Chronic Medication Use Research Articles

Severe obstructive sleep apnea is associated with cochlear function impairment.

The purpose of this study is to investigate the association between obstructive sleep apnea (OSA) with middle ear acoustic transference and cochlear function. Male individuals with and without mild, moderate, and severe OSA according to standard criteria of full polysomnography and no co-morbidities were studied. Subjects with BMI ≥40kg/m2, present or past treatment for OSA, with heart failure, diabetes, hypertension, dyslipidemia, stroke, use of chronic medications, and previous history of risk for hearing loss were excluded. All subjects were submitted to full polysomnography, evaluation of wideband acoustic immittance by energy of absorbance (EA), and distortion product otoacoustic emissions (DPOAE). We studied 38 subjects (age 35.8±7.2years, BMI 28.8±3.8kg/m2) divided into no OSA (n=10, age 33.6±6.4years, BMI 26.9±4.1kg/m2), mild (n=11, age 32.8±2.9years, BMI 28.5±3.5kg/m2), moderate (n=8, age 34.1±6.8years, BMI 29.6±3.3kg/m2), and severe OSA (n=9, age 41.2±9.2years, BMI 30.5±3.8kg/m2). EA was similar between groups. In contrast, patients with severe OSA presented significantly lower DPOAE amplitudes when compared to the control, mild, and moderate OSA groups (p≤0.03, for all comparisons). Acoustic transference function of middle ear is similar in adults with and without OSA. Severe OSA is independently associated with cochlear function impairment in patients with no significant co-morbidities.

Ocular lubricant use in medically and surgically treated glaucoma: a retrospective longitudinal analysis.

BackgroundChronic use of intraocular pressure-lowering medications is associated with ocular surface disease (OSD). In this study, we assess the incidence of topical lubricant use as a surrogate marker for underlying OSD, in medically and surgically treated glaucoma patients.MethodsRetrospective chart review was performed for newly diagnosed glaucoma patients who were started on topical medications in 2007 and followed up over a 5-year period. Primary outcome measure was the incidence of topical lubricant use in these patients and a subset of these patients who required glaucoma or cataract surgery during follow-up.ResultsCharts of 505 newly diagnosed glaucoma patients with no prior history of ocular lubricant use were analyzed. Mean age was 63.9 years (SD 11.1), 42.8% were women. One hundred one (20.0%) patients underwent phacoemulsification surgery, 80 underwent mitomycin C (MMC) augmented phacotrabeculectomy, 16 underwent MMC-augmented trabeculectomy and 3 underwent tube surgery during the course of follow-up as their only type of surgery. Five-year incidence of lubricant use was 59% in all glaucoma subjects; 54.1% of patients were on medical treatment and 74.0% of patients who underwent phacotrabeculectomy or trabeculectomy were started on lubricants, respectively (P=0.0011); 60.4% of glaucoma subjects who underwent phacoemulsification surgery were started on lubricants. Incidence of lubricant use increased from 17.7% preoperatively to 74.0% postoperatively in subjects who required trabeculectomy or phacotrabeculectomy. Incidence of lubricant use was similar in patients on one or multiple glaucoma medications, with the mean onset of lubricant use being 10 months after starting glaucoma medication in both groups. Females were more likely to use artificial tears compared with males (P=0.002).ConclusionBoth medical and surgical management of glaucoma have an adverse effect on the ocular surface. Chronic use of glaucoma medications was associated with a high incidence of ocular lubricant use. MMC-augmented trabeculectomy was associated with an even higher incidence of ocular lubricant use.

Economic outcomes of pharmacist-physician medication therapy management for polypharmacy elderly: A prospective, randomized, controlled trial.

