Nevin Manimala

Drug Alcohol Depend. 2021 Sep 25;228:109108. doi: 10.1016/j.drugalcdep.2021.109108. Online ahead of print.

ABSTRACT

BACKGROUND: The 2016 Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain (Guideline hereafter) emphasized tapering patients from long-term opioid therapy (LTOT) when the harms outweigh the benefits.

METHODS: To examine tapering from LTOT before and after the Guideline release, we conducted a retrospective cohort study of adults with high-dose LTOT (mean of >50 Morphine Milligram Equivalents [MME]/day) from 2014 to 2018 from one Midwest state’s Health Information Exchange. We identified tapering (dose reductions in mean MME/day greater than 15%, 30%, 50%) and rapid discontinuation episodes (reduction to zero MME/day) over a 6-month follow-up period relative to a 3-month baseline period. We used segmented regressions to estimate outcomes adjusted for time trends and relevant state laws limiting opioid prescribing.

RESULTS: The Guideline release was associated with statistically significant immediate increase in the patient likelihood of experiencing tapering (15%: 1.8% point [95% confidence interval (CI): 1.2-2.6; 30%: 1.4% point, 95% CI: 0.7-2.2; 50%: 0.8% point, 95% CI: 0.2-1.4) and rapid discontinuation episodes (0.006% point, 95% CI: 0.001-0.01). After the Guideline release, the patient likelihood of tapering increased over time (15%: 0.4% point/month, 95% CI: 0.3-0.5; 30%: 0.3% point/month, 95% CI:0.2-0.4; 50%: 0.3% point/month, 95% CI: 0.2-0.3; rapid discontinuation: 0.01% point/month, 95% CI: 0.007-0.01). Tapering and rapid discontinuation trends was similar among gender and race categories.

CONCLUSION: The Guideline may be a useful tool in altering opioid prescribing practices, particularly for patients on shorter durations of LTOT.

PMID:34688106 | DOI:10.1016/j.drugalcdep.2021.109108

Psychiatry Res. 2021 Oct 12;306:114241. doi: 10.1016/j.psychres.2021.114241. Online ahead of print.

ABSTRACT

This study assessed the effects of aerobic exercise on cardiac autonomic nervous system function (based on heart rate variability [HRV]) and executive function among individuals with methamphetamine use disorder (MUD). We further examine the role of autonomic nervous system control in aerobic exercise (assessed via cardiopulmonary fitness) and executive function. A total of 330 individuals with MUD were randomly divided into exercise (n = 165) and control (n = 165) groups, who underwent eight-week aerobic exercise/health education program consisting of five 60 min sessions a week. The outcome measures included cardiopulmonary fitness, HRV time-domain and frequency-domain parameters, and executive function. Our statistical analyses comprised repeated-measures analyses of variance, correlation analyses, and mediation and moderation effect tests. The results indicated that aerobic exercise could simultaneously improve autonomic nervous system function and executive function among individuals with MUD. Moreover, the changes in cardiopulmonary fitness, high frequency HRV, and executive function were positively correlated. HRV did not significantly mediate the relationship between aerobic exercise and executive function; however, it did have a moderating effect, which was eliminated after adjusting for demographic and drug-use covariates. Among the covariates, age was the greatest confounder and was inversely proportional to cardiopulmonary function, HRV, and executive function. Cardiac autonomic nervous system function exerted a moderating, rather than a mediating, effect on the relationship between aerobic exercise and executive function. However, this potential effect was largely influenced by covariates, particularly age.

PMID:34688059 | DOI:10.1016/j.psychres.2021.114241

Sleep Med. 2021 Sep 20;87:250-256. doi: 10.1016/j.sleep.2021.09.005. Online ahead of print.

ABSTRACT

SUBJECT: A meta-analysis of a randomized placebo-controlled trial was used to evaluate the effectiveness and safety of Zolpidem in the treatment of insomnia disorder for one month.

