effectiveness of the selected acupuncture intervention(s) on pain reduction compared to usual care only (UC). Licensed acupuncturists delivered AA and PA. They saw and evaluated but did not deliver acupuncture to the UC group as an attention control. All participants received UC from blinded ED providers. Primary outcome was 1-hour change in 11-point pain numeric rating scale. RESULTS Stage 1 interim analysis found both acupuncture styles similar, so Stage 2 continued all 3 treatment arms. Among 236 participants randomized, demographics and baseline pain were comparable across groups. When compared to UC alone, reduction in pain was 1.6 (95% confidence interval [CI]: 0.7 to 2.6) points greater for AA+UC and 1.2 (95% CI: 0.3 to 2.1) points greater for PA+UC patients. Participants in both treatment arms reported high satisfaction with acupuncture. CONCLUSION ED acupuncture is feasible and acceptable and can reduce acute musculoskeletal pain better than UC alone.
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Affiliation(s)
| | - Oliver Glass
- Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC
| | | | - Amy O'Regan
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Alexander Gordee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC; Biostatistics, Epidemiology, and Research Design Methods Core, Duke University, Durham, NC
| | - Cindy Li
- Department of Emergency Medicine, Duke University, Durham, NC
| | | | - Olivia TumSuden
- Adams School of Dentistry, University of North Carolina, Chapel Hill, NC
| | - Alena Pauley
- Department of Emergency Medicine, Duke University, Durham, NC
| | - Harrison J Chen
- Department of Emergency Medicine, Duke University, Durham, NC
| | - Anna Tupetz
- Department of Emergency Medicine, Duke University, Durham, NC; School of Nursing, Duke University, Durham, NC
| | - Catherine A Staton
- Department of Emergency Medicine, Duke University, Durham, NC; Duke Global Health Institute, Duke University, Durham, NC
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC; Duke Aging Center, Duke University, Durham, NC
| | - Shein-Chung Chow
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
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Qaseem A, Campos K, MacDonald S, Mount C, Tierney S, Fitterman N. Quality Indicators for Pain in Adults: A Review of Performance Measures by the American College of Physicians. Ann Intern Med 2024. [PMID: 39312776 DOI: 10.7326/annals-24-00773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/25/2024] Open
Abstract
Pain is a debilitating symptom generally caused by injuries or various conditions. It can be acute, subacute, or chronic and can have a significant impact on a patient's quality of life. The goal of managing pain is to relieve or reduce suffering and improve patient functioning. Several performance measures that address the treatment of pain are used in payment, public reporting, or accountability programs. The American College of Physicians (ACP) embraces performance measurement as a means to improve quality of care. ACP believes that a performance measure must be methodologically sound and evidence-based to be considered for inclusion in payment, accountability, or reporting programs. However, a plethora of performance measures that provide minimal or no value to patient care have inundated physicians, practices, and systems with the burden of collecting and reporting data. ACP's Performance Measurement Committee (PMC) reviews performance measures using a validated process to recognize high-quality performance measures, address gaps and areas for improvement in performance measures, and help reduce reporting burden. There is a need for a higher standard for a performance measure when reputation and reimbursement are on the line. This paper aims to present a review of current performance measures for pain to inform physicians, payers, and policymakers in their selection and use of performance measures. The PMC reviewed 6 performance measures for pain relevant to internal medicine physicians, of which 3 were considered valid at their intended levels of attribution ("Use of Imaging for Low Back Pain," "Use of Opioids at High Dosage in Persons Without Cancer," and "Use of Opioids From Multiple Providers in Persons Without Cancer"). This paper also proposes a performance measure concept to address a quality-of-care gap based on the current clinical guideline from ACP and the American Academy of Family Physicians, "Nonpharmacologic and Pharmacologic Management of Acute Pain From Non-low Back, Musculoskeletal Injuries in Adults."
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Affiliation(s)
- Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania (A.Q., K.C., S.T.)
| | - Karen Campos
- American College of Physicians, Philadelphia, Pennsylvania (A.Q., K.C., S.T.)
| | | | - Cristin Mount
- Virginia Mason Franciscan Health, Seattle, Washington (C.M.)
| | - Samantha Tierney
- American College of Physicians, Philadelphia, Pennsylvania (A.Q., K.C., S.T.)
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Emary PC, Corcoran KL, Coleman BC, Brown AL, Ciraco C, DiDonato J, Wang L, Couban RJ, Sud A, Busse JW. The impact of chiropractic care on prescription opioid use for non-cancer spine pain: protocol for a systematic review and meta-analysis. Syst Rev 2024; 13:232. [PMID: 39267131 PMCID: PMC11394937 DOI: 10.1186/s13643-024-02654-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/02/2024] [Indexed: 09/14/2024] Open
Abstract
BACKGROUND In recent studies, receipt of chiropractic care has been associated with lower odds of receiving prescription opioids and, among those already prescribed, reduced doses of opioids among patients with non-cancer spine pain. These findings suggest that access to chiropractic services may reduce reliance on opioids for musculoskeletal pain. OBJECTIVE To assess the impact of chiropractic care on initiation, or continued use, of prescription opioids among patients with non-cancer spine pain. METHODS We will search for eligible randomized controlled trials (RCTs) and observational studies indexed in MEDLINE, Embase, AMED, CINAHL, Web of Science, and the Index to Chiropractic Literature from database inception to June 2024. Article screening, data extraction, and risk-of-bias assessment will be conducted independently by pairs of reviewers. We will conduct separate analyses for RCTs and observational studies and pool binary outcomes (e.g. prescribed opioid receipt, long-term opioid use, and higher versus lower opioid dose) as odds ratios (ORs) with associated 95% confidence intervals (CIs). When studies provide hazard ratios (HRs) or relative risks (RRs) for time-to-event data (e.g. time-to-first opioid prescription) or incidence rates (number of opioid prescriptions over time), we will first convert them to an OR before pooling. Continuous outcomes such as pain intensity, sleep quality, or morphine equivalent dose will be pooled as weighted mean differences with associated 95% CIs. We will conduct meta-analyses using random-effects models and explore sources of heterogeneity using subgroup analyses and meta-regression. We will evaluate the certainty of evidence of all outcomes using the GRADE approach and the credibility of all subgroup effects with ICEMAN criteria. Our systematic review will follow the PRISMA statement and MOOSE guidelines. DISCUSSION Our review will establish the current evidence informing the impact of chiropractic care on new or continued prescription opioid use for non-cancer spine pain. We will disseminate our results through peer-reviewed publication and conference presentations. The findings of our review will be of interest to patients, health care providers, and policy-makers. TRIAL REGISTRATION Systematic review registration: PROSPERO CRD42023432277.
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Affiliation(s)
- Peter C Emary
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada.
- Chiropractic Department, D'Youville University, Buffalo, NY, USA.
- Private Practice, Cambridge, ON, N3H 4L5, Canada.
| | - Kelsey L Corcoran
- Yale School of Medicine, New Haven, CT, USA
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, Veterans Affairs of Connecticut Healthcare System, West Haven, CT, USA
| | - Brian C Coleman
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, Veterans Affairs of Connecticut Healthcare System, West Haven, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Health Informatics, Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Amy L Brown
- Private Practice, Cambridge, ON, N3H 4L5, Canada
| | | | | | - Li Wang
- Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Rachel J Couban
- Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, ON, Canada
| | - Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Humber River Hospital, Toronto, ON, Canada
| | - Jason W Busse
- Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Centre for Medicinal Cannabis Research, McMaster University, Hamilton, ON, Canada
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Motaghi S, Mulazzani F, Karam SG, Fashami FM, Buchan T, Ibrahim S, Langeroodi SMF, Khademioore S, Couban RJ, Mbuagbaw L, Mertz D, Loeb M. Antibiotic prophylaxis for the prevention of surgical site infections following colorectal surgery: protocol for network meta-analysis of randomized trials. Syst Rev 2024; 13:224. [PMID: 39227872 PMCID: PMC11370109 DOI: 10.1186/s13643-024-02639-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 08/19/2024] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND Surgical site infections continue to be a significant challenge following colorectal surgery. These can result in extended hospital stays, hospital readmissions, increased treatment costs, and negative effects on patients' quality of life. Antibiotic prophylaxis plays a crucial role in preventing infection during surgery, specifically in preventing surgical site infections after colorectal surgery in adult patients. However, the optimal antibiotic regimen is still unclear based on current evidence. Considering the limitations of existing reviews, our goal is to conduct a comprehensive systematic review and network meta-analysis of randomized controlled trials to evaluate the comparative benefits and harms of available antibiotic prophylaxis regimens for preventing surgical site infections following colorectal surgery in adult patients. METHODS We will search the Medline, EMBASE, CINAHL, Scopus, and Cochrane Central Register of Controlled Trials databases to identify relevant randomized controlled trials. We will include trials that (1) enrolled adults who underwent colorectal surgeries and (2) randomized them to any systemic administration of antibiotic (single or combined) prophylaxis before surgery compared to an alternative systemic antibiotic (single or combined antibiotic), placebo, control, or no prophylactic treatment. Pairs of reviewers will independently assess the risk of bias among eligible trials using a modified Cochrane risk of bias instrument for randomized trials. Our outcomes of interest include the rate of surgical site infection within 30 days of surgery, hospital length of stay, 30-day mortality, and treatment-related adverse effects. We will perform a contrast-based network meta-analysis using a frequentist random-effects model assuming a common heterogeneity parameter. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach will be utilized to assess the certainty of evidence for treatment effects. DISCUSSION By synthesizing evidence from available RCTs, this study will provide valuable insight for clinicians, patients, and health policymakers on the most effective antibiotics for preventing surgical site infection. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42023434544.
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Affiliation(s)
- Shahrzad Motaghi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Francesca Mulazzani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Samer G Karam
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Cochrane Canada and McMaster GRADE Centre, McMaster University, Hamilton, ON, Canada
| | - Fatemeh Mirzayeh Fashami
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tayler Buchan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Sara Ibrahim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Sahar Khademioore
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Rachel J Couban
- The Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Biostatistics Unit/The Research Institute, St Joseph's Healthcare, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Dominik Mertz
- Department of Medicine, Division of Infectious Diseases, McMaster University, Hamilton, ON, Canada
| | - Mark Loeb
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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Løvsletten PO, Hunskaar BS, Heen AF, Bekkering G, Poel LV, Zeraatkar D, Vermandere M, Aertgeerts B, Delvaux N, Achille F, Busse JW, Agoritsas T, Vandvik PO. Physicians found an interactive tool displaying structured evidence summaries for multiple comparisons understandable and useful: a qualitative user testing study. J Clin Epidemiol 2024; 172:111399. [PMID: 38810842 DOI: 10.1016/j.jclinepi.2024.111399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 05/11/2024] [Accepted: 05/21/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVES To evaluate and improve "Making Alternative Treatment Choices Intuitive and Trustworthy" (MATCH-IT)-a digital, interactive decision support tool displaying structured evidence summaries for multiple comparisons-to help physicians interpret and apply evidence from network meta-analysis (NMA) for their clinical decision-making. STUDY DESIGN AND SETTING We conducted a qualitative user testing study, applying principles from user-centered design in an iterative development process. We recruited a convenience sample of practicing physicians in Norway, Belgium, and Canada, and asked them to interpret structured evidence summaries for multiple comparisons-linked to clinical guideline recommendations-displayed in MATCH-IT. User testing included (a) introduction of a clinical scenario, (b) a think-aloud session with participant-tool interaction, and (c) a semistructured interview. We video recorded, transcribed, and analyzed user tests using directed content analysis. The results informed new updates in MATCH-IT. RESULTS Distributed across 5 development cycles we tested MATCH-IT with 26 physicians. Of these, 24 (94%) reported either no or sparse prior experience with interpretation of NMA. Physicians perceived MATCH-IT as easy to interpret and navigate, and appreciated its ability to provide an overview of the evidence. Visualization of effects in pictograms and inclusion of information on burden of treatment ("practical issues") were highlighted as potentially useful features in interacting with patients. We also identified problems, including undiscovered functionalities (drag and drop), suboptimal tutorial, and cumbersome navigation of the tool. In addition, physicians wanted definition/explanation of key terms (eg, outcomes and "certainty"), and there were concerns that overwhelming evidence from a large NMA would complicate applicability to clinical practice. This led to several updates with development of a new start page, tutorial, updated user interface for more efficient maneuvering, solutions to display definition of key terms and a "frequently asked questions" section. To facilitate interpretation of large networks, we improved categorization of results using color coding and added filtering functionality. These modifications allowed physicians to focus on interventions of interest and reduce information overload. CONCLUSION This study provides proof of concept that physicians can use MATCH-IT to understand NMA evidence. Key features of MATCH-IT in a clinical context include providing an overview of the evidence, visualization of effects, and the display of information on burden of treatments. However, unfamiliarity with the Grading of Recommendations Assessment, Development and Evaluation concepts, time constraints, and accessibility at the point of care may be challenges for use. To what extent our results are transferable to real-world clinical contexts remains to be explored.