With an increasing geriatric population, the need for effective management of chronic conditions and medication use in the elderly is growing. Medication use in the elderly presents significant challenges due to changes in pharmacodynamic and pharmacokinetic profiles. We aimed to examine the impact of a collaborative physician-pharmacist medication therapy management (MTM) program for polypharmacy elderly patients. Elderly patients with multiple chronic conditions on polypharmacy were enrolled in this prospective, randomized, and controlled study over 16 months of implementation. The intervention group consisted of patients randomized to a collaborative pharmacist-physician MTM program. They were monitored continuously by a clinical pharmacist, while patients in the control group received only usual care with follow-up assessment. Primary outcome was economic differences, measured in total medical expenditure. Secondary outcomes of clinical and humanistic effects were compared between the two groups. The total number of enrolled patients was 87 and 91 in the MTM and usual groups, respectively. The difference-in-difference estimate on medical expenditure during the 16-month implementation period was $3,758,373 New Taiwan Dollars ($127,015 US Dollars) less than the usually care group. Impact was also seen in humanistic outcomes while lipid profiles and mortality trended toward improvement. The pharmacist-physician collaborative MTM program for polypharmacy elderly had significant cost savings and improvement in humanistic measures, demonstrating the importance of clinical pharmacists and MTM programs for elderly patients in Taiwan. The results suggest the possibility of clinical benefits, but the study was not substantially powered to find a statistical difference.

0478 CLINICAL PRACTICE GUIDELINE FOR DIAGNOSTIC TESTING FOR ADULT OBSTRUCTIVE SLEEP APNEA; AN UPDATE FOR 2016: AN AMERICAN ACADEMY OF SLEEP MEDICINE CLINICAL PRACTICE GUIDELINE

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine to develop updated clinical practice recommendations based on a systematic review of the literature. 1. We recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used to diagnose OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. (STRONG) 2. We recommend that if a single home sleep apnea test is negative, inconclusive or technically inadequate, PSG be performed for the diagnosis of OSA in symptomatic patients. (STRONG) 3. We recommend that polysomnography, rather than home sleep apnea testing, be used for the diagnosis of OSA in patients with significant cardiorespiratory disease, neuromuscular disease with respiratory muscle impairment, awake hypoventilation or high risk of sleep related hypoventilation, chronic opioid medication use, or severe insomnia. (STRONG) 4. We suggest that, if clinically appropriate, a split-night diagnostic protocol, rather than a full-night diagnostic protocol for polysomnography be used for the diagnosis of OSA. (WEAK) 5. We suggest that when the initial polysomnogram is negative and there is still clinical suspicion for OSA, a second polysomnogram be considered for the diagnosis of OSA in symptomatic patients. (WEAK) 6. We recommend that clinical tools, questionnaires and prediction algorithms not be used to diagnose OSA in adults, in the absence of objective sleep testing. (STRONG)

Anticholinergic Exposure in a Cohort of Adults Aged 80 years and Over: Associations of the MARANTE Scale with Mortality and Hospitalization.

Anticholinergics are frequently prescribed for older adults and can lead to adverse drug events. The novel MARANTE (Muscarinic Acetylcholinergic Receptor ANTagonist Exposure) scale measures the anticholinergic exposure by incorporating potency and dosages of each medication into its calculations. The aims were to assess prevalence and intensity of the anticholinergic exposure in a longitudinal cohort study of community-dwelling patients aged 80years and over (n=503) and to study the impact on mortality and hospitalization. Chronic medication use at baseline (November 2008-September 2009) was entered and codified with the Anatomical Therapeutic Chemical classification. Time-to-event analysis until first hospitalization or death was performed at 18months after inclusion, using Kaplan-Meier curves. Cox regression was performed to control for covariates. Mean age was 84years (range 80-102), and mean number of medications was 5 (range 0-16). Prevalence of anticholinergic use was 31.8%, with 9% taking ≥2 anticholinergics (range 0-4). Main indications for anticholinergics were depression, pain and gastric dysfunction. Female gender, the level of multi-morbidity and the number of medications were associated with anticholinergic use. Mortality and hospitalization rate were 8.9% and 31.0%, respectively. After adjustment for the level of multi-morbidity and medication intake, multi-variable analysis showed increased risks of mortality (HR 2.3, 95% CI: 1.07-4.78) and hospitalization (HR 1.7; 95% CI: 1.13-2.59) in those with high anticholinergic exposure. The longitudinal study among Belgian community-dwelling oldest old demonstrated great anticholinergic exposure, which was associated with increased risk of mortality and hospitalization after 18months.

An exploratory study Evaluating the impact of opioid and non-opioid pain medications on serum/plasma free testosterone and free estradiol concentrations.

