-
PloS One 2024Opioids administered in hospital during the immediate postoperative period are likely to influence post-surgical outcomes, but inpatient prescribing during the admission...
BACKGROUND
Opioids administered in hospital during the immediate postoperative period are likely to influence post-surgical outcomes, but inpatient prescribing during the admission is challenging to access. Modified-release(MR) preparations have been especially associated with harm, whilst certain populations such as the elderly or those with renal impairment may be vulnerable to complications. This study aimed to assess postoperative opioid utilisation patterns during hospital stay for people admitted for major/orthopaedic surgery.
METHODS
Patients admitted to a teaching hospital in the North-West of England between 2010-2021 for major/orthopaedic surgery with an admission for ≥1 day were included. We examined opioid administrations in the first seven days post-surgery in hospital, and "first 48 hours" were defined as the initial period. Proportions of MR opioids, initial immediate-release(IR) oxycodone and initial morphine milligram equivalents (MME)/day were calculated and summarised by calendar year. We also assessed the proportion of patients prescribed an opioid at discharge.
RESULTS
Among patients admitted for major/orthopaedic surgery, 71.1% of patients administered opioids during their hospitalisation. In total 50,496 patients with 60,167 hospital admissions were evaluated. Between 2010-2017 MR opioids increased from 8.7% to 16.1% and dropped to 11.6% in 2021. Initial use of oxycodone IR among younger patients (≤70 years) rose from 8.3% to 25.5% (2010-2017) and dropped to 17.2% in 2021. The proportion of patients on ≥50MME/day ranged from 13% (2021) to 22.9% (2010). Of the patients administered an opioid in hospital, 26,920 (53.3%) patients were discharged on an opioid.
CONCLUSIONS
In patients hospitalised with major/orthopaedic surgery, 4 in 6 patients were administered an opioid. We observed a high frequency of administered MR opioids in adult patients and initial oxycodone IR in the ≤70 age group. Patients prescribed with ≥50MME/day ranged between 13-22.9%. This is the first published study evaluating UK inpatient opioid use, which highlights opportunities for improving safer prescribing in line with latest recommendations.
Topics: Humans; Analgesics, Opioid; Male; Female; Middle Aged; Aged; Retrospective Studies; Pain, Postoperative; Orthopedic Procedures; Adult; Electronic Prescribing; Inpatients; England; Hospitalization; Aged, 80 and over; Oxycodone; Adolescent
PubMed: 38917135
DOI: 10.1371/journal.pone.0305531 -
BioRxiv : the Preprint Server For... Jun 2024La-related protein 6 regulates the highly organized biosynthesis of type I procollagen polypeptides and affects proper assembly of procollagen peptides into...
La-related protein 6 regulates the highly organized biosynthesis of type I procollagen polypeptides and affects proper assembly of procollagen peptides into heterotrimers of type I procollagen. LARP6-mediated regulation of collagen biosynthesis is mediated through interaction with the 5' stem loop motif found in type I and III collagen mRNA. Recent studies highlight the involvement of HsLARP6 in fibroproliferative diseases and its potential as a target for therapeutic intervention. The intrinsic instability of the La domain of HsLARP6 hampers studies probing the molecular basis of biologically- and disease-relevant structure-function relationship, particularly when high concentrations are required. This work provides detailed procedures to produce milligram amounts of RNase-free and functional La domain of HsLARP6. Furthermore, we investigated the effect of the construct length as well as RNA binding on protein stability. N- and C-terminal extensions greatly impact stability based on interactions with the core domain and modulation of the pI. When in complex with its cognate 5'SL RNA, the La domain shows unprecedented stability compared to the aggregation-prone unbound state. The protein-RNA complex remains stable for at least 50x longer than the unbound state, under identical conditions, likely due to a global change in conformational plasticity upon RNA binding. These results provide a foundation for further studies of the molecular recognition of 5'SL by HsLARP6 as well as a platform for refining potential antifibrotic therapeutics.