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Affiliation(s)
- Per Olav Løvsletten
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway; Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Birk Stokke Hunskaar
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anja Fog Heen
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway; MAGIC Evidence Ecosystem Foundation, Oslo, Norway
| | - Geertruida Bekkering
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Belgian Centre for Evidence Based Medicine (Cebam), Leuven, Belgium; Cochrane Belgium, Leuven, Belgium
| | - Louise Vanden Poel
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Dena Zeraatkar
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Mieke Vermandere
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Bert Aertgeerts
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Belgian Centre for Evidence Based Medicine (Cebam), Leuven, Belgium
| | - Nicolas Delvaux
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | | | - Jason W Busse
- Department of Anaesthesia, McMaster University, Hamilton, Canada; Department of Health, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Thomas Agoritsas
- MAGIC Evidence Ecosystem Foundation, Oslo, Norway; Department of Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Per Olav Vandvik
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway; Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway; MAGIC Evidence Ecosystem Foundation, Oslo, Norway.
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Diallo S, Marchand S, Dumais A, Potvin S. The impact of an immersive digital therapeutic tool on experimental pain: a pilot randomized within-subject experiment with an active control condition. FRONTIERS IN PAIN RESEARCH 2024; 5:1366892. [PMID: 38903416 PMCID: PMC11187308 DOI: 10.3389/fpain.2024.1366892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 05/20/2024] [Indexed: 06/22/2024] Open
Abstract
Background Pain is a complex and multifaced sensory and emotional experience. Virtual reality (VR) has shown promise in reducing experimental pain and chronic pain. This study examines an immersive VR environment initially designed for endometriosis patients, which demonstrated short-term analgesic effects. The research aims to determine the impact of the VR environment on experimental pain intensity and unpleasantness both during and after VR exposure (3D with binaural beats), while using an active control condition (2D with no binaural beats). Additionally, a secondary objective of the study was to identify the psychological and psychophysical factors that predict the analgesic effects of the immersive digital therapeutic tool. Methods The study involved twenty-one healthy individuals and used a within-subject design, comparing a VR treatment with an active control condition. Continuous heat stimulation was applied to the left forearm with a Peltier thermode. Pain ratings were collected for immediate and short-term effects. Results In both the VR and Control conditions, there were no significant differences in pain intensity before, during, and after exposure. However, during VR exposure, there was a significant decrease in pain unpleasantness as compared to before exposure (p < 0.001), with a 27.2% pain reduction. In the Control condition, there were no significant differences in pain unpleasantness during and after exposure. Furthermore, no psychological and psychophysical factors predicted the analgesic effects. Discussion The study investigated how a VR environment affected experimentally induced pain in healthy volunteers. It showed that VR reduced pain unpleasantness during exposure but had no lasting impact. The VR environment mainly influenced the emotional aspect of pain, possibly due to its inclusion of binaural beats and natural stimuli. The study suggests that the VR environment should be tested in chronic pain population with high distress levels. Registration number clinicaltrialsgov NCT06130267.
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Affiliation(s)
- Sanoussy Diallo
- Centre de Recherche de l’Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada
- Department of Psychiatry and Addiction, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Serge Marchand
- Department of Surgery, Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Alexandre Dumais
- Centre de Recherche de l’Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada
- Department of Psychiatry and Addiction, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
- Institut National de Psychiatrie Légale Philippe-Pinel, Montreal, QC, Canada
| | - Stéphane Potvin
- Centre de Recherche de l’Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada
- Department of Psychiatry and Addiction, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
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Moretti A, Snichelotto F, Liguori S, Paoletta M, Toro G, Gimigliano F, Iolascon G. The challenge of pharmacotherapy for musculoskeletal pain: an overview of unmet needs. Ther Adv Musculoskelet Dis 2024; 16:1759720X241253656. [PMID: 38799611 PMCID: PMC11119417 DOI: 10.1177/1759720x241253656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 04/10/2024] [Indexed: 05/29/2024] Open
Abstract
Musculoskeletal disorders are characterized by several impairments, including pain, affecting muscles, bones, joints and adjacent connective tissue, resulting in temporary or permanent functional limitations and disability. Musculoskeletal pain is particularly prevalent worldwide and greatly impacts the quality of life, social participation and economic burden. To date, several issues persist about the classification of musculoskeletal pain and its management strategies and resources. The treatment of musculoskeletal pain conditions is complex and often requires a multimodal approach, including pharmacological and non-pharmacological therapy that might be ineffective in many cases, resulting in poor patient satisfaction and controversial expectations about the potential benefits of available interventions. This manuscript provides an overview of unmet needs in managing musculoskeletal pain, particularly focusing on pharmacotherapeutic pitfalls in this context.
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Affiliation(s)
- Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples 80138, Italy
| | - Francesco Snichelotto
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Sara Liguori
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Francesca Gimigliano
- Department of Physical and Mental Health and Preventive Medicine, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
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Thompson HM, Govindarajulu U, Doucette J, Nabeel I. Short-acting opioid prescriptions and Workers' Compensation using the National Ambulatory Medical Care Survey. Am J Ind Med 2024; 67:474-482. [PMID: 38491940 DOI: 10.1002/ajim.23581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/20/2024] [Accepted: 02/29/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Short-acting opioids have been utilized for pain management with little known about their use in patients on Workers' Compensation (WC) insurance. Our goal was to investigate this association in the ambulatory care setting. METHODS Using the National Ambulatory Medical Care Survey, visits from patients aged 18-64 during the years 2010 until 2018 were evaluated (excluding 2017 due to data availability). Demographic and co-morbidity data from each visit was obtained along with the visit year. The first short-acting opioid medication prescribed in the database was considered. Survey-weighted frequencies were evaluated. Logistic regression estimated the crude and adjusted odds ratios (OR) with 95% confidence intervals for the use of short-acting opioid prescription. RESULTS There were 155,947 included visits with 62.5% for female patients. Most patients were White with 11.7% identifying as Black, and 6% identifying as another race. Over 13% of the sample was of Hispanic descent. WC was the identified insurance type in 1.6% of the sample population. Of these patients, 25.6% were prescribed a short-acting opioid, compared with 10.1% of those with another identified insurance. On multivariable regression, Black patients had increased odds of being prescribed a short-acting opioid compared to white patients (OR: 1.22, 95% CI: 1.11-1.34). Those on WC had 1.7-fold higher odds of being prescribed short-acting opioids (95% CI: 1.46-2.06). CONCLUSION Certain patient characteristics, including having WC insurance, increased the odds of a short-acting opioid prescription. Further work is needed to identify prescribing patterns in specific high-risk occupational groups, as well as to elicit potential associated health outcomes.
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Affiliation(s)
- Hannah M Thompson
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Usha Govindarajulu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, Center for Biostatistics, New York, New York, USA
| | - John Doucette
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ismail Nabeel
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Brakenridge CL, Smits EJ, Gane EM, Andrews NE, Williams G, Johnston V. Effectiveness of Interventions on Work Outcomes After Road Traffic Crash-Related Musculoskeletal Injuries: A Systematic Review and Meta-analysis. JOURNAL OF OCCUPATIONAL REHABILITATION 2024:10.1007/s10926-024-10185-z. [PMID: 38578601 DOI: 10.1007/s10926-024-10185-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/18/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Musculoskeletal injuries are common after road traffic crash (RTC) and can lead to poor work-related outcomes. This review evaluated the impact of interventions on work-related (e.g. sick leave), health, and functional outcomes in individuals with a RTC-related musculoskeletal injury, and explored what factors were associated with work-related outcomes. METHODS Searches of seven databases were conducted up until 9/03/2023. Eligible interventions included adults with RTC-related musculoskeletal injuries, a comparison group, and a work-related outcome, and were in English. Meta-analyses were conducted using RevMan and meta-regressions in Stata. RESULTS Studies (n = 27) were predominantly conducted in countries with third-party liability schemes (n = 26), by physiotherapists (n = 17), and in participants with whiplash injuries (94%). Pooled effects in favour of the intervention group were seen overall (SMD = - 0.14, 95% CI: - 0.29, 0.00), for time to return to work (- 17.84 days, 95% CI: - 24.94, - 10.74), likelihood of returning to full duties vs. partial duties (RR = 1.17, 95% CI: 1.01, 1.36), decreased pain intensity (- 6.17 units, 95% CI: - 11.96, - 0.39, 100-point scale), and neck disability (- 1.77 units, 95% CI: - 3.24, - 0.30, 50-point scale). DISCUSSION Interventions after RTC can reduce time to return to work and increase the likelihood of returning to normal duties, but the results for these outcomes were based on a small number of studies with low-quality evidence. Further research is needed to evaluate a broader range of interventions, musculoskeletal injury types, and to include better quality work-related outcomes.
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Affiliation(s)
- Charlotte L Brakenridge
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, QLD, Australia.
- School of Human Movements and Nutrition Sciences, The University of Queensland, Brisbane, QLD, Australia.
| | - Esther J Smits
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Elise M Gane
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
- Physiotherapy Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Centre for Functioning and Health Research, Metro South Health, Brisbane, QLD, Australia
| | - Nicole E Andrews
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Occupational Therapy Department, Metro North Hospital and Health Service, The Royal Brisbane and Women's Hospital, Herston, QLD, Australia
- Tess Cramond Pain and Research Centre, Metro North Hospital and Health Service, The Royal Brisbane and Women's Hospital, Herston, QLD, Australia
- Surgical Treatment and Rehabilitation Service (STARS) Education and Research Alliance, The University of Queensland and Metro North Health, Herston, QLD, Australia
| | - Gina Williams
- Tess Cramond Pain and Research Centre, Metro North Hospital and Health Service, The Royal Brisbane and Women's Hospital, Herston, QLD, Australia
- Physiotherapy Department, Metro North Hospital and Health Service, The Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Venerina Johnston
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
- Centre for Health Research, University of Southern Queensland, Ipswich, QLD, Australia
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10
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Jones CMP, Langford A, Maher CG, Abdel Shaheed C, Day R, Lin CWC. Opioids for Acute Musculoskeletal Pain: A Systematic Review with Meta-Analysis. Drugs 2024; 84:305-317. [PMID: 38451443 PMCID: PMC10982090 DOI: 10.1007/s40265-024-01999-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE To evaluate the efficacy of opioids for people with acute musculoskeletal pain against placebo. STUDY DESIGN Systematic review and meta-analyses of randomised, placebo-controlled trials of opioid analgesics for acute musculoskeletal pain in any setting. The primary outcomes were pain and disability at the immediate timepoint (< 24 h). DATA SOURCES Multiple databases were searched from their inception to February 22nd, 2023. DATA SYNTHESIS Continuous outcomes were converted to a 0-100 scale. Dichotomous outcomes were presented as risk differences. Risk of bias and certainty of evidence was assessed. RESULTS We located 17 trials (1 intravenous and 16 oral route of administration). For adults, high certainty evidence from 11 comparisons shows that oral opioids provide small benefits relative to placebo in the immediate term for pain (mean difference [MD] - 8.8 95% confidence interval [CI] - 12.0 to - 5.6). For disability, the difference is uncertain (MD - 6.2, 95% CI - 17.8 to 5.4). Opioid groups were at higher risk of adverse events (MD 14.3%, 95% CI 8.3-20.4%, very low certainty). There was moderate certainty evidence of a large effect of IV morphine on sciatica pain (MD -42.5, 95% CI - 49.9 to - 35.1, n = 197, 1 study). In paediatric populations, moderate certainty evidence from 3 trials shows that oral opioids probably do not provide benefit beyond that of placebo for pain (MD 6.1, 95% CI - 1.7 to 12.8) and there was no evidence for disability. There was low certainty evidence that there may be no difference in adverse events (MD 10.4%, 95% CI - 0.6 to 21.4%). DISCUSSION Intravenous morphine likely offers benefits, but oral opioids may not provide clinically meaningful benefits. PROSPERO REGISTRATION CRD42021249346.
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Affiliation(s)
- Caitlin M P Jones
- Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.
- , Level 10N KGV Building, Missenden Road, Camperdown, NSW, 2050, Australia.
| | - Aili Langford
- School of Pharmacy, The University of Sydney and the Centre for Medicine Use and Safety, Monash University, Melbourne, Australia
| | - Chris G Maher
- Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christina Abdel Shaheed
- Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Richard Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney and St Vincent's Clinical Campus, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Chung-Wei Christine Lin
- Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
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11
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Ren J, Ma J, Cappelleri JC. Appropriateness of conducting and reporting random-effects meta-analysis in oncology. Res Synth Methods 2024; 15:326-331. [PMID: 38219287 DOI: 10.1002/jrsm.1702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/30/2023] [Accepted: 12/30/2023] [Indexed: 01/16/2024]
Abstract
A random-effects model is often applied in meta-analysis when considerable heterogeneity among studies is observed due to the differences in patient characteristics, timeframe, treatment regimens, and other study characteristics. Since 2014, the journals Research Synthesis Methods and the Annals of Internal Medicine have published a few noteworthy papers that explained why the most widely used method for pooling heterogeneous studies-the DerSimonian-Laird (DL) estimator-can produce biased estimates with falsely high precision and recommended to use other several alternative methods. Nevertheless, more than half of studies (55.7%) published in top oncology-specific journals during 2015-2022 did not report any detailed method in the random-effects meta-analysis. Of the studies that did report the methodology used, the DL method was still the dominant one reported. Thus, while the authors recommend that Research Synthesis Methods and the Annals of Internal Medicine continue to increase the publication of its articles that report on specific methods for handling heterogeneity and use random-effects estimates that provide more accurate confidence limits than the DL estimator, other journals that publish meta-analyses in oncology (and presumably in other disease areas) are urged to do the same on a much larger scale than currently documented.
