Faster Spinal Anesthesia For Cancer Patients At End Of Life

Faster Spinal Anesthesia For Cancer Patients At End Of Life

For patients with uncontrolled pain from terminal cancer, a fresh approach to calculating initial dosage may authorize a quicker start of spinal analgesia - and not so much time in the hospital, according to a study in the June end of Anesthesia & Analgesia, official journal of the International Anesthesia Research Society (IARS).

Led the agency of Dr Vivek Tim Malhotra of Memorial Sloan Kettering Cancer Center, New York, the researchers developed a place of equations for estimating the in the first stages dose of intrathecal spinal pain relievers, in this manner avoiding the need for a test period of epidural anesthesia in the hospital. The researchers expectancy their method will shorten the time to sufficient pain control in patients with solicitude from advanced cancer, allowing them to spend more of their remaining days at home.

New Equations on the side of Estimating Intrathecal Analgesia Dose

Intrathecal analgesia is every important option for "intractable" cancer misery that no longer responds to vocal or injected pain medications. In this technique, a catheter is placed in the intrathecal space around the spinal cord, with individualized doses of high-flavored opioid pain relievers given through a physic pump. The standard approach to determining the at the beginning dose is a trial period of one more type of spinal drug injection - epidural analgesia - performed in the hospital.

However, through the time patients are referred to a torment specialist for spinal analgesia, they typically be under the necessity advanced cancer with limited life expectancy. Dr Malhotra and colleagues were looking because of some way of calculating the at the beginning intrathecal analgesia dose without the stand in want of for an epidural trial.

The researchers performed y in-depth analysis of 46 patients, treated past a six-year period, who underwent every epidural drug trial before intrathecal analgesia. The goal was to be ed a way of predicting the incipient intrathecal dose based on the invalid's last oral or injected ("systemic") put s into dosage.

Based on this and other factors - including the indefatigable's age, type of pain, impressed sign of cancer, and pain severity cut - the researchers were able to unfold relatively simple equations for predicting the at the head intrathecal opioid dose needed to repress the patients' pain. The equations if at least a guideline for estimating the in the first stages spinal analgesia dose, while avoiding the be in want of for an epidural trial.

In the 46 patients learned, time spent in the hospital against placement of the spinal catheter and epidural chagrin was between 9 and 17 days. Dr Malhotra and coauthors estimated that using the study equations - and avoiding the strait for an epidural trial - could remodel hospital days by about half.

"This reduces time in the hospital since those with an already limited life expectance and minimizes medical cost and potential complications," Dr Malhotra and coauthors draw up. For the patients studied, median life expectation after leaving the hospital was less than three months.

The researchers annotation that their equations had a distant statistical range, indicating that they are superlatively good used for patients expected to outlive only a short time. But with regard to these patients, the study equation desire provide a useful starting point, allowing patients to pass more of their final days at home tolerably than in the hospital. Dr Mahtola and colleagues process further research - including data on espouse a cause effects and quality of life - to split hairs their equations and better evaluate the benefits of intrathecal analgesia in favor of intractable cancer pain.

Analgesics And Asthma Link Likely Due To Early Childhood Respiratory Infections

Analgesics And Asthma Link Likely Due To Early Childhood Respiratory Infections

A of recent origin study conducted by Boston researchers reports that the copula between asthma and early childhood conversion to an act of acetaminophen or ibuprofen may be driven by underlying respiratory infections that set on the use of these analgesics, rather than the drugs themselves.

The results of the recently made known study were presented at the ATS 2013 International Conference.

Analgesics like ibuprofen and acetaminophen are routinely given to bargain fever in infants, and several studies be under the necessity shown a link between the conversion to an act of analgesics during infancy and the subsequent development of asthma and asthma symptoms including breathe hard. However, although respiratory infections are a stale cause of fever in infants, these earlier studies did not contemplate whether the underlying respiratory infection played a role in the final development of asthma and asthma symptoms in these children.