PubMed: 38915490
DOI: 10.1101/2024.06.11.598414 -
Journal of Plastic, Reconstructive &... Jun 2024Protocols surrounding opioid reduction have become commonplace in plastic surgery to improve peri-operative outcomes. Within such protocols, opioid requirement is a... (Review)
Review
INTRODUCTION
Protocols surrounding opioid reduction have become commonplace in plastic surgery to improve peri-operative outcomes. Within such protocols, opioid requirement is a frequently analyzed outcome. Though often examined, there is no literature standard conversion for morphine milligram equivalents (MME) at present, leading to questionable external validity. We hypothesized significant heterogeneity in MME reporting would exist within plastic surgery literature.
METHODS
Following the PRISMA guidelines, the authors conducted a systematic review of 16 journals. Clinical studies focused on opioid reduction within plastic surgery were identified. Primary outcomes included reporting of morphine equivalents (ME) delivery (IV/oral), operative ME, inpatient ME, outpatient ME, timeline, and method of calculation.
RESULTS
Among the 101 studies analyzed, 73% reported opioid requirements in the form of ME. Among those that used ME, 3% reported IV ME, 41% reported oral, 32% reported both, and 25% gave no indication of either. Operative ME were reported in 19% of studies. Furthermore, 54% of studies reported inpatient ME whereas 32% of studies reported outpatient ME. Only 19% reported the number of days opioids were consumed postoperatively. Moreover, 27% of the studies reported the actual method of ME conversion, with 17 unique methods described. Only 8 studies (8%) reported using the Center for Disease Control and Prevention guidelines for ME conversion.
CONCLUSION
There is significant variability among the reported ME conversion methodology within plastic surgery literature. Highlighting these discrepancies is an essential step in creating and implementing a single, standard method to mitigate opioid morbidity in plastic surgery and to optimize enhanced recovery protocols.
PubMed: 38909598
DOI: 10.1016/j.bjps.2024.06.001 -
Analytical Sciences : the International... Jun 2024Organotin compounds (OTC), mainly tributyltin (TBT), have been used since the 1970s as biocides in the composition of antifouling paints. Due to its physical-chemical...
Organotin compounds (OTC), mainly tributyltin (TBT), have been used since the 1970s as biocides in the composition of antifouling paints. Due to its physical-chemical characteristics, TBT has high toxicity to the marine environment affecting non-target organisms. The present study aims to develop a method of direct visual identification of TBT in antifouling paints using the cyclopalladate complex, 4- (2-thiazolylazo) resorcinol (TAR-Pd), synthesized in our laboratory. Tests were performed in blank and in the paint matrix with the following OTC: TBT-O; TBT-Cl; TPT-Cl; DBT-Cl (tributyltin oxide, tributyltin chloride, triphenyltin chloride, dibutyltin chloride), in addition to the SnCl and SnCl compounds (tin IV chloride and tin II chloride), all at a concentration of approximately 20 g/ kg of dry paint). The test was performed by applying paint samples to test bodies and scraping a few tens of milligrams of the dry paint film. The scraped paint samples were submitted to the test, showing a different staining reaction for the TBT-Cl and SnCl samples concerning blank and other samples (TBT-O, TPT, DBT-Cl, and SnCl). Solution tests were performed to characterize reaction products by spectroscopy in the visible band. The method developed has potential for application in real samples, being selective for TBT-Cl and SnCl in an acid medium, obtaining a limit of detection, in the range of 1-10 mg/kg dry paint.
PubMed: 38907795
DOI: 10.1007/s44211-024-00620-9 -
Journal of Back and Musculoskeletal... Jun 2024Sustained acoustic medicine (SAM) is a noninvasive long-term treatment that provides essential mechanical and thermal stimulus to accelerate soft tissue healing,...
BACKGROUND
Sustained acoustic medicine (SAM) is a noninvasive long-term treatment that provides essential mechanical and thermal stimulus to accelerate soft tissue healing, alleviate pain, and improve physical activity. SAM increases localized deep tissue temperature, blood flow, cellular proliferation, migration, and nutrition exchange, resulting in reduced inflammation and an increased rate of tissue regeneration.