METHOD: Searched from PubMed, EMBASE, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials and web of science from inception to May 13, 2021. In addition, we also searched ClinicalTrials.gov trials register to obtain relevant research and related data. Include all randomized controlled trials that meet the criteria. The primary efficacy outcome were total sleep time and sleep latency. The secondary outcome was wake-time after sleep onset. And to evaluate the safety of Zolpidem in the treatment of insomnia.

RESULTS: Total of 6 randomized placebo-controlled trials involving 1068 patients with insomnia disorder were included in our study. Our analysis results showed that compared with placebo, zolpidem treatment for one month was more effective in increasing the total sleep time of patients with insomnia disorder, reducing sleep latency and improving sleep quality. There was no significant statistical difference between the two groups in the amount of change in the wake after sleep onset. Meanwhile, there was no significant statistical difference in adverse events between Zolpidem and placebo after one month of treatment.

CONCLUSION: Our meta-analysis showed that zolpidem is an effective and safe therapy option to treat insomnia disorder for one month. However, when using zolpidem to treat insomnia, its effect on sleep structure should be considered. In the future, large-scale clinical trials are needed to compare the effectiveness and safety of zolpidem in the treatment of insomnia from subjective and objective indicators combined with zolpidem on sleep structure.

PMID:34688027 | DOI:10.1016/j.sleep.2021.09.005

Seizure. 2021 Oct 17;93:44-50. doi: 10.1016/j.seizure.2021.10.010. Online ahead of print.

ABSTRACT

PURPOSE: In patients diagnosed with epilepsy, decreased ratio of N-acetyl aspartate to creatine (NAA/Cr) measured in magnetic resonance spectroscopy (MRS) has been accepted as a sign of neuronal cell loss or dysfunction. In this study, we aimed to determine whether a similar neuronal cell loss is present in a group of encephalopathy with electrical status epilepticus in sleep (ESES) patients METHODS: We performed this case-control study at a tertiary pediatric neurology center with patients with ESES. Inclusion criteria for the patient group were as follows: 1) a spike-wave index of at least 50%, 2) acquired neuropsychological regression, 3) normal cranial MRI. Eventually, a total of 21 patients with ESES and 17 control subjects were enrolled in the study. MRI of all control subjects was also within normal limits. 3D Slicer program was used for the analysis of thalamic and brain volumes. LCModel spectral fitting software was used to analyze single-voxel MRS data from the right and left thalamus of the subjects.

RESULTS: The mean age was 8.0 ± 1.88 years and 8.3 ± 1.70 years in ESES patients and the control subjects. After correcting for the main potential confounders (age and gender) with a linear regression model, NAA/Creatine ratio of the right thalamus was significantly lower in the ESES patient group compared to the healthy control group (p = 0.026). Likewise, the left thalamus NAA/Cr ratio was significantly lower in the ESES patient group than the healthy control group (p = 0.007). After correcting for age and gender, right thalamic volume was not statistically significantly smaller in ESES patients than in healthy controls (p = 0.337), but left thalamic volume was smaller in ESES patients than in healthy controls (p = 0.024).

CONCLUSION: In ESES patients, the NAA/Creatine ratio, which is an indicator of neuronal cell loss or dysfunction in the right and left thalamus, which appears regular on MRI, was found to be significantly lower than the healthy control group. This metabolic-induced thalamic dysfunction, which was reported for the first time up to date, may play a role in ESES epileptogenesis.

PMID:34687985 | DOI:10.1016/j.seizure.2021.10.010

Foot (Edinb). 2021 May 27;49:101839. doi: 10.1016/j.foot.2021.101839. Online ahead of print.

ABSTRACT

BACKGROUND: Despite the current recommendations that stable Weber B ankle fractures can be treated with functional bracing and weightbearing as tolerated, some reluctance exists among trauma surgeons to follow these recommendations. This paper reports on our institution’s experience in managing these injuries and compare it to the national guidelines.

