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The Journal of Arthroplasty Jan 2022The opioid epidemic is a health crisis in the United States. Within orthopedic surgery, opioid misuse and incautious prescription remains a concern. In the last several...
BACKGROUND
The opioid epidemic is a health crisis in the United States. Within orthopedic surgery, opioid misuse and incautious prescription remains a concern. In the last several years, there has been a growing interest and public effort toward reducing opioid use in total joint arthroplasty (TJA) in response to the opioid epidemic in the United States. We aim to review opioid-limiting practices, policies, and legislations that are implemented at the state level and nationally that are relevant to TJA, as well as evaluate studies that measure the efficacy of these policies in the management of patients undergoing TJA.
METHODS
Two independent reviewers conducted a systematic review of national and state level opioid-limiting policies implemented in the United States and their effects on opioid prescription, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA).
RESULTS
We identified 3 national bills and 9 policies set forth by national organizations that imposed limits on opioid prescription. Opioid-reducing legislation was also identified in 24 states, with the majority specifying a 7-day limit on initial opioid prescription for acute pain management. Six research studies evaluating the impact of opioid-restricting policies on postoperative opioid prescription for TJA patients were found. Three studies assessed legislation at the state level while the others were institution-based guidelines. Overall, these studies demonstrated a significant decrease in mean morphine milligram equivalents of initial opioid prescription after implementing the policies.
CONCLUSION
Recent opioid-restricting legislation is effective in decreasing postoperative opioid prescriptions following TJA.
Topics: Analgesics, Opioid; Arthroplasty; Humans; Opioid-Related Disorders; Pain Management; Pain, Postoperative; Practice Patterns, Physicians'; Retrospective Studies; United States
PubMed: 34456092
DOI: 10.1016/j.arth.2021.07.013 -
JAMA Pediatrics Nov 2015Metformin hydrochloride use is increasing in children and adolescents. Previous meta-analyses have identified a large variability in the effects of metformin use on body... (Meta-Analysis)
Meta-Analysis Review
IMPORTANCE
Metformin hydrochloride use is increasing in children and adolescents. Previous meta-analyses have identified a large variability in the effects of metformin use on body mass index changes but have not considered height changes as a confounder, to our knowledge.
OBJECTIVE
To conduct a systematic review and meta-analysis of the effects of metformin use on height in children and adolescents.
DATA SOURCES
Computerized databases, including MEDLINE and EMBASE, were searched up to September 9, 2014, for terms related to metformin and childhood or adolescence.
STUDY SELECTION
Randomized clinical trials examining the effects of metformin use on height of participants younger than 19 years were considered eligible. Trials with cointerventions other than lifestyle changes were excluded.
DATA EXTRACTION AND SYNTHESIS
Height, weight, body mass index, age, sex, metformin dosage, and study duration were independently extracted by 2 reviewers. The weighted mean differences for changes in height, weight, and body mass index were compared between the metformin and control groups using random-effects models.
MAIN OUTCOME AND MEASURE
Height changes.
RESULTS
Ten studies were included, with a total of 562 participants, 330 (58.7%) of whom were female. The mean age within the studies ranged from 7.9 to 16.1 years, with a high variability in most studies. The duration of metformin interventions lasted from 3 to 48 months. Overall, height changes were not significantly different between the metformin and control groups. However, stratified analyses according to the cumulative metformin dose (in milligrams per day times the number of days of treatment) showed a greater increase in height with metformin use in the 5 studies providing the largest cumulative metformin doses (weighted mean difference, 1.0; 95% CI, 0.0 to 2.0 cm) but not in the 5 studies providing the lowest doses (weighted mean difference, -0.1; 95% CI, -0.7 to 1.0 cm) compared with the control group.
CONCLUSIONS AND RELEVANCE
Preliminary evidence suggests a dose-response relationship between metformin use and increases in height in children and adolescents compared with a control group. While an approximate 1-cm increase in height may appear small, it is likely underestimated given that many studies were of short duration and included older adolescents, potentially after epiphyseal growth plate closure.
Topics: Adolescent; Body Height; Body Mass Index; Body Weight; Child; Female; Humans; Hypoglycemic Agents; Male; Metformin; Randomized Controlled Trials as Topic
PubMed: 26414449
DOI: 10.1001/jamapediatrics.2015.2186 -
Colorectal Disease : the Official... Mar 2021Reducing postoperative opioid consumption is a key aim of enhanced recovery after colorectal surgery protocols. Potential solutions include anaesthetic techniques such... (Meta-Analysis)
Meta-Analysis Review
AIM
Reducing postoperative opioid consumption is a key aim of enhanced recovery after colorectal surgery protocols. Potential solutions include anaesthetic techniques such as local infiltration of anaesthetic agents or transversus abdominis plane (TAP) blocks. This study aimed to assess the efficacy of liposomal bupivacaine (LB) for colorectal resections, across a variety of anaesthetic techniques.