"Many children are given throughout-the-counter analgesics to treat the agitation that accompanies respiratory infections, so it seemed unclear to us whether asthma and wheeze were really linked to the employment of these drugs or perhaps to the respiratory pollution itself," explained study lead author Joanne Sordillo, ScD., instructor of medicine at Brigham and Women's Hospital in Boston.

"In our study, we wanted to try to decide if accounting for early life respiratory infections mitigated the connection between analgesic use and development of breathe hard and asthma in children," she declared.

The researchers used data from 1,139 origin-child pairs who participated in Project Viva, a exploration study of pregnant women and their children that examined lifestyle factors for the period of pregnancy and after birth and evaluated their movables on the development of asthma and other minority conditions. Mothers completed questionnaires during at the opening of day pregnancy, at mid-pregnancy and at person year following birth to determine acetaminophen and ibuprofen conversion to an act. Also, during the first three years of harvested land child's life, every mother supposing an annual report of any teacher's diagnosis of asthma or wheezing symptoms.

To quantify prenatal exposure in early and mid-pregnancy, the researchers divided subjects' acetaminophen exposure into three categories: those who in no degree used the drug; those who used it smaller than 10 times; and those who used acetaminophen further than 10 times. Ibuprofen use was a great quantity less frequent during early pregnancy and mothers were grouped into couple categories: those who took the physic and those who did not. Ibuprofen appliance beyond the first trimester was infrequent and was not included in the dissection.

For childhood exposure during the earliest year of life, the researchers divided infants into four groups on the side of each drug: those who were not given the drug; those who were given the drug one to five times; those who were given the drug six to 10 times; and those who accepted more than 10 doses of the physic during the first year of life.

Reviewing the study premises, the researchers found a higher exposing to acetaminophen both prenatally and for the period of the first 12 months of life compared to ibuprofen: 70 percent of mothers reported acetaminophen exercise during pregnancy while only 16 percent of mothers reported they had used ibuprofen while gravid; 95 percent of children were given at least one dose of acetaminophen during pupilage versus 70 percent of children who had been given at in the smallest degree one dose of ibuprofen. About 43 percent of children were given greater amount of than 10 doses of acetaminophen control they were a year old compared to 25 percent of children who received more than 10 doses of ibuprofen.

Next, the researchers looked at drug use and the occurrence of asthma and asthma-like symptoms overall, and that time adjusted the analysis to account in favor of respiratory infections the children experienced dint of the age of three. These infections included bronchiolitis, pneumonitis, bronchitis, croup or any other respiratory pest.

At the conclusion of their study, the researchers set that while use of the drugs was associated by wheeze and asthma in unadjusted models, succeeding adjusting the results to account beneficial to respiratory infections, the association between medication exercise in early childhood and asthma symptoms was solidly reduced.

"These results suggest that respiratory infections in babyhood, and not analgesic use, are the positive underlying risk factor for asthma and wheeze in children," said Dr. Sordillo.

The researchers moreover found that prenatal exposure to analgesics was associated through wheeze and asthma in the children. However, for they did not have information touching why the women took analgesics in which case pregnant, the researchers were unable to put for those potential factors; for at this moment, this link must be interpreted with caution, she said.

"Future studies have a mind need to carefully collect information regarding the reasons for taking such from one side to the other-the-counter drugs as analgesics during pregnancy," she said.

Study Suggests Certain Noncancer Pain Conditions Associated With Increased Risk Of Suicide

Study Suggests Certain Noncancer Pain Conditions Associated With Increased Risk Of Suicide

JAMA Psychiatry Study Highlights

A study dint of Mark A. Ilgen, Ph.D, of the Veterans Affairs Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, Michigan and colleagues examined the associations between clinical diagnosis of noncancer pain stipulations and suicide. (Online First)

Data conducive to this retrospective analysis were extracted from the National Death Index and management records from the Department of Veterans Affairs Healthcare System. Researchers identified 4,863,036 individuals who admitted services in fiscal year 2005 and were in existence at the start of fiscal year 2006. The given conditions were examined for associations between baseline clinical diagnoses of worry-related conditions (arthritis, back pain, migraine, neuropathy, headache or tension headache, fibromyalgia, and psychogenic chagrin (which results from psychological factors) and succeeding suicide death (assessed in fiscal years 2006-2008).

