Shung-Tai Ho

Trends in the Consumption of Opioid Analgesics in Taiwan From 2002 to 2007: A Population-Based Study

CONTEXT Morphine consumption is an important indicator of a countrys progress in cancer pain relief. However, opioid prescription data are lacking for Taiwan. OBJECTIVES To investigate opioid consumption patterns in Taiwan, compare the results with those from selected countries, identify differences between patients with and without cancer, and determine the associated expenditure. METHODS Data on prescriptions for three so-called strong opioids (fentanyl, morphine, and pethidine [meperidine]) and one so-called weak opioid (codeine) were obtained from the Taiwan National Health Insurance Research Database for 2002-2007. The data were converted into a defined daily dose for statistical purposes per million inhabitants per day. Associated payments and diagnoses also were obtained from the database. RESULTS From 2002 to 2007, opioid consumption in Taiwan increased by 55% from 362 to 560 defined daily dose for statistical purposes per million inhabitants per day. This ranks Taiwan as 56th among 181 countries and areas according to the statistical data for 2005-2007 from the International Narcotics Control Board. Among the investigated opioids, prescriptions for transdermal fentanyl and oral morphine increased markedly from 2002 to 2007. Pethidine (meperidine) was predominantly prescribed to patients without cancer diagnoses (around 80%). The total expenditure on opioid prescriptions was US

Efficacy of mirtazapine in preventing intrathecal morphine-induced nausea and vomiting after orthopaedic surgery*.

10.2 million in 2007 for a population of 23 million. CONCLUSION Opioid prescriptions and expenditure increased steadily from 2002 to 2007 in Taiwan, as in nearby Asian countries, but remained much lower than in developed countries. Pethidine (meperidine) was predominantly prescribed to noncancer patients, whereas morphine and fentanyl were mainly prescribed for cancer patients.

Factors Related to Daily Life Interference in Lung Cancer Patients: A Cross-Sectional Regression Tree Study

Nausea and vomiting are frequent complications of intrathecal morphine. In this randomised, double‐blind trial, we tested the efficacy of mirtazapine, an antidepressant that blocks receptors associated with vomiting, on the incidence of nausea and vomiting after intrathecal morphine. One hundred patients receiving spinal anaesthesia for lower limb surgery were assigned equally to take either an orally disintegrating form of 30 mg mirtazapine or matching placebo 1 h before surgery. Spinal anaesthesia was performed by injection of 15 mg isobaric bupivacaine 0.5% along with 0.2 mg preservative‐free morphine. Nausea and vomiting were evaluated 3, 6, 12, 18 and 24 h after intrathecal morphine administration. The incidence of nausea and vomiting was significantly lower in patients receiving mirtazapine compared with placebo (26.5% vs 56.3%, respectively; p = 0.005). The mean (SD) onset time of postoperative nausea and vomiting was significantly delayed in mirtazapine patients: 9.4 (2.5) vs 5.2 (1.8) h, respectively; p < 0.0001. The severity of nausea and vomiting was also decreased after mirtazapine at the 3‐6 h and 6‐12 h periods. Our data indicate that pre‐operative mirtazapine decreases the incidence, delays the onset and reduces the severity of nausea and vomiting induced by intrathecal morphine in patients undergoing spinal anaesthesia.

Auricular Acupressure for Managing Postoperative Pain and Knee Motion in Patients with Total Knee Replacement: A Randomized Sham Control Study

PURPOSE To identify the symptom combination patterns and symptom severity levels that induce severe symptom interference in daily life activities, including physical and psychological activity interference in lung cancer patients. METHODS In a cross-sectional descriptive study using convenience sampling, 131 participants were recruited at a medical center in northern Taiwan. The Eastern Cooperative Oncology Group (ECOG) performance status was used to assess performance status, and the Taiwanese version of the M.D. Anderson Symptom Inventory (MDASI-T) was used to assess symptom severity and symptom interference in daily life activities including physical and psychological activities. Regression tree models were applied to examine variable combinations for symptom interference level in daily life activities, including physical and psychological activity interference. RESULTS Study results revealed that the performance status is the key discriminator of the symptom interference level in daily life and physical activities, but distress severity is the key discriminating factor of the symptom interference level in psychological activities. The performance status and distress severity, plus other factors, further specifically show the discrimination paths and interactions between the risk groups. CONCLUSIONS This study provided an alternative approach to identify low- and high-risk groups of symptom interference among lung cancer patients in Taiwan. Increased awareness and further understanding of the risk combinations and discriminate levels of symptom severity that induced high symptom interference offer different perspectives to develop patient-centered care planning for lung cancer patient rehabilitation.