Chronic use of opioid medications has been reported to cause altered sexual function. It is not known if non-opioid pain medications have similar effects. Assessment of this effect through the measurement of concentrations of free hormones is limited. Positivity of opioid medications (hydrocodone, oxycodone, morphine, methadone, tramadol and fentanyl) and non-opioid pain medications (gabapentin or pregabalin) in human serum and plasma samples from adult men and women were evaluated for association with concentrations of free testosterone (fTe) and free estradiol (fE2) measured using equilibrium dialysis-liquid chromatography-tandem mass spectrometry methods. Lower concentrations of fTe (p = 0.0253) were observed in samples positive for the hydrocodone, oxycodone and morphine group compared to age matched controls. The presence of methadone, tramadol, fentanyl and pregabalin had no effect on fTe. When compared with age-matched controls, women between 48-55 years of age showed reduced fE2 concentrations in samples positive for tramadol, fentanyl and gabapentin (p = 0.0243, 0.0045 and 0.0050, respectively). Particular opioid medications such as methadone, tramadol or fentanyl and non-opioid medications such as pregabalin or gabapentin may offer advantages over opioid medications for treating pain with fewer endocrinologic side effects. Measurement of free hormones in pain medication users could be important in determining their association with sexual function. Copyright © 2017 John Wiley & Sons, Ltd.

Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline.

This guideline establishes clinical practice recommendations for the diagnosis of obstructive sleep apnea (OSA) in adults and is intended for use in conjunction with other American Academy of Sleep Medicine (AASM) guidelines on the evaluation and treatment of sleep-disordered breathing in adults. The AASM commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use. In addition, the task force adopted foundational recommendations from prior guidelines as "good practice statements", that establish the basis for appropriate and effective diagnosis of OSA. The AASM Board of Directors approved the final recommendations. The following recommendations are intended as a guide for clinicians diagnosing OSA in adults. Under GRADE, a STRONG recommendation is one that clinicians should follow under most circumstances. A WEAK recommendation reflects a lower degree of certainty regarding the outcome and appropriateness of the patient-care strategy for all patients. The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources. Good Practice Statements: Diagnostic testing for OSA should be performed in conjunction with a comprehensive sleep evaluation and adequate follow-up. Polysomnography is the standard diagnostic test for the diagnosis of OSA in adult patients in whom there is a concern for OSA based on a comprehensive sleep evaluation.Recommendations: We recommend that clinical tools, questionnaires and prediction algorithms not be used to diagnose OSA in adults, in the absence of polysomnography or home sleep apnea testing. (STRONG). We recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. (STRONG). We recommend that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA. (STRONG). We recommend that polysomnography, rather than home sleep apnea testing, be used for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia. (STRONG). We suggest that, if clinically appropriate, a split-night diagnostic protocol, rather than a full-night diagnostic protocol for polysomnography be used for the diagnosis of OSA. (WEAK). We suggest that when the initial polysomnogram is negative and clinical suspicion for OSA remains, a second polysomnogram be considered for the diagnosis of OSA. (WEAK).

Location of cardiac arrest and impact of pre-arrest chronic disease and medication use on survival

IntroductionCardiac arrest in a private location is associated with a higher mortality when compared to public location. Past studies have not accounted for pre-arrest factors such as chronic disease and medication. AimTo investigate whether the association between cardiac arrest in a private location and a higher mortality can be explained by differences in chronic diseases and medication. MethodsWe identified 27,771 out-of-hospital cardiac arrest patients ≥18 years old from the Danish Cardiac Arrest Registry (2001–2012). Using National Registries, we identified pre-arrest chronic disease and medication. To investigate the importance of cardiac arrest related factors and chronic disease and medication use we performed adjusted Cox regression analyses during day 0–7 and day 8–365 following cardiac arrest to calculate hazard ratios (HR) for death. ResultsDay 0–7: Un-adjusted HR for death day 0–7 was 1.21 (95%CI:1.18–1.25) in private compared to public location. When including cardiac arrest related factors HR for death was 1.09 (95%CI:1.06–1.12). Adding chronic disease and medication to the analysis changed HR for death to 1.08 (95%CI:1.05–1.12). 8–365 day: The un-adjusted HR for death day 8–365 was 1.70 (95% CI: 1.43–2.02) in private compared to public location. When including cardiac arrest related factors the HR decreased to 1.39 (95% CI: 1.14–1.68). Adding chronic disease and medication to the analysis changed HR for death to 1.27 (95% CI:1.04–1.54). ConclusionThe higher mortality following cardiac arrest in a private location is partly explained by a higher prevalence of chronic disease and medication use in patients surviving until day 8.

