Introduction
Although a growing body of evidence suggests that buprenorphine is a safe alternative to methadone in the treatment of opioid‐dependent pregnant women, little is known about ...breastfeeding in this population. The first objective of this study was to describe breastfeeding rates among opioid‐dependent pregnant women maintained on buprenorphine in an integrated medical and behavioral health program. The second objective was to determine whether breastfeeding is related to the duration, severity, and frequency of pharmacologic treatment for neonatal abstinence syndrome (NAS).
Methods
A retrospective chart review was conducted for all infants born to opioid‐dependent pregnant women treated in the integrated buprenorphine program between December 2007 and August 2012.
Results
Eighty‐five maternal‐infant pairs were identified. Sixty‐five women (76%) chose to breastfeed their infants after birth; of the women who initiated breastfeeding in the hospital, 66% were still breastfeeding 6 to 8 weeks postpartum. Although the data suggest that infants who were breastfed had less severe NAS (mean peak NAS, 8.83 vs 9.65 on a modified Finnegan Scoring System) and were less likely to require pharmacologic treatment (23.1% vs 30.0%) than infants who were not breastfed, these results were not statistically significant.
Discussion
More than three‐quarters of the opioid‐dependent pregnant women in this case series chose to breastfeed after birth. Although a direct comparison of care models is not possible, the integrated model of care potentially reduced some of the barriers to breastfeeding as the women accessed all their care in a single, infant‐friendly setting. Further work is needed to definitively determine whether breastfeeding mitigates NAS.
•Prenatal marijuana exposure does not appear to impact pregnancy or delivery.•Prenatal marijuana exposure may increase likelihood of treatment for neonatal abstinence syndrome (NAS).•Prenatal ...marijuana exposure may lengthen duration of infant hospitalization.
To determine whether maternal and infant outcomes are associated with exposure to marijuana during the third trimester in a population of opioid dependent pregnant women maintained on buprenorphine.
This retrospective cohort study of 191 maternal-infant dyads exposed to buprenorphine during pregnancy examines a variety of variables including gestational age, birthweight, method of delivery, Apgar scores at one and five minutes, duration of infant hospital stay, peak neonatal abstinence syndrome (NAS) score, duration of NAS and incidence of pharmacologic treatment of NAS in infants exposed to marijuana during the third trimester as compared to infants not exposed to marijuana during the third trimester.
Analyses failed to support any significant relationship between marijuana use in the third trimester and a variety of maternal and infant outcomes. Two important variables – the likelihood of requiring pharmacologic treatment for NAS (27.6% in marijuana exposed infants vs. 15.7% in non-marijuana exposed infants, p=0.066) and the duration of infant hospital stay (7.7days in marijuana exposed infants vs. 6.6days in non-exposed infants, p=0.053) trended toward significance.
Preliminary results indicate that marijuana exposure in the third trimester does not complicate the pregnancy or the delivery process. However, the severity of the infant withdrawal syndrome in the immediate postnatal period may be impacted by marijuana exposure. Because previous study of prenatal marijuana exposure has yielded mixed results, further analysis is needed to determine whether these findings are indeed significant.
Summary
Background
Children with symptoms of sleep‐disordered breathing (SDB) appear to be at risk for perioperative respiratory events (PRAE). Furthermore, these children may be more sensitive to ...the respiratory‐depressant effects of opioids compared with children without SDB.
Aims
The aim of this prospective observational study was to confirm that otherwise healthy children with symptoms of SDB are at greater risk for PRAE compared with children with no symptoms and to determine if these children are also at increased risk for postoperative opioid‐related adverse events (ORAE).
Methods
Six hundred and seventy‐eight parents of children scheduled for surgery completed the Snoring, Trouble Breathing, and Un‐Refreshed (STBUR) questionnaire preoperatively. Data regarding the incidence of PRAE were collected prospectively. Postoperative pulse oximetry desaturation alarm events were downloaded from the institutional secondary alarm notification system.
Results
Children with symptoms of SDB per STBUR (≥3 symptoms) had a two‐fold increased likelihood of PRAE compared with children without SDB (52.8% vs 27.9% respectively, LR+ = 2.00, 95% CI = 1.60–2.49, P = 0.0001). A subset analysis of children undergoing airway procedures requiring hospital admittance (n = 179) showed that those with SDB were given the same postoperative opioid doses as children without SDB. However, children with SDB symptoms generated a greater number of postoperative oxygen desaturation alarms (14.14 ± 29.3 vs 7.12 ± 13.2, mean difference = 7.02, 95% CI = 0.39–13.64, P = 0.038) and more frequently required escalation of care (15.3% vs 7.1%, LR+ = 1.67, 95% CI = 1.22–2.16, P = 0.001) compared with children with no SDB symptoms.