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Affiliation(s)
- Jinma Ren
- Statistical Research & Data Science Center, Pfizer Inc, Collegeville, Pennsylvania, USA
| | - Jia Ma
- Statistical Research & Data Science Center, Pfizer Inc, Groton, Connecticut, USA
| | - Joseph C Cappelleri
- Statistical Research & Data Science Center, Pfizer Inc, Groton, Connecticut, USA
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12
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Müller D, Scholz SM, Thalmann NF, Trippolini MA, Wertli MM. Increased Use and Large Variation in Strong Opioids and Metamizole (Dipyrone) for Minor and Major Musculoskeletal Injuries Between 2008 and 2018: An Analysis of a Representative Sample of Swiss Workers. JOURNAL OF OCCUPATIONAL REHABILITATION 2024; 34:157-168. [PMID: 37040000 PMCID: PMC10899285 DOI: 10.1007/s10926-023-10115-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE Musculoskeletal (MSK) injuries are a major contributing factor for chronic pain. To date, little is known how pain medication use in MSK injuries has changed over time. We assessed pain medication prescription for MSK injuries in a representative sample of Swiss workers between 2008 and 2018. METHODS Retrospective analysis of the Swiss Accident Insurance Fund (Suva) data. We calculated annual pain medication use, treatment days, and costs associated with pain medication use in minor and major MSK injuries. RESULTS In total, 1,921,382 cases with MSK injuries with ≥ 1 pain medication were analyzed. Whereas MSK injuries with ≥ 1 pain medication increased by 9.4%, we observed a larger increase in metamizole (+ 254%), strong opioids (+ 88.4%), coxibs (+ 85.8%), and paracetamol (+ 28.1%). Strong opioids were increasingly used in minor (+ 91.4%) and major (+ 88.3%) injuries. The increase in metamizole (+ 390.6%) and coxibs (+ 115.5%) was larger in minor injuries compared to major injuries (+ 238.7% and + 80.6%, respectively). Medical expenses decreased in all medications except for strong opioids where a substantial increase was observed (+ 192.4% in minor; + 34% in major injuries). CONCLUSIONS We observed a disproportionate increase in metamizole, strong opioids, coxibs, and paracetamol prescriptions even in minor MSK injuries between 2008 and 2018. Whereas treatment costs decreased for all pain medications, there was a substantial increase in strong opioids. A more liberal prescription practice of opioids conflict with current evidence-based practice recommendations and need to be addressed by physicians and policy makers.
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Affiliation(s)
- Dominic Müller
- Department of General Internal Medicine, University Hospital of Bern, Inselspital, Freiburgstrasse 18, 3010, Bern, Switzerland.
| | - Stefan M Scholz
- Department of Statistics, Suva (Swiss National Accident Insurance Fund), Lucerne, Switzerland
| | - Nicolas Fabrice Thalmann
- Department of General Internal Medicine, University Hospital of Bern, Inselspital, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Maurizio Alen Trippolini
- Bern University of Applied Sciences, School of Health Professions, Murtenstrasse 10, 3008, Bern, Switzerland
- Institute of Physiotherapy, University Hospital of Bern, Inselspital, Freiburgstrasse 18, 3010, Bern, Switzerland
- Evidence-Based Insurance Medicine (EbIM), Division of Clinical Research, Department of Clinical Epidemiology, University Hospital Basel, University of Basel, Totengässlein 3, 4051, Basel, Switzerland
| | - Maria M Wertli
- Department of General Internal Medicine, University Hospital of Bern, Inselspital, Freiburgstrasse 18, 3010, Bern, Switzerland
- Department of Internal Medicine, Kantonsspital Baden, Im Ergel 1, 5404, Baden, Switzerland
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13
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Scholz SM, Thalmann NF, Müller D, Trippolini MA, Wertli MM. Factors influencing pain medication and opioid use in patients with musculoskeletal injuries: a retrospective insurance claims database study. Sci Rep 2024; 14:1978. [PMID: 38263185 PMCID: PMC10805862 DOI: 10.1038/s41598-024-52477-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 01/19/2024] [Indexed: 01/25/2024] Open
Abstract
Opioid use is only recommended in selected cases of musculoskeletal (MSK) injuries. We assessed factors associated with increased opioid use in MSK injuries. In a retrospective analysis of over four million workers with MSK injuries using the Swiss National Accident Insurance Fund (Suva) database, we analyzed risk factors by multivariate logistic regression. Injury severity was associated with pain medication, opioid, and strong opioid use. Whereas fractures, contusions, and ruptures had higher odds for any pain medication use, increased odds for strong opioids were observed in fractures, superficial injuries, and other injuries. Injuries of the shoulders, elbow, chest, back/spine, thorax, and pelvis/hips showed high odds for opioid use (odds ratio (OR) > 2.0). Injuries of the shoulders had higher odds for strong opioid use (OR 1.136; 95% CI 1.040-1.241). The odds for using strong opioids increased from 2008 OR 0.843 (95% confidence interval (CI) 0.798-0.891) to 2018 OR 1.503 (95% CI 1.431-1.578), compared to 2013. Injury severity, type of injury, and injured body parts influenced the use of pain medication and overall opioid use in musculoskeletal injuries. Strong opioids were more often used in fractures but also in superficial and other minor injuries, which indicates that other factors play a role when prescribing strong opioids.
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Affiliation(s)
- Stefan Markus Scholz
- Department of Statistics, Suva (Swiss National Accident Insurance Fund), Lucerne, Switzerland
| | - Nicolas Fabrice Thalmann
- Department of General Internal Medicine, University Hospital of Bern, Inselspital, Freiburgstrasse 18, 3010, Bern, Switzerland.
| | - Dominic Müller
- Department of General Internal Medicine, University Hospital of Bern, Inselspital, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Maurizio Alen Trippolini
- School of Health Professions, Bern University of Applied Sciences, Murtenstrasse 10, 3008, Bern, Switzerland
- Institute of Physiotherapy, University Hospital of Bern, Inselspital, Freiburgstrasse 18, 3010, Bern, Switzerland
- Evidence-Based Insurance Medicine (EbIM), Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Totengässlein 3, 4051, Basel, Switzerland
| | - Maria Monika Wertli
- Department of General Internal Medicine, University Hospital of Bern, Inselspital, Freiburgstrasse 18, 3010, Bern, Switzerland
- Department of Internal Medicine, Kantonsspital Baden, Baden, Switzerland
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14
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Stokke Hunskaar B, Løvsletten PO, Muller A, Vandvik PO. Interpretation and use of a decision support tool for multiple treatment options: a combined randomised controlled trial and survey of medical students. BMJ Evid Based Med 2024; 29:29-36. [PMID: 37833036 PMCID: PMC10850623 DOI: 10.1136/bmjebm-2023-112370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/15/2023]
Abstract
OBJECTIVES To investigate medical students' ability to interpret evidence, as well as their self-assessed understandability, perceived usefulness and preferences for design alternatives in an interactive decision support tool, displaying GRADE evidence summaries for multiple treatment options (Making Alternative Treatment CHoices Intuitive and Trustworthy, MATCH-IT). DESIGN A combined randomised controlled trial and survey. Participants were presented with a clinical scenario and randomised to one of two versions of the MATCH-IT tool (A/B), instructed to explore the evidence and decide on a recommendation. Participants answered a questionnaire assessing interpretation, treatment recommendation self-assessed understandability and perceived usefulness before exposure to the other MATCH-IT version and asked questions on design preferences. SETTING Online lecture in an evidence-based medicine (EBM) introductory course. PARTICIPANTS 149 third-year medical students. 52% (n=77) had 6 months of clinical training and 48% (n=72) had preclinical training only. INTERVENTIONS The MATCH-IT tool version A uses colour coding to categorise interventions by magnitude and direction of effects and displays all outcomes in a table on entry. Version B has no colour coding, and the user must decide which outcomes to display in the table. MAIN OUTCOME MEASURES Interpretation of evidence, treatment recommendation, perceived usefulness and understandability, preference for format and design alternatives. RESULTS 82.5% (n=123) of medical students correctly answered ≥4 out of 5 multiple choice questions assessing interpretation of data. 75.8% (n=114) of students made a treatment recommendation in accordance with an expert panel for the same clinical scenario. 87.2% (n=130) found the tool understandable while 91.9% perceived the tool as useful in addressing the clinical scenario. CONCLUSION Medical students with no prior training in EBM can interpret and use the MATCH-IT tool. Certain design alternatives were preferred but had no bearing on interpretation of evidence or understandability of the tool.
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Affiliation(s)
- Birk Stokke Hunskaar
- Institute of Health and Society, University of Oslo Faculty of Medicine, Oslo, Norway
| | - Per Olav Løvsletten
- Institute of Health and Society, University of Oslo Faculty of Medicine, Oslo, Norway
- Department of Medicine, Lovisenberg Diakonale Hospital, Oslo, Norway
| | - Ashley Muller
- Norwegian Centre for Addiction Research, University of Oslo Faculty of Medicine, Oslo, Norway
- Sørlandet sykehus HF Kristiansand, Kristiansand, Norway
| | - Per Olav Vandvik
- Institute of Health and Society, University of Oslo Faculty of Medicine, Oslo, Norway
- Department of Medicine, Lovisenberg Diakonale Hospital, Oslo, Norway
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15
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Yao L, Sadeghirad B, Li M, Li J, Wang Q, Crandon HN, Martin G, Morgan R, Florez ID, Hunskaar BS, Wells J, Moradi S, Zhu Y, Ahmed MM, Gao Y, Cao L, Yang K, Tian J, Li J, Zhong L, Couban RJ, Guyatt GH, Agoritsas T, Busse JW. Management of chronic pain secondary to temporomandibular disorders: a systematic review and network meta-analysis of randomised trials. BMJ 2023; 383:e076226. [PMID: 38101924 DOI: 10.1136/bmj-2023-076226] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
OBJECTIVE We explored the comparative effectiveness of available therapies for chronic pain associated with temporomandibular disorders (TMD). DESIGN Systematic review and network meta-analysis of randomised clinical trials (RCTs). DATA SOURCES MEDLINE, EMBASE, CINAHL, CENTRAL, and SCOPUS were searched to May 2021, and again in January 2023. STUDY SELECTION Interventional RCTs that enrolled patients presenting with chronic pain associated with TMD. DATA EXTRACTION AND SYNTHESIS Pairs of reviewers independently identified eligible studies, extracted data, and assessed risk of bias. We captured all reported patient-important outcomes, including pain relief, physical functioning, emotional functioning, role functioning, social functioning, sleep quality, and adverse events. We conducted frequentist network meta-analyses to summarise the evidence and used the GRADE approach to rate the certainty of evidence and categorise interventions from most to least beneficial. RESULTS 233 trials proved eligible for review, of which 153-enrolling 8713 participants and exploring 59 interventions or combinations of interventions-were included in network meta-analyses. All subsequent effects refer to comparisons with placebo or sham procedures. Effects on pain for eight interventions were supported by high to moderate certainty evidence. The three therapies probably most effective for pain relief were cognitive behavioural therapy (CBT) augmented with biofeedback or relaxation therapy (risk difference (RD) for achieving the minimally important difference (MID) in pain relief of 1 cm on a 10 cm visual analogue scale: 36% (95% CI 33 to 39)), therapist-assisted jaw mobilisation (RD 36% (95% CI 31 to 40)), and manual trigger point therapy (RD 32% (29 to 34)). Five interventions were less effective, yet more effective than placebo, showing RDs ranging between 23% and 30%: CBT, supervised postural exercise, supervised jaw exercise and stretching, supervised jaw exercise and stretching with manual trigger point therapy, and usual care (such as home exercises, self stretching, reassurance).Moderate certainty evidence showed four interventions probably improved physical functioning: supervised jaw exercise and stretching (RD for achieving the MID of 5 points on the short form-36 physical component summary score: 43% (95% CI 33 to 51)), manipulation (RD 43% (25 to 56)), acupuncture (RD 42% (33 to 50)), and supervised jaw exercise and mobilisation (RD 36% (19 to 51)). The evidence for pain relief or physical functioning among other interventions, and all evidence for adverse events, was low or very low certainty. CONCLUSION When restricted to moderate or high certainty evidence, interventions that promote coping and encourage movement and activity were found to be most effective for reducing chronic TMD pain. REGISTRATION PROSPERO (CRD42021258567).