Effect of Moderate-Intensity Exercise on Inflammatory Markers Among Postmenopausal Women.

Declines in ovarian function in postmenopausal women may contribute to increase inflammatory cytokines, which can lead to chronic diseases. However, studies have shown that exercise interventions are important to manage inflammatory conditions. Thus, the objective of this study was to analyze the effect of exercise intervention on inflammatory markers among obese and postmenopausal women. 70 women composed the sample (Exercise group [EG; n = 35] and nonexercise group [nEG; n = 35]). IL-6, TNF-α, and IL-10 were the inflammatory markers analyzed. Exercise program was 20 weeks long and consisted of aerobic and neuromuscular training. Data about chronic diseases, medication use, dietary intake, body composition and biochemical variables were collected. EG showed significant reductions in body mass index, waist circumference and body fat percentage, as well as increased lean body mass. EG showed significant reductions in TNF-α and significant interaction between group and intervention time. Reductions in IL-10 were identified only in nEG. Substantial effect of exercise intervention was observed with increased ratio of IL-10/IL-6 and IL-10/TNF-α. Combination of aerobic exercise and resistance training was effective in reducing inflammation. Thus, implementation and maintenance of similar exercise programs can contribute to reduce chronic inflammation among obese postmenopausal women.

Are the New Therapeutic Agents Worth Their Cost?

Are the New Therapeutic Agents Worth Their Cost?

LEISURE CYCLISTS AT RISK OF MEDICAL COMPLICATIONS: OUTCOMES OF ONLINE PRE-PARTICIPATION SCREENING AMONG 22 650 ENDURANCE CYCLISTS, USING CURRENT EUROPEAN GUIDELINES - SAFER CYCLING

BackgroundEuropean guidelines have been introduced to screen masters and leisure athletes prior to participation in moderate- to high-intensity exercise, with the purpose of identifying the high risk athlete who should...

NOVEL RISK FACTORS ASSOCIATED WITH MORE SEVERE EXERCISE ASSOCIATED MUSCLE CRAMPING (EAMC): A PROSPECTIVE COHORT STUDY OF 41 698 DISTANCE RUNNERS

BackgroundEAMC is a common clinical syndrome in endurance runners, and can range in severity. Risk factors for EAMC have been identified and include age, gender, racing distance, a history of...

Abstract A26: Diet quality vs quantity in relation to the fecal microbiome among colonoscopy patients

