Prescription Of Paracetamol Research Articles

Changes in analgesic prescriptions in Dutch general practice

Background Increases in opioid prescriptions have been described; however, recent trends and prescribing patterns of analgesics in Dutch general practice are largely unknown. Objective To investigate recent changes in the number of analgesic prescriptions, and the indications for prescribing strong opioids. Furthermore, we aim to identify risk factors for chronic opioid use in Dutch general practice. Design and setting A retrospective cohort study from 1 July 2013 to 31 June 2022, using a primary care practice based research network. Subjects Patients with ≥1 prescription for analgesics during the study period were included. Main outcome measure Changes in the number of prescriptions for paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in Dutch general practice during the 9-year study period. Moreover, we analyzed indications for prescribing strong opioids by the general practitioner (GP). Results A total of 18,433 analgesic users were identified. Over time, prescriptions for paracetamol, NSAIDs and weak opioids decreased, while the number of strong opioid prescriptions increased. General practitioners prescribed more strong opioids for non-malignant pain, whereas prescriptions for malignant pain remained stable over time. Risk factors for chronic opioid use (≥90 days) included older age, lower educational level, smoking status and having a history of a musculoskeletal or psychological disorder, a malignancy or sexual, physical or psychological abuse. Conclusions Considering the increase in strong opioid prescriptions for benign conditions, GPs need to be vigilant for patients who are at risk for chronic use. Regular monitoring and awareness for psychosocial factors in treatment of chronic pain may be key in preventing harms associated with persistent opioid use.

Clinical Effectiveness of Transversus Abdominis Plane (TAP) Block versus Local Anesthesia Wound Infiltration for Postoperative Pain Relief After Laparoscopic Appendicectomy in Children: A Study Protocol for a Multicenter Double-Blind Randomized Controlled Phase III Trial.

Postoperative pain relief after laparoscopic appendicectomy is a key determinant of early rehabilitation in children. Recent guidelines recommend performing either a transversus abdominis plane (TAP) block or local anesthesia (LA) wound infiltration as part of multimodal postoperative analgesia after appendectomy. To date, the clinical effectiveness of TAP block versus LA wound infiltration has never been compared. The hypothesis of this study is that the TAP block may provide a greater opioid-sparing effect after laparoscopic appendicectomy in children than LA wound infiltration. We designed a multicenter double-blind randomized controlled phase III trial and aim to include 110 children who undergo laparoscopic appendicectomy. Children are randomized to receive either TAP block (TAP group) or LA wound infiltration (infiltration group). Multimodal analgesia is standardized in the two groups using the same protocol, which includes the stepwise prescription of paracetamol, phloroglucinol, ketoprofene, and nalbuphine according to the hetero-evaluation of pain performed by the nurses who were blinded to the treatment allocated using the validated FLACC scale. The primary outcome is the total dose of nalbuphine administered within 24 hours after surgery. No study has specifically compared the clinical effectiveness of TAP block versus LA wound infiltration for postoperative pain relief after laparoscopic appendectomy in children. This paper describes the protocol for a randomized trial that addresses this issue. The results of this trial will be useful for editing guidelines with a higher level of evidence on this topic.

Yarning to reduce take own leave events in First Nations patients presenting to the Emergency Department-presenting the qualitative themes and co-design of the Deadly RED project.

The Deadly RED redesign and implementation research aimed to improve take own leave (TOL) rates within a Queensland emergency department by providing a culturally competent care pathway. A mixed methods pre/post evaluation of the feasibility, acceptability and usability of the Deadly RED pathway for First Nations patients presenting to ED was performed. This pathway combined early welcome and information sharing, introduction of screening and follow up for patients who TOL and enhanced access to alternative community healthcare. Yarning circles facilitated co-design of research protocols and tools while a purposefully designed research Yarn enhanced understanding of the 'story' of the people. Qualitative analysis of Yarns allowed deductive themes to be extracted. A Participatory Action Research (PAR) approach and Indigenous research methodology involving First Nations people in design, knowledge sharing and joint ownership of results was used. Common themes from the 85 yarns included the negative impact of long waiting times and positive impact from wholistic care. Unique themes identified included interpretation of waiting room placement and paracetamol prescription as a dismissal. Knowledge dissemination from yarning drove improvements in communications and processes to promote treatment completion resulting in elimination of these themes in post implementation yarns. Eighteen patients who had TOL were included in the post implementation yarns, however only eight of these believed that their treatment was incomplete. The use of yarning for consumer engagement has allowed deeper understanding of the reasons for TOL in First Nations emergency patients. The reciprocal knowledge sharing has guided targeted improvements in wholistic emergency care and communication resulting in First Nations patients feeling their care is complete even when the 'number' reports otherwise. SO WHAT?: Indigenous Research methodology including yarning with First Nations patients suggests alternative engagement methods to guide enhanced quality of care monitoring for ED presentations.