METHODS
PubMed, Scopus and Embase databases were searched for relevant studies assessing LB, administered by any anaesthetic technique. The primary outcome was postoperative morphine consumed (milligrams) and the secondary outcome was length of stay (days). A Bayesian network meta-analysis comparing LB versus non-LB analgesia was performed alongside meta-regression for different surgical approaches.
RESULTS
Twelve trials were included, with a total of 2512 patients. LB-based wound infiltration was most likely to reduce length of stay followed by TAP block with LB (sum under the cumulative ranking [SUCRA] 85.55 and 70.26, respectively). TAP block with LB was most likely to reduce morphine requirements, followed by wound infiltration with LB (SUCRA 83.94 and 75.73, respectively). Compared to standard analgesia, LB-based wound infiltration reduced morphine usage (mean difference 36.64 mg, 95% credibility interval 15.64-59.20) and length of stay (mean difference 1.79 days, 95% credibility interval 0.59-3.81). On meta-regression, the findings held for minimally invasive surgery only.
CONCLUSION
Although LB-based interventions were associated with reduced postoperative morphine requirements and length of stay in this network meta-analysis, the confidence in these estimates was graded as very low. Further well-executed trials are required before LB can be recommended as a first-line agent.
Topics: Abdominal Muscles; Analgesics, Opioid; Anesthetics, Local; Bayes Theorem; Bupivacaine; Colorectal Neoplasms; Humans; Length of Stay; Network Meta-Analysis; Pain, Postoperative
PubMed: 32966662
DOI: 10.1111/codi.15377 -
Orthopaedic Journal of Sports Medicine Jul 2022Postoperative treatment plans after orthopaedic procedures frequently include opioids for pain relief. (Review)
Review
BACKGROUND
Postoperative treatment plans after orthopaedic procedures frequently include opioids for pain relief.
PURPOSE
To evaluate opioid use in the early postoperative phase after arthroscopic rotator cuff repair (ARCR) to develop a procedure-specific understanding of the current role of opioids in pain management for this procedure.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
A PubMed search was used to identify eligible studies. Data on patient demographics, visual analog scale pain scores, and opioid use patterns (in morphine milligram equivalents [MMEs]) were collected and assessed. Cumulative MMEs were reported on postoperative day (POD) zero, and mean MMEs were reported on subsequent PODs (days 1, 2, 3, 5, 7, and 14). Metaregression, indices, and Cochran tests were used to evaluate study variation, heterogeneity, and variance.
RESULTS
A total of 1487 patients in 22 studies were included in the analysis. An estimated 51% (95% CI, 31%-70%) of patients with nerve blocks (NBs) were opioid-free through POD-0 versus 40% (95% CI, 1.2%-97%) of patients without NBs, which increased to 65% (95% CI, 55%-74%) versus 25% (95% CI, 1.7%-86%) by POD-1. Opioid requirements were highest in the first 72 hours after ARCR. NB use reduced opioid requirement on POD-0 compared with no NB use (15.8 vs 45.0 MMEs, respectively; < .001) but did not reduce requirements after that. In addition, NB use led to a statistically significant increase in opioid requirements on POD-7 (28.6 vs 9.5 MMEs, respectively; < .001). Using a model that assumes stable opioid requirements between our time points, weighted mean cumulative opioid consumption was 163 MMEs in the first week and 273 MMEs in the first 2 weeks (150 and 287 MMEs in patients with NB; 180 and 261 MMEs in patients without NB, respectively).
CONCLUSION
Opioid use is relatively common in the early postoperative period after ARCR. Pain scores and opioid requirements may spike on POD-1; however, patients should be educated and reassured that they will gradually decrease usage over the initial 2-week postoperative period.
PubMed: 35898204
DOI: 10.1177/23259671221112086 -
Journal of Drug Assessment 2018The objective of the study was to systematically investigate the outcomes of Liposomal Bupivacaine following major colorectal resections. We conducted a comprehensive...