Abstract Diet remains a promising target with the potential to impact colorectal cancer risk via the balance of energy and body weight, as well via specific food components with known anti-carcinogenic properties. Growing evidence implicates the importance of the gut microbiome in the interaction of diet, energy balance, and inflammation—key mechanisms associated with colorectal cancer development. The tight coupling of diet and the gut microbiota may hold new answers for colorectal cancer prevention. Methods: We conducted a pilot epidemiologic study among 50 cancer-free MD Anderson colonoscopy patients with no underlying familial/genetic or chronic inflammatory bowel conditions. With the overall goal to identify dietary intervention targets in obese and lean individuals at varied risk of colorectal neoplasia, patients provided fasting blood at colonoscopy, stool samples via mail ~ 1 month post-polypectomy, and comprehensive dietary assessments. Total energy intake was derived from responses to both the Diet History (DH) and 24-hour dietary recalls (24HR) and diet quality was defined by the Healthy Eating Index (HEI). We conducted 16S rRNA gene sequencing of the fecal microbiota and measured circulating blood adipocytokines via Luminex multiplex assays (Millipore). Results: Majority of colonoscopy patients recruited into the study were female (67%) and diagnosed with precancerous colorectal polyps (57%), primarily tubular and sessile serrated adenomas. Patients with precancerous polyps removed at colonoscopy were more likely to be obese than patients without precancerous polyps, but otherwise similar by age, macronutrient composition, and HEI. Differences in the overall composition of the fecal microbiome via weighted and unweighted unifrac were observed by reason for colonoscopy (symptomatic vs asymptomatic screening), chronic medication use (yes vs. no), total energy and alcohol intake (tertiles); and effects of each these factors were considered in subsequent analyses. No differences were observed by other clinicopathologic features, demographics, or lifestyle factors. High total energy intake was significantly correlated with higher alpha diversity of the fecal microbiome. This linear relationship remained following adjustment for diet quality and was consistent across colonoscopy status, BMI, medication use and alcohol intake (FDR-adj P<0.05). Total energy intake was inversely correlated with the relative abundance of Bacteroides (r2=0.27; FDR-adj P<0.001), while diet quality was positively associated with multiple bacteria involved in short chain fatty acid metabolism, including Faecalibacterium, Subdoligranulum, and Pseudobutyrivibrio (all P<0.05). Many of these same bacteria were significantly correlated with blood levels of circulating adipocytokines, including C-peptide, TNF-alpha, lipocalin-2, and PAI-1. Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) analysis further revealed that gut bacteria may mediate the relationship between diet quality and adipocytokine signaling pathways. Conclusion: Modifiable aspects of diet quality and quantity were more closely linked to the composition of the gut microbiome than obesity or a recent diagnosis of precancerous colorectal polyps. In general, low microbial diversity has been associated with states of disease/poor health, but in our case, eating more may mean exposure to a more varied diet, promoting proliferation of a number of distinct bacteria, both “good” and “bad”. We plan to further explore functional relationships and pathways between diet, the microbiome, and adipocytokines with ongoing metagenomic analysis of the fecal microbiome. Citation Format: Carrie R. Daniel, Kristi L. Hoffman, Akhil Sood, G.S. Raju, Samir M. Hanash, Xifeng Wu, Joseph F. Petrosino. Diet quality vs quantity in relation to the fecal microbiome among colonoscopy patients. [abstract]. In: Proceedings of the AACR Special Conference on Colorectal Cancer: From Initiation to Outcomes; 2016 Sep 17-20; Tampa, FL. Philadelphia (PA): AACR; Cancer Res 2017;77(3 Suppl):Abstract nr A26.

Elimination of pain improves specificity of clinical diagnostic criteria for adult chronic rhinosinusitis.

Determine whether the elimination of pain improves accuracy of clinical diagnostic criteria for adult chronic rhinosinusitis. Retrospective cohort study. History, symptoms, nasal endoscopy, and computed tomography (CT) results were analyzed for 1,186 adults referred to an academic otolaryngology clinic with presumptive diagnosis of chronic rhinosinusitis. Clinical diagnosis was rendered using the 1997 Rhinosinusitis Taskforce (RSTF) Guidelines and a modified version eliminating facial pain, ear pain, dental pain, and headache. Four hundred seventy-nine subjects (40%) met inclusion criteria. Among subjects positive by RSTF guidelines, 45% lacked objective evidence of sinonasal inflammation by CT, 48% by endoscopy, and 34% by either modality. Applying modified RSTF diagnostic criteria, 39% lacked sinonasal inflammation by CT, 38% by endoscopy, and 24% by either modality. Using either abnormal CT or endoscopy as the reference standard, modified diagnostic criteria yielded a statistically significant increase in specificity from 37.1% to 65.1%, with a nonsignificant decrease in sensitivity from 79.2% to 70.3%. Analysis of comorbidities revealed temporomandibular joint disorder, chronic cervical pain, depression/anxiety, and psychiatric medication use to be negatively associated with objective inflammation on CT or endoscopy. Clinical diagnostic criteria overestimate the prevalence of chronic rhinosinusitis. Removing facial pain, ear pain, dental pain, and headache increased specificity without a concordant loss in sensitivity. Given the high prevalence of sinusitis, improved clinical diagnostic criteria may assist primary care providers in more accurately predicting the presence of inflammation, thereby reducing inappropriate antibiotic use or delayed referral for evaluation of primary headache syndromes. 4. Laryngoscope, 127:1011-1016, 2017.