Older Adult-Onset of Inflammatory Bowel Diseases Is Associated With Higher Utilization of Analgesics: A Nationwide Cohort Study.

Patients with inflammatory bowel diseases (IBD) commonly require analgesic medications to treat pain, which may be associated with complications. We examined trends of analgesic use according to age at IBD onset. This nationwide cohort study included adults diagnosed with IBD between 1996 and 2021 in Denmark. Patients were stratified according to their age at IBD onset: 18-39 years (young adult), 40-59 years (adult), and older than 60 years (older adult). We examined the proportion of patients who received prescriptions for analgesic medications within 1 year after IBD diagnosis: strong opioids, tramadol, codeine, nonsteroidal anti-inflammatory drugs, and paracetamol. Multivariable logistic regression analysis was performed to examine the association between age at IBD onset and strong opioid prescriptions and the composite of strong opioid/tramadol/codeine prescriptions. We identified 54,216 adults with IBD. Among them, 25,184 (46.5%) were young adults, 16,106 (29.7%) were adults, and 12,926 (23.8%) were older adults at IBD onset. Older adults most commonly received analgesic prescriptions of every class. Between 1996 and 2021, strong opioid, tramadol, and codeine prescriptions were stable, while paracetamol prescriptions increased and nonsteroidal anti-inflammatory drug prescriptions decreased. After multivariable logistic regression analysis, older adults had higher adjusted odds of receiving strong opioid prescriptions (adjusted odds ratio 1.95, 95% confidence interval 1.77-2.15) and the composite of strong opioid/tramadol/codeine prescriptions (adjusted odds ratio 1.93, 95% confidence interval 1.81-2.06) within 1 year after IBD diagnosis compared with adults. In this nationwide cohort, older adults most commonly received analgesic prescriptions within 1 year after IBD diagnosis. Additional research is needed to examine the etiology and sequelae of increased analgesic prescribing to this demographic.

Pain and quality of life in nursing home residents with dementia after admission – a longitudinal study

BackgroundPain in nursing home (NH) residents with dementia is commonly reported and may affect Quality of Life (QoL) negatively. Few longitudinal studies have explored how pain and QoL develop in NH residents with dementia starting from their admission to the NH.AimThe aim was to explore pain, QoL, and the association between pain and QoL over time in persons with dementia admitted to a NH.MethodsA convenience sample, drawn from 68 non-profit NHs, included a total of 996 Norwegian NH residents with dementia (mean age 84.5 years, SD 7.6, 36.1% men) at NH admission (A1), with annual follow-ups for two years (A2 and A3). Pain and QoL were assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale and the Quality of Life in Late-Stage Dementia (QUALID) scale, respectively, at all assessments. Severity of dementia, personal level of activities of daily living, general medical health, neuropsychiatric symptoms, and the prescription of psychotropic drugs and analgesics (opioids and/or paracetamol) were also assessed at all assessments.ResultsMean (SD) MOBID-2 pain intensity scores were 2.1 (2.1), 2.2 (2.2), and 2.4 (2.1) at A1, A2, and A3, respectively. Participants who were prescribed analgesics had higher pain intensity scores at all assessments than participants not prescribed analgesics. The mean (SD) QUALID scores at each assessment were 19.8 (7.1), 20.8 (7.2), and 22.1 (7.5) at A1, A2, and A3, respectively. In the adjusted linear mixed model, higher pain intensity score, prescription of opioids, and prescription of paracetamol were associated with poorer QoL (higher QUALID total score and higher scores in the QoL dimensions of sadness and tension) when assessed simultaneously. No time trend in QoL was found in these adjusted analyses.ConclusionNH residents with dementia who have higher pain intensity scores or are prescribed analgesics are more likely to have poorer QoL. Clinicians, NH administrators, and national healthcare authorities need to look into strategies and actions for pharmacological and non-pharmacological pain treatment to reduce pain intensity while simultaneously avoiding negative side effects of pain treatment that hamper QoL.

