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.

Longitudinal relationships among exclusionary school discipline, adolescent substance use, and adult arrest: Public health implications of the school-to-prison pipeline

PURPOSE

Exclusionary school discipline is an initiating component of the school-to-prison pipeline that is racialized and may lead to short- and long-term negative substance use and criminal legal outcomes. However, these impacts, and racial disparities therein, have not been well explored empirically at the individual-level.

PROCEDURES

We analyzed data from the National Longitudinal Study of Adolescent to Adult Health (1995-2009). We fit survey-weighted multivariable logistic regression models to estimate reciprocal relationships between exclusionary discipline and adolescent substance use, between these factors and subsequent exposure to the adult criminal legal system, and whether these relationships were modified by race or ethnicity.

RESULTS

We found that students reporting substance use had 2.07 (95% CI 1.57, 2.75) times greater odds of reporting subsequent school discipline, and students exposed to school discipline had 1.59 (95% CI 1.26, 2.02) times greater odds of reporting subsequent substance use. Substance use and school discipline were associated with 2.69 (95% CI 2.25, 3.22) and 2.98 (95% CI 2.46, 3.60) times the odds of reporting subsequent adult criminal legal system exposure, respectively. There was little evidence of effect modification by race/ethnicity.

CONCLUSIONS

Findings indicate that school discipline and substance use are reciprocally associated and have direct implications for adolescent health and future criminal legal system exposure.

Risks and benefits of oral modified-release compared with oral immediate-release opioid use after surgery: a systematic review and meta-analysis

Prescription of modified-release opioids for acute postoperative pain is widespread despite evidence to show their use may be associated with an increased risk of adverse effects. This systematic review and meta-analysis aimed to examine the available evidence on the safety and efficacy of modified-release, compared with immediate-release, oral opioids for postoperative pain in adults. We searched five electronic databases from 1 January 2003 to 1 January 2023. Published randomised clinical trials and observational studies on adults who underwent surgery which compared those who received oral modified-release opioids postoperatively with those receiving oral immediate-release opioids were included. Two reviewers independently extracted data on the primary outcomes of safety (incidence of adverse events) and efficacy (pain intensity, analgesic and opioid use, and physical function) and secondary outcomes (length of hospital stay, hospital readmission, psychological function, costs, and quality of life) up to 12 months postoperatively. Of the eight articles included, five were randomised clinical trials and three were observational studies. The overall quality of evidence was low. Modified-release opioid use was associated with a higher incidence of adverse events (n = 645, odds ratio (95%CI) 2.76 (1.52-5.04)) and worse pain (n = 550, standardised mean difference (95%CI) 0.2 (0.04-0.37)) compared with immediate-release opioid use following surgery. Our narrative synthesis concluded that modified-release opioids showed no superiority over immediate-release opioids for analgesic consumption, length of hospital stay, hospital readmissions or physical function after surgery. One study showed that modified-release opioid use is associated with higher rates of persistent postoperative opioid use compared with immediate-release opioid use. None of the included studies reported on psychological function, costs or quality of life.

Implementation fidelity to a behavioral diabetes prevention intervention in two New York City safety net primary care practices

BACKGROUND

It is critical to assess implementation fidelity of evidence-based interventions and factors moderating fidelity, to understand the reasons for their success or failure. However, fidelity and fidelity moderators are seldom systematically reported. The study objective was to conduct a concurrent implementation fidelity evaluation and examine fidelity moderators of CHORD (Community Health Outreach to Reduce Diabetes), a pragmatic, cluster-randomized, controlled trial to test the impact of a Community Health Workers (CHW)-led health coaching intervention to prevent incident type 2 Diabetes Mellitus in New York (NY).

METHODS

We applied the Conceptual Framework for Implementation Fidelity to assess implementation fidelity and factors moderating it across the four core intervention components: patient goal setting, education topic coaching, primary care (PC) visits, and referrals to address social determinants of health (SDH), using descriptive statistics and regression models. PC patients with prediabetes receiving care from safety-net patient-centered medical homes (PCMHs) at either, VA NY Harbor or at Bellevue Hospital (BH) were eligible to be randomized into the CHW-led CHORD intervention or usual care. Among 559 patients randomized and enrolled in the intervention group, 79.4% completed the intake survey and were included in the analytic sample for fidelity assessment. Fidelity was measured as coverage, content adherence and frequency of each core component, and the moderators assessed were implementation site and patient activation measure.

RESULTS

Content adherence was high for three components with nearly 80.0% of patients setting ≥ 1 goal, having ≥ 1 PC visit and receiving ≥ 1 education session. Only 45.0% patients received ≥ 1 SDH referral. After adjusting for patient gender, language, race, ethnicity, and age, the implementation site moderated adherence to goal setting (77.4% BH vs. 87.7% VA), educational coaching (78.9% BH vs. 88.3% VA), number of successful CHW-patient encounters (6 BH vs 4 VA) and percent of patients receiving all four components (41.1% BH vs. 25.7% VA).

CONCLUSIONS

The fidelity to the four CHORD intervention components differed between the two implementation sites, demonstrating the challenges in implementing complex evidence-based interventions in different settings. Our findings underscore the importance of measuring implementation fidelity in contextualizing the outcomes of randomized trials of complex multi-site behavioral interventions.

TRIAL REGISTRATION

The trial was registered with ClinicalTrials.gov on 30/12/2016 and the registration number is NCT03006666 .

