Long QT interval syndrome with increased QT dispersion

This case report describes the anaesthetic management of a patient with sporadic-type long QT interval syndrome (LQTS), and increased QT dispersion, who presented for removal of an ovarian cyst. Beta adrenergic blockade and adequate depth of anaesthesia for successful management is emphasized. The Successful use of epidural administration of lignocaine and opioids in addition to general anaesthesia is described.     

Modification of the Phe3 aromatic moiety in delta receptor-selective dermorphin/deltorphin-related tetrapeptides Effects on opioid receptor binding

The previously described cyclic delta opioid receptor-selective tetrapeptide H-Tyr-d -Cys-Phe-d -Pen-OH (JOM-13) was modified at residue 3 by incorporation of both natural and unnatural amino acids with varying steric, electronic, and lipophilic properties. Effects on mu and delta opioid receptor binding affinities were evaluated by testing the compounds for displacement of radiolabeled receptor-selective ligands in a guinea pig brain receptor binding assay. Results obtained with the bulky aromatic 1-Nal³ and 2-Nal³ substitutions suggest that the shape of the receptor subsite with which the side chain of the internal aromatic residue interacts differs for delta and mu receptors. This subsite of either receptor can accommodate the transverse steric bulk of the 1-Nal³ side chain but only the delta receptor can readily accept the more elongated 2-Nal³ side chain. Several analogs with pi-excessive heteroaromatic side chains in residue 3 were examined. In general, these analogs display diminished binding to mu and delta receptors, consistent with previous findings for analogs with residue 3 substitutions of modified electronic character. Several analogs with alkyl side chains in residue 3 were also examined. While delta receptor binding affinity is severely diminished with Val³, Ile³, and Leu³ substitutions, Cha³ substitution is very well tolerated, indicating that, contrary to the widely held belief, an aromatic side chain in this portion of the ligand is not required for delta receptor binding. Where possible, comparison of results in this delta-selective tetrapeptide series with those reported for analogous modification in the cyclic delta-selective pentapeptide [d -Pen², d -Pen⁵]enkephalin (DPDPE) and linear pentapeptide enkephalins reveals similar trends.     

Noradrenaline- and Enkephalin-Induced Inhibition of Voltage-Sensitive Calcium Currents in NG108-15 Hybrid Cells

Voltage-sensitive calcium currents were recorded from chemically differentiated neuroblastoma x glioma hybrid (NG108-15) cells using the whole-cell clamp technique. Both noradrenaline and [D-Ala2, D-Leu5] enkephalin (DADLE) reversibly depressed the amplitude of the calcium current by up to 30%. The response to noradrenaline occluded that to DADLE suggesting that both agonists depress the same fraction of current. The response to DADLE but not that to noradrenaline desensitized rapidly. Cells responded normally to noradrenaline when desensitized to the opioid. Responses to either agonist were absent in cells pre-incubated with pertussis toxin. In addition the response to noradrenaline became irreversible in cells dialysed internally with a non-hydrolysable analogue of GTP. The response to noradrenaline was not affected by treatment of the cells with either membrane-permeable analogues of cAMP or a combination of forskolin and isobutylmethylxanthine. It is concluded that both noradrenaline and DADLE depress the same fraction of voltage-dependent calcium current in NG108-15 cells; that the responses are mediated by a pertussis-sensitive GTP-binding protein but are not secondary to a reduction in the intracellular concentration of cAMP; and that desensitization of the opioid response occurs at a site linked intimately to the opioid receptor rather than at a common site in the transduction pathway between receptor activation and reduction in the calcium channel current.     

Effects of epidural bupivacaine and epidural morphine on bowel function and pain after hysterectomy

A comparison was made of the effects of continuous epidural analgesia with bupivacaine and intermittent epidural morphine on bowel function after abdominal hysterectomy. The duration of postoperative ileus was assessed as the time from the end of operation to the first postoperative passage of flatus and feces. Twenty-two patients were randomly allocated to two equal groups. An "epidural morphine" group received general anesthesia and epidural morphine for postoperative pain relief, and an "epidural bupivacaine" group was given combined general anesthesia and epidural anesthesia with 0.5% bupivacaine intraoperatively and epidural analgesia with 0.25% bupivacaine postoperatively. Epidural morphine or bupivacaine was given for 42 h postoperatively. Pain intensity (visual analog scale) was low in both groups, but lower (P less than 0.05) in the epidural bupivacaine group. The time to first passage of flatus was 22 +/- 16 h in the epidural bupivacaine group and 56 +/- 22 h in the epidural morphine group (P less than 0.001). The time to first postoperative passage of feces was shorter (P less than 0.05) in the former than in the latter 57 +/- 44 h vs 92 +/- 22 h). The patients of the epidural bupivacaine group started intake of oral fluids earlier (P less than 0.01) and to a greater extent (P less than 0.05) than those in the epidural morphine group. It is concluded that the duration of postoperative ileus after hysterectomy is shorter when epidural bupivacaine is given for postoperative pain relief than when this is achieved by epidural morphine.     