PATIENTS AND METHODS: This is a retrospective cohort study. Consecutive patients with isolated Weber B fractures referred to the local outpatient clinic over the period of six months were included in the study. Radiographs and clinic letters were examined, the patients were interviewed via telephone to obtain outcome scores [Olerud and Molander score]. Method of immobilisation, weight-bearing status, radiological fracture union, clinical outcomes and complications were all assessed and analysed.

RESULTS: One hundred and twenty-three patients with isolated Weber B fractures were identified. This cohort of patients did not show clinical or radiographic evidence of instability, they were deemed stable and were initially treated non-operatively. Minimum follow-up period was six months. Sixty-two patients were treated in plaster and were non-weight bearing on the affected limb, while 61 were treated with functional bracing in a boot and were allowed early weight bearing. Three patients showed displacement requiring surgical fixation. All fractures progressed to union and patients were discharged irrespective of the method of immobilisation or weightbearing status during treatment. There was no statistically significant difference in the functional outcome measures between the two groups. The protocol of functional bracing and weightbearing was associated with fewer outpatient clinics and a reduced number of radiographs obtained in the clinic and fewer complications.

CONCLUSION: Isolated trans-syndesmotic Weber B ankle fractures, that are clinically and radiologically stable, can be safely treated with functional bracing in a boot and weightbearing as tolerated.

PMID:34687981 | DOI:10.1016/j.foot.2021.101839

Foot (Edinb). 2021 Jun 12;49:101842. doi: 10.1016/j.foot.2021.101842. Online ahead of print.

ABSTRACT

PURPOSE: Gastrocnemius recession has been described in the treatment of gastrocnemius contracture. The aims of this study were: (1) to assess the change in ankle dorsiflexion after isolated medial gastrocnemius recession performed according to L.S. Barouk’s technique; (2) to compare ankle dorsiflexion after isolated medial head with complete proximal gastrocnemius recession.

METHODS: A cadaveric study was performed on 15 lower limb adult specimens. Isolated medial gastrocnemius head recession was initially performed, followed by an additional recession of the lateral gastrocnemius head. Ankle dorsiflexion torque was applied with 2 and 4 kg forces on second metatarsal head. Ankle dorsiflexion was measured with the knee both in extension and at 90° of flexion and values were recorded before surgery (T0), after medial head recession (T1) and after both heads recession (T2). Normality of data was assessed using the Shapiro-Wilk test, then measurements were compared in the three conditions with appropriate statistical tests.

RESULTS: After isolated medial gastrocnemius recession (Δ = T1-T0), ankle dorsiflexion assessed with the knee in extension significantly increased by 5° ± 3 (range, -2 to 10) with a 2-kg torque (p = 0.02) and by 4.5° ± 3 (range, -4 to 10) with a 4-kg torque (p = 0.04). No significant difference was observed with the knee flexed at 90° (p > 0.05 for all measurements). After both gastrocnemius heads recession (Δ = T2-T1), although a further increase in dorsiflexion was noticed, statistical significance was not reached neither with the knee in extension nor at 90° of flexion (p > 0.05 for all measurements).

CONCLUSION: In this study, isolated medial gastrocnemius head recession performed according to LS Barouk’s technique was effective in improving ankle dorsiflexion, whereas the additional release of the lateral head did not produce any significant change.

LEVEL OF EVIDENCE: Level V, cadaveric study.

PMID:34687979 | DOI:10.1016/j.foot.2021.101842

Clin Gastroenterol Hepatol. 2021 Oct 20:S1542-3565(21)01129-0. doi: 10.1016/j.cgh.2021.10.016. Online ahead of print.

ABSTRACT

BACKGROUND AND AIMS: Gastrointestinal cancer risk is influenced by the presence of metabolic syndrome [MetS]. However, previous epidemiological studies lacked full serological biomarker data for the classification of MetS and the interaction of MetS with germline cancer risk variants is unknown.