Elevated self-murder risks were observed for each trouble condition except arthritis and neuropathy. When analyses controlled despite accompanying psychiatric conditions, the associations between pain conditions and suicide death were reduced; in whatever manner, significant associations remained for back wretchedness, migraine, and psychogenic pain, the study finds.

"There is a require for increased awareness of suicide peril in individuals with certain noncancer distress diagnoses, in particular back pain, migraine, and psychogenic distress," the study concludes.

Survey Finds Teen Misuse And Abuse Of Prescription Drugs Up 33 Percent Since 2008

Survey Finds Teen Misuse And Abuse Of Prescription Drugs Up 33 Percent Since 2008

New, nationally projectable survey results released by The Partnership at Drugfree.org and MetLife Foundation confirmed that one in four teens has misused or abused a prescription (Rx) drug at least once in their lifetime - a 33 percent increase over the past five years. The Partnership Attitude Tracking Study (PATS) also found troubling data on teen misuse or abuse of prescription stimulants. One in eight teens (13 percent) now reports that they have taken the stimulants Ritalin or Adderall when it was not prescribed for them, at least once in their lifetime.

Contributing to this sustained trend in teen medicine abuse are the lax attitudes and beliefs of parents and caregivers. In fact, nearly one-third of parents say they believe Rx stimulants like Ritalin or Adderall, normally prescribed for attention deficit hyperactivity disorder (ADHD), can improve a teen's academic performance, even if the teen does not have ADHD. Parents are not effectively communicating the dangers of Rx medicine misuse and abuse to their kids, nor are they safeguarding their medications at home and disposing of unused medications properly.

The Partnership at Drugfree.org Responds to Rx Epidemic with The Medicine Abuse Project

In response to the continued high prevalence of teen prescription medicine abuse as reported in the 2012 PATS data, The Partnership at Drugfree.org is helping educate parents, community stakeholders and others about the risks of this dangerous behavior. The Partnership at Drugfree.org leads The Medicine Abuse Project, a multi-year initiative with the goal of preventing half a million teens from abusing prescription medicine by 2017.

The Medicine Abuse Project provides comprehensive resources to parents, educators, health care providers, law enforcement officials and others about the growing problem of teen medicine abuse. The Project aims to mobilize parents and the public at large to take action and help solve the problem of teen substance abuse. This includes learning about the issue, talking with their kids about the dangers of misuse and abuse of prescription drugs and properly monitoring, safeguarding and disposing of excess Rx drugs in their homes.

Drug Enforcement Administration (DEA) Holds Nationwide Prescription Take-Back Day on April 27th

One way parents, grandparents and other caretakers can take immediate action is by participating in the upcoming DEA-facilitated National Prescription Drug Take-Back Day, taking place this Saturday, April 27, 2013.

"Medicine cabinets are the number one access point for teens who want to misuse and abuse prescription drugs. That's why we are making a concerted effort to let parents and caregivers know how important it is to safely dispose of their unused, unwanted or expired medicines. Doing so can literally save a life," said Marcia Lee Taylor,

SVP of Government Affairs at The Partnership at Drugfree.org. "This Saturday's DEA Take-Back event gives everyone a chance to protect their kids from the dangers that medicine abuse poses in their own homes. We should all take this simple step and clean out our medicine cabinets."

Collection sites will be set up around the country, open for medicine drop-off between the hours of 10:00 a.m. and 2:00 p.m. Those interested in disposing of their medicine at a take-back location this Saturday can visit The Medicine Abuse Project website to find the nearest site to safely drop off their unused, unwanted or expired prescription medicines. In the five previous Take-Back events, more than 2 million pounds of prescription medicines were safely dropped off and removed from circulation.