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Affiliation(s)
- Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, 1280 Main St. West, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, 1280 Main St. West, Hamilton, Ontario, Canada
| | - Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Health Technology Assessment Centre, Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Jing Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Health Technology Assessment Centre, Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Qi Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Holly N Crandon
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Institute for Management and Innovation, University of Toronto, Mississauga, Ontario, Canada
| | - Grace Martin
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca Morgan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Ivan D Florez
- Department of Pediatrics, University of Antioquia, Medellin, Colombia
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
- Pediatric Intensive Care Unit, Clínica Las Americas, Medellin, Colombia
| | | | - Jeff Wells
- Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Sara Moradi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, Ontario, Canada
| | - Ying Zhu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Muhammad Muneeb Ahmed
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ya Gao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Liujiao Cao
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Health Technology Assessment Centre, Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Jialing Li
- Department of Orthodontics, Nanjing Stomatological Hospital, Medical School of Nanjing University, China
| | - Linda Zhong
- School of Biological Sciences, Nanyang Technological University, Singapore
| | - Rachel J Couban
- Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Division of General Internal Medicine, Department of Medicine, University Hospitals of Geneva, Geneva, Switzerland
- The MAGIC Evidence Ecosystem Foundation, Oslo, Norway
| | - Jason W Busse
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, 1280 Main St. West, Hamilton, Ontario, Canada
- Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, Ontario, Canada
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Daoust R, Paquet J, Marquis M, Williamson D, Fontaine G, Chauny JM, Frégeau A, Orkin AM, Upadhye S, Lessard J, Cournoyer A. Efficacy of prescribed opioids for acute pain after being discharged from the emergency department: A systematic review and meta-analysis. Acad Emerg Med 2023; 30:1253-1263. [PMID: 37607265 DOI: 10.1111/acem.14790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/21/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Opioids are often prescribed for acute pain to patients discharged from the emergency department (ED), but there is a paucity of data on their short-term use. The purpose of this study was to synthesize the evidence regarding the efficacy of prescribed opioids compared to nonopioid analgesics for acute pain relief in ED-discharged patients. METHODS MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and gray literature databases were searched from inception to January 2023. Two independent reviewers selected randomized controlled trials investigating the efficacy of prescribed opioids for ED-discharged patients, extracted data, and assessed risk of bias. Authors were contacted for missing data and to identify additional studies. The primary outcome was the difference in pain intensity scores or pain relief. All meta-analyses used a random-effect model and a sensitivity analysis compared patients treated with codeine versus those treated with other opioids. RESULTS From 5419 initially screened citations, 46 full texts were evaluated and six studies enrolling 1161 patients were included. Risk of bias was low for five studies. There was no statistically significant difference in pain intensity scores or pain relief between opioids versus nonopioid analgesics (standardized mean difference [SMD] 0.12; 95% confidence interval [CI] -0.10 to 0.34). Contrary to children, adult patients treated with opioid had better pain relief (SMD 0.28, 95% CI 0.13-0.42) compared to nonopioids. In another sensitivity analysis excluding studies using codeine, opioids were more effective than nonopioids (SMD 0.30, 95% CI 0.15-0.45). However, there were more adverse events associated with opioids (odds ratio 2.64, 95% CI 2.04-3.42). CONCLUSIONS For ED-discharged patients with acute musculoskeletal pain, opioids do not seem to be more effective than nonopioid analgesics. However, this absence of efficacy seems to be driven by codeine, as opioids other than codeine are more effective than nonopioids (mostly NSAIDs). Further prospective studies on the efficacy of short-term opioid use after ED discharge (excluding codeine), measuring patient-centered outcomes, adverse events, and potential misuse, are needed.
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Affiliation(s)
- Raoul Daoust
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| | - Jean Paquet
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
| | - Martin Marquis
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
| | - David Williamson
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
| | - Guillaume Fontaine
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jean-Marc Chauny
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| | - Amélie Frégeau
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - Aaron M Orkin
- Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, St. Joseph's Health Centre, Unity Health, Toronto, Ontario, Canada
| | - Suneel Upadhye
- McMaster University, Division of Emergency Medicine, Hamilton, Ontario, Canada
| | - Justine Lessard
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| | - Alexis Cournoyer
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
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17
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Barrett TW, Rief K, Parisi F. The OPAL Trial Provides a Treasure of Evidence to Stop Using Opioids for Acute Neck and Back Pain: December 2023 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2023; 82:758-759. [PMID: 37993223 DOI: 10.1016/j.annemergmed.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Affiliation(s)
- Tyler W Barrett
- Department of Emergency Medicine, MSCI Vanderbilt University Medical Center, Nashville, TN
| | - Katherine Rief
- Department of Emergency Medicine, MSCI Vanderbilt University Medical Center, Nashville, TN
| | - Frank Parisi
- Department of Emergency Medicine, MSCI Vanderbilt University Medical Center, Nashville, TN
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Chen Q, Maher CG, Han CS, Abdel Shaheed C, Lin CWC, Rogan EM, Machado GC. Continued Opioid Use and Adverse Events Following Provision of Opioids for Musculoskeletal Pain in the Emergency Department: A Systematic Review and Meta-Analysis. Drugs 2023; 83:1523-1535. [PMID: 37768540 PMCID: PMC10624756 DOI: 10.1007/s40265-023-01941-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND The prevalence of continued opioid use or serious adverse events (SAEs) following opioid therapy in the emergency department (ED) for musculoskeletal pain is unclear. The aim of this review was to examine the prevalence of continued opioid use and serious adverse events (SAEs) following the provision of opioids for musculoskeletal pain in the emergency department (ED) or at discharge. METHODS Records were searched from MEDLINE, EMBASE and CINAHL from inception to 7 October 2022. We included randomised controlled trials and observational studies enrolling adult patients with musculoskeletal pain who were administered and/or prescribed opioids in the ED. Continued opioid use and opioid misuse data after day 4 since ED discharge were extracted. Adverse events were coded using the Common Terminology Criteria for Adverse Events (CTCAE), and those rated as grades 3-4 (severe or life-threatening) and grade 5 (death) were considered SAEs. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. RESULTS Seventy-two studies were included. Among opioid-naïve patients who received an opioid prescription, 6.8-7.0% reported recent opioid use at 3-12 months after discharge, 4.4% filled ≥ 5 opioid prescriptions and 3.1% filled > 90-day supply of opioids within 6 months. The prevalence of SAEs was 0.02% [95% confidence interval (CI) 0, 0.2%] in the ED and 0.1% (95% CI 0, 1.5%) within 2 days. One study observed 42.9% of patients misused opioids within 30 days after discharge. CONCLUSIONS Around 7% of opioid-naïve patients with musculoskeletal pain receiving opioid therapy continue opioid use at 3-12 months after ED discharge. SAEs following ED administration of an opioid were uncommon; however, studies only monitored patients for 2 days. PROTOCOL REGISTRATION 10.31219/osf.io/w4z3u.
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Affiliation(s)
- Qiuzhe Chen
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia.
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Christopher S Han
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Eileen M Rogan
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
- Emergency Department, Canterbury Hospital, Campsie, NSW, Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
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Forestell B, Sabbineni M, Sharif S, Chao J, Eltorki M. Comparative Effectiveness of Ketorolac Dosing Strategies for Emergency Department Patients With Acute Pain. Ann Emerg Med 2023; 82:615-623. [PMID: 37178102 DOI: 10.1016/j.annemergmed.2023.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/04/2023] [Accepted: 04/10/2023] [Indexed: 05/15/2023]
Abstract
STUDY OBJECTIVES Ketorolac is a commonly used nonopioid parenteral analgesic for treating emergency department (ED) patients with acute pain. Our systematic review aims to summarize the available evidence by comparing the efficacy and safety of differing ketorolac dosing strategies for acute pain relief in the ED. METHODS The review was registered on PROSPERO (CRD42022310062). We searched MEDLINE, PubMed, EMBASE, and unpublished sources from inception through December 9, 2022. We included randomized control trials of patients presenting with acute pain to the ED, comparing ketorolac doses less than 30 mg (low dose) to ketorolac doses more than or equal to 30 mg (high dose) for the outcomes of pain scores after treatment need for rescue analgesia, and incidence of adverse events. We excluded patients in non-ED settings, including postoperative settings. We extracted data independently and in duplicate and pooled them using a random-effects model. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool and the overall certainty of the evidence for each outcome using the Grading Recommendations Assessment, Development, and Evaluation approach. RESULTS This review included 5 randomized controlled trials (n=627 patients). Low-dose parenteral ketorolac (15 to 20 mg), as compared to high-dose ketorolac (≥30 mg), probably has no effect on pain scores (mean difference 0.05 mm lower on 100 mm visual analog scale, 95% confidence interval [CI] -4.91 mm to +5.01 mm; moderate certainty). Further, low-dose ketorolac at 10 mg may have no effect on pain scores compared to high-dose ketorolac (mean difference 1.58 mm lower on 100 mm visual analog scale, 95% CI -8.86 mm to +5.71 mm; low certainty). Low-dose ketorolac may increase the need for rescue analgesia (risk ratio 1.27, 95% CI 0.86 to 1.87; low certainty) and may have no difference on rates of adverse events (risk ratio 0.84, 95% CI 0.54 to 1.33; low certainty). CONCLUSION In adult ED patients with acute pain, parenteral ketorolac given at doses of 10 mg to 20 mg is probably as effective in relieving pain as doses of 30 mg or higher. Low-dose ketorolac may have no effect on adverse events, but these patients may require more rescue analgesia. This evidence is limited by imprecision and is not generalizable to children or those at higher risk of adverse events.
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Affiliation(s)
- Ben Forestell
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Monica Sabbineni
- Department of Medicine, Michael G DeGroote Medical School, McMaster University, Hamilton, Ontario, Canada
| | - Sameer Sharif
- Division of Critical Care, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer Chao
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver and Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, McMaster Children's Hospital, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Wang Y, Florez ID, Morgan RL, Foroutan F, Chang Y, Crandon HN, Zeraatkar D, Bala MM, Mao RQ, Tao B, Shahid S, Wang X, Beyene J, Offringa M, Sherman PM, El Gouhary E, Guyatt GH, Sadeghirad B. Probiotics, Prebiotics, Lactoferrin, and Combination Products for Prevention of Mortality and Morbidity in Preterm Infants: A Systematic Review and Network Meta-Analysis. JAMA Pediatr 2023; 177:1158-1167. [PMID: 37782505 PMCID: PMC10546299 DOI: 10.1001/jamapediatrics.2023.3849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/01/2023] [Indexed: 10/03/2023]
Abstract
Importance Modulation of intestinal microbiome by administering probiotics, prebiotics, or both may prevent morbidity and mortality in premature infants. Objective To assess the comparative effectiveness of alternative prophylactic strategies through a network meta-analysis (NMA) of randomized clinical trials. Data Sources MEDLINE, EMBASE, Science Citation Index Expanded, CINAHL, Scopus, Cochrane CENTRAL, and Google Scholar from inception until May 10, 2023. Study Selection Eligible trials tested probiotics, prebiotics, lactoferrin, and combination products for prevention of morbidity or mortality in preterm infants. Data Extraction and Synthesis A frequentist random-effects model was used for the NMA, and the certainty of evidence and inferences regarding relative effectiveness were assessed using the GRADE approach. Main Outcomes and Measures All-cause mortality, severe necrotizing enterocolitis, culture-proven sepsis, feeding intolerance, time to reach full enteral feeding, and duration of hospitalization. Results A total of 106 trials involving 25 840 preterm infants were included. Only multiple-strain probiotics were associated with reduced all-cause mortality compared with placebo (risk ratio [RR], 0.69; 95% CI, 0.56 to 0.86; risk difference [RD], -1.7%; 95% CI, -2.4% to -0.8%). Multiple-strain probiotics alone (vs placebo: RR, 0.38; 95% CI, 0.30 to 0.50; RD, -3.7%; 95% CI, -4.1% to -2.9%) or in combination with oligosaccharides (vs placebo: RR, 0.13; 95% CI, 0.05 to 0.37; RD, -5.1%; 95% CI, -5.6% to -3.7%) were among the most effective interventions reducing severe necrotizing enterocolitis. Single-strain probiotics in combination with lactoferrin (vs placebo RR, 0.33; 95% CI, 0.14 to 0.78; RD, -10.7%; 95% CI, -13.7% to -3.5%) were the most effective intervention for reducing sepsis. Multiple-strain probiotics alone (RR, 0.61; 95% CI, 0.46 to 0.80; RD, -10.0%; 95% CI, -13.9% to -5.1%) or in combination with oligosaccharides (RR, 0.45; 95% CI, 0.29 to 0.67; RD, -14.1%; 95% CI, -18.3% to -8.5%) and single-strain probiotics (RR, 0.61; 95% CI, 0.51 to 0.72; RD, -10.0%; 95% CI, -12.6% to -7.2%) proved of best effectiveness in reduction of feeding intolerance vs placebo. Single-strain probiotics (MD, -1.94 days; 95% CI, -2.96 to -0.92) and multistrain probiotics (MD, -2.03 days; 95% CI, -3.04 to -1.02) proved the most effective in reducing the time to reach full enteral feeding compared with placebo. Only single-strain and multistrain probiotics were associated with greater effectiveness compared with placebo in reducing duration of hospitalization (MD, -3.31 days; 95% CI, -5.05 to -1.58; and MD, -2.20 days; 95% CI, -4.08 to -0.31, respectively). Conclusions and Relevance In this systematic review and NMA, moderate- to high-certainty evidence demonstrated an association between multistrain probiotics and reduction in all-cause mortality; these interventions were also associated with the best effectiveness for other key outcomes. Combination products, including single- and multiple-strain probiotics combined with prebiotics or lactoferrin, were associated with the largest reduction in morbidity and mortality.