OBJECTIVE
To assess the efficacy of SAM treatment of discogenic back pain in the lower spinal column to reduce pain, improve quality of life, and lower pharmacotherapy use.
METHODS
Sixty-five subjects with chronic low back pain were randomly assigned to SAM (N= 33) or placebo (N= 32) groups. Subjects self-applied SAM device bilaterality on the lower lumbar region for 4 hours daily for 8 weeks and completed daily pain diaries before, during, and after treatment. Subjects recorded pain reduction using a numeric rating scale (NRS), medication use, and physical activity using the Global Rating of Change (GROC) and Oswestry Disability Index (ODI).
RESULTS
SAM treatment significantly reduced chronic lower back pain from baseline relative to placebo treatment (p< 0.0001). SAM treated subjects reported significantly lower back pain at 4 weeks, with the highest pain reduction (-2.58 points NRS, p< 0.0001) reported at 8 weeks. Similar trends were observed in improved physical activity (3.48 GROC, p< 0.0001, 69-88% ODI, p< 0.0001) and 22.5% (15.2 morphine milligram equivalent) reduction in the use of opioid medication from baseline to 8 weeks.
CONCLUSION
Daily, home-use SAM treatment significantly improves the clinical symptoms of chronic lower back pain, improves physical mobility, and reduces daily medication use. SAM treatment is well-tolerated by patients and may be considered a safe, non-invasive treatment option for chronic discogenic, lower back pain.
PubMed: 38905030
DOI: 10.3233/BMR-230402 -
The Journal of Arthroplasty Jun 2024Successful revision hip arthroplasty (rTHA) requires major resource allocation and a surgical team adept at managing these complex cases. The purpose of this study was...
INTRODUCTION
Successful revision hip arthroplasty (rTHA) requires major resource allocation and a surgical team adept at managing these complex cases. The purpose of this study was to compare the results of rTHA performed by fellowship-trained and non-fellowship-trained surgeons.
METHODS
A national administrative database was utilized to identify 5,880 patients who underwent aseptic rTHA and 1,622 patients who underwent head-liner exchange for infection by fellowship- and non-fellowship-trained surgeons from 2010 to 2020 with a 5-year follow-up. Postoperative opioid and anticoagulant prescriptions were compared among surgeons. Patients treated by fellowship- and non-fellowship-trained surgeons had propensity scores matched based on age, sex, comorbidity index, and diagnosis. The five-year surgical complications were compared using descriptive statistics. Multivariable analysis was performed to determine the odds of failure following head-liner exchange when performed by a fellowship-trained versus non-fellowship-trained surgeon.
RESULTS
Aseptic rTHA patients treated by fellowship-trained surgeons received fewer opioids (132 versus 165 milligram morphine equivalents per patient) and non-aspirin anticoagulants (21.4 versus 32.0%, P < 0.001). Fellowship-training was associated with lower dislocation rates (9.9 versus 14.2%, P = 0.011), fewer postoperative infections, and fewer periprosthetic fractures and re-revisions (15.2 versus 21.3%, P < 0.001). Head-liner exchange for infection performed by fellowship-trained surgeons was associated with lower odds of failure (31.2 versus 45.7%, odds ratio (OR) 0.76, 95% confidence interval (CI) 0.62 to 0.91, P < 0.001).
CONCLUSIONS
Revision THA performed by adult reconstruction fellowship-trained surgeons results in fewer re-revisions in aseptic cases and head-liner exchanges. Variations in resources, volumes, and perioperative protocols may account for some of the differences.
PubMed: 38901710
DOI: 10.1016/j.arth.2024.06.029 -
Urology Practice Jul 2024Gabapentin has been used in enhanced recovery after surgery (ERAS) pathways for pain control for patients undergoing ambulatory uro-oncologic surgery; however, it may...