The objective of the study was to systematically investigate the outcomes of Liposomal Bupivacaine following major colorectal resections. We conducted a comprehensive literature search of PubMed, Medline, Google scholar, Cochrane Central Registry and clinical trials.gov databases through May 2017 for studies published regarding liposomal bupivacaine. Studies were filtered based on relevance to perioperative analgesia in colorectal resections. Data comparing type of study, techniques of resection, mode of administration of liposomal bupivacaine, details of control group, outcomes were collected. A total of 1008 patients from seven studies were included in this systematic review and meta-analysis. The studies were mostly retrospective or prospective cohort studies with one randomized controlled trial (RCT). Meta-analysis showed that liposomal bupivacaine was associated with decreased length of stay, standard mean difference in days (SMD) - 0.34, (95% confidence intervals [CI] - 0.56, -0.13, = .001) and decreased IV opioid use (expressed as intravenous morphine equivalent in milligrams) in the first 48-72 h, SMD -0.49 (95% CI -0.69, -0.28, < .00001). Pain scores were also significantly low in patients who received liposomal bupivacaine, SMD -0.56 (95% CI -1.07, -0.06, = .03]. There was no significant difference in hospitalization costs between the two groups. Use of liposomal bupivacaine is associated with decreased IV opioid use, length of stay and lower pain scores. However, our data needs to be interpreted cautiously given the relative paucity of randomized controlled trials.
PubMed: 29988796
DOI: 10.1080/21556660.2018.1487445 -
Journal of Diabetes and Metabolic... Jun 2024Prior research has yielded mixed results regarding the impact of acarbose intake on glycemic markers. To provide a more comprehensive analysis, a systematic review and... (Review)
Review
PURPOSE
Prior research has yielded mixed results regarding the impact of acarbose intake on glycemic markers. To provide a more comprehensive analysis, a systematic review and meta-analysis was performed to compile data from various randomized controlled trials (RCTs) examining the effects of acarbose intake on fasting blood sugar (FBS), insulin, hemoglobin A1C (HbA1c), and homeostasis model assessment of insulin resistance (HOMA-IR) in adults.
METHODS
To identify relevant literature up to April 2023, a comprehensive search was conducted on various scholarly databases, including PubMed, Web of Science, and Scopus databases. The effect size of the studies was evaluated using a random-effects model to calculate the weighted mean differences (WMD) and 95% confidence intervals (CI). Heterogeneity between studies was assessed using Cochran's Q test and I.
RESULTS
This systematic review and meta-analysis included a total of 101 RCTs with a total of 107 effect sizes. The effect sizes for FBS in milligrams per deciliter (mg/dl), insulin in picomoles per liter (pmol/l), hemoglobin A1C (HbA1c) in percentage (%), and homeostasis model assessment of insulin resistance (HOMA-IR) were 92, 46, 80, and 22, respectively. The pooled analysis indicated that acarbose intake resulted in significant decreases in FBS ( = 0.018), insulin ( < 0.001), HbA1c ( < 0.001), and HOMA-IR ( < 0.001).
CONCLUSION
The findings of this systematic review and meta-analysis suggest that acarbose intake can potentially lead to significant improvements in glycemic parameters by decreasing the levels of FBS, HbA1c, and insulin. However, larger and more rigorously designed studies are still needed to further evaluate and strengthen this association.
PubMed: 38932875
DOI: 10.1007/s40200-023-01336-9 -
Pain Medicine (Malden, Mass.) Sep 2023The purpose of this study was to investigate the analgesic effects of duloxetine, specifically on postoperative pain, opioid consumption, and related side effects... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
The purpose of this study was to investigate the analgesic effects of duloxetine, specifically on postoperative pain, opioid consumption, and related side effects following total hip or knee arthroplasty.
METHODS
In this systematic review and meta-analysis, Medline, Cochrane, EMBASE, Scopus, and Web of Science were searched until November 2022 for studies which compared duloxetine with placebo when added to routine pain management protocols. Individual study risk of bias assessment was conducted based on Cochrane risk of bias tool 2. Random effect model meta-analysis was done on mean differences, to evaluate the outcomes.
RESULTS
Nine randomized clinical trials (RCT) were included in the final analysis, totaling 806 patients. Duloxetine reduced opioid consumption (oral morphine milligram equivalents) on postoperative days (POD) 2 (mean difference (MD): -14.35, P = .02), POD 3 (MD: -13.6, P < .001), POD 7 (MD: -7.81, P < .001), and POD 14 (MD: -12.72, P < .001). Duloxetine decreased pain with activity on POD 1, 3, 7, 14, 90 (All P < .05), and pain at rest on POD 2, 3, 7, 14, and 90 (all P < .05). There was no significant difference in the prevalence of the side effects, except for increased risk of somnolence/drowsiness (risk ratio: 1.87, P = .007).