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Affiliation(s)
- Yuting Wang
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Ivan D. Florez
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, University of Antioquia, Medellin, Colombia
- Pediatric Intensive Care Unit, Clínica Las Americas-AUNA, Medellin, Colombia
| | - Rebecca L. Morgan
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Farid Foroutan
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Holly N. Crandon
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Malgorzata M. Bala
- Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Randi Q. Mao
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Brendan Tao
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shaneela Shahid
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Xiaoqin Wang
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Joseph Beyene
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Philip M. Sherman
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Enas El Gouhary
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
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Horn ME, Simon CB, Lee HJ, Eucker SA. Associations Between Management Pathway and Opioid Prescriptions for Patients Entering the Emergency Department With Neck and Back Pain. Mayo Clin Proc Innov Qual Outcomes 2023; 7:490-498. [PMID: 37842687 PMCID: PMC10568062 DOI: 10.1016/j.mayocpiqo.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Objective To determine associations between post-emergency department (ED) management pathways and downstream opioid prescriptions in patients seeking care for incident neck and/or back pain. Patients and Methods We identified patients seeking first-time ED care for neck and/or back pain from January 1, 2013, through November 6, 2017. We reported demographic characteristics and opioid prescriptions across management pathways using descriptive statistics and assessed the relative risk of any opioid prescription 12 months post-ED visit among 5 different post-ED management pathways using Poisson regression adjusted for patient demographic characteristics. Results Within 12 months after the index ED visit, 58.0% (n=10,949) were prescribed an opioid, with most patients prescribed an opioid within the first week (average daily morphine milligram equivalents of 6.8 mg (SD 9.6 mg). The morphine milligram equivalents decreased to 0.7 mg (SD 8.2 mg) by week 4 and remained consistently less than 1 mg between week 4 and 12 months. Compared with the ED to primary care provider pathway, the relative risk of opioid prescription between 7 days and 12 months after the index ED visit was similar for the ED to physical therapy pathway, higher for both the ED to hospital admission or repeat ED visit pathway (30% increase; relative risk (RR), 1.3; 95% CI, 1.17-1.44) and the ED to specialist pathway (19% increase; RR, 1.19; 95% CI, 1.07-1.33), and lower in the ED with no follow-up visits pathway (41% decrease; RR, 0.59; 95% CI, 0.54-0.65). Conclusion In general, more conservative care was associated with lower opioid prescription rates, and escalated care was associated with higher opioid prescription rates.
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Affiliation(s)
- Maggie E. Horn
- Department of Orthopaedic Surgery, Division of Physical Therapy, Duke University, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Corey B. Simon
- Department of Orthopaedic Surgery, Division of Physical Therapy, Duke University, Durham, NC
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
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Jones CMP, Day RO, Koes BW, Latimer J, Maher CG, McLachlan AJ, Billot L, Shan S, Lin CWC. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet 2023; 402:304-312. [PMID: 37392748 DOI: 10.1016/s0140-6736(23)00404-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Opioid analgesics are commonly used for acute low back pain and neck pain, but supporting efficacy data are scarce. We aimed to investigate the efficacy and safety of a judicious short course of an opioid analgesic for acute low back pain and neck pain. METHODS OPAL was a triple-blinded, placebo-controlled randomised trial that recruited adults (aged ≥18 years) presenting to one of 157 primary care or emergency department sites in Sydney, NSW, Australia, with 12 weeks or less of low back or neck pain (or both) of at least moderate pain severity. Participants were randomly assigned (1:1) using statistician-generated randomly permuted blocks to guideline-recommended care plus an opioid (oxycodone-naloxone, up to 20 mg oxycodone per day orally) or guideline-recommended care and an identical placebo, for up to 6 weeks. The primary outcome was pain severity at 6 weeks measured with the pain severity subscale of the Brief Pain Inventory (10-point scale), analysed in all eligible participants who provided at least one post-randomisation pain score, by use of a repeated measures linear mixed model. Safety was analysed in all randomly assigned eligible participants. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615000775516). FINDINGS Between Feb 29, 2016, and March 10, 2022, 347 participants were recruited (174 to the opioid group and 173 to the placebo group). 170 (49%) of 346 participants were female and 176 (51%) were male. 33 (19%) of 174 participants in the opioid group and 25 (15%) of 172 in the placebo group had discontinued from the trial by week 6, due to loss to follow-up and participant withdrawals. 151 participants in the opioid group and 159 in the placebo group were included in the primary analysis. Mean pain score at 6 weeks was 2·78 (SE 0·20) in the opioid group versus 2·25 (0·19) in the placebo group (adjusted mean difference 0·53, 95% CI -0·00 to 1·07, p=0·051). 61 (35%) of 174 participants in the opioid group reported at least one adverse event versus 51 (30%) of 172 in the placebo group (p=0·30), but more people in the opioid group reported opioid-related adverse events (eg, 13 [7·5%] of 174 participants in the opioid group reported constipation vs six [3·5%] of 173 in the placebo group). INTERPRETATION Opioids should not be recommended for acute non-specific low back pain or neck pain given that we found no significant difference in pain severity compared with placebo. This finding calls for a change in the frequent use of opioids for these conditions. FUNDING National Health and Medical Research Council, University of Sydney Faculty of Medicine and Health, and SafeWork SA.
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Affiliation(s)
- Caitlin M P Jones
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney and St Vincent's Clinical Campus, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Bart W Koes
- Department of General Practice, Erasmus MC, Rotterdam, Netherlands; Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
| | - Jane Latimer
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW, Australia
| | - Chris G Maher
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Sana Shan
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Chung-Wei Christine Lin
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW, Australia.
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Different Dosage Regimens of Tanezumab for the Treatment of Chronic Low Back Pain: A Meta-analysis of Randomized Controlled Trials. Clin Neuropharmacol 2023; 46:6-16. [PMID: 36542785 DOI: 10.1097/wnf.0000000000000530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The aim of this study was to assess the efficacy of different dosage regimens of tanezumab among individuals living with chronic low back pain (CLBP). METHODS PubMed, Embase, The Cochrane Library, and other databases were searched from inception until August 2021. Randomized controlled trials investigating the efficacy and safety of tanezumab in individuals with CLBP were included. Data were extracted independently by 2 investigators and assessed the study quality by the Cochrane risk-of-bias tool. The measurements include low back pain intensity and Roland-Morris Disability Questionnaire. The incidence of adverse events and serious adverse events was set to assess the safety of tanezumab for CLBP. RESULTS AND DISCUSSION Three high-quality randomized controlled trials with 3414 patients were finally included in our analysis. Tanezumab, respectively, led to a notable decrease compared with placebo in low back pain intensity (mean difference, -0.62; 95% confidence interval [CI], -0.77 to -0.46; P < 0.01) and Roland-Morris Disability Questionnaire (mean difference, -0.64; 95% CI, -0.80 to -0.47; P = 0.01). In addition, no significant difference existed between tanezumab and placebo groups (risk ratio, 1.10; 95% CI, 0.81-1.49; P = 0.55) in the adverse events and (risk ratio, 1.06; 95% CI, 0.34-3.27; P = 0.93) serious adverse events. CONCLUSIONS Intravenous and subcutaneous tanezumab injections as treatment for improving CLBP have promising clinical application as its great improvement on all efficacy and its controllable safety issues. Furthermore, intravenous and subcutaneous tanezumab injections were proved to achieve excellent and long-term curative effect on CLBP through our subgroup analysis and comparison.
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Larson MJ, Bauer MR, Moresco N, Huntington N, Ritter G, Paul-Kagiri R, Hyppolite R, Richard P. Variation in prescribing of opioids for emergency department encounters: A cohort study in the Military Health System. J Eval Clin Pract 2022; 28:1157-1167. [PMID: 35666601 PMCID: PMC10281196 DOI: 10.1111/jep.13702] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES: Emergency department (ED) clinicians account for approximately 13% of all opioid prescriptions to opioid-naïve patients and variability in the rates of prescribing have been noted among individual clinicians and different EDs. This study elucidates the amount of variability within a unified health system (the U.S. Military Health System [MHS]) with the expectation that understanding the sources of variability will enable health system leaders to improve the quality of decision making. METHODS The design was a retrospective cohort study examining variation in opioid prescribing within EDs of the US MHS. Participants were Army soldiers who returned from a deployment and received care between October 2009 and September 2016. The exposure was ED encounters at a military treatment facility. Key measures were the proportion of ED encounters with an opioid prescription fill; total opioid dose of the fill (morphine milligram equivalent, MME); and total opioid days-supply of the fill. RESULTS The mean proportion of ED encounters with an opioid fill across providers was 19.7% (SD 8.8%), median proportion was 18.6%, and the distribution was close to symmetric with the 75th percentile provider prescribing opioids in 24.6% of their ED encounters and the 25th percentile provider prescribing in 13.4% of their encounters. The provider-level mean opioid dose per encounter was 113.1 MME (SD 56.0) with the 75th percentile (130.1) 50% higher than the 25th percentile (87.4). The mean opioid supply per encounter was 6.8 days (SD 3.9) with more than a twofold ratio between the 75th percentile (8.3) and the 25th (4.1). Using a series of multilevel regression models to examine opioid fills associated with ED encounters and their dose levels, the variation among providers within facilities was much larger in magnitude than the variation among facilities. CONCLUSION Among ED encounters of Army soldiers at military treatment facilities, there was substantial variation among providers in prescribing opioid prescriptions that were not explained by patient case-mix. These results suggest that programmes and protocols to address less than optimal prescribing in the ED should be initiated to improve the quality of care.
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Affiliation(s)
- Mary Jo Larson
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | - Mark R. Bauer
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | - Natalie Moresco
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | - Nick Huntington
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | - Grant Ritter
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | | | - Regine Hyppolite
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Patrick Richard
- Uniformed Services University of the Health Sciences, Bethesda, MD
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Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep 2022; 71:1-95. [PMID: 36327391 PMCID: PMC9639433 DOI: 10.15585/mmwr.rr7103a1] [Citation(s) in RCA: 541] [Impact Index Per Article: 270.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.
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Wang M, Wang Y, Lei J. Assessing safety and efficacy in a network meta-analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3047. [PMID: 36357054 DOI: 10.1016/j.jaip.2022.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 07/25/2022] [Accepted: 08/21/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Miaomiao Wang
- The First Clinical Medical College of Lanzhou University, Lanzhou City, Gansu Province, China; Department of Radiology, The First Hospital of Lanzhou University, Lanzhou City, Gansu Province, China; Intelligent Imaging Medical Engineering Research Center of Gansu Province, Lanzhou City, Gansu Province, China
| | - Yinzhong Wang
- Department of Radiology, The First Hospital of Lanzhou University, Lanzhou City, Gansu Province, China; Intelligent Imaging Medical Engineering Research Center of Gansu Province, Lanzhou City, Gansu Province, China
| | - Junqiang Lei
- Department of Radiology, The First Hospital of Lanzhou University, Lanzhou City, Gansu Province, China; Intelligent Imaging Medical Engineering Research Center of Gansu Province, Lanzhou City, Gansu Province, China.
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Jones CMP, Lin CWC, Jamshidi M, Abdel Shaheed C, Maher CG, Harris IA, Patanwala AE, Dinh M, Mathieson S. Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain : A Systematic Review and Meta-analysis. Ann Intern Med 2022; 175:1572-1581. [PMID: 36252245 DOI: 10.7326/m22-2162] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The comparative benefits and harms of opioids for musculoskeletal pain in the emergency department (ED) are uncertain. PURPOSE To evaluate the comparative effectiveness and harms of opioids for musculoskeletal pain in the ED setting. DATA SOURCES Electronic databases and registries from inception to 7 February 2022. STUDY SELECTION Randomized controlled trials of any opioid analgesic compared with placebo or a nonopioid analgesic administered or prescribed to adults in or on discharge from the ED. DATA EXTRACTION Pain and disability were rated on a scale of 0 to 100 and pooled using a random-effects model. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. DATA SYNTHESIS Forty-two articles were included (n = 6128). In the ED, opioids were statistically but not clinically more effective in reducing pain in the short term (about 2 hours) than placebo and paracetamol (acetaminophen) but were not clinically or statistically more effective than nonsteroidal anti-inflammatory drugs (NSAIDs) or local or systemic anesthetics. Opioids may carry higher risk for harms than placebo, paracetamol, or NSAIDs, although evidence is very uncertain. There was no evidence of difference in harms associated with local or systemic anesthetics. LIMITATIONS Low or very low GRADE ratings for some outcomes, unexplained heterogeneity, and little information on long-term outcomes. CONCLUSION The risk-benefit balance of opioids versus placebo, paracetamol, NSAIDs, and local or systemic anesthetics is uncertain. Opioids may have equivalent pain outcomes compared with NSAIDs, but evidence on comparisons of harms is very uncertain and heterogeneous. Although factors such as route of administration or dosage may explain some heterogeneity, more work is needed to identify which subgroups will have a more favorable benefit-risk balance for one analgesic over another. Longer-term pain management once dose thresholds are reached is also uncertain. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42021275293).
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Affiliation(s)
- Caitlin M P Jones
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Masoud Jamshidi
- Department of Sports Physiology, University of Tehran, Tehran, Iran (M.J.)
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Sydney, Sydney, New South Wales, Australia (I.A.H.)
| | - Asad E Patanwala
- Royal Prince Alfred Hospital, and School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (A.E.P.)
| | - Michael Dinh
- Sydney Local Health District and The University of Sydney, Sydney, New South Wales, Australia (M.D.)