Paracetamol prescriptions in older people hospitalized in a French geriatric hospital.

Paracetamol prescriptions in older people hospitalized in a French geriatric hospital.

Sodium-based paracetamol: impact on blood pressure, cardiovascular events, and all-cause mortality.

Effervescent formulations of paracetamol containing sodium bicarbonate have been reported to associate with increased blood pressure and a higher risk of cardiovascular diseases and all-cause mortality. Given the major implications of these findings, the reported associations were re-examined. Using linked electronic health records data, a cohort of 475 442 UK individuals with at least one prescription of paracetamol, aged between 60 and 90 years, was identified. Outcomes in patients taking sodium-based paracetamol were compared with those taking non-sodium-based formulations of the same. Using a deep learning approach, associations with systolic blood pressure (SBP), major cardiovascular events (myocardial infarction, heart failure, and stroke), and all-cause mortality within 1 year after baseline were investigated. A total of 460 980 and 14 462 patients were identified for the non-sodium-based and sodium-based paracetamol exposure groups, respectively (mean age: 74 years; 64% women). Analysis revealed no difference in SBP [mean difference -0.04 mmHg (95% confidence interval -0.51, 0.43)] and no association with major cardiovascular events [relative risk (RR) 1.03 (0.91, 1.16)]. Sodium-based paracetamol showed a positive association with all-cause mortality [RR 1.46 (1.40, 1.52)]. However, after further accounting of other sources of residual confounding, the observed association attenuated towards the null [RR 1.08 (1.01, 1.16)]. Exploratory analyses revealed dysphagia and related conditions as major sources of uncontrolled confounding by indication for this association. This study does not support previous suggestions of increased SBP and an elevated risk of cardiovascular events from short-term use of sodium bicarbonate paracetamol in routine clinical practice.

Is paracetamol prescribed appropriately in elderly patients admitted for a fall? – A Geriatrician’s perspective

Background Paracetamol is a commonly used analgesic among older adults. There have been reports of adverse events with chronic paracetamol use even at therapeutic doses. The objective of this clinical audit is twofold – 1. To evaluate the prevalence of inappropriate paracetamol prescription in the elderly admitted for falls; 2. To introduce strategies to reduce the rate of inappropriate paracetamol prescription in this population. Methods A clinical audit was performed on 100 patients aged 75 years and older who were admitted to the Geriatric Medicine department of a tertiary hospital between July 2019 and October 2019 with a primary diagnosis of a fall. Data collected included demographic data, relevant medical history of cirrhosis, cognitive impairment, alcohol use and weight <50 kg, prescription pattern of paracetamol on day 1 or two of admission and on discharge as well as clinical data on the documented indications for paracetamol use. Results Paracetamol was prescribed in 84 patients. Out of these 84 patients, 56 were prescribed round-the-clock paracetamol with a median duration of 9 (IQR = 10) days. In this group, paracetamol use was inappropriate in 32 (57%) of them and 32 (57%) patients were discharged with round-the-clock paracetamol for a median duration of 17.5 (IQR = 46) days. Conclusion This clinical audit revealed a high prevalence of round-the-clock and inappropriate paracetamol prescription in elderly patients admitted for a fall. Moving forward, we hope that the implementation of a paracetamol prescribing algorithm may reduce the rates of inappropriate paracetamol prescribing in this population.

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

PurposeMusculoskeletal (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.MethodsRetrospective 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.ResultsIn 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).ConclusionsWe 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.

Prevalence and persistent prescription of analgesic drugs in persons admitted with dementia to a nursing home - A longitudinal study.