Conclusions
Children presenting for surgery with SDB symptoms are at increased risk for PRAE. Children undergoing airway‐related procedures also appear to be at increased risk for ORAE. Furthermore, regardless of the preoperative assessment of risk using the STBUR questionnaire, children received the same doses of opioids postoperatively. Given the increased incidence of postoperative oxygen desaturations among children with SDB symptoms, it would seem prudent to consider titration of opioid doses according to identified risk.
To determine variables related to treatment retention in women six and twelve months postpartum that were in medication treatment using buprenorphine during pregnancy.
Methods: This retrospective ...cohort study of 190 maternal-infant dyads exposed to buprenorphine during pregnancy examines rates of treatment retention at six and twelve months postpartum and also analyzes a variety of potential predictors of treatment retention including illicit drug use in the third trimester, delayed entry into medication treatment and co-occurring mental health diagnoses requiring prescription medication.
At 12months postpartum, women appeared more likely to remain in medication treatment if they entered treatment early in pregnancy (defined as either being in treatment at the time of conception, p=0.001, or entering medication treatment prior to 13weeks gestation, p=0.037). Being prescribed an antidepressant medication during the third trimester was also associated with enhanced treatment retention at six months postpartum (p=0.005). At both six and twelve months postpartum, the use of illicit drugs (including opioids, cocaine and benzodiazepines) during the third trimester was negatively correlated with treatment retention (p=0.012 and p<0.001, respectively).
Early access to medication treatment is associated with treatment retention in women prescribed buprenorphine during pregnancy. This has important public health implications as access to treatment is limited in many parts of the country and many women are only able to obtain treatment after becoming pregnant. Being prescribed an antidepressant medication during pregnancy may enhance treatment retention, supporting the work of previous authors.
•Early access to treatment appears associated with sustained treatment retention in pregnant women prescribed buprenorphine.•Being prescribed an antidepressant during the third trimester was also associated with enhanced treatment retention.•The use of illicit drugs during the third trimester was negatively correlated with treatment retention.
Fear of pain during insertion of intrauterine contraception (IUC) is a barrier to use of this method. IUC includes copper-containing intrauterine devices and levonorgestrel-releasing intrauterine ...systems. Interventions for pain control during IUC insertion include non-steroidal anti-inflammatory drugs (NSAIDs), local cervical anesthetics, and cervical ripening agents such as misoprostol.
To review randomized controlled trials (RCTs) of interventions for reducing IUC insertion-related pain
We searched for trials in CENTRAL, MEDLINE, EMBASE, POPLINE, ClinicalTrials.gov, and ICTRP. The most recent search was 22 June 2015. We examined reference lists of pertinent articles. For the initial review, we wrote to investigators to find other published or unpublished trials.
We included RCTs that evaluated an intervention for preventing IUC insertion-related pain. The comparison could have been a placebo, no intervention, or another active intervention. The primary outcomes were self-reported pain at tenaculum placement, during IUC insertion, and after IUC insertion (up to six hours).
Two authors extracted data from eligible trials. For dichotomous variables, we calculated the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). For continuous variables, we computed the mean difference (MD) with 95% CI. In meta-analysis of trials with different measurement scales, we used the standardized mean difference (SMD).
We included 33 trials with 5710 participants total; 29 were published from 2010 to 2015. Studies examined lidocaine, misoprostol, NSAIDs, and other interventions. Here we synthesize results from trials with sufficient outcome data and moderate- or high-quality evidence.For lidocaine, meta-analysis showed topical 2% gel had no effect on pain at tenaculum placement (two trials) or on pain during IUC insertion (three trials). Other formulations were effective compared with placebo in individual trials. Mean score for IUC-insertion pain was lower with lidocaine and prilocaine cream (MD -1.96, 95% CI -3.00 to -0.92). Among nulliparous women, topical 4% formulation showed lower scores for IUC-insertion pain assessed within 10 minutes (MD -15.90, 95% CI -22.77 to -9.03) and at 30 minutes later (MD -11.10, 95% CI -19.05 to -3.15). Among parous women, IUC-insertion pain was lower with 10% spray (median 1.00 versus 3.00). Compared with no intervention, pain at tenaculum placement was lower with 1% paracervical block (median 12 versus 28).For misoprostol, meta-analysis showed a higher mean score for IUC insertion compared with placebo (SMD 0.27, 95% CI 0.07 to 0.46; four studies). In meta-analysis, cramping was more likely with misoprostol (OR 2.64, 95% CI 1.46 to 4.76; four studies). A trial with nulliparous women found a higher score for IUC-insertion pain with misoprostol (median 46 versus 34). Pain before leaving the clinic was higher for misoprostol in two trials with nulliparous women (MD 7.60, 95% CI 6.48 to 8.72; medians 35.5 versus 20.5). In one trial with nulliparous women, moderate or severe pain at IUC insertion was less likely with misoprostol (OR 0.30, 95% CI 0.16 to 0.55). In the same trial, the misoprostol group was more likely to rate the experience favorably. Within two trials of misoprostol plus diclofenac, shivering, headache, or abdominal pain were more likely with misoprostol. Participants had no vaginal delivery. One trial showed the misoprostol group less likely to choose or recommend the treatment.Among multiparous women, mean score for IUC-insertion pain was lower for tramadol 50 mg versus naproxen 550 mg (MD -0.63, 95% CI -0.94 to -0.32) and for naproxen versus placebo (MD -1.94, 95% CI -2.35 to -1.53). The naproxen group was less likely than the placebo group to report the insertion experience as unpleasant and not want the medication in the future. An older trial showed repeated doses of naproxen 300 mg led to lower pain scores at one hour (MD -1.04, 95% CI -1.67 to -0.41) and two hours (MD -0.98, 95% CI -1.64 to -0.32) after insertion. Most women were nulliparous and also had lidocaine paracervical block.