Effects of low-level microwave irradiation on amphetamine hyperthermia are blockable by naloxone and classically conditionable

In a series of experiments, we investigated the effects of pulsed low-level microwave irradiation on amphetamine-induced hyperthermia in the rat. Rats were irradiated in a 2,450-MHz cylindrical waveguide exposure system at 1 mW/cm², 2 s pulses, 500 pps, average SAR of 0.6 W/kg. Acute (45 min) exposure to microwaves attenuated amphetamine-induced hyperthermia. This effect was blocked by pretreatment of the animals with the narcotic antagonist naloxone. In another experiment, rats were subjected to ten daily sessions of microwave exposure (45 min/session). On day 11, amphetamine-induced hyperthermia was studied in the animals immediately after a session of either microwave or sham exposure. Similar to the acute effect, amphetamine-induced hyperthermia was attenuated in rats irradiated with microwaves (unconditioned effect). In the sham-irradiated animals we observed a potentiation of the amphetamine-induced hyperthermia, which was a conditioned effect of microwaves. Thus, the conditioned effect (potentiation) was opposite in direction to the unconditioned effect (attenuation). No tolerance developed to the unconditioned effect after subchronic exposure. Furthermore, both conditioned and unconditioned effects of microwaves on amphetamine-induced hyperthermia could be blocked by treatment with naloxone. These data suggest that (1) microwave irradiation may activate endogenous opioids, which in turn alter the actions of psychoactive drugs, and (2) the effect of microwaves on drug action can be classically conditioned. Offprint requests to: H. Lai     

Increases in Naloxone Administrations by Emergency Medical Services Providers During the COVID-19 Pandemic: Retrospective Time Series Study

BackgroundThe opioid crisis in the United States may be exacerbated by the COVID-19 pandemic. Increases in opioid use, emergency medical services (EMS) runs for opioid-related overdoses, and opioid overdose deaths have been reported. No study has examined changes in multiple naloxone administrations, an indicator of overdose severity, during the COVID-19 pandemic.ObjectiveThis study examines changes in the occurrence of naloxone administrations and multiple naloxone administrations during EMS runs for opioid-related overdoses during the COVID-19 pandemic in Guilford County, North Carolina (NC).MethodsUsing a period-over-period approach, we compared the occurrence of opioid-related EMS runs, naloxone administrations, and multiple naloxone administrations during the 29-week period before (September 1, 2019, to March 9, 2020) and after NC’s COVID-19 state of emergency declaration (ie, the COVID-19 period of March 10 to September 30, 2020). Furthermore, historical data were used to generate a quasi-control distribution of period-over-period changes to compare the occurrence of each outcome during the COVID-19 period to each 29-week period back to January 1, 2014.ResultsAll outcomes increased during the COVID-19 period. Compared to the previous 29 weeks, the COVID-19 period experienced increases in the weekly mean number of opioid-related EMS runs (25.6, SD 5.6 vs 18.6, SD 6.6; P<.001), naloxone administrations (22.3, SD 6.2 vs 14.1, SD 6.0; P<.001), and multiple naloxone administrations (5.0, SD 1.9 vs 2.7, SD 1.9; P<.001), corresponding to proportional increases of 37.4%, 57.8%, and 84.8%, respectively. Additionally, the increases during the COVID-19 period were greater than 91% of all historical 29-week periods analyzed.ConclusionsThe occurrence of EMS runs for opioid-related overdoses, naloxone administrations, and multiple naloxone administrations during EMS runs increased during the COVID-19 pandemic in Guilford County, NC. For a host of reasons that need to be explored, the COVID-19 pandemic appears to have exacerbated the opioid crisis.     