INTRODUCTION
Gabapentin has been used in enhanced recovery after surgery (ERAS) pathways for pain control for patients undergoing ambulatory uro-oncologic surgery; however, it may cause undesirable side effects. We studied the causal association between gabapentin and rapidity of recovery and perioperative pain management after minimally invasive uro-oncologic surgery.
METHODS
We identified 2397 patients ≤ 65 years undergoing prostatectomies or nephrectomies between 2018 and 2022; 131 (5.5%) did not receive gabapentin. We tested the effect of gabapentin use on time of discharge and perioperative opioid consumption, respectively, using multivariable linear regression adjusting for potential confounders including age, gender, BMI, American Society of Anesthesiologists score, and surgery type.
RESULTS
On adjusted analysis, we found no evidence of a difference in discharge time among those who did vs did not receive gabapentin (adjusted difference 0.07 hours shorter on gabapentin; 95% CI -0.17, 0.31; = .6). There was no evidence of a difference in intraoperative opioid consumption by gabapentin receipt (adjusted difference -1.5 morphine milligram equivalents; 95% CI -4.2, 1.1; = .3) or probability of being in the top quartile of postoperative opioid consumption within 24 hours (adjusted difference 4.2%; 95% CI -4.8%, 13%; = .4). We saw no important differences in confounders by gabapentin receipt suggesting causal conclusions are justified.
CONCLUSIONS
Our confidence intervals did not include clinically meaningful benefits from gabapentin, when used with an ERAS protocol, in terms of length of stay or perioperative opioid use. These results support the omission of gabapentin from ERAS protocols for minimally invasive uro-oncologic surgeries.
Topics: Humans; Gabapentin; Male; Middle Aged; Female; Pain, Postoperative; Analgesics; Ambulatory Surgical Procedures; Prostatectomy; Minimally Invasive Surgical Procedures; Nephrectomy; Retrospective Studies; Analgesics, Opioid; Time Factors
PubMed: 38899668
DOI: 10.1097/UPJ.0000000000000570 -
Preventive Medicine Jun 2024Understanding the clinical and demographic profile of patients on gabapentinoids can highlight areas of prescribing disparities, inform clinical practice, and guide...
OBJECTIVE
Understanding the clinical and demographic profile of patients on gabapentinoids can highlight areas of prescribing disparities, inform clinical practice, and guide future research to optimize effectiveness and safety of gabapentinoids for pain management. We used a national sample of Medicare beneficiaries to examine trends, patterns, and patient-level predictors of gabapentinoid use among long-term opioid users.
METHODS
Using a national Medicare sample between 2014 and 2020, we examined factors associated with gabapentinoid use among long-term opioid users. We included Medicare eligible long-term opioid users with no prior gabapentinoid use. The primary outcome was gabapentinoid use after the long-term opioid use episode. Logistic regression was used to test the association with gabapentinoid use for year, age, sex, race/ethnicity, region, Medicare entitlement, low-income status, frailty, pain locations, anxiety, depression, opioid use disorder, and opioid morphine milligrams equivalent.
RESULTS
Gabapentinoid use among long-term opioid users increased from 12.6% in 2014 to 16.8% in 2019 (p < .0001). Factors associated with increased gabapentinoid use were Hispanic ethnicity, back pain, nerve pain, and moderate or high opioid usage. Factors associated with decreased gabapentinoid use were older age and Medicare entitlement due to old age.
CONCLUSIONS
Variation of gabapentinoid use by socio-demographics and insurance status indicates opportunities to improve pain management and a need for shared therapeutic decision making informed by discussion between pain patients and providers regarding safety and effectiveness of pain therapies. Our findings underscore the need for future research into the comparative effectiveness and safety of gabapentinoids for non-cancer chronic pain in various subpopulations.
PubMed: 38897356
DOI: 10.1016/j.ypmed.2024.108046 -
The Journal of Pediatrics Jun 2024To determine whether an enteral, clonidine-based sedation strategy (CLON) during therapeutic hypothermia (TH) for hypoxic-ischemic encephalopathy (HIE) would decrease...