METHODS: We investigated the associations between MetS and gastrointestinal cancer risk (overall, colorectal, pancreatic, esophageal adenocarcinoma, esophageal squamous cell carcinoma, stomach cardia, stomach non-cardia, hepatocellular carcinoma, and intrahepatic bile duct cancer) in 366,016 UK Biobank participants with comprehensive serum biomarker and genotype data. MetS status was determined by three different definitions at baseline and, in 15,152 participants, at a repeat assessment after a median of 4.3 years of follow-up. Multivariable hazard ratios [HR] and 95% confidence intervals [CI] for cancer outcomes were estimated using Cox proportional hazards models. Analyses stratified by polygenic risk score [PRS] were conducted for colorectal and pancreatic cancers.

RESULTS: During a median follow-up of 7.1 years, 4,238 incident cases of a gastrointestinal cancer occurred. MetS at baseline was associated with higher risk of overall gastrointestinal cancer by any definition (HR 1.21, 95% CI 1.13-1.29, harmonized definition). MetS was associated with increased risks of colorectal cancer, colon cancer, rectal cancer, hepatocellular carcinoma, pancreatic cancer in women, and esophageal adenocarcinoma in men. Associations for colorectal cancer and pancreatic cancer did not differ by PRS strata (P-heterogeneity 0.70 and 0.69, respectively), and 80% of participants with MetS at baseline retained this status at the repeat assessment.

CONCLUSIONS: These findings underscore the importance of maintaining good metabolic health in reducing the burden of gastrointestinal cancers, irrespective of genetic predisposition.

PMID:34687971 | DOI:10.1016/j.cgh.2021.10.016

J Acad Nutr Diet. 2021 Oct 20:S2212-2672(21)01426-X. doi: 10.1016/j.jand.2021.10.019. Online ahead of print.

ABSTRACT

BACKGROUND: Nearly a third of young US children take multivitamin/mineral (MVM) dietary supplements, yet it is unclear how formulations compare to requirements.

OBJECTIVE: Describe the number and amounts of micronutrients contained in MVM for young children and compare suggested amounts on product labels to micronutrient requirements.

DESIGN: Cross sectional.

SETTING: All 288 MVM on the market in the US in NIH’s Dietary Supplement Label Database (DSLD) in 2018 labeled for children 1-<4 years old.

MAIN OUTCOME MEASURES: Number of MVM products and amounts/day of micronutrients in each product suggested on labels compared with requirements represented by age-appropriate Daily Values (DV). Micronutrients of public health concern identified by the Dietary Guidelines for Americans 2015-2020 (DGA 2015) and DGA 2020-2025 (DGA 2020) or those of concern for exceeding the upper tolerable intake levels (UL). Statistical Analyses Number of products and %DV per day provided by each micronutrient in each product.

RESULTS: The 288 MVM contained a mean of 10.1±2.27 vitamins and 4.59± 2.27 minerals. The most common were, in rank order, vitamins C, A, D, E, B-6, B-12, zinc, biotin, pantothenic acid, iodine, and folic acid. For micronutrients denoted by the DGA 2015 and DGA 2020 of public health concern, 56% of the 281 products containing vitamin D, 4% of the 144 with calcium and none of the 60 containing potassium provided at least half of the DV. The UL was exceeded by 49% of 197 products with folic acid, 17% of 283 with vitamin A, and 14% of 264 with zinc. Most MVM contained many of 16 other vitamins and minerals identified in national surveys as already abundant in children’s diets.

CONCLUSIONS: A reexamination of the amounts and types of micronutrients in MVMs may be suggested in order to consider formulations that better fill critical gaps in intakes and avoid excess.

PMID:34687947 | DOI:10.1016/j.jand.2021.10.019

J Minim Invasive Gynecol. 2021 Oct 20:S1553-4650(21)01224-3. doi: 10.1016/j.jmig.2021.10.008. Online ahead of print.

ABSTRACT

STUDY OBJECTIVE: To develop a preoperative risk assessment tool that quantifies the risk of postoperative complications within 30 days of hysterectomy.