The overall aim was to explore the prevalence and persistent regular prescription of opioids and paracetamol among nursing home (NH) residents with dementia at admission and over time. A total of 996 residents with dementia, mean (SD) age 84.5 (7.6) years and (36.1% men), were included at admission (A1). Yearly assessments were performed for two years (A2 and A3) or until death. Pain was assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale. Information regarding prescription of analgesics, general physical health, personal activities of daily living, severity of dementia, neuropsychiatric symptoms, and prescription of psychotropic drugs was collected. A generalized linear mixed model was used to explore whether pain severity was associated with persistent and persistent prescription of opioids and/or paracetamol across timepoints. At A1, 495 of 996 (49.7%) NH residents were prescribed analgesics and prevalence increased at the follow-ups (A2: n = 630, 65.1%; A3: n = 382, 71.2%). Paracetamol was the most frequently prescribed analgesic at all assessments (A1: 45.5%; A2: 59.5%; A3: 67.1%). Opioid prescriptions were quite prevalent (A1: 18.1%; A2: 25.1%; A3: 28.3%), with odds approximately 13 times (OR = 13.3, 95% CI 6.8-26.0) and 9 times (OR = 8.6, 95% CI 3.7-20.3) higher for prescription at follow-up A2 and A3, respectively, relative to prescription at A1. In adjusted analyses, higher pain intensity and poor physical health were associated with prescription and persistent prescription of opioids and paracetamol. In conclusion, prevalence and persistent prescription of analgesics were high in NH residents with dementia. The odds for the prescription of opioids at follow-up were high if prescribed at baseline. Interdisciplinary collaboration, routine assessment of pain at admission and regularly thereafter, and systematic drug reviews are essential to adequately assess and treat pain in NH residents with dementia.

Paracetamol Use in Patients With Osteoarthritis and Lower Back Pain: Infodemiology Study and Observational Analysis of Electronic Medical Record Data.

Lower back pain (LBP) and osteoarthritis (OA) are common musculoskeletal disorders and account for around 17.0% of years lived with disability worldwide; however, there is a lack of real-world data on these conditions. Paracetamol brands are frequently prescribed in France for musculoskeletal pain and include Doliprane, Dafalgan, and Ixprim (tramadol-paracetamol). The objective of this retrospective study was to understand the journey of patients with LBP or OA when treated with paracetamol. Three studies were undertaken. Two studies analyzed electronic medical records from general practitioners (GPs) and rheumatologists of patients with OA or LBP, who had received at least one paracetamol prescription between 2013 and 2018 in France. Data were extracted, anonymized, and stratified by gender, age, and provider specialty. The third study, an infodemiology study, analyzed associations between terms used on public medical forums and Twitter in France and the United States for OA only. In the first 2 studies, among patients with LBP (98,998), most (n=92,068, 93.0%) saw a GP, and Doliprane was a first-line therapy for 87.0% (n=86,128) of patients (71.0% [n=61,151] in combination with nonsteroidal anti-inflammatory drugs [NSAIDs] or opioids). Among patients with OA (99,997), most (n=84,997, 85.0%) saw a GP, and Doliprane was a first-line therapy for 83.0% (n=82,998) of patients (62.0% [n=51,459] in combination). Overall, paracetamol monotherapy prescriptions decreased as episodes increased. In the third study, in line with available literature, the data confirmed that the prevalence of OA increases with age (91.5% [212,875/232,650] above 41 years), OA is more predominant in females (46,530/232,650, 20.0%), and paracetamol use varies between GPs and rheumatologists. This health surveillance analysis provides a better understanding of the journey for patients with LBP or OA. These data confirmed that although paracetamol remains the most common first-line analgesic for patients with LBP and OA, usage varies among patients and health care specialists, and there are concerns over efficacy.

Knowledge and practice of prescription and administration of correct dose of paracetamol to children among a selected group of doctors and nurses