Nearly all trials used modern IUC. Most effectiveness evidence was of moderate quality, having come from single trials. Lidocaine 2% gel, misoprostol, and most NSAIDs did not help reduce pain. Some lidocaine formulations, tramadol, and naproxen had some effect on reducing IUC insertion-related pain in specific groups. The ineffective interventions do not need further research.
We reviewed intervention studies that reported dementia caregiver outcomes published since 1996, including psychosocial interventions for caregivers and environmental and pharmacological ...interventions for care recipients. Our goal was to focus on issues of clinical significance in caregiver intervention research in order to move the field toward a greater emphasis on achieving reliable and clinically meaningful outcomes.
MEDLINE, PsycINFO, and Cumulative Index to Nursing & Allied Health databases from 1996 through 2001 were searched to identify articles and book chapters mapping to two medical subject headings: caregivers and either dementia or Alzheimer's disease. Articles were evaluated on two dimensions, outcomes in four domains thought to be important to the individual or society and the magnitude of reported effects for these outcomes in order to determine if they were large enough to be clinically meaningful.
Although many studies have reported small to moderate statistically significant effects on a broad range of outcomes, only a small proportion of these studies achieved clinically meaningful outcomes. Nevertheless, caregiving intervention studies have increasingly shown promise of affecting important public health outcomes in areas such as service utilization, including delayed institutionalization; psychiatric symptomatology, including the successful treatment of major and minor depression; and providing services that are highly valued by caregivers.
Assessment of clinical significance in addition to statistical significance is needed in this research area. Specific recommendations on design, measurement, and conceptual issues are made to enhance the clinical significance of future research.
The legality of nonprice vertical practices in the U.S. is determined by their likely competitive effects. An optimal enforcement rule combines evidence with theory to update prior beliefs, and ...specifies a decision that minimizes the expected loss. Because the welfare effects of vertical practices are theoretically ambiguous, optimal decisions depend heavily on prior beliefs, which should be guided by empirical evidence. Empirically, vertical restraints appear to reduce price and/or increase output. Thus, absent a good natural experiment to evaluate a particular restraint's effect, an optimal policy places a heavy burden on plaintiffs to show that a restraint is anticompetitive.
Whether attending physicians, residents, nurses, and medical students agree on what constitutes medical student abuse, its severity, or influencing factors is unknown.
We surveyed 237 internal ...medicine attending physicians, residents, medical students, and nurses at 13 medical schools after viewing five vignettes depicting potentially abusive behaviors.
The majority of each group felt the belittlement, ethnic insensitivity, and sexual harassment scenarios represented abuse but that excluding a student from participating in a procedure did not. Only a majority of attending physicians considered the negative feedback scenario as abuse. Medical students rated abuse severity significantly lower than other groups in the belittlement scenario (p<.05). Respondents who felt abused as students were more likely to rate behaviors as abusive (p<.05).
The groups generally agree on what constitutes abuse, but attending physicians and those abused as students may perceive more behaviors as abusive.
Of 15 patients with fibromyalgia who were first evaluated for the presence of Axis I psychiatric diagnoses by use of the Structured Clinical Interview for DSM-IV, 11 completed an open 8-week trial ...with the novel antidepressant venlafaxine. Six (55%) of 11 completers experienced a ≥
50% reduction of fibromyalgia symptoms. The presence of lifetime psychiatric disorders, particularly depressive and anxiety disorders, predicted a positive response to venlafaxine. These findings suggest that it is important to assess for comorbid psychiatric disorders in patients with fibromyalgia and that venlafaxine may be helpful to some of these patients.
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