Impact of modified-release opioid use on clinical outcomes following total hip and knee arthroplasty: a propensity score-matched cohort study

Modified-release opioids are often prescribed for the management of moderate to severe acute pain following total hip and knee arthroplasty, despite recommendations against their use due to increasing concerns regarding harm. The primary objective of this multicentre study was to examine the impact of modified-release opioid use on the incidence of opioid-related adverse events compared with immediate-release opioid use, among adult inpatients following total hip or knee arthroplasty. Data for total hip and knee arthroplasty inpatients receiving an opioid analgesic for postoperative analgesia during hospitalisation were collected from electronic medical records of three tertiary metropolitan hospitals in Australia. The primary outcome was the incidence of opioid-related adverse events during hospital admission. Patients who received modified with or without immediate-release opioids were matched to those receiving immediate-release opioids only (1:1) using nearest neighbour propensity score matching with patient and clinical characteristics as covariates. This included total opioid dose received. In the matched cohorts, patients given modified-release opioids (n = 347) experienced a higher incidence of opioid-related adverse events overall, compared with those given immediate-release opioids only (20.5%, 71/347 vs. 12.7%, 44/347; difference in proportions 7.8% [95%CI 2.3–13.3%]). Modified-release opioid use was associated with an increased risk of harm when used for acute pain during hospitalisation after total hip or knee arthroplasty.     

Patellofemoral joint arthroplasty: patient selection,surgical technique and outcomes

Isolated patellofemoral arthritis is an increasingly recognized entity, and is usually associated with previous patellofemoral dysplasia or instability. Patellofemoral arthroplasty (PFA) has evolved significantly in recent years, both in terms of implant design and importantly in the understanding of appropriate patient selection. This review outlines the indications and investigations for PFA, provides a brief history of the development of contemporary implants, and presents the clinical outcomes for the prostheses most commonly used in the UK. In addition, it provides a detailed surgical technique for implantation of an onlay implant, with tips on how to optimize patellofemoral biomechanics and thus achieve a consistently good outcome.     

Systematic review of enhanced recovery after gastro-oesophageal cancer surgery

Introduction

Fast track methodology or enhanced recovery schemes have gained increasing popularity in perioperative care. While evidence is strong for colorectal surgery, its importance in gastric and oesophageal surgery has yet to be established. This article reviews the evidence of enhanced recovery schemes on outcome for this type of surgery.

Methods

A systematic literature search was conducted up to March 2014. Studies were retrieved and analysed using predetermined criteria.

Results

From 34 articles reviewed, 18 eligible studies were identified: 7 on gastric and 11 on oesophageal resection. Three randomised controlled trials, five case-controlled studies and ten case series were identified. The reported protocols included changes to each stage of the patient journey from pre to postoperative care. The specific focus following oesophageal resections was on early mobilisation, a reduction in intensive care unit stay, early drain removal and early (or no) contrast swallow studies. Following gastric resections, the emphasis was on reducing epidural anaesthesia along with re-establishing oral intake in the first three postoperative days and early removal of nasogastric tubes.In the papers reviewed, mortality rates following fast track surgery were 0.8% (9/1,075) for oesophageal resection and 0% (0/329) for gastric resection. The reported morbidity rate was 16.5% (54/329) following gastric resection and 38.6% (396/1,075) following oesophageal resection. Length of stay was reduced in both groups compared with conventional recovery groups in comparative studies.

Conclusions

The evidence for enhanced recovery schemes following gastric and oesophageal resection is weak, with only three (low volume) published randomised controlled trials. However, the enhanced recovery approach appears safe and may be associated with a reduction in length of stay.     

P21 Design and operation of a human breath freshness panel

Objective  Practical treatment of halitosis requires tongue cleaning since volatile sulphur compounds (VSC) seems mainly to be from the tongue coating. From this point of view, mechanical tools such as tongue brushes or scrapers have been developed. However, approaches by chemical tongue cleaning have not been reported. Thus we developed tablets containing protease from kiwifruits, which could resolve tongue coating, and assessed the effects of the protease tablet to control tongue coating.
Methods  Crossover studies and double blind experiments were designed using volunteers with informed consent. The trial was done twice per volunteer, that is, they had a tablet with or without the addition of protease from kiwifruits (test and placebo) with intervening washout periods of at least 2 weeks. The degree of change in tongue coating was evaluated visually using a tongue coating score which consisted of an area component (0–3) and a thickness component (0–3). An image analyzer was also used to measure the changing in actual area of coating.
Results  The average value of the tongue coating scores after taking a test tablet (11.4 ± 5.2) was significantly smaller ( P  < 0.01) than before taking the tablet (18.8 ± 7.0). Image analyzer measurements also showed significant reduction ( P  < 0.01) of tongue coating by taking test tablet. On the other hand, a placebo tablet showed no significant effects in both analyses.
Conclusions  This study indicated that taking protease tablets could reduce tongue coating. We are planning further clinical trials that can show reduced VSC concentrations in mouth air with decreasing tongue coating.     