RELATIONSHIP OF POLYPHARMACY AND POLYPATHOLOGY WITH FALLS AMONG INSTITUTIONALIZED ELDERLY

ABSTRACT Objective: identify relationships of association between the risk of falls in institutionalized elderly people with polypharmacy and polypathy, as well as to outline the epidemiological profile of its casuistry. Method: a prospective obseracional study with 271 elderly residents in long-stay institutions in the Federal District (Brazil). The date were a actualized by inferencial statistics. Results: a monitoring of elderly confirmed the association between polypathology and falls (p: 0.0028), however, it did not follow the trend of other studies in identifying polypharmacy as a risk factor for falls (p: 0.141). Among the most prevalent comorbidities, changes in blood pressure levels (77.4%), followed by Diabetes Mellitus (27.37%), depression (17.7%) and dementia (46.8%) may be highlighted. The most identified drugs were antihypertensives (73.8%), sleep inducers (61.2%), diuretics (50.1%) and antidepressants (34.3%). Conclusion: multiple disabilities associated with chronic-degenerative diseases and the chronic use of medications may interfere with the incidence of falls, ratifying factors related to the diagnosis of risk for falls presented in the NANDA-I Taxonomy I. This contribution to the nurses’ diagnostic rationale ensures better evaluation of the elderly, ensuring a care plan focused on prevention and detection of risk conditions.

DSM-5 Psychiatric Diagnoses and Opioid Use Disorder

The treatment of pain with opioid medications is a nowadays frequently discussed and concerning topic. Opioid medications have been prescribed since ancient years even though they are known to cause severe adverse reactions and co-morbid reactions. Depression and anxiety are the most common co-morbid psychiatric conditions observed in patients receiving opioid treatment. In the majority of cases, the provider for the pain medicine and the provider for the mood disturbance are not the same, which complicates diagnosis and treatment. The presenting symptoms of depression and anxiety are frequently not contributed to the opioid medication. Opioids cause anxiety through development of dependence and withdrawal as evidenced by the need to dose opioids frequently throughout a 24 h period. To treat opioid induced anxiety and depression associated with chronic use of opioid medications, physicians frequently concomitantly prescribe anxiolytics like benzodiazepines. Benzodiazepines significantly exacerbate both substance induced depression and anxiety. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) clearly requires the exclusion of the influence of a substance in order to diagnose major depressive disorder or generalized anxiety disorder but those are frequently given even though the patient is receiving treatment with opioid medications. Ultimately the correct diagnosis is crucial for the right treatment. This article is a review of literature discussing the correlation of opioid treatment and co-morbid psychiatric diagnoses including the differentiation as well as diagnostic criteria.

An integrated perspective on diabetic, alcoholic, and drug-induced neuropathy, etiology, and treatment in the US.

Neuropathic pain (NeuP) is a syndrome that results from damaged nerves and/or aberrant regeneration. Common etiologies of neuropathy include chronic illnesses and medication use. Chronic disorders, such as diabetes and alcoholism, can cause neuronal injury and consequently NeuP. Certain medications with antineoplastic effects also carry an exquisitely high risk for neuropathy. These culprits are a few of many that are fueling the NeuP epidemic, which currently affects 7%–10% of the population. It has been estimated that approximately 10% and 7% of US adults carry a diagnosis of diabetes and alcohol disorder, respectively. Despite its pervasiveness, many physicians are unfamiliar with adequate treatment of NeuP, partly due to the few reviews that are available that have integrated basic science and clinical practice. In light of the recent Centers for Disease Control and Prevention guidelines that advise against the routine use of μ-opioid receptor-selective opioids for chronic pain management, such a review is timely. Here, we provide a succinct overview of the etiology and treatment options of diabetic and alcohol- and drug-induced neuropathy, three different and prevalent neuropathies fusing the combined clinical and preclinical pharmacological expertise in NeuP of the authors. We discuss the anatomy of pain and pain transmission, with special attention to key ion channels, receptors, and neurotransmitters. An understanding of pain neurophysiology will lead to a better understanding of the rationale for the effectiveness of current treatment options, and may lead to better diagnostic tools to help distinguish types of neuropathy. We close with a discussion of ongoing research efforts to develop additional treatments for NeuP.