The Osmopressor Response Is Linked to Upregulation of Aquaporin-1 Tyrosine Phosphorylation on Red Blood Cell Membranes

Background. Postoperative pain management remains a significant challenge for all healthcare providers. A randomized controlled trial was conducted to examine the adjuvant effects of auricular acupressure on relieving postoperative pain and improving the passive range of motion in patients with total knee replacement (TKR). Method. Sixty-two patients who had undergone a TKR were randomly assigned to the acupressure group and the sham control group. The intervention was delivered three times a day for 3 days. A visual analog scale (VAS) and the Short-Form McGill Pain Questionnaire were used to assess pain intensity. Pain medication consumption was recorded, and the knee motion was measured using a goniometer. Results. The patients experienced a moderately severe level of pain postoperatively (VAS 58.66 ± 20.35) while being on the routine PCA. No differences were found in pain scores between the groups at all points. However, analgesic drug usage in the acupressure group patients was significantly lower than in the sham control group (P < 0.05), controlling for BMI, age, and pain score. On the 3rd day after surgery, the passive knee motion in the acupressure group patients was significantly better than in the sham control group patients (P < 0.05), controlling for BMI. Conclusion. The application of auricular acupressure at specific therapeutic points significantly reduces the opioid analgesia requirement and improves the knee motion in patients with TKR.

Coagulation abnormalities in sepsis

Studies in patients with an impaired efferent baroreflex led us to discover that ingesting water induces a robust increase in blood pressure and vascular resistance. This response was also present in healthy subjects with intact baroreflexes, described as osmopressor response. This study was to discover the physiology of the osmopressor response by determining functional activation of the aquaporin-1 water channel receptor on red blood cell membranes in young healthy subjects. In a randomized, controlled, crossover fashion, 22 young healthy subjects (age, 19–27 years) ingested either 500 or 50 mL of water. Heart rate, blood pressure, cardiac index, and total peripheral vascular resistance were measured using a Finometer hemodynamic monitor. Blood sampling was performed at 5 minutes before and at 25 and 50 minutes after either the water ingestion or control session. Immunoblotting for aquaporin-1 tyrosine phosphorylation was performed before and after subjects ingested either 500 or 50 mL of water. At 25 minutes after the ingestion of 500 mL of water, total peripheral resistance increased significantly, and plasma osmolality decreased. Functional expression of aquaporin-1 tyrosine phosphorylation on red blood cell membranes increased significantly at 25 and 50 minutes after subjects ingested 500 mL of water compared with that before water ingestion. This study concludes that water ingestion produces upregulation of aquaporin-1 tyrosine phosphorylation on red blood cell, which presents as a novel biological marker that occurs simultaneously with the osmopressor response.

Anesthetic premedication: New horizons of an old practice

Although the pathophysiology of sepsis has been elucidated with the passage of time, sepsis may be regarded as an uncontrolled inflammatory and procoagulant response to infection. The hemostatic changes in sepsis range from subclinical activation of blood coagulation to acute disseminated intravascular coagulation (DIC). DIC is characterized by widespread microvascular thrombosis, which contributes to multiple organ dysfunction/failure, and subsequent consumption of platelets and coagulation factors, eventually causing bleeding manifestations. The diagnosis of DIC can be made using routinely available laboratory tests, scoring algorithms, and thromboelastography. In this cascade of events, the inhibition of coagulation activation and platelet function is conjectured as a useful tool for attenuating inflammatory response and improving outcomes in sepsis. A number of clinical trials of anticoagulants were performed, but none of them have been recognized as a standard therapy because recombinant activated protein C was withdrawn from the market owing to its insufficient efficacy in a randomized controlled trial. However, these subgroup analyses of activated protein C, antithrombin, and thrombomodulin trials show that overt coagulation activation is strongly associated with the best therapeutic effect of the inhibitor. In addition, antiplatelet drugs, including acetylsalicylic acid, P2Y12 inhibitors, and glycoprotein IIb/IIIa antagonists, may reduce organ failure and mortality in the experimental model of sepsis without a concomitant increased bleeding risk, which should be supported by solid clinical data. For a state-of-the-art treatment of sepsis, the efficacy of anticoagulant and antiplatelet agents needs to be proved in further large-scale prospective, interventional, randomized validation trials.