Introduction: In children, paracetamol is the most common agent involved in drug toxicity. Therefore, accurate prescription of paracetamol in healthcare facilities is important in paediatric patients. This study aimed to explore the knowledge and practice of doctors and nurses on administration of correct dose of paracetamol. Methods: A descriptive cross-sectional study was carried out recruiting doctors and nurses from paediatric units and Emergency Treatment Unit (ETU) at Teaching Hospital, Karapitiya, Galle. A self-administered pre-tested questionnaire and bed head tickets were used to collect data. Results: There were 100 participants in the study. Majority (98%) knew correct single therapeutic dose of paracetamol. Ninety three percent of them did not know the maximum daily dose of paracetamol for children. Statistically significant association was seen being a doctor (χ2 = 11.4, p = 0.004) and a doctor in ETU (χ2= 9.02, p = 0.009) on- the knowledge of maximum dose of paracetamol to a child/24 hours. Half of the participants (56%) knew the acute toxic single dose of paracetamol. There was a significant association between work experience in paediatric unit/ ETU with the knowledge of acute single toxic dose of paracetamol (χ2 = 14.8, p = 0.04). Almost all participants (99%) were aware that paracetamol dose calculation depends on the weight of the child. Eighty three percent of prescriptions for inward patients were prescribed with therapeutic doses. Conclusion: Even though paracetamol is a common drug there is a knowledge gap among nurses and doctors on prescription of paracetamol in the selected setting.

Perioperative oral paracetamol: kicking the intravenous habit to promote sustainable healthcare

Background: The NHS is a significant contributor to the UK’s carbon footprint and has committed to net zero carbon emissions by 2040.1 Oral (p.o.) paracetamol is more sustainable than intravenous (i.v.), producing less waste whilst maintaining analgesic efficacy.2 We proposed that patients presenting for elective surgery should be premedicated with p.o. paracetamol to reduce plastic waste and financial costs. We aimed to develop a quality improvement project to achieve this. Methods: Strategies to assess local attitudes and consider potential impact of paracetamol prescribing changes were initially devised. An online survey was distributed to anaesthetists in the North West of England, and educational material highlighting the environmental benefit and efficacy of p.o. paracetamol disseminated. A local audit was performed to assess i.v. paracetamol use and estimate potential financial savings, with results presented at a local audit meeting for discussion and review. A perioperative paracetamol infographic was produced and distributed on anaesthetic carts and in theatres, with an embedded QR code for continual monitoring of feedback. Results: Our survey of 147 anaesthetists at 12 hospitals demonstrated frequent i.v. paracetamol use, with a willingness to alter prescribing: 91% of respondents reported routine administration of i.v. paracetamol to elective patients, with 67% suggesting intent to change this practice after review of educational material. Local audit data estimated potential annual savings of £7166 with 384 kg less plastic waste for a single local hospital site. The produced infographic (Fig. 13) was rolled out in January 2022. Monitoring of prescribing habits is ongoing. Conclusions: P.O. paracetamol is equally effective as i.v. pre- and postoperatively in patients undergoing many elective surgical procedures; however, current anaesthetic behaviours favour i.v. administration. The switch to p.o. paracetamol would reduce the environmental costs of healthcare delivery, lowering plastic waste and associated carbon emissions. 1.Karliner J, et al. HCCP 2019; Paper 1: 6–482.Mallama M, Valencia A, Rijs K, Rietdijk W, Klimek M, Espana JC. Anaesthesia 2021; 76: 270–6

The association between exacerbation of chronic obstructive pulmonary disease and timing of paracetamol use: a cohort study in elderly Australians

BackgroundIn elderly populations, paracetamol may be used regularly for conditions such as osteoarthritis. Paracetamol has been associated with respiratory disease through a proposed mechanism of glutathione depletion and oxidative stress. Given that chronic obstructive pulmonary disease (COPD) is frequently co-morbid with osteoarthritis, this study investigated whether the dose and timing of paracetamol exposure may induce COPD exacerbations.MethodsThe study population was 3523 Australian Government Department of Veterans’ Affairs full entitlement holders who had existing COPD on 1 January 2011, who were dispensed at least one prescription of paracetamol between 1 January 2011 and 30 September 2015, and had no paracetamol dispensed in the 6 months prior to 1 January 2011. The outcome was time to first hospitalisation for COPD exacerbation after initiation of paracetamol. A weighted cumulative exposure approach was used.ResultsThe association between paracetamol exposure and COPD exacerbation was protective or harmful depending on the dose, duration, and recency of exposure. Compared to non-use, current use at the maximum dose of 4 g daily for 7 days was associated with a lower risk (HR = 0.78, 95% CI = 0.67–0.92) and a higher risk after 30 days (HR = 1.27, 95% CI = 1.06–1.52). Risk declined to baseline after 2 months. For past use, there was a short-term increase in risk on discontinuation depending of dose, duration and time since stopping.ConclusionsPatients and doctors should be aware of the possible risk of COPD exacerbation with higher dose paracetamol 1 to 6 weeks after initiation or discontinuation, but no increased risk after 2 months.