The DEA Take-Back Day provides a tangible way for parents to help curb medicine abuse. The PATS data released today confirms that misuse and abuse of prescription drugs is now a normalized behavior among teens.

Concerning Trends in Teen Prescription Drug Abuse According to the New PATS Data (2008-2012)

One in four teens (24 percent) reports having misused or abused a prescription drug at least once in their lifetime (up from 18 percent in 2008 to 24 percent in 2012), which translates to about 5 million teens. That is a 33 percent increase over a five-year period:

Of those kids who said they abused Rx medications, one in five (20 percent) has done so before the age of 14.

More than a quarter of teens (27 percent) mistakenly believe that "misusing and abusing prescription drugs to get high is safer than using street drugs," and one-third of teens (33 percent) say they believe "it's okay to use prescription drugs that were not prescribed to them to deal with an injury, illness or physical pain."

"These data make it very clear: the problem is real, the threat immediate and the situation is not poised to get better," said Steve Pasierb, President and CEO of The Partnership at Drugfree.org. "Parents fear drugs like cocaine or heroin and want to protect their kids. But the truth is that when misused and abused, medicines - especially stimulants and opioids - can be every bit as dangerous and harmful as illicit street drugs. Medicine abuse is one of the most significant and preventable adolescent health problems facing our families today. As parents and caring adults, we need to take action to address the risks that intentional medicine abuse poses to the lives and the long-term health of our teens."

Significant Increase in Teen Abuse of Stimulants Ritalin and Adderall, Rx Painkiller Abuse Flattening

Rx stimulants are a key area of concern, with misuse and abuse of Ritalin and Adderall in particular driving the noted increases in teen medicine abuse. Stimulants are a class of drugs that enhance brain activity and are commonly prescribed to treat health conditions including ADHD and obesity. The 2012 data found:

One in eight teens (about 2.7 million) now reports having misused or abused the Rx stimulants Ritalin or Adderall at least once in their lifetime.

9 percent of teens (about 1.9 million) report having misused or abused the Rx stimulants Ritalin or Adderall in the past year (up from 6 percent in 2008) and 6 percent of teens (1.3 million) report abuse of Ritalin or Adderall in the past month (up from 4 percent in 2008).

One in four teens (26 percent) believes that prescription drugs can be used as a study aid.

Abuse of prescription pain medicine remains at unacceptably high levels among teens, but the new PATS data show it may be flattening. Teen abuse of prescription pain relievers like Vicodin and OxyContin has remained stable since 2011 with one in six teens (16 percent) reporting abuse or misuse of an Rx pain reliever at least once in their lifetime. One in 10 teens (10 percent) admits to abusing or misusing an Rx painkiller in the past year.

Parents' Missed Opportunity: Lax Attitudes and Permissiveness About Rx Drugs Linked to Teen Abuse

Parent permissiveness and lax attitudes toward abuse and misuse of Rx medicines, coupled with teens' ease of access to prescription medicines in the home, are key factors linked to teen medicine misuse and abuse. The availability of prescription drugs (in the family medicine cabinet, in the homes of friends and family) makes them that much easier to abuse. The new survey findings stress that teens are more likely to abuse Rx medicines if they think their parents "don't care as much if they get caught using prescription drugs, without a doctor's prescription, than they do if they get caught using illegal drugs."

Almost one-third of parents (29 percent) say they believe ADHD medication can improve a child's academic or testing performance, even if the teen does not have ADHD.

One in six parents (16 percent) believes that using prescription drugs to get high is safer than using street drugs.