Septal Perforation Repair Without Intraoperative Mucosal Closure in a Patient With Graft Versus Host Disease

We report a technique used to achieve successful repair of 2 large septal perforations in a patient with graft versus host disease, chronic use of corticosteroids, and chronic use of immunosuppressive medications. A multilayered interposition graft was constructed out of temporal fascia and flexible polydioxanone plates and placed between the mucoperichondrial flaps. Due to large size of the perforations and poor tissue quality, no attempt at mucosal closure of the perforations was made. Instead, silicone sheets were placed for 52 days to facilitate healing. Complete healing of both perforations sites was obtained along with resolution of the patient’s symptoms. The described technique provided an optimal surgical outcome in the setting of multiple large septal perforations, graft versus host disease, chronic corticosteroids, and chronic immunosuppressive medications.

Epidemiology, prehospital care and outcomes of patients arriving by ambulance with dyspnoea: an observational study.

BackgroundThis study aimed to determine epidemiology and outcome for patients presenting to emergency departments (ED) with shortness of breath who were transported by ambulance.MethodsThis was a planned sub-study of a prospective, interrupted time series cohort study conducted at three time points in 2014 and which included consecutive adult patients presenting to the ED with dyspnoea as a main symptom. For this sub-study, additional inclusion criteria were presentation to an ED in Australia or New Zealand and transport by ambulance. The primary outcomes of interest are the epidemiology and outcome of these patients. Analysis was by descriptive statistics and comparisons of proportions.ResultsOne thousand seven patients met inclusion criteria. Median age was 74 years (IQR 61-68) and 46.1 % were male. There was a high rate of co-morbidity and chronic medication use. The most common ED diagnoses were lower respiratory tract infection (including pneumonia, 22.7 %), cardiac failure (20.5%) and exacerbation of chronic obstructive pulmonary disease (19.7 %). ED disposition was hospital admission (including ICU) for 76.4 %, ICU admission for 5.6 % and death in ED in 0.9 %. Overall in-hospital mortality among admitted patients was 6.5 %.DiscussionPatients transported by ambulance with shortness of breath make up a significant proportion of ambulance caseload and have high comorbidity and high hospital admission rate. In this study, >60 % were accounted for by patients with heart failure, lower respiratory tract infection or COPD, but there were a wide range of diagnoses. This has implications for service planning, models of care and paramedic training.ConclusionThis study shows that patients transported to hospital by ambulance with shortness of breath are a complex and seriously ill group with a broad range of diagnoses. Understanding the characteristics of these patients, the range of diagnoses and their outcome can help inform training and planning of services.

Abstract # 1733 The perioperative use of a beta-adrenergic blocker and a COX-2 inhibitor in colorectal cancer patients for the prevention of cancer recurrence: A preliminary study assessing feasibility and safety

Translational studies, including our studies in various tumor models, indicate that excess perioperative release of catecholamines and prostaglandins synergistically mediate surgery-induced promotion of cancer metastasis. Here we assessed the clinical feasibility and safety of the combined perioperative use of the beta-adrenergic blocker, propranolol, and the COX-2 inhibitor, etodolac. A double-blind placebo-controlled clinical trial was conducted in non-metastatic colorectal cancer patients undergoing curative resection (2010-2015, Sheba Medical Center, Israel). Of the diagnosed patients, ∼60% were excluded, mainly due to asthma, diabetes, or chronic use of similar medications, and ∼50% of eligible patients agreed to participate. A continuous 20-day oral drug treatment was initiated five days before surgery; perioperative drug-related and overall complication rates were studied; and a three-year follow-up for cancer recurrence is ongoing. Of the 15 patients randomly allocated to drug treatment, two (13%) were excluded due to low compliance, one due to bradycardia (6.7%); and two more (13%) had tolerable bradycardia levels. Of the 20 placebo patients, one suffered breathing difficulties (5%). No other medication-related complications were recorded. One patient per group exhibited metastases during surgery (excluded). A total of 15 post-operative adverse events (in 11 categories) occurred, with no overall difference between the groups (p = 0.3). Cancer recurrence occurred in 4 placebo patients (21%) and 1 drug-treated patient (8%) (p = 0.35). Overall, the herein perioperative use of propranolol and etodolac is feasible and apparently safe.