756 ORTHOPAEDIC SURGEONS CAN PRESCRIBE LAXATIVES & ANALGESICS TOO - A QUALITY IMPROVEMENT PROJECT SPANNING 7 YEARS

Abstract Background Patients admitted with age 60 years and over with a hip fracture admitted to a District General Hospital. Introduction The aim was to improve the prescribing of regular laxatives and analgesia at the time of admission to hospital. Methods There were repeated PDSA cycles. Data was collected on consecutive patients (by admission date) identified from the National Hip Fracture Database. Data was collected at baseline (10 patients in November 2013) and after Phase 1 intervention (20 patients, December 2013—January 2014), after Phase 2 (20 patients, February 2014), after Phase 3 (39 patients, April—June 2017) and after Phase 4 (September—October 2020). The interventions were as follows: Phase 1: Prompts at new doctor induction (‘Induction’) + prompts in hip fracture admission document. Phase2: Phase 1 intervention + flow diagram in fracture admission document. Phase 3: Prompts at Induction + electronic prescribing protocol (including laxatives and analgesics) + removal of flow diagram from admission document. Phase 4: Phase 3 intervention + more effort to explain to new locum doctors. Results Laxative prescribing: Baseline = 40%, Phase 1 = 80%, Phase 2 = 80%, Phase 3 = 56%, Phase 4 = 74% (24 hours post-admission = 90%). Paracetamol prescribing: Baseline 100%, Phase 1,100%, Phase 2,100%, Phase 3 64%, Phase 4 82% (24 h post-admission = 90%). Regular strong opioid prescribing: Admission: Baseline 60%, Phase 1 90%, Phase 2,100%, Phase 3 44%, Phase 4 80% (24 h post-admission = 90%). Conclusion 1. Orthopaedic Surgeons can prescribe laxatives and analgesia well—given sufficient prompts 2. The electronic solution is not always sufficient—locum doctors may not be aware of it. 3. Do not assume continued success Future Plans Re-introduce flow diagram to admission document. Acknowledgements Many people have helped with previous phases & will be acknowledged.

Electronic prescribing systems should consider patients’ weight for supply of oral paracetamol, concludes report

Electronic prescribing and medication administration (ePMA) systems should include prompts to document a patient’s weight when supplying oral paracetamol, a report from the Healthcare Safety Investigation Branch (HSIB) has concluded. The report, published on 24 February 2022, investigated the prescription of oral paracetamol in adult inpatients in England who, on admission to hospital, have low […]

GP consultation rates for sequelae after acute covid-19 in patients managed in the community or hospital in the UK: population based study.