CONCLUSION
Current evidence shows low to moderate opioid sparing effects of perioperative duloxetine and a statistically but not clinically significant reduction in pain scores. Patients treated with duloxetine had an increased risk for somnolence and drowsiness.
Topics: Humans; Analgesics, Opioid; Duloxetine Hydrochloride; Arthroplasty, Replacement, Hip; Sleepiness; Randomized Controlled Trials as Topic; Pain, Postoperative
PubMed: 37027215
DOI: 10.1093/pm/pnad045 -
Disability and Rehabilitation Jul 2018To synthesise and critically appraise randomised controlled trials examining the effect of symptom-controlling medication on gait outcomes in people with multiple... (Review)
Review
PURPOSE
To synthesise and critically appraise randomised controlled trials examining the effect of symptom-controlling medication on gait outcomes in people with multiple sclerosis (MS).
METHOD
The literature search examined five databases (Medline, Embase, AMED, Cochrane (CENTRAL), and CINAHL until the end of November 2016. Eligible studies included medication to address symptoms associated with MS and an objective gait outcome measure. Two reviewers independently extracted data and assessed study quality using structured data extraction forms and the PEDro scale.
RESULTS
From 249 papers identified, 13 papers met inclusion criteria, examining three medications. Fampridine was found to significantly increase gait speed, but only in those people who responded to medication, which was less than half (pooled mean: 39%). Ten milligrams of fampridine twice daily significantly improves gait endurance. No definitive conclusions can be made about the efficacy of cannabinoid medication due to conflicting results across three studies. A single study of baclofen did not provide evidence to support the use of this medication to improve gait.
CONCLUSIONS
Limited evidence is available to guide gait symptom control for people with MS. Further research that includes three-dimensional gait analysis, patient perceived measures of gait dysfunction and explores combined efficacy of other modalities on gait is needed. Implications for Rehabilitation Gait disturbance is a common and disabling symptom of multiple sclerosis. Fampridine and cannabis medication may increase gait speed, baclofen does not. Fampridine can be used to improve gait endurance. Future research should include both quantitative and qualitative outcome measures of gait and investigate the combined efficacy of pharmacological and non-pharmacological interventions to assist clinicians to maximise gait improvements.
Topics: 4-Aminopyridine; Baclofen; Cannabinoids; Gait Disorders, Neurologic; Humans; Multiple Sclerosis; Muscle Relaxants, Central; Potassium Channel Blockers
PubMed: 28376639
DOI: 10.1080/09638288.2017.1309581 -
Environmental Health Perspectives Oct 2014In contrast to current methods of expert-based narrative review, the Navigation Guide is a systematic and transparent method for synthesizing environmental health... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
In contrast to current methods of expert-based narrative review, the Navigation Guide is a systematic and transparent method for synthesizing environmental health research from multiple evidence streams. The Navigation Guide was developed to effectively and efficiently translate the available scientific evidence into timely prevention-oriented action.
OBJECTIVES
We applied the Navigation Guide systematic review method to answer the question "Does fetal developmental exposure to perfluorooctanoic acid (PFOA) or its salts affect fetal growth in animals ?" and to rate the strength of the experimental animal evidence.
METHODS
We conducted a comprehensive search of the literature, applied prespecified criteria to the search results to identify relevant studies, extracted data from studies, obtained additional information from study authors, conducted meta-analyses, and rated the overall quality and strength of the evidence.
RESULTS
Twenty-one studies met the inclusion criteria. From the meta-analysis of eight mouse gavage data sets, we estimated that exposure of pregnant mice to increasing concentrations of PFOA was associated with a change in mean pup birth weight of -0.023 g (95% CI: -0.029, -0.016) per 1-unit increase in dose (milligrams per kilogram body weight per day). The evidence, consisting of 15 mammalian and 6 nonmammalian studies, was rated as "moderate" and "low" quality, respectively.
CONCLUSION
Based on this first application of the Navigation Guide methodology, we found sufficient evidence that fetal developmental exposure to PFOA reduces fetal growth in animals.
Topics: Animals; Birth Weight; Caprylates; Environmental Health; Environmental Pollutants; Evidence-Based Medicine; Female; Fetal Development; Fluorocarbons; Mice; Pregnancy
PubMed: 24968374
DOI: 10.1289/ehp.1307177 -
The Cochrane Database of Systematic... Dec 2018Endometrial carcinoma is the most common gynaecologic malignancy in the world and develops through preliminary stages of endometrial hyperplasia....