Teens reported that during the last conversation they had with their parents regarding substance abuse, only 16 percent said they discussed the misuse or abuse of prescription pain relievers with their parents, and just 14 percent indicate the same for discussions about any type of prescription drug. In comparison, a majority of teens (81 percent) say they have discussed the risks of marijuana use with their parents, 80 percent have discussed alcohol and nearly one-third of teens (30 percent) have discussed crack/cocaine.

More than half of teens (56 percent) indicate that it's easy to get prescription drugs from their parent's medicine cabinet. In fact, about half of parents (49 percent) say anyone can access their medicine cabinet.

More than four in 10 teens (42 percent) who have misused or abused a prescription drug obtained it from their parent's medicine cabinet. Almost half (49 percent) of teens who misuse or abuse Rx medicines obtained them from a friend.

Teens are more likely to use prescription drugs if they believe that their parents are more lenient toward prescription drug misuse or abuse compared to illegal drug abuse, and their parents use drugs themselves.

One in five parents (20 percent) report that they have given their teen a prescription drug that was not prescribed for them.

The PATS survey also found that 17 percent of parents do not throw away expired medications, and 14 percent of parents say that they themselves have misused or abuse prescription drugs within the past year.

View drug information on Adderall XR; OxyContin; Ritalin LA.

General On-Off Switch Suggested By Structure Of Cell Signaling Molecule

General On-Off Switch Suggested By Structure Of Cell Signaling Molecule

A three-dimensional image of one of the proteins that serves as an on-off switch as it binds to receptors on the surface of a cell suggests there may be a sort of main power switch that could be tripped. These surface receptors are responsible for helping cells discern light, set the heart racing, or detect pain.

The finding, published online in the journal Nature by a research collaboration involving this year's Nobel laureates in chemistry, could help in the development of more effective drugs to switch on or off the cell receptors that regulate nearly every bodily function. Already, up to half of all drugs engage these receptors, including antihistamines and beta blockers, but many of the intricacies of how these important proteins work remain unknown.

"It's important to understand how this extraordinary family of receptors work," said co-author Robert J. Lefkowitz, M.D., James B. Duke Professor of Medicine and Howard Hughes Medical Institute Investigator. "This is the kind of finding that answers a basic curiosity, but can also be of benefit if we can develop new drugs or improve the ones we have."

The research marks a collaborative reunion between Lefkowitz and Brian K. Kobilka, M.D., chair of molecular and cellular physiology at Stanford University School of Medicine. The two researchers - friends who first collaborated when Kobilka was a trainee in Lefkowitz's laboratory at Duke - shared the 2012 Nobel Prize in Chemistry for their discoveries involving the G-protein coupled receptors (GPCRs), which are activated by signaling proteins to detect hormones, neurotransmitters, pain, light.

In the current work, the researchers used X-ray crystallography to develop an atom-scale image of one of the principal signaling molecules that regulate GPCRs. This protein is called beta-arrestin1, which, among other things, works to dim a cell's response to hormones such as adrenalin.

The researchers were able to isolate and capture the beta-arrestin1 protein in an active state as it binds to a segment of the GPCR - a first. That snapshot, in high resolution, revealed that the structural conformation or shape of the protein in its active state is strikingly different than when it is inactive.

Such changes suggest there may be a general molecular mechanism that activates the beta-arrestin1 - a sort of main switch that controls the multi-functional signaling proteins.

"It's like there are brakes on in beta-arrestin1, and then when the beta-arrestin1 binds to a GPCR, the brakes are released, thereby activating beta-arrestin1," said Arun K. Shukla, PhD, assistant professor of medicine at Duke and co-lead author of the study.

The researchers are now pursuing additional structural imaging of the signaling complex consisting of beta-arrestin1 and the entire receptor protein.

The Epigenetics Of Pain In Endometriosis

The Epigenetics Of Pain In Endometriosis

Most of us probably know at least one woman, and maybe quite a few more, with endometriosis. Despite the disease's prevalence, there is no consensus on the cause of it, the existing treatment options leave a lot to be desired, and there are too few ways for women to, at the very least, effectively numb the pain that the disease provokes.