ObjectivesTo describe the rates for consulting a general practitioner (GP) for sequelae after acute covid-19 in patients admitted to hospital with covid-19 and those managed in the community, and to determine how the rates change over time for patients in the community and after vaccination for covid-19.DesignPopulation based study.Setting1392 general practices in England contributing to the Clinical Practice Research Datalink Aurum database.Participants456 002 patients with a diagnosis of covid-19 between 1 August 2020 and 14 February 2021 (44.7% men; median age 61 years), admitted to hospital within two weeks of diagnosis or managed in the community, and followed-up for a maximum of 9.2 months. A negative control group included individuals without covid-19 (n=38 511) and patients with influenza before the pandemic (n=21 803).Main outcome measuresComparison of rates for consulting a GP for new symptoms, diseases, prescriptions, and healthcare use in individuals admitted to hospital and those managed in the community, separately, before and after covid-19 infection, using Cox regression and negative binomial regression for healthcare use. The analysis was repeated for the negative control and influenza cohorts. In individuals in the community, outcomes were also described over time after a diagnosis of covid-19, and compared before and after vaccination for individuals who were symptomatic after covid-19 infection, using negative binomial regression.ResultsRelative to the negative control and influenza cohorts, patients in the community (n=437 943) had significantly higher GP consultation rates for multiple sequelae, and the most common were loss of smell or taste, or both (adjusted hazard ratio 5.28, 95% confidence interval 3.89 to 7.17, P<0.001); venous thromboembolism (3.35, 2.87 to 3.91, P<0.001); lung fibrosis (2.41, 1.37 to 4.25, P=0.002), and muscle pain (1.89, 1.63 to 2.20, P<0.001); and also for healthcare use after a diagnosis of covid-19 compared with 12 months before infection. For absolute proportions, the most common outcomes ≥4 weeks after a covid-19 diagnosis in patients in the community were joint pain (2.5%), anxiety (1.2%), and prescriptions for non-steroidal anti-inflammatory drugs (1.2%). Patients admitted to hospital (n=18 059) also had significantly higher GP consultation rates for multiple sequelae, most commonly for venous thromboembolism (16.21, 11.28 to 23.31, P<0.001), nausea (4.64, 2.24 to 9.21, P<0.001), prescriptions for paracetamol (3.68, 2.86 to 4.74, P<0.001), renal failure (3.42, 2.67 to 4.38, P<0.001), and healthcare use after a covid-19 diagnosis compared with 12 months before infection. For absolute proportions, the most common outcomes ≥4 weeks after a covid-19 diagnosis in patients admitted to hospital were venous thromboembolism (3.5%), joint pain (2.7%), and breathlessness (2.8%). In patients in the community, anxiety and depression, abdominal pain, diarrhoea, general pain, nausea, chest tightness, and tinnitus persisted throughout follow-up. GP consultation rates were reduced for all symptoms, prescriptions, and healthcare use, except for neuropathic pain, cognitive impairment, strong opiates, and paracetamol use in patients in the community after the first vaccination dose for covid-19 relative to before vaccination. GP consultation rates were also reduced for ischaemic heart disease, asthma, and gastro-oesophageal disease.ConclusionsGP consultation rates for sequelae after acute covid-19 infection differed between patients with covid-19 who were admitted to hospital and those managed in the community. For individuals in the community, rates of some sequelae decreased over time but those for others, such as anxiety and depression, persisted. Rates of some outcomes decreased after vaccination in this group.

Zika and Chikungunya Virus and Risk for Venous Thromboembolism

Introduction: Zika virus (ZIKV) and Chikungunya virus (CHIKV) infections are transmitted by various species of aedes mosquitoes. A fair number of young patients suspicious of the virus presented to the hospital with unusual edema of upper or lower limbs which was initially thought to be due to systemic inflammation. Although for ZIKV infected patients the disease is typically self-limiting, cases of neurologic manifestations and Guillain-Barré syndrome have been described in infected patients in Brazil. Reports of high D-dimer levels (greater than 15.00 µg/mL FEU) in a Guillain-Barré syndrome patient in the ICU suggested the possibility of linking this infection to the development of venous thromboembolism (VTE).Methods: Following informed consent, serum and plasma was prepared from blood samples collected from 172 patients with symptoms of ZIKV or CHIKV infection. Viral RNA was extracted from serum using the QIAamp Viral RNA Mini kit (QIAGEN, Germany) and subjected to reverse transcription (SuperScript® III Platinum® kit, Invitrogen). Samples with a threshold number (CT) ≤ 38 were considered positive for infection caused by the Zika and Chikungunya viruses. D-dimer levels were measured in plasma samples by ELISA (Hyphen BioMed, France). The reference concentration of D-dimer was less than 0.5 µg/mL fibrinogen-equivalent units (FEU). We also report two cases of DVT events associated with ZIKV infection.Results: PCR confirmed that of the 172 patients studied, 31 were infected with ZIKV and 141 were infected with CHIKV. Although D-dimer levels were elevated above the reference range in 19.4% of 31 patients with ZIKV and in 63.8% of 141 patients with CHIKV, none of the patients had developed symptomatic VTE at the time of the study. Case 1 : In early January 2016, a 46-year-old female previously healthy arrived at the emergency room of the University Hospital of Sergipe with history of 3 days with high fever (>39°C), joint pain, arthralgia, and a red cutaneous rash. She was treated with hydration and discharged with a paracetamol prescription. She returned to the emergency room 4 days later with right upper extremity painful edema. An upper limb duplex scan revealed right brachial vein thrombosis. She was treated with unfractionated heparin followed by vitamin K antagonists (VKA). PCR test confirmed ZIKV infection. Case 2: In the subsequent month, a 53-year-old male presented to the same emergency room with fever, asthenia, headache, and arthralgia with onset 5 days previously. The arthralgia had increased in intensity and was accompanied by pain in the left calf and bilateral edema of the ankles, more intense on the left. Color Doppler ultrasonography examination confirmed thrombosis of the left popliteal vein. Patient was treated with low-molecular weight heparin and VKA therapy and had a full recovery. He tested positive for ZIKV.Conclusions: A relationship between systemic viral infection with H1N1, HIV and hepatitis and inflammatory/hypercoagulable states has previously been demonstrated. Although the mechanism behind this interplay is not yet well elucidated, factors such as direct endothelial injury, increased expression of tissue factor and the release of microparticles might be involved. A better understanding of the pathophysiology underlying the association of viral infections and coagulation disorders is crucial for developing therapeutic strategies. Patients at high risk of VTE with viral infections may be good candidates for VTE prophylaxis with current anticoagulants. DisclosuresNo relevant conflicts of interest to declare.