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
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Kolli S, Friedman BW, Latev A, Chang AK, Naeem F, Feliciano C, Afrifa F, Walker C, Izzo A, Irizarry E. A Randomized Study of Intravenous Hydromorphone Versus Intravenous Acetaminophen for Older Adult Patients with Acute Severe Pain. Ann Emerg Med 2022; 80:432-439. [PMID: 35965162 PMCID: PMC9588558 DOI: 10.1016/j.annemergmed.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/05/2022] [Accepted: 06/16/2022] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE We conducted a randomized study to compare the efficacy and adverse event profile of 1,000 mg of intravenous acetaminophen to that of 0.5 mg of intravenous hydromorphone among patients aged 65 years or more with acute pain of severity that was sufficient enough to warrant intravenous opioids. METHODS This randomized comparative effectiveness study with 162 participants was conducted in 2 urban emergency departments (EDs). The primary outcome was an improvement in a 0 to 10 pain scale from baseline to 60 minutes later. Secondary outcomes included the need for additional analgesic medication and adverse events that were attributable to the investigational medication. The minimum clinically important difference was an improvement of 1.3 on the 0 to 10 pain scale. RESULTS The median baseline pain score was 10 (interquartile range 8 to 10) in both the groups. By 60 minutes, patients taking acetaminophen improved by 3.6 (standard deviation 2.9) on the 0 to 10 pain scale, whereas patients taking hydromorphone improved by 4.6 (standard deviation 3.3) (95% confidence interval [CI] for the difference of 1.0 was 0.1 to 2.0). Additional analgesic medications were required for 37 (46%) of 81 patients taking acetaminophen and 31 (38%) of 81 patients taking hydromorphone (95% CI for the rounded difference of 7% was -8% to 23%). Adverse events were reported by 6 (7%) of 81 patients taking acetaminophen and 10 (12%) of 81 patients taking hydromorphone (95% CI for the difference of 5% was -4% to 14%) and included dizziness, drowsiness, headache, and nausea. CONCLUSION Although 0.5 mg of the intravenously administered hydromorphone was statistically superior to 1,000 mg of intravenous acetaminophen administered in older patients with acute severe pain in the ED, this difference was not clinically significant. Regardless of the medication received, many participants experienced minimal or incomplete pain relief.
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Affiliation(s)
- Shilpa Kolli
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY.
| | - Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Alex Latev
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Andrew K Chang
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Farnia Naeem
- Department of Emergency Medicine, Mount Sinai Health System, New York, NY
| | - Carmen Feliciano
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | | | - Christopher Walker
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Al Izzo
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Eddie Irizarry
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
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Gazendam A, Ekhtiari S, Horner NS, Simunovic N, Khan M, de Sa DL, Madden K, Ayeni OR. Effect of a Postoperative Multimodal Opioid-Sparing Protocol vs Standard Opioid Prescribing on Postoperative Opioid Consumption After Knee or Shoulder Arthroscopy: A Randomized Clinical Trial. JAMA 2022; 328:1326-1335. [PMID: 36194219 PMCID: PMC9533185 DOI: 10.1001/jama.2022.16844] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE In arthroscopic knee and shoulder surgery, there is growing evidence that opioid-sparing protocols may reduce postoperative opioid consumption while adequately addressing patients' pain. However, there are a lack of prospective, comparative trials evaluating their effectiveness. OBJECTIVE To evaluate the effect of a multimodal, opioid-sparing approach to postoperative pain management compared with the current standard of care in patients undergoing arthroscopic shoulder or knee surgery. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was performed at 3 clinical sites in Ontario, Canada, and enrolled 200 patients from March 2021 to March 2022 with final follow-up completed in April 2022. Adult patients undergoing outpatient arthroscopic shoulder or knee surgery were followed up for 6 weeks postoperatively. INTERVENTIONS The opioid-sparing group (100 participants randomized) received a prescription of naproxen, acetaminophen (paracetamol), and pantoprazole; a limited rescue prescription of hydromorphone; and a patient educational infographic. The control group (100 participants randomized) received the current standard of care determined by the treating surgeon, which consisted of an opioid analgesic. MAIN OUTCOMES AND MEASURES The primary outcome was postoperative oral morphine equivalent (OME) consumption at 6 weeks after surgery. There were 5 secondary outcomes, including pain, patient satisfaction, opioid refills, quantity of OMEs prescribed at the time of hospital discharge, and adverse events at 6 weeks all reported at 6 weeks after surgery. RESULTS Among the 200 patients who were randomized (mean age, 43 years; 73 women [38%]), 193 patients (97%) completed the trial; 98 of whom were randomized to receive standard care and 95 the opioid-sparing protocol. Patients in the opioid-sparing protocol consumed significantly fewer opioids (median, 0 mg; IQR, 0-8.0 mg) than patients in the control group (median, 40.0 mg; IQR, 7.5-105.0; z = -6.55; P < .001). Of the 5 prespecified secondary end points, 4 showed no significant difference. The mean amount of OMEs prescribed was 341.2 mg (95% CI, 310.2-372.2) in the standard care group and 40.4 mg (95% CI, 39.6-41.2) in the opioid-sparing group (mean difference, 300.8 mg; 95% CI, 269.4-332.3; P < .001). There was no significant difference in adverse events at 6 weeks (2 events [2.1%] in the standard care group vs 3 events [3.2%] in the opioid-sparing group), but more patients reported medication-related adverse effects in the standard care group (32% vs 19%, P = .048). CONCLUSIONS AND RELEVANCE Among patients who underwent arthroscopic knee or shoulder surgery, a multimodal opioid-sparing postoperative pain management protocol, compared with standard opioid prescribing, significantly reduced postoperative opioid consumption over 6 weeks. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04566250.
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Affiliation(s)
| | - Aaron Gazendam
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Seper Ekhtiari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nolan S Horner
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Simunovic
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Moin Khan
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Darren L de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kim Madden
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Zhou F, Deng J, Banfield L, Thabane L, Sadeghirad B, Samaan MC. Pharmacotherapy in paediatric type 2 diabetes mellitus: a protocol for a systematic review and network meta-analysis of randomised trials. BMJ Open 2022; 12:e065287. [PMID: 36167361 PMCID: PMC9516159 DOI: 10.1136/bmjopen-2022-065287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 09/08/2022] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION The rates of type 2 diabetes mellitus (T2DM) in children and adolescents have risen globally over the past few years. While a few diabetes pharmacotherapies have been used in this population, their comparative benefits and harms are unclear. Thus, we will conduct a systematic review and network meta-analysis (NMA) of randomised controlled trials (RCTs) to compare the efficacy and safety of pharmacotherapies for managing paediatric T2DM. METHODS AND ANALYSIS We will include RCTs that enrolled T2DM patients ≤18 years of age and who were randomised to monotherapy or combination pharmacotherapies with or without lifestyle interventions. Comparator groups will include placebo or non-pharmacological treatments including lifestyle interventions.Treatment outcomes will include change from baseline in glycated haemoglobin A1c, body mass index z-score, weight, systolic/diastolic blood pressure, fasting plasma glucose, fasting insulin and lipid profiles, T2DM-related complications, as well as the incidence of treatment-related adverse events.Literature searches will be conducted in Medline, Embase, CINAHL, CENTRAL and Web of Science. We will also search the grey literature and the reference list of included trials and relevant reviews. Two reviewers will assess the eligibility of articles identified through our searches and will extract data from eligible studies independently. We will use a modified Cochrane instrument to evaluate the risk of bias. Disagreements will be resolved through consensus or arbitration by a third reviewer.A frequentist random-effects model will be used for conducting NMA. The quality of evidence will be assessed using the Confidence in Network Meta-Analysis platform. We will assess the effect modification through network meta-regression and subgroup analyses for sex, age at study inclusion, duration of T2DM, follow-up duration and risk of bias ratings. ETHICS AND DISSEMINATION This study will not require ethics approval. We will disseminate our findings through publication in a peer-reviewed journal and conference presentations. PROSPERO REGISTRATION NUMBER CRD42022310100.
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Affiliation(s)
- Fangwen Zhou
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Division of Pediatric Endocrinology, McMaster University, Hamilton, Ontario, Canada
| | - Jiawen Deng
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Division of Pediatric Endocrinology, McMaster University, Hamilton, Ontario, Canada
| | - Laura Banfield
- Health Sciences Library, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - M Constantine Samaan
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Division of Pediatric Endocrinology, McMaster University, Hamilton, Ontario, Canada
- Michael G. De Groote School of Medicine, McMaster University, Hamilton, Ontario, Canada
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31
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Eucker SA, Glass O, Staton CA, Knisely MR, O'Regan A, De Larco C, Mill M, Dixon A, TumSuden O, Walker E, Dalton JC, Limkakeng A, Maxwell AMW, Gordee A, Kuchibhatla M, Chow S. Acupuncture for acute musculoskeletal pain management in the emergency department and continuity clinic: a protocol for an adaptive pragmatic randomised controlled trial. BMJ Open 2022; 12:e061661. [PMID: 36153034 PMCID: PMC9511597 DOI: 10.1136/bmjopen-2022-061661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/05/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Chronic musculoskeletal pain causes a significant burden on health and quality of life and may result from inadequate treatment of acute musculoskeletal pain. The emergency department (ED) represents a novel setting in which to test non-pharmacological interventions early in the pain trajectory to prevent the transition from acute to chronic pain. Acupuncture is increasingly recognised as a safe, affordable and effective treatment for pain and anxiety in the clinic setting, but it has yet to be established as a primary treatment option in the ED. METHODS AND ANALYSIS This pragmatic clinical trial uses a two-stage adaptive randomised design to determine the feasibility, acceptability and effectiveness of acupuncture initiated in the ED and continued in outpatient clinic for treating acute musculoskeletal pain. The objective of the first (treatment selection) stage is to determine the more effective style of ED-based acupuncture, auricular acupuncture or peripheral acupuncture, as compared with no acupuncture. All arms will receive usual care at the discretion of the ED provider blinded to treatment arm. The objective of the second (effectiveness confirmation) stage is to confirm the impact of the selected acupuncture arm on pain reduction. An interim analysis is planned at the end of stage 1 based on probability of being the best treatment, after which adaptations will be considered including dropping the less effective arm, sample size re-estimation and unequal treatment allocation ratio (eg, 1:2) for stage 2. Acupuncture treatments will be delivered by licensed acupuncturists in the ED and twice weekly for 1 month afterward in an outpatient clinic. ETHICS AND DISSEMINATION This study has been reviewed and approved by the Duke University Health System Institutional Review Board. Informed consent will be obtained from all participants. Results will be disseminated through peer-review publications and public and conference presentations. TRIAL REGISTRATION NUMBER NCT04290741.
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Affiliation(s)
- Stephanie A Eucker
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Oliver Glass
- Department of Medicine, Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Catherine A Staton
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
| | | | - Amy O'Regan
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Christi De Larco
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michelle Mill
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Austin Dixon
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Olivia TumSuden
- UNC Adams School of Dentistry, Chapel Hill, North Carolina, USA
| | - Erica Walker
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Juliet C Dalton
- Duke Office of Clinical Research, Duke University, Durham, North Carolina, USA
| | - Alexander Limkakeng
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Alex Gordee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Maggie Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
- Center for Aging, Duke University, Durham, North Carolina, USA
| | - Sheinchung Chow
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
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Willingness to use nonpharmacologic treatments for musculoskeletal pain in the emergency department: a cross-sectional study. Pain Rep 2022; 7:e1027. [PMID: 35999902 PMCID: PMC9387978 DOI: 10.1097/pr9.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/06/2022] [Accepted: 06/25/2022] [Indexed: 11/27/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. Patients in emergency department with musculoskeletal pain report high willingness to try nonpharmacologic treatments, and health care provider encouragement correlated with greater nonpharmacologic treatment use. Objectives: Pain is an individual experience that should incorporate patient-centered care. This study seeks to incorporate patient perspectives toward expanding nonpharmacologic treatment options for pain from the emergency department (ED). Methods: In this cross-sectional study of adult patients in ED with musculoskeletal neck, back, or extremity pain, patient-reported outcomes were collected including willingness to try and prior use of various nonpharmacologic pain treatments, sociodemographics, clinical characteristics, functional outcomes, psychological distress, and nonmusculoskeletal symptoms. Least absolute shrinkage and selection operator regression identified variables associated with (1) willingness to try and (2) having previously tried nonpharmacologic treatments. Results: Responses were analyzed from 206 adults, with a mean age of 45.4 (SD 16.4) years. The majority (90.3%) of patients in ED were willing to try at least one form of nonpharmacologic pain treatment, with 70.4%, 81.6%, and 70.9% willing to try respective subcategories of active (eg, exercise), passive (eg, heat), and psychosocial (eg, prayer) modalities. Only 56.3% of patients had previously tried any, with 35.0%, 52.4%, and 41.3% having tried active, passive, and psychosocial modalities, respectively. Patient-level factors associated with willingness included pain in upper back, more severe pain-related symptoms, and functional impairments. The factor most consistently associated with treatment use was health care provider encouragement to do so. Conclusions: Patients in ED report high willingness to try nonpharmacologic treatments for pain. Higher pain severity and interference may indicate greater willingness, while health care provider encouragement correlated with treatment use. These findings may inform future strategies to increase the introduction of nonpharmacologic treatments from the ED.