Scientists - who over the years have suspected hormones, the immune system, environmental toxins, genetics or some combination - still have a long way to go in terms of better understanding the disease's molecular bases. Researchers at the Joan C. Edwards School of Medicine at Marshall University, in Huntington, W.V., say that a great deal more attention should be paid to the daily pain suffered by endometriosis patients.

"Endometriosis is a not a well understood disease ," says Nalini Santanam, who is heading up the West Virginia research team looking into the epigenetics of pain in endometriosis. Santanam, who has studied the disease for more than 20 years, expresses disappointment in the lack of notice given to the pain associated with the disease.

"First of all, even though it's highly prevalent, we don't really have people talking about the disease. It's a woman's disease. It's pain," she says. "Women have menstrual pain, and in most countries we don't even talk about this. It's taboo. People say, 'It's just pain. Get over it. In a few days, it's gone.' And they don't think that there's actually an underlying disease there."

About the disease

Endometriosis occurs when cells normally present within the uterus migrate outside the organ and attach to other parts in the pelvis. This outgrowth causes scarring, nodules of bumps on pelvic organs, or ovarian cysts. In some cases, organs can become fused by the scar tissue. The disease affects about one out of every seven women, but, because some don't exhibit symptoms, the actual number could be larger.

A common cause of infertility, endometriosis usually presents itself during the teen years in the form of pain in the pelvic region and lower back, but it it's not usually diagnosed till women are in their mid-20s, often because they are having difficulty having babies. Hormones, including birth-control pills, can ease the symptom. Over-the-counter painkillers are often recommended.

"Unfortunately, there are few options for treatment," says Kristeena Ray, a doctoral student in Santanam's lab. "More complex treatment can involve surgeries to remove the damaged tissue or, in extreme cases, a complete hysterectomy." It's not uncommon for endometriosis to recur after surgery.

Pain can't be ignored

Much like the tissue does when situated correctly in the uterus, the misplaced endometriosis grows, breaks down and sloughs off; however, because of its location, the detritus cannot exit the body, and it is believed that this misplaced chemical cocktail causes pain.

"It is extremely common for the pain suffered by these women to interfere with their day-to-day activities," says Ray.

Women often report pain during and after sexual intercourse. Interestingly, the stage of endometriosis is not necessarily indicative of the amount of pain.

When Santanam was working at Emory University a few years ago, her group looked into how nutritional supplementation affects potential endometriosis biomarkers. "One of the projects was a clinical study where we'd given patients vitamin E and C to see if it changes any markers related to endometriosis, and we found that it did," she explains. "What also was interesting was that it also decreased pain in these women. So in our mind, there must be something else, some other pain-related markers. So over the past few years I've been trying to concentrate on that particular aspect: What are the pain-related markers? And then there's the epigenetics."

The epigenetics of endometriosis and pain

Though several large gene-expression studies have identified many deregulated genes in endometriosis patients, the specific genetic factors remain elusive. The West Virginia group, meanwhile, is focusing on epigenetic mechanisms, the changes caused to DNA and gene expression by the environment and lifestyle.

Ray is heading up the group's investigation. Her preliminary findings were presented at the annual meeting of the American Society for Biochemistry and Molecular Biology, which is held in conjunction with the Experimental Biology conference in Boston.

"We're looking at epigenetic markers in patients with endometriosis," Ray explains. "We believe that our continuing research in this area will help us better understand what leads to endometriosis in some women and find alternate treatment options for its symptoms."

Unlike DNA mutations, epigenetic modifications are dynamic, constantly affected by environmental and lifestyle factors, which makes enzymes that affect epigenetic changes sought-after targets for drug development.

Santanam emphasizes that so little is known about the epigenetics of pain. "When you look at pain research, they mostly focus on back pain, fibromyalgia - those types of diseases. There are only now looking at epigenetics of pain," says Santanam. "If you look at all the other fields, there are already epigenetic-related drugs available in the market."