89 Improving Pain Assessment and Management for Patients with Cognitive Impairment on the Care of the Older Person (COOP) Wards

Abstract Introduction Patients with cognitive impairment are at risk of underassessment and inadequate management of pain. Self-reporting is unlikely to be a reliable indicator of pain and numerical scales have reduced validity, hence an alternative assessment tool must be used. The Abbey Pain Scale is widely regarded to be user friendly. Regular analgesia should be used for these patients where possible instead of “as required” (PRN). Using QIP methodology, we aimed to improve the use of the Abbey Pain Scale for assessment of patients with cognitive impairment and better analgesia prescribing. Methods Audit of patient records on COOP wards (computer and physical notes, n = 48 first cycle, n = 32 second cycle) before and after staff training, assessing patients with cognitive impairment for: use of Abbey Pain Scale; use of regular paracetamol; pain assessments documented by different healthcare professionals. Results In the first cycle, 16 patients had cognitive impairment: only 1 of these patients (6%) was assessed using the Abbey Pain Scale. Group teaching for the multidisciplinary team on pain assessments was undertaken with practice development nurses. In the re-audit, 13 patients had cognitive impairment and 6 of these (46%) were assessed using the Abbey Pain Scale, showing a clear improvement following staff training. The second cycle showed a 50% increase in the prescription of regular paracetamol for patients with cognitive impairment. There was also a 2.5-fold improvement in therapy staff documenting pain assessments between the two audits. Conclusions Staff training in the use of the Abbey Pain Scale led to an almost 8-fold increase in its use for patients with cognitive impairment. Training on the use of the Abbey Pain Scale should be regularly provided to nurses, physiotherapists and doctors on the care of the older person wards.

Practical Challenges-Use of Paracetamol in Children and YouthWho are Overweight or Obese: A Narrative Review.

Worldwide, > 380 million children and adolescents are overweight or obese, including 41 million children aged < 5 years. Obesity can change the pharmacokinetic properties of drugs by altering their distribution, metabolism, and elimination. Thus, children who are overweight or obese are at increased risk for receiving inappropriate doses of commonly used drugs, which can result in treatment failure, adverse events, and/or drug toxicity. This review analyzes available data on paracetamol dosing for pain and fever in children and adolescents who are overweight or obese to identify gaps and challenges in optimal dosing strategies. Literature searches using Medline, Embase, and ClinicalTrials.gov were conducted to identify English-language articles reporting paracetamol pharmacokinetics, dosing practices, and guidelines in children and adolescents who are overweight or obese. Of 24 relevant studies identified, 20 were specific to overweight/obese individuals and 15 were specific to children and/or adolescents. Data on paracetamol pharmacokinetics in children and adolescents who are overweight or obese are lacking, and there is no high-quality evidence to guide paracetamol prescribing practices in these patients. Adult data have been extrapolated to pediatric populations; however, extrapolation does not address differences in paracetamol metabolism in adults versus children; the efficacy and safety effects of such differences are unknown. Given the growing worldwide prevalence of obesity in children and adolescents and the likelihood that paracetamol use in this population will increase accordingly, obesity-specific pediatric dosing guidelines for paracetamol are urgently needed. High-quality research is necessary to inform such guidelines.