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Wang M, Wang Y, Lei J. Commentary on Xue et al. The efficacy and safety of dual orexin receptor antagonists in primary insomnia: A systematic review and network meta-analysis. Sleep Med Rev 2022; 65:101685. [PMID: 36007458 DOI: 10.1016/j.smrv.2022.101685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Miaomiao Wang
- The First Clinical Medical College of Lanzhou University, No.1 Donggang West Road, Lanzhou City, Gansu Province, China; Department of Radiology, The First Hospital of Lanzhou University, No.1 Donggang West Road, Lanzhou City, Gansu Province, China
| | - Yinzhong Wang
- Department of Radiology, The First Hospital of Lanzhou University, No.1 Donggang West Road, Lanzhou City, Gansu Province, China
| | - Junqiang Lei
- Department of Radiology, The First Hospital of Lanzhou University, No.1 Donggang West Road, Lanzhou City, Gansu Province, China.
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Koscso JM, McElheny K, Carr JB, Hippensteel KJ. Lower Extremity Muscle Injuries in the Overhead Athlete. Curr Rev Musculoskelet Med 2022; 15:500-512. [PMID: 35913667 PMCID: PMC9789236 DOI: 10.1007/s12178-022-09786-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Lower extremity (LE) injuries are a common source of disability and time-loss for overhead athletes, and muscles have been found to be the predominant soft tissue structure affected. The current review highlights the orthopaedic literature examining lower extremity muscle injuries in overhead athletes in regard to epidemiology, diagnosis, and conventional and emerging treatment measures. RECENT FINDINGS The hamstring muscles have been found to be the most commonly injured lower extremity muscle group in professional baseball, followed by the adductors, quadriceps, iliopsoas, and gastrocnemius-soleus complex. Strains and contusions comprise over 90% of these muscle injuries. Various advanced imaging grading systems have been developed to help characterize the nature of a muscle injury, although a clear and consistent prognostic utility of these systems is still unclear. The vast majority of lower extremity muscle injuries in overhead athletes are managed nonoperatively, and there is promising data on the use of emerging treatments such as platelet-rich plasma and blood flow restriction therapy. Lower extremity muscle injuries-often referred to as strains-are a relatively common issue in high-demand overhead athletes and can be a significant source of time-loss. Within baseball, position players are affected far more often than pitchers, and sprinting and fielding are the most common activities leading to strains. Magnetic resonance imaging (MRI) is considered the gold standard imaging modality to evaluate these muscle injuries and will allow for a detailed assessment of tissue damage. Nonetheless, return-to-play is often dictated by a given athlete's progression through a nonoperative rehabilitation protocol, with surgical intervention reserved for less common, select injury patterns.
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Affiliation(s)
| | - Kathryn McElheny
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021 USA
| | - James B. Carr
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021 USA
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Wang G, Yang M, Hong M, Krauss J, Bailey JF. Clinical Outcomes After a Digital Musculoskeletal Program for Acute and Subacute Pain: Observational, Longitudinal Study With Comparison Group. JMIR Rehabil Assist Technol 2022; 9:e38214. [PMID: 35759317 PMCID: PMC9274396 DOI: 10.2196/38214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/01/2022] [Accepted: 06/15/2022] [Indexed: 12/02/2022] Open
Abstract
Background Telerehabilitation for musculoskeletal (MSK) conditions may produce similar or better outcomes than usual care, but most telerehabilitation studies address only chronic or postsurgical pain. Objective We aimed to examine pain and function at 3, 6, and 12 weeks for individuals with acute and subacute MSK pain who took part in a digital MSK program versus a nonparticipant comparison group. Methods We conducted an observational, longitudinal study with a nonparticipant comparison group. The intervention group had video visits with physical therapists who recommended exercise therapies and educational articles delivered via an app. Nonparticipants were those who were registered but unable to participate because their benefit coverage had not yet begun. We collected pain and function outcomes through surveys delivered at 3-, 6-, and 12-week follow-ups. We conducted descriptive analyses, unadjusted regression, and mixed effects regression adjusting for baseline characteristics, time as fixed effects, and a time*group interaction term. Results The analysis included data from 675 nonparticipants and 262 intervention group participants. Compared to baseline, the intervention group showed significantly more pain improvement at 3, 6, and 12 weeks versus nonparticipants after adjusting for baseline factors. Specifically, the intervention group’s pain scores decreased by 55.8% at 3 weeks versus baseline, 69.1% at 6 weeks, and 73% at 12 weeks. The intervention group’s adjusted pain scores decreased from 43.7 (95% CI 41.1-46.2) at baseline to 19.3 (95% CI 16.8-21.8) at 3 weeks to 13.5 (95% CI 10.8-16.2) at 6 weeks to 11.8 (95% CI 9-14.6) at 12 weeks. In contrast, nonparticipants’ pain scores decreased by 30.8% at 3 weeks versus baseline, 45.8% at 6 weeks, and 46.7% at 12 weeks. Nonparticipants’ adjusted pain scores decreased from 43.8 (95% CI 42-45.5) at baseline to 30.3 (95% CI 27.1-33.5) at 3 weeks to 23.7 (95% CI 20-27.5) at 6 weeks to 23.3 (95% CI 19.6-27) at 12 weeks. After adjustments, the percentage of participants reporting that pain was better or much better at follow-up was significantly higher by 40.6% at 3 weeks, 31.4% at 6 weeks, and 31.2% at 12 weeks for intervention group participants versus nonparticipants. After adjustments, the percentage of participants with meaningful functional improvement at follow-up was significantly higher by 15.2% at 3 weeks and 24.6% at 12 weeks for intervention group participants versus nonparticipants. Conclusions A digital MSK program may help to improve pain and function in the short term among those with acute and subacute MSK pain.
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Affiliation(s)
- Grace Wang
- Hinge Health, Inc, San Francisco, CA, United States
| | - Manshu Yang
- Department of Psychology, University of Rhode Island, Kingston, RI, United States
| | - Mindy Hong
- Hinge Health, Inc, San Francisco, CA, United States
| | | | - Jeannie F Bailey
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, United States
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Phillips MR, Sadeghirad B, Busse JW, Brignardello-Petersen R, Cuello-Garcia CA, Kenji Nampo F, Guo YJ, Bzovsky S, Bannuru RR, Thabane L, Bhandari M, Guyatt GH. Development and design validation of a novel network meta-analysis presentation tool for multiple outcomes: a qualitative descriptive study. BMJ Open 2022; 12:e056400. [PMID: 35688599 PMCID: PMC9189833 DOI: 10.1136/bmjopen-2021-056400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The Grades of Recommendations, Assessment, Development and Evaluation working group recently developed an innovative approach to interpreting results from network meta-analyses (NMA) through minimally and partially contextualised methods; however, the optimal method for presenting results for multiple outcomes using this approach remains uncertain. We; therefore, developed and iteratively modified a presentation method that effectively summarises NMA results of multiple outcomes for clinicians using this new interpretation approach. DESIGN Qualitative descriptive study. SETTING A steering group of seven individuals with experience in NMA and design validation studies developed two colour-coded presentation formats for evaluation. Through an iterative process, we assessed the validity of both formats to maximise their clarity and ease of interpretation. PARTICIPANTS 26 participants including 20 clinicians who routinely provide patient care, 3 research staff/research methodologists and 3 residents. MAIN OUTCOME MEASURES Two team members used qualitative content analysis to independently analyse transcripts of all interviews. The steering group reviewed the analyses and responded with serial modifications of the presentation format. RESULTS To ensure that readers could easily discern the benefits and safety of each included treatment across all assessed outcomes, participants primarily focused on simple information presentations, with intuitive organisational decisions and colour coding. Feedback ultimately resulted in two presentation versions, each preferred by a substantial group of participants, and development of a legend to facilitate interpretation. CONCLUSION Iterative design validation facilitated the development of two novel formats for presenting minimally or partially contextualised NMA results for multiple outcomes. These presentation approaches appeal to audiences that include clinicians with limited familiarity with NMAs.
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Affiliation(s)
- Mark R Phillips
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Jason W Busse
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | | | - Carlos A Cuello-Garcia
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Fernando Kenji Nampo
- Department of Latin-American Institute of Life and Nature science, Federal University of Latin-American Integration, Foz do Iguacu, Brazil
| | - Yu Jia Guo
- Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sofia Bzovsky
- Department of Surgery - Division of Orthopaedics, McMaster University, Hamilton, Ontario, Canada
| | - Raveendhara R Bannuru
- Center for Treatment Comparison and Integrative Analysis, Tufts Medical Center, Boston, Massachusetts, USA
| | - Lehana Thabane
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Orthopaedic Surgery, Mcmaster University, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a comment. Am J Obstet Gynecol 2022; 226:869-870. [PMID: 35183500 DOI: 10.1016/j.ajog.2022.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/06/2022] [Accepted: 02/01/2022] [Indexed: 11/23/2022]
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Goldstick JE, Guy GP, Losby JL, Baldwin GT, Myers MG, Bohnert ASB. Patterns in Nonopioid Pain Medication Prescribing After the Release of the 2016 Guideline for Prescribing Opioids for Chronic Pain. JAMA Netw Open 2022; 5:e2216475. [PMID: 35687334 PMCID: PMC9187961 DOI: 10.1001/jamanetworkopen.2022.16475] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE In 2016, the Centers for Disease Control and Prevention (CDC) released the evidence-based Guideline for Prescribing Opioids for Chronic Pain. How the release of this guideline coincided with changes in nonopioid pain medication prescribing rates remains unknown. OBJECTIVE To evaluate changes in nonopioid pain medication prescribing after the 2016 CDC guideline release and to assess the heterogeneity in these changes as a function of patient demographic and clinical characteristics. DESIGN, SETTING, AND PARTICIPANTS This cohort study constructed 7 (4 preguideline and 3 postguideline) annual cohorts using claims data from the national Optum Clinformatics Data Mart Database for the period January 1, 2011, through December 31, 2018. The cohorts included adults with commercial insurance, no cancer or palliative care claims, and 2 years of continuous insurance enrollment. Individuals could qualify for inclusion in multiple cohorts. Each cohort covered a 2-year period, with year 1 as the baseline period used to calculate opioid exposure and other clinical characteristics and year 2 as the follow-up period used to calculate prescribing outcomes. Data were analyzed in March 2022. EXPOSURES The CDC guideline, which was released in March 2016. MAIN OUTCOMES AND MEASURES The primary outcome was receipt of any nonopioid pain medication prescriptions (analgesics or antipyretics, anticonvulsants, antidepressants, and nonsteroidal anti-inflammatory drugs) during the follow-up period. This postguideline prescribing pattern was compared with estimates based on the preguideline prescribing pattern, and then the differences were stratified by patient clinical characteristics (chronic pain, recent opioid exposure, substance use disorder, anxiety disorder, and mood disorder). RESULTS A total of 15 879 241 individuals (2015 mean [SD] age, 50.2 [18.6] years; 8 298 271 female patients [52.3%]) qualified for inclusion in 1 or more cohorts. Logistic regression models showed that nonopioid pain medication prescribing odds were higher by 3.0% (95% CI, 2.6%-3.3%) in postguideline year 1, by 8.7% (95% CI, 8.3%-9.2%) in postguideline year 2, and by 9.7% (95% CI, 9.2%-10.3%) in postguideline year 3 than the preguideline pattern-based estimates. The magnitude of the postguideline departures from the preguideline pattern varied by several clinical characteristics (chronic pain, recent opioid exposure, anxiety disorder, and mood disorder). The largest departure was found among those with chronic pain, with postguideline prescribing being higher than estimated in postguideline year 2 (13.6%; 95% CI, 12.7%-14.6%) and postguideline year 3 (14.9%; 95% CI, 13.8%-16.0%). CONCLUSIONS AND RELEVANCE Results of this study showed increases in nonopioid pain medication prescribing after the release of the 2016 CDC guideline, suggesting that the guideline may be associated with an increase in guideline-concordant care, but additional studies are needed to understand the role of other secular changes in the opioid policy landscape and other sources of nonopioid medication use.
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Affiliation(s)
- Jason E. Goldstick
- Injury Prevention Center, University of Michigan, Ann Arbor
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Gery P. Guy
- Division of Overdose Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jan L. Losby
- Division of Overdose Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Grant T. Baldwin
- Division of Overdose Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew G. Myers
- Injury Prevention Center, University of Michigan, Ann Arbor
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Amy S. B. Bohnert
- Injury Prevention Center, University of Michigan, Ann Arbor
- Department of Anesthesiology, University of Michigan, Ann Arbor
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
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Li J, Li Q, Wang J, Zhao X, Li Y. Short Duration of DAPT vs De-Escalation After Percutaneous Coronary Intervention for Acute Coronary Syndromes. JACC Cardiovasc Interv 2022; 15:999. [PMID: 35512925 DOI: 10.1016/j.jcin.2022.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
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Minotti B, Mansella G, Sieber R, Ott A, Nickel CH, Bingisser R. Intravenous acetaminophen does not reduce morphine use for pain relief in emergency department patients: A multicenter, randomized, double-blind, placebo-controlled trial. Acad Emerg Med 2022; 29:954-962. [PMID: 35491963 PMCID: PMC9544852 DOI: 10.1111/acem.14517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 11/29/2022]
Abstract
Background Pain is one of the main reasons to present to emergency departments (EDs). Opioids are indispensable for acute pain management but are associated with side effects, misuse, and dependence. The aim of this study was to test whether a single dose of intravenous (IV) acetaminophen (paracetamol) can reduce the use of morphine for pain relief and/or morphine‐related adverse events (AEs). Methods ED patients >18 years with acute pain (i.e., Numeric Rating Scale [NRS] > 4) were screened for eligibility. Patients with analgesia in the past 6 h, chronic pain, or clinical instability were excluded. Patients were randomized in a 1:1 ratio to receive either morphine 0.1 mg/kg and 1 g acetaminophen IV or morphine 0.1 mg/kg and placebo IV. The intervention was double‐blinded. Additional morphine 0.05 mg/kg IV was administered every 15 minutes until pain relief (defined as NRS < 4) and whether the pain recurred. The primary outcome was the mean morphine dose for pain relief. Secondary outcomes were the total amount of morphine given, time to achieve pain relief, and AEs. Results A total of 220 patients were randomized and 202 evaluated for the primary outcome. The mean morphine dose for pain relief was similar in both groups (acetaminophen 0.15 mg ± 0.07 mg/kg, placebo 0.16 ± 0.07 mg/kg). There were no differences in the total amount of morphine given (acetaminophen 0.19 ± 0.09 mg/kg, placebo 0.19 ± 0.1 mg/kg), the time to achieve pain relief (acetaminophen 30 min [95% CI 17–31 min], placebo 30 min [95% CI 30–35 min]), and the frequency of AEs (overall 27.4%). Time to pain recurrence did not differ significantly between the groups (hazard ratio 1.23 [0.76–1.98], p = 0.40). Conclusions In ED patients, acetaminophen had no additional effect on pain control or morphine‐sparing effect at the time of first morphine administration. Titrated morphine with the algorithm used was highly effective, with 80% of all patients reporting pain relief within 60 min of starting therapy.