DESIGN: Retrospective analysis.

SETTING: Michigan Surgical Quality Collaborative hospitals.

PATIENTS: Women who underwent hysterectomy for gynecologic indications.

INTERVENTIONS: Development of a nomogram to create a clinical risk assessment tool.

MEASUREMENTS AND MAIN RESULTS: Postoperative complications within 30 days were the primary outcome. Bivariate analysis was performed comparing women who did and did not have a complication. The patient registry was randomly divided. A logistic regression model developed and validated from the Collaborative database was externally validated with hysterectomy cases from the National Surgical Quality Improvement Program and a nomogram was developed to create a clinical risk assessment tool. Of the 41,147 included women, the overall postoperative complication rate was 3.98% (n=1,638). Preoperative factors associated with postoperative complications were sepsis (OR 7.98, CI 1.98-32.20); abdominal approach (OR 2.27, CI 1.70-3.05); dependent functional status (OR 2.20, CI 1.34-3.62); bleeding disorder (OR 2.10, CI 1.37-3.21); diabetes mellitus with HbA1c ≥9% (OR 1.93, CI 1.16-3.24); gynecologic cancer (OR 1.86, CI 1.49-2.31); blood transfusion (OR 1.84, CI 1.15-2.96); American Society of Anesthesiologists Physical Status Classification System class ≥3 (OR 1.46, CI 1.24-1.73); government insurance (OR 1.3, CI 1.40-1.90); and Body Mass Index ≥40 (OR 1.25, CI 1.04-1.50). Model discrimination was consistent in the derivation, internal validation, and external validation cohorts (C-statistics 0.68, 0.69, 0.68, respectively).

CONCLUSION: We validated a preoperative clinical risk assessment tool to predict postoperative complications within 30 days of hysterectomy. Modifiable risk factors identified were preoperative blood transfusion, poor glycemic control, and open abdominal surgery.

PMID:34687927 | DOI:10.1016/j.jmig.2021.10.008

J Shoulder Elbow Surg. 2021 Oct 20:S1058-2746(21)00752-7. doi: 10.1016/j.jse.2021.10.002. Online ahead of print.

ABSTRACT

BACKGROUND: The purpose of this study was to compare the preoperative magnetic resonance arthrography (MRA) findings in patients who underwent glenohumeral stabilization with a history of primary instability, recurrent instability or failed prior stabilization.

METHODS: All patients who presented with glenohumeral instability and underwent stabilization under a single surgeon in our institution between 2008 and 2020 were considered for inclusion in this study. The MRA findings of all were recorded. Imaging findings were compared between those with primary instability, recurrent instability, and those with failed prior stabilization. A p-value of p < 0.05 was considered statistically significant.

RESULTS: Overall, 871 patients were included; 814 of whom were male (93.5%) with a mean age of 23.1 years (range 13-55). There were 200 patients with primary instability, 571 patients with recurrent instability, and 100 patients who required revision stabilization surgery, with no significant differences in demographics between the groups. There was a significantly higher amount of glenoid bone loss in those with recurrent instability (43.4%) and failed prior stabilization (56%) than those with primary instability (26.5%), p < 0.0001. Additionally, there was a significantly higher number of Hill-Sachs lesions in those with recurrent instability (70.1%) and failed prior stabilization (89%) than those with primary instability (67.5%), p < 0.0001. There were no significant differences between the groups for articular cartilage damage, GLAD lesions, ALPSA lesions, HAGL lesions or SLAP tears (P>0.05).

CONCLUSION: Patients presenting for stabilization with recurrent instability or following a failed prior stabilization possess higher rates of glenohumeral bone loss when compared to those with primary instability. Therefore, stabilization of primary instability, particularly in high functioning athletes with a view to preventing recurrence may reduce overall progression of glenohumeral bone loss and potential subsequent inferior clinical outcomes.

PMID:34687918 | DOI:10.1016/j.jse.2021.10.002