Demographic characteristics and prevalence of serologic markers among donors who use the confidential unit exclusion process: the Retrovirus Epidemiology Donor Study

BACKGROUND: Most blood centers utilize a confidential unit exclusion (CUE) process, intended to reduce the risk of transfusion-associated infectious diseases by allowing high-risk donors confidentially to exclude their blood from use for transfusion. The effectiveness of this method remains controversial. STUDY DESIGN AND METHODS: Confirmatory or supplemental test results for antibodies to human immunodeficiency virus, human T-lymphotropic virus type I, and hepatitis C virus, as well as hepatitis B surface antigen and syphilis and screening test results for antibodies to hepatitis B core (antigen) and alanine aminotransferase levels were obtained for approximately 1.8 million units donated during 1991 and 1992 at five blood centers within the United States. The prevalences of these infectious disease markers in units that the donors confidentially excluded (CUE+) and units that the donors did not exclude (CUE-) were calculated and examined within demographic subgroups. RESULTS: Units that were CUE+ were 8 to 41 times more likely to be seropositive for antibodies to human immunodeficiency virus and hepatitis C virus, hepatitis B surface antigen, and syphilis and three to four times more likely to react for antibody to hepatitis B core (antigen) or to have elevated alanine aminotransferase levels than units that were CUE- (p < 0.001). The positive predictive value of CUE (the percentage of CUE+ units that were confirmed seropositive for any marker) was 3.5 percent, and the sensitivity of CUE (the percentage of confirmed-seropositive units that were CUE+) was 2.3 percent. CONCLUSION: The current CUE process has low sensitivity and apparently low positive predictive value, and in many cases, it appeared that donors misunderstood it. Yet, CUE was not a “random process,” as CUE+ units were more likely to be seropositive for any infectious disease marker than CUE- units. This suggests that efforts to improve the CUE system may be warranted. As risk factors for transfusion-transmitted infection become more difficult to identify by history-based screening, however, such efforts may have limited effect.     

Plasmodium vivax: a cause of malnutrition in young children

We studied the aetiology of malnutrition in a cohort of 1511 children < 10 years old in Espiritu Santo, Vanuatu. Malnutrition was categorized using standard anthropometric criteria as: underweight [weight-for-age (WA) Z score < -2], wasting [weight-for-height (WH) Z < -2], or stunting [height-for-age (HA) Z < -2]. On multiple logistic regression analysis, the only factors significantly associated with wasting were age < 5 years [OR (95% CI) 1.8 (1.2-2.9), p = 0.01] and having suffered one or more episodes of clinical P. vivax malaria in the 6 months preceding nutritional assessment [OR 2.4 (1.3-4.4), p = 0.006]. The incidence of P. vivax infection was significantly higher during the 6 months preceding assessment in underweight vs. non-underweight children [incidence rate ratio (IRR) 2.6 (1.5-4.4), p < or = 0.0001). These groups had similar incidences of clinical P. falciparum infection during the same period [IRR 1.1 (0.57-2.1) p = 0.8] and of either species during the 6 months following assessment [IRR P. vivax 1.3 (0.9- 2.0) p = 0.2; IRR P. falciparum 1.3 (0.9-1.9) p = 0.2]. In these children, P. vivax malaria was a major predictor of acute malnutrition; P. falciparum was not. Wasting neither predisposed to nor protected against malaria of either species. Although P. vivax malaria is generally regarded as benign, it may produce considerable global mortality through malnutrition.      

氟尼辛葡甲铵的解热镇痛效应

目的:通过小白鼠醋酸扭体法、家兔蛋白胨致热法观察氟尼辛葡甲铵的解热、镇痛作用。方法:实验于2004-03/06在南京农业大学药理及毒理教研室实验室完成。①小鼠扭体实验:取清洁级KM小鼠80只按随机数字表法分为8组,每组10只:双氯芬酸钠16.25mg/kg组、安乃近32.5mg/kg组、氟尼辛葡甲铵10,5,2.5,1.25,0.625mg/kg组、生理盐水对照组。除双氯芬酸钠采取口服外,其余各组分别肌肉注射相应剂量的药品,生理盐水对照组给予等体积量的生理盐水。给药30min后立即给各组小鼠腹腔注射1.2%的冰醋酸溶液0.2mL/只,观察记录15min内出现扭体反应的次数。②蛋白胨致热实验:健康家兔36只,按随机数字表法分成6组,每组6只:空白对照组(生理盐水1mL/kg)、氟尼辛葡甲铵1,2,4mg/kg组、安乃近0.2g/kg组和氨基比林0.2g/kg组。实验前测定各组兔子的直肠体温。在家兔大腿肌肉注射40%蛋白胨,剂量为2mL/kg,然后按上述分组分别给予相应的药物。给药后8h内每小时各测体温1次。结果:80只小鼠和36只家兔均进入结果分析,中途无脱落。①与生理盐水对照组相比,安乃近32.5mg/kg组、氟尼辛葡甲铵10,5,2.5,1.25mg/kg组和双氯芬酸钠16.25mg/kg组对醋酸所致小鼠的扭体反应有显著的镇痛作用[(4.3±4.1),(10.4±5.7),(0.0±0.0),(0.9±1.9),(1.8±2.4),(3.2±4.2),(3.6±3.9)次/15min;P<0.05,P<0.01]。②与空白对照组比较,氟尼辛葡甲铵高、中剂量组及安乃近0.2g/kg组、氨基比林0.2g/kg组对由蛋白胨引起的家兔发热,在给药后4～8h均有显著的抑制作用(P<0.05),氟尼辛葡甲铵高、中剂量和安乃近0.2g/kg组在给药后6～8h作用极显著(P<0.01)。氟尼辛葡甲铵高剂量组在给药后5～7h显著强于安乃近0.2g/kg组(P<0.05),与氨基比林0.2g/kg组相比,差异极显著(P<0.01)。氟尼辛葡甲铵中剂量组作用稍逊于安乃近0.2g/kg组,差异不显著。氟尼辛葡甲铵低剂量组与氨基比林0.2g/kg组相当。结论:氟尼辛葡甲铵具有明显的解热、镇痛作用。