Management of Chronic Pain in Nursing Homes: Navigating Challenges to Improve Person-Centered Care

Despite the dynamic demands in the nursing home (NH), a definitive approach to managing chronic pain in older adults has yet to be established. Due to concerns for potential adverse pharmacologic effects, balancing appropriate pain management is a challenge among NH residents. The challenges encompass but are not limited to medical complexities, functional disabilities, and physical frailty. Barriers to the successful implementation of a comprehensive chronic pain management at the NH may include ambiguous directions on specific therapeutic interventions, insufficient guidance on treatment duration, and limited available treatment options. The Centers for Medicare and Medicaid Services’ reporting requirement of adequate pain control among NH residents coupled with widely variable clinician-prescribing habits highlights the difficulties in overcoming the preceding challenges and barriers. The Coronavirus Disease 2019 (COVID-19) pandemic has further complicated pain management due to its negative consequences on well-being of residents of NHs. Associated symptoms of psychosocial stress, anxiety and depression, and chronic pain symptoms can exacerbate during the COVID-19 pandemic, leading to increased requirement for pain medications including but not limited to opioids.Pain is a multidimensional symptom and requires a strategic multimodal approach for its management. Nonpharmacologic modalities are underutilized in the NH setting and are the preferred first steps for mild pain, and nonopioid pharmacological agents can be added as a second step for a synergistic effect for moderate to severe pain. Opioids should be used as a last resort. Short-acting opioids are preferred over extended-release/long-acting opioids for chronic pain. Clinicians are encouraged to engage residents in proactive strategies in managing their pain, and to set realistic expectations toward improving their quality of life, as complete elimination of pain is not feasible in most cases.This review article provides the interdisciplinary team with a contemporary perspective of the multitude of changes and challenges influencing the prescribing as well as deprescribing of various pain medications.     

The associations of medical marijuana policies with opioid‐related health care utilization

ObjectiveTo examine the associations between medical marijuana policies and opioid‐related hospitalizations and emergency department visits.Data SourcesWe utilized quarterly rates of hospital discharge data from the Healthcare Cost and Utilization Project''s (HCUP) Fast Stats Database from 2005 to 2016 along with state‐level sociodemographic data from US Census Bureau and Bureau of Labor Statistics and opioid‐related state health policy data from publicly available sources for the analysis.Study DesignAnalyses were carried out using a difference‐in‐differences regression approach. We estimate heterogeneous effects of medical marijuana policies such as initial policy, presence of active dispensary, and home cultivation on opioid‐related hospitalizations and emergency department visits related to opioids.Data Collection/Extraction MethodsPublicly available secondary data were collected, linked, and analyzed. Observations with missing values for explanatory variables were excluded from the analysis.Principal FindingsRegression results indicate that type of medical marijuana policy has varying effects on opioid‐related hospitalizations and emergency department visits. States that allow home cultivation of medical marijuana experienced significant positive associations with opioid‐related hospitalizations and emergency department visits, while no effect was observed with medical marijuana dispensaries. Moreover, recreational marijuana policies were positively associated with opioid‐related hospitalizations.ConclusionsThe findings indicate that the effects of medical marijuana policies on opioid‐related hospitalizations and emergency department visits vary depending on the type of medical marijuana policy. Our findings indicate that the implementation of home cultivation of marijuana is positively associated with hospitalizations and emergency department visits related to opioids, suggesting that easier access to marijuana among opioid users may result in adverse health conditions that need treatment.     

Investigation of the involvement of opioid receptors in the action of anticonvulsants

This study investigates the possible involvement of opioid receptors in the action of a variety of anticonvulsant agents. The opioid antagonist naloxone (0.3, 1 mg/kg IP) and the selective -opioid antagonist cyprodime (3 mg/kg IP) significantly inhibited the increase in electroshock seizure threshold induced by phenytoin (3 mg/kg IP) in mice. The anticonvulsant effects of ethanol (1 g/kg IP) were also significantly antagonised by naloxone (1 mg/kg IP) but not by a 0.3 mg/kg IP dose or by cyprodime (3 mg/kg IP). The results with naloxone were confirmed using higher doses of phenytoin (10 mg/kg IP) and ethanol (1.5 g/kg IP). In contrast to the above findings, naloxone (0.3, 1 mg/kg IP) had no effect on the increase in seizure threshold induced by sodium valproate (200 mg/kg IP) or dizocilpine (MK801, 0.5 mg/kg IP) and paradoxically potentiated the increase in seizure threshold produced by phenobarbitone (15 mg/kg IP); carbamazepine (10 mg/kg IP) and the benzodiazepine agonist loprazolam (1 mg/kg IP), clearly differentiating these compounds from phenytoin and ethanol. These findings suggest that the anticonvulsant effects of phenytoin and ethanol (as assessed by their ability to prevent tonic hindlimb extension in the mouse electroshock model) may be mediated, at least in part, by the release of endogenous opioids and subsequent activation of opioid receptors (, in the case of phenytoin, but non-, in the case of ethanol) although direct activity at opioid receptors cannot be precluded.