OBJECTIVE
To determine whether an enteral, clonidine-based sedation strategy (CLON) during therapeutic hypothermia (TH) for hypoxic-ischemic encephalopathy (HIE) would decrease opiate use, while maintaining similar short-term safety and efficacy profiles to a morphine-based strategy (MOR).
STUDY DESIGN
This was a single-center, observational study conducted at a level IV neonatal intensive care unit from January 1, 2017, to October 1, 2021. From April 13, 2020, to August 13, 2020, MOR was transitioning to CLON. Thus, patients receiving TH for HIE were grouped to MOR (before April 13, 2020) and CLON (after August 13, 2020). We calculated the total and rescue morphine milligram equivalent (MME)/ kg (primary outcome) and frequency of hemodynamic changes (secondary outcome) for both groups.
RESULTS
MOR and CLON groups (74 and 25 neonates, respectively) had similar baseline characteristics and need for rescue sedative intravenous infusion (21.6% MOR and 20% CLON). Both, MME/ kg and need for rescue opiates (combined bolus and infusions) were higher in MOR than CLON (p < 0.001). As days in TH advanced, a lower percentage of CLON patients needed rescue opiates (92% on day 1 to 68% on day 3). MOR patients received a higher cumulative dose of dopamine and more frequently required a second inotrope and hydrocortisone for hypotension. MOR had a lower respiratory rate during TH (p=0.01 vs. CLON).
CONCLUSIONS
Our CLON protocol is non-inferior to MOR, maintaining perceived effectiveness and hemodynamic safety, with an apparently reduced need for opiates and inotropes.
PubMed: 38889855
DOI: 10.1016/j.jpeds.2024.114158 -
JBJS Reviews Jun 2024The effectiveness of tranexamic acid (TXA) as an antifibrinolytic agent in total shoulder arthroplasty (TSA) is well documented; however, there remains considerable... (Review)
Review
BACKGROUND
The effectiveness of tranexamic acid (TXA) as an antifibrinolytic agent in total shoulder arthroplasty (TSA) is well documented; however, there remains considerable practice variability concerning the optimal route of administration and dosing protocols concerning the medication's use. Our aim was to conduct a scoping review of the literature regarding the efficacy of various methods of TXA administration in TSA and to identify knowledge gaps that may be addressed.
METHODS
A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. The PubMed and MEDLINE electronic databases were searched to identify all articles published before March 2023 investigating the administration of TXA in TSA. Randomized controlled trials and cohort studies were included, and data were extracted to capture information regarding intervention details and related outcomes such as blood loss, transfusion needs, and complication rates.
RESULTS
A total of 15 studies were included in this review. All selected studies used either intravenous (IV) or topical TXA, with 1 study also including a combined approach of both topical and IV TXA. Of the studies that used an IV approach, the most commonly reported favorable outcomes were a reduction in blood volume loss, reduction in hemoglobin or hematocrit change, and decreased drain output. Dosing varied significantly between all identified studies because some used a standard dosing amount in grams or milligrams for all treatment group participants, whereas others used weight-based dosing amounts. All studies that used a weight-based dosing regimen as well as studies using a standard dosing amount between 1,000 and 5,000 mg reported favorable outcomes for postoperative blood loss.
CONCLUSION
Both IV and topical TXA clearly demonstrate favorable perioperative hematologic profiles in TSA. Although both approaches have demonstrated a successful association with decreased blood loss and transfusion requirements, there is no definitive benefit to choosing one over the other. Furthermore, the use of oral TXA either in combination or isolation warrants further study in TSA because of its comparable efficacy profiles and significantly lower associated costs of application.
Topics: Tranexamic Acid; Humans; Arthroplasty, Replacement, Shoulder; Antifibrinolytic Agents; Blood Loss, Surgical
PubMed: 38889236
DOI: 10.2106/JBJS.RVW.24.00035