Duration effect of desflurane anesthesia and its awakening time and arterial concentration in gynecologic patients

The practice of anesthetic premedication embarked upon soon after ether and chloroform were introduced as general anesthetics in the middle of the 19(th) century. By applying opioids and anticholinergics before surgery, the surgical patients could achieve a less anxious state, and more importantly, they would acquire a smoother course during the tedious and dangerous induction stage. Premedication with opioids and anticholinergics was not a routine practice in the 20(th) century when intravenous anesthetics were primarily used as induction agents that significantly shorten the induction time. The current practice of anesthetic premedication has evolved into a generalized scheme that incorporates several aspects of patient care: decreasing preoperative anxiety, dampening intraoperative noxious stimulus and its associated neuroendocrinological changes, and minimizing postoperative adverse effects of anesthesia and surgery. Rational use of premedication in modern anesthesia practice should be justified by individual needs, the types of surgery, and the anesthetic agents and techniques used. In this article, we will provide our readers with updated information about premedication of surgical patients with a focus on the recent application of second generation serotonin type 3 antagonist, antidepressants, and anticonvulsants.

Trends in Clinically Significant Pain Prevalence Among Hospitalized Cancer Patients at an Academic Hospital in Taiwan: A Retrospective Cohort Study.

OBJECTIVES: To determine the awakening arterial blood concentration of desflurane and its relationship with the end-tidal concentration during emergence from various durations of general anesthesia. METHOD: In total, 42 American Society of Anesthesiologists physical status class I-II female patients undergoing elective gynecologic surgery were enrolled. General anesthesia was maintained with fixed 6% inspiratory desflurane in 6 l min-1 oxygen until shutoff of the vaporizer at the end of surgery. One milliliter of arterial blood was obtained for desflurane concentration determination by gas chromatography at 20 and 10 minutes before and 0, 5, 10, 15, and 20 minutes after the discontinuation of desflurane and at the time of eye opening upon verbal command, defined as awakening. Concentrations of inspiratory and end-tidal desflurane were simultaneously detected by an infrared analyzer. RESULTS: The mean arterial blood concentration of desflurane was 1.20% at awakening, which correlated with the awakening end-tidal concentration of 0.96%. The mean time from the discontinuation of desflurane to eye opening was 5.2 minutes (SD = 1.6, range 3-10), which was not associated with the duration of anesthesia (60-256 minutes), total fentanyl dose, or body mass index (BMI). CONCLUSIONS: The mean awakening arterial blood concentration of desflurane was 1.20%. The time to awakening was independent of anesthetic duration within four hours. Using well-assisted ventilation, the end-tidal concentration of desflurane was proven to represent the arterial blood concentration during elimination and could be a clinically feasible predictor of emergence from general anesthesia.

Arterial blood and end-tidal concentrations of sevoflurane during the emergence from anesthesia in gynecologic patients

AbstractClinically significant pain (CSP) is one of the most common complaints among cancer patients during repeated hospitalizations, and the prevalence ranges from 24% to 86%. This study aimed to characterize the trends in CSP among cancer patients and examine the differences in the prevalence of CSP across repeated hospitalizations.A hospital-based, retrospective cohort study was conducted at an academic hospital. Patient-reported pain intensity was assessed and recorded in a nursing information system. We examined the differences in the prevalence of worst pain intensity (WPI) and last evaluated pain intensity (LPI) of ≥4 or ≥7 points among cancer inpatients from the 1st to the 18th hospitalization. Linear mixed models were used to determine the significant difference in the WPI and LPI (≥4 or ≥7 points) at each hospitalization.We examined 88,133 pain scores from the 1st to the 18th hospitalization among cancer patients. The prevalence of the 4 CSP types showed a trend toward a reduction from the 1st to the 18th hospitalization. There was a robust reduction in the CSP prevalence from the 1st to the 5th hospitalization, except in the case of LPI ≥ 7 points. The prevalence of a WPI ≥ 4 points was significantly higher (0.240-fold increase) during the 1st hospitalization than during the 5th hospitalization. For the 2nd, 3rd, and 4th hospitalizations, there was a significantly higher prevalence of a WPI ≥ 4 points compared with the 5th hospitalization. We also observed significant reductions in the prevalence of a WPI ≥ 7 points during the 1st to the 4th hospitalizations, an LPI ≥ 4 points during the 1st to the 3rd hospitalizations, and an LPI ≥ 7 points during the 1st to the 2nd hospitalization.Although the prevalence of the 4 CSP types decreased gradually, it is impossible to state the causative factors on the basis of this observational and descriptive study. The next step will examine the factors that determine the CSP prevalence among cancer patients. However, based on these positive findings, we can provide feedback to nurses, physicians, and pharmacists to empower them to be more committed to pain management.