But, if epigenetic aberrations are found by her group or others, Santanam says, that could go a long way toward narrowing down biomarkers to be used in diagnostics and perhaps a personalized approach to endometriosis and its associated symptoms such as pain.

Painkillers Taken Before Marathons Linked To Potentially Serious Side Effects

Painkillers Taken Before Marathons Linked To Potentially Serious Side Effects

Risk increases with dose; unrecognised problem, doctors warn

Attempts to ward off pain in marathons and other endurance sports by taking over the counter painkillers may be ill advised, because these drugs may cause serious side effects in these circumstances, suggests research published in the online journal BMJ Open.

Many competitors try to prevent pain interfering with their performance by taking painkillers that are readily available in pharmacies and supermarkets, say the authors.

And in a bid to find out what impact these common drugs might have, the authors quizzed participants in the 2010 Bonn Marathon/Half-Marathon about their use of medication and any symptoms they had during and/or after the race.

In all, just under 4000 (56%) of all 7048 competitors returned their online questionnaires. Most (87%) had run marathons before.

Of those who took painkillers before the race, 1 in 5 said they also used painkillers during training to curb or ward off pain; 1 in 10 said they had pain symptoms before the start of the race. This compares with 1% of those who didn't touch painkillers.

Over half the drugs taken (54%) were bought over the counter without a prescription, and included diclofenac, asprin, and ibuprofen.

The numbers of those forced to withdraw during the race because of pain and other health symptoms differed little between those who took painkillers and those who didn't.

But withdrawal from competition because of gastrointestinal problems was significantly more common among those taking painkillers, and while withdrawal as a result of muscle cramps was rare, it was significantly more common in those who had taken these drugs.

Runners who popped painkillers were five times as likely to experience symptoms as those who didn't take these drugs; the overall difference in risk was 13%.

Symptoms included stomach cramps, cardiovascular problems, gastrointestinal bleeds, blood in the urine and joint and muscle pain.

The rate of symptoms rose in parallel with increasing dose. One in 10 of those taking diclofenac took over 100 mg; 43% of those who took ibuprofen, the second most popular choice, took doses of 800 mg or more--twice the recommended dose.

Virtually none of the respondents said they were aware of any risks associated with taking painkillers for endurance sports.

Nine runners who took painkillers said they had ended up in hospital: three for temporary kidney failure after taking ibuprofen; four for bleeding ulcers (aspirin), and two after a heart attack (aspirin), one of whom had taken 500 mg for mild foot pain.

None of the runners who competed without having topped up on painkillers was admitted to hospital.

Painkillers block enzymes called cyclooxygenases, which regulate the production of prostaglandins. But the authors suggest that prostaglandins also protect tissues when the body is under extreme stress, such as during endurance sports.

"Taken together, our data indicate that the widespread use of cyclooxygenase inhibitors in connection with endurance sports is potentially damaging. Further investigations are warranted to examine whether the use of analgesics before and during sports activities should be avoided altogether," they conclude.

Lower Rates Of Complications In Hip And Knee Replacement Using Regional Anesthesia Technique

Lower Rates Of Complications In Hip And Knee Replacement Using Regional Anesthesia Technique

A highly underutilized anesthesia technique called neuraxial anesthesia, also known as spinal or epidural anesthesia, improves outcomes in patients undergoing hip or knee replacement, according to a new study by researchers at Hospital for Special Surgery. The study, which appears in the May issue of the journal Anesthesiology, found that neuraxial anesthesia, a type of regional anesthesia, reduced morbidity, mortality, length of hospital stay and costs when compared with general anesthesia.

"The influence that the type of anesthetic can have on perioperative outcomes has been vastly underestimated. Indeed, our study suggests that the type of anesthesia chosen may have important impacts on all kind of medical and economic outcomes in orthopedic surgical patients," said Stavros Memtsoudis, M.D., Ph.D., director of Critical Care Services at Hospital for Special Surgery, New York City. "It is not something to be taken lightly." The findings of this comparative effectiveness research could be applied to over one million patients undergoing joint arthroplasty in the United States each year.