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Affiliation(s)
- Bruno Minotti
- Emergency Department Cantonal Hospital of St. Gallen St. Gallen Switzerland
| | - Gregory Mansella
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
| | - Robert Sieber
- Emergency Department Cantonal Hospital of St. Gallen St. Gallen Switzerland
| | - Alexander Ott
- Interdisciplinary Pain Center Cantonal Hospital of St. Gallen St. Gallen Switzerland
| | - Christian H. Nickel
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
| | - Roland Bingisser
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
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Hung CW, Riggan ND, Hunt TR, Halawi MJ. What's Important: A Rallying Call for Nonsteroidal Anti-Inflammatory Drugs in Musculoskeletal Pain: Improving Value of Care While Combating the Opioid Epidemic. J Bone Joint Surg Am 2022; 104:659-663. [PMID: 34437306 DOI: 10.2106/jbjs.21.00466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Chun Wai Hung
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Thomas R Hunt
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas
| | - Mohamad J Halawi
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas
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Eltorki M, Busse JW, Freedman SB, Thompson G, Beattie K, Serbanescu C, Carciumaru R, Thabane L, Ali S. Intravenous ketorolac versus morphine in children presenting with suspected appendicitis: a pilot single-centre non-inferiority randomised controlled trial. BMJ Open 2022; 12:e056499. [PMID: 35383071 PMCID: PMC8984007 DOI: 10.1136/bmjopen-2021-056499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Despite a lack of evidence demonstrating superiority to non-steroidal anti-inflammatory drugs, like ketorolac, that are associated with lower risk of harms, opioids remain the most prescribed analgesic for acute abdominal pain. In this pilot trial, we will assess the feasibility of a definitive trial comparing ketorolac with morphine in children with suspected appendicitis. We hypothesise that our study will be feasible based on a 40% consent rate. METHODS AND ANALYSIS A single-centre, non-inferiority, blinded (participant, clinician, investigators and outcome assessors), double-dummy randomised controlled trial of children aged 6-17 years presenting to a paediatric emergency department with ≤5 days of moderate to severe abdominal pain (≥5 on a Verbal Numerical Rating Scale) and are investigated for appendicitis. We will use variable randomised blocks of 4-6 and allocate participants in 1:1 ratio to receive either intravenous (IV) ketorolac 0.5 mg/kg+IV morphine placebo or IV morphine 0.1 mg/kg+IV ketorolac placebo. Analgesic co-intervention will be limited to acetaminophen (commonly used as first-line therapy). Participants in both groups will be allowed rescue therapy (morphine 0.5 mg/kg) within 60 min of our intervention. Our primary feasibility outcome is the proportion of eligible patients approached who provide informed consent and are enrolled in our trial. Our threshold for feasibility will be to achieve a ≥40% consent rate, and we will enrol 100 participants into our pilot trial. ETHICS AND DISSEMINATION Our study has received full approval by the Hamilton integrated Research Ethics Board. We will disseminate our study findings at national and international paediatric research conferences to garner interest and engage sites for a future multicentre definitive trial. TRIAL REGISTRATION NCT04528563, Pre-results.
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Affiliation(s)
- Mohamed Eltorki
- Pediatrics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Jason W Busse
- Department of Health Research Methods, Evidence & Impact, McMaster, Hamilton, Ontario, Canada
- Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | | | - Graham Thompson
- Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Karen Beattie
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Redjana Carciumaru
- Pediatrics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Pediatrics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- St Joseph's Research Institute, St Joseph's Health Care, Hamilton, Ontario, Canada
| | - Samina Ali
- Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
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Holloway GL, Weymiller AJ, Allemand A. Goal-Directed Opioid Stewardship in Acute-on-Chronic Nonmalignant Pain Management. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Li M, Yao L, Wang Q, Wang X, Yang K. Ranking treatments in the network meta-analysis should consider the certainty of evidence. Lancet Gastroenterol Hepatol 2022; 7:287-288. [PMID: 35278397 DOI: 10.1016/s2468-1253(21)00470-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/09/2021] [Accepted: 12/10/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Meixuan Li
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China; Health Technology Assessment Center, Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou 730000, China; Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Qi Wang
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Xiaoqin Wang
- Michael G DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - Kehu Yang
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China; Health Technology Assessment Center, Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou 730000, China.
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Du J, Li M, Yin R. A Systematic Review and Network Meta-Analysis of Pharmacological Treatment of HFrEF. JACC. HEART FAILURE 2022; 10:292-293. [PMID: 35361453 DOI: 10.1016/j.jchf.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 06/14/2023]
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Dayyani M, Sadeghirad B, Grotta JC, Zabihyan S, Ahmadvand S, Wang Y, Guyatt GH, Amin-Hanjani S. Prophylactic Therapies for Morbidity and Mortality After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Network Meta-Analysis of Randomized Trials. Stroke 2022; 53:1993-2005. [PMID: 35354302 DOI: 10.1161/strokeaha.121.035699] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and morbidity. We aimed to determine the relative benefits of pharmacological prophylactic treatments in patients with aneurysmal subarachnoid hemorrhage by performing a network meta-analysis of randomized trials. METHODS We searched Medline, Web of Science, Embase, Scopus, ProQuest, and Cochrane Central to February 2020. Pairs of reviewers independently identified eligible trials, extracted data, and assessed the risk of bias. Eligible trials compared the prophylactic effects of any oral or intravenous medications or intracranial drug-eluting implants to one another or placebo or standard of care in adult hospitalized patients with confirmed aneurysmal subarachnoid hemorrhage. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the certainty of the evidence. RESULTS We included 53 trials enrolling 10 415 patients. Nimodipine likely reduces all-cause mortality compared to placebo (odds ratio [OR],0.73 [95% CI, 0.53-1.00]; moderate certainty; absolute risk reduction (ARR), -3.35%). Nimodipine (OR, 1.46 [95% CI, 1.07-1.99]; high certainty; absolute risk increase, 8.25%) and cilostazol (OR, 3.73 [95% CI, 1.14-12.18]; moderate certainty; absolute risk increase, 23.15%) were the most effective treatments in improving disability at the longest follow-up. Compared to placebo, clazosentan (10 mg/kg; OR, 0.39 [95% CI, 0.22-0.68]; high certainty; ARR, -16.65%), nicardipine (OR, 0.48 [95% CI, 0.24-0.94]; moderate certainty; ARR, -13.70%), fasudil (OR, 0.55 [95% CI, 0.31-0.98]; moderate certainty; ARR, -11.54%), and magnesium (OR, 0.66 [95% CI, 0.46-0.94]; high certainty; ARR, -8.37%) proved most effective in reducing the likelihood of delayed cerebral ischemia. CONCLUSIONS Nimodipine and cilostazol are likely the most effective treatments in preventing morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage. Clazosentan, nicardipine, fasudil, and magnesium showed beneficial effects on delayed cerebral ischemia and vasospasm but they were not found to reduce mortality or disability. Future trials are warranted to elaborately investigate the prophylactic effects of medications that may improve mortality and long-term functional outcomes, such as cilostazol and clazosentan. REGISTRATION URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42019122183.
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Affiliation(s)
- Mojtaba Dayyani
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, TX (M.D.).,Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.).,Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada. (B.S.).,The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada. (B.S.)
| | - James C Grotta
- Stroke Research and Mobile Stroke Unit, Memorial Hermann Hospital-Texas Medical Center (J.C.G.)
| | - Samira Zabihyan
- Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Saba Ahmadvand
- Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran (M.D., S.Z., S.A.)
| | - Yuting Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. (G.H.G., B.S., Y.W.)
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Factors that influence how adults select oral over-the-counter analgesics: A systematic review. J Am Pharm Assoc (2003) 2022; 62:1113-1123.e8. [DOI: 10.1016/j.japh.2022.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/04/2022] [Accepted: 03/09/2022] [Indexed: 11/22/2022]
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Kithulegoda N, Strachan PH, Zacharias R, Buckley N, Busse JW. Exploring Canadian Veterans’ priorities regarding chronic pain research: A qualitative study. JOURNAL OF MILITARY, VETERAN AND FAMILY HEALTH 2021. [DOI: 10.3138/jmvfh-2021-0045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
LAY SUMMARY In 2020, the Canadian Federal Government launched the Chronic Pain Centre of Excellence for Canadian Veterans (CPCoE). A higher proportion of Veterans experience chronic pain than the general population and the Centre wanted to understand what research topics Veterans thought the new Centre should prioritize. One-on-one interviews were conducted with 11 Canadian Veterans living with chronic pain from five provinces. Eight priority areas for future research were determined: 1) pain care in the military, 2) postoperative care in the military, 3) coordination of services through Veterans Affairs Canada, 4) military-to-civilian transition, 5) primary care provider access outside the military, 6) knowledge of pain management among civilian health care providers, 7) engaging Veterans as partners in their care, and 8) identifying effective strategies for chronic pain management. These findings will help guide research efforts of the new CPCoE.
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Affiliation(s)
- Natasha Kithulegoda
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
| | | | - Ramesh Zacharias
- The Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, Ontario, Canada
| | - Norman Buckley
- The Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, Ontario, Canada
| | - Jason W. Busse
- The Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, Ontario, Canada
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Affiliation(s)
- Howard S Kim
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Associate Editor, JAMA Network Open
| | - Danielle M McCarthy
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patrick M Lank
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Toxikon Consortium, Chicago, Illinois
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Limkakeng AT, Manandhar P, Erkanli A, Eucker SA, Root A, Voora D. United States Emergency Department Use of Medications with Pharmacogenetic Recommendations. West J Emerg Med 2021; 22:1347-1354. [PMID: 34787561 PMCID: PMC8597689 DOI: 10.5811/westjem.2021.5.51248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 05/17/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Emergency departments (ED) use many medications with a range of therapeutic efficacy and potential significant side effects, and many medications have dosage adjustment recommendations based on the patient’s specific genotype. How frequently medications with such pharmaco-genetic recommendations are used in United States (US) EDs has not been studied. Methods We conducted a cross-sectional analysis of the 2010–2015 National Hospital Ambulatory Medical Care Survey (NHAMCS). We reported the proportion of ED visits in which at least one medication with Clinical Pharmacogenetics Implementation Consortium (CPIC) recommendation of Level A or B evidence was ordered. Secondary comparisons included distributions and 95% confidence intervals of age, gender, race/ethnicity, ED disposition, geographical region, immediacy, and insurance status between all ED visits and those involving a CPIC medication. Results From 165,155 entries representing 805,726,000 US ED visits in the 2010–2015 NHAMCS, 148,243,000 ED visits (18.4%) led to orders of CPIC medications. The most common CPIC medication was tramadol (6.3%). Visits involving CPIC medications had higher proportions of patients who were female, had private insurance and self-pay, and were discharged from the ED. They also involved lower proportions of patients with Medicare and Medicaid. Conclusion Almost one fifth of US ED visits involve a medication with a pharmacogenetic recommendation that may impact the efficacy and toxicity for individual patients. While direct application of genotyping is still in development, it is important for emergency care providers to understand and support this technology given its potential to improve individualized, patient-centered care.
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Affiliation(s)
- Alexander T Limkakeng
- Duke University School of Medicine, Division of Emergency Medicine, Durham, North Carolina
| | - Pratik Manandhar
- Duke University School of Medicine, Department of Biostatistics and Bioinformatics, Durham, North Carolina
| | - Alaatin Erkanli
- Duke University School of Medicine, Department of Biostatistics and Bioinformatics, Durham, North Carolina
| | - Stephanie A Eucker
- Duke University School of Medicine, Division of Emergency Medicine, Durham, North Carolina.,Duke University School of Medicine, Department of Orthopedics, Durham, North Carolina
| | - Adam Root
- Duke University Hospital, Department of Pharmacy, Durham, North Carolina
| | - Deepak Voora
- Duke University School of Medicine, Division of Cardiology, Durham, North Carolina
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