BACKGROUND
Endometrial carcinoma is the most common gynaecologic malignancy in the world and develops through preliminary stages of endometrial hyperplasia. Atypical endometrial hyperplasia suggests a significant pre-malignant state with frank progression to endometrial carcinoma, and tends to occur at a young age. Oral progestins have been used as conservative treatment in young women with atypical endometrial hyperplasia, but they are associated with poor tolerability and side effects that may limit their overall efficacy. So it has become increasingly important and necessary to find a safe and effective fertility-sparing treatment with better tolerability and fewer side effects than the options currently available. The levonorgestrel-releasing intrauterine system (LNG-IUS) has been used to provide endometrial protection in women with breast cancer who are on adjuvant tamoxifen. The antiproliferative function of levonorgestrel is thought to reduce the risk of endometrial hyperplasia.
OBJECTIVES
To determine the efficacy and safety of oral and intrauterine progestogens in treating atypical endometrial hyperplasia.
SEARCH METHODS
In July 2018 we searched CENTRAL; MEDLINE; Embase; CINAHL, PsycINFO and the China National Knowledge Infrastructure for relevant trials. Cochrane Gynaecology and Fertility (CGF) Specialised Register and Embase were searched in November 2018. We attempted to identify trials from references in published studies. We also searched for ongoing trials in five major clinical trials registries.
SELECTION CRITERIA
Randomised controlled trials (RCTs) of oral and intrauterine progestogens (LNG-IUS) versus each other or placebo in women with a confirmed histological diagnosis of simple or complex endometrial hyperplasia with atypia.
DATA COLLECTION AND ANALYSIS
Two review authors assessed trial eligibility and risk of bias and extracted the data. The primary outcomes of the review were rate of regression and adverse effects. Secondary outcomes included rate of recurrence and proportion of women undergoing hysterectomy. We have used GRADE methodology to judge the quality of the evidence.
MAIN RESULTS
We included one RCT (153 women) comparing the LNG-IUS administering 20 micrograms (μu) levonorgestrel per day versus 10 milligrams of continuous or cyclical oral medroxyprogesterone (MPA) for treating any type of endometrial hyperplasia. Only 19 women in this study were histologically confirmed with atypical complex hyperplasia before treatment. The evidence was of low or very low quality. The included study was at low risk of bias, but the quality of the evidence was very seriously limited by imprecision and indirectness. We did not find any RCTS comparing the LNG-IUS or oral progestogens versus placebo in women with atypical endometrial hyperplasia.Among the 19 women with atypical complex hyperplasia, after six months of treatment there was insufficient evidence to determine whether there was a difference in regression rates between the LNG-IUS group and the progesterone group (odds ratio (OR) 2.76, 95% confidence interval (CI) 0.26 to 29.73; 1 RCT subgroup, 19 women, very low-quality evidence). The rate of regression was 100% in the LNG-IUS group (n = 6/6) and 77% in the progesterone group (n = 10/13).Among the total study population (N = 153), over the six months' treatment the main adverse effects were nausea and vaginal bleeding. There was no evidence of a difference between the groups in rates of nausea (OR 0.58, 95% CI 0.28 to 1.18; 1 RCT, 153 women, very low-quality evidence). Vaginal bleeding was more common in the LNG-IUS group (OR 2.89, 95% CI 1.11 to 7.52; 1 RCT, 153 women, low-quality evidence). Except for nausea and vaginal bleeding, no other adverse effects were reported.
AUTHORS' CONCLUSIONS
We did not find any RCTS of women with atypical endometrial hyperplasia, and our findings derive from a subgroup of 19 women in a larger RCT. All six women who used the LNG-IUS system achieved regression of atypical hyperplasia, but there was insufficient evidence to draw any conclusions regarding the relative efficacy of LNG-IUS versus oral progesterone (MPA) in this group of women. When assessed in a population of women with any type of endometrial hyperplasia, there was no clear evidence of a difference between LNG-IUS and oral progesterone (MPA) in risk of nausea, but vaginal bleeding was more likely to occur in women using the LNG-IUS. Larger studies are necessary to assess the efficacy and safety of oral and intrauterine progestogens in treating atypical endometrial hyperplasia.
Topics: Administration, Oral; Endometrial Hyperplasia; Female; Humans; Intrauterine Devices, Medicated; Levonorgestrel; Medroxyprogesterone; Randomized Controlled Trials as Topic
PubMed: 30521671
DOI: 10.1002/14651858.CD009458.pub3