Using neuraxial anesthesia over general anesthesia reduced the risk of pulmonary compromise by twofold in knee replacement patients and over threefold in hip replacement patients. "When one considers the modest decrease in risk of adverse outcomes associated with the use of a number of widely used medications such as anti-cholesterol drugs, the effect sizes seen in this study are really impressive," said Dr. Memtsoudis.

Neuraxial anesthesia involves injecting medication into fatty tissue that surrounds the nerve roots in the spine (known as an epidural) or into the cerebrospinal fluid that surrounds the spinal cord. Currently, the majority of joint replacements in the United States are performed under general anesthesia. Anesthesiologists at the Hospital for Special Surgery, however, use regional anesthesia for over 90% of hip and knee replacements. In the past, several small studies have shown that compared with general anesthesia, regional anesthesia reduces intraoperative blood loss and the need for blood transfusions.

In the new study, researchers at Hospital for Special Surgery conducted a retrospective review of hip and knee replacements performed between 2006 and 2010 in the United States using data collected by Premier Perspective. This administrative database contains discharge information from approximately 400 acute care hospitals located throughout the United States.

Information on the type of anesthesia used was available in 71.4% of 528,495 patients. Eleven percent received neuraxial anesthesia, 14.2% received combined neuraxial and general anesthesia, and 74.8% received general anesthesia. Thirty-day mortality was significantly higher in patients who received general anesthesia, 0.18%, compared with those who received neuraxial, 0.10%, or neuraxial-general, 0.10%.

"Other studies have suggested some benefit of neuraxial over general anesthesia, but they looked at very limited outcomes, primarily at risk of bleeding and blood transfusions. What this study does for the first time is really explore the impact of anesthesia on a wider range of important outcomes," said Dr. Memtsoudis. "We found lower rates of complications including pulmonary compromise, pneumonia, infections, and acute renal failure when neuraxial anesthesia is used. The choice of anesthesia seemed to basically affect every organ system."

When patients who received general anesthesia were compared to patients who received neuraxial or a combination of neuraxial and general, they were found to have higher rates of pulmonary compromise (0.81% vs. 0.37% vs. 0.61%), infections (4.5% vs. 3.11% vs. 3.87%) and acute renal failure (1.75% vs. 1.1% vs. 1.43%).

Neuraxial anesthesia was also associated with shorter hospital stays and lower health care costs. Patients were defined as having a prolonged hospital stay, if they fell in the 75th percentile of the study cohort in terms of stay duration. The researcher found that more patients receiving general anesthesia (35.4%) had a prolonged hospital stay than patients who received neuraxial (28.7%) or neuraxial and general (27.4%). Patients were less likely to fall into the upper 75th percentile in terms of health care costs if they received neuraxial anesthesia (21.4%) or combined neuraxial-general (18.3%) than in the general anesthesia group (23.4%). "Patients were 30% more likely to be in the group that had the highest costs if they received general anesthesia alone," said Dr. Memtsoudis.

Anesthesia medications used during surgeries are a small fraction of overall health care costs, and the costs of regional and general anesthesia are similar.

Dr. Memtsoudis pointed out that educating patients is key. "Some patients don't like the idea of having an injection in their back and their legs being numb, but a thorough discussion of risks, benefits and alternatives can go a long way to help an educated patient make rational decisions," he said. "For the anesthesiologist, a number of factors come into play, including patient comorbidities and preferences as well as other practice specific factors, such as the choice for anticoagulation, but regional anesthesia should, at the very least, be considered in every patient."

While randomized clinical trials are the gold standard of clinical research, such trials are not feasible for testing anesthesia technique in joint replacement surgeries, because the low incidence outcomes would require a huge number of patients.