Evaluating biodiversity for coral reef reformation and monitoring on complex 3D structures using environmental DNA (eDNA) metabarcoding

Quantifying coral reef biodiversity is challenging for cryptofauna and organisms in early life stages. We demonstrate the utility of eDNA metabarcoding as a tool for comprehensively evaluating invertebrate communities on complex 3D structures for reef reformation, and the role these structures play in provisioning habitat for organisms. 3D design and printing were used to create 18 complex tiles, which were used to form artificial reef structures. eDNA was collected from scraping tile surfaces for organismal biomass and from seawater samples around the artificial reefs in the Gulf of Eilat/Aqaba, Red Sea. Metabarcoding targeted the mitochondrial COI gene with specific primers for marine biodiversity. We provide the first eDNA biodiversity baseline for the Gulf of Eilat/Aqaba, capturing extensive information on species abundance, richness, and diversity. Tile tops had higher phylogenetic diversity and richness, despite a higher abundance of organisms on tile bottoms, highlighting the detection of cryptic organisms with eDNA. We recommend eDNA metabarcoding for reef restoration initiatives, especially for complex marine structures, to improve success and evaluation of biodiversity.

Abstract P012: Agreement In Same Day Research-Quality And Casual Systolic Blood Pressure Measurements: Insights From BETTER-BP

Introduction: Prior studies suggest that BPs measured casually during routine clinic workflow are higher than research-grade measurements. However, BPs in these studies were typically collected on different days. We sought to compare the influence of day of assessment on this difference, within the context of an ongoing randomized trial.

Methods: This is a cross-sectional interim analysis of the BETTER-BP trial, which examines the effect of behavioral economic incentives for medication adherence on BP. Our study focused on concordance between baseline BP measurements and did not analyze trial outcome data. We included the first 171 participants (1/1/20-3/31/22). Research BP was measured in a seated position after a 5 minute rest period using a standard cuff (Omron HEM 907-XL). Casual BP measurements (most recent recording prior to the research measurement) as well as baseline characteristics were abstracted from the EHR. Participants were divided into two groups based on whether their casual BP was measured on the same day (vs different day) as their research BP. The mean systolic BP (SBP) obtained for research versus casual measurements were compared, for the two separate groups, using paired T-tests.

Results: Mean age was 55 years, 49.1% were female, 93.2% were nonwhite, and 48.5% were Spanish-speaking. Common comorbidities were diabetes (48.5%) and obesity (49.1%). Among the 132 patients with same day measurements, mean research SBP was 139.2 ± 20.4 mmHg and casual SBP was 137.9 ± 16.4 mmHg (mean within person difference=1.3 mmHg; P=0.259). Among the 39 patients with different days of measurement (median 14 [IQR 6-47] days), mean research SBP was 136.5 ± 23.3 mmHg and casual SBP was 144.2 ± 18.9 mmHg (mean within person difference= -7.7 mmHg; P=0.007). Casual SBP was higher among patients with measurements on different days compared to patients with same day measurements (P=0.043).

Conclusion: SBP measured casually during clinical practice were concordant with research-quality measurements when obtained on the same day. SBP measurements differed significantly when obtained on different days. These findings suggest that prior reports showing casual BPs to be consistently higher than research BPs may have been influenced by temporal variability.

Emerging 3D technologies for future reformation of coral reefs: Enhancing biodiversity using biomimetic structures based on designs by nature

The rapid decline of vulnerable coral reefs has increased the necessity of exploring interdisciplinary methods for reef restoration. Examining how to upgrade these tools may uncover options to better support or increase biodiversity of coral reefs. As many of the issues facing reef restoration today deal with the scalability and effectiveness of restoration efforts, there is an urgency to invest in technology that can help reach ecosystem-scale. Here, we provide an overview on the evolution to current state of artificial reefs as a reef reformation tool and discuss a blueprint with which to guide the next generation of biomimetic artificial habitats for ecosystem support. Currently, existing artificial structures have difficulty replicating the 3D complexity of coral habitats and scaling them to larger areas can be problematic in terms of production and design. We introduce a novel customizable 3D interface for producing scalable, biomimetic artificial structures, utilizing real data collected from coral ecosystems. This interface employs 3D technologies, 3D imaging and 3D printing, to extract core reef characteristics, which can be translated and digitized into a 3D printed artificial reef. The advantages of 3D printing lie in providing customized tools by which to integrate the vital details of natural reefs, such as rugosity and complexity, into a sustainable manufacturing process. This methodology can offer economic solutions for developing both small and large-scale biomimetic structures for a variety of restoration situations, that closely resemble the coral reefs they intend to support.

Opioid prescription at postoperative discharge: a retrospective observational cohort study

Opioid misuse is now considered a major public health epidemic in North America, with substantial social and financial consequences. As well as socio-economic and commercial drivers, modifiable risk-factors that have resulted in this crisis have been identified. The purpose of this study was to identify whether, within England, modifiable drivers for persistent postoperative opioid use were present. This was a retrospective cohort study of practice at 14 National Health Service hospitals across England. Data were collected retrospectively and validated for adult patients undergoing elective intermediate and major or complex major general surgical procedures between 1 and 31 March 2019. Of the 509 patients enrolled from 14 centres, 499 were included in the data analysis. In total, 31.5% (157/499) patients were in the intermediate surgery cohort and 68.5% (342/499) were in the major or complex major surgery cohort, with 21.0% (33/157) and 21.6% (74/342) discharged with opioid medicines to be taken at regular intervals, respectively. There were similar median oral morphine equivalent doses prescribed at discharge. Of patients prescribed regular opioid medicines, 76.6% (82/107) had a specified duration at discharge. However, 72.9% (78/107) had no written deprescribing advice on discharge. Similarly, of patients prescribed 'when required' opioids, 59.6% (93/156) had a specified duration of their prescription and 33.3% (52/156) were given written deprescribing advice. This study has identified a pattern of poor prescribing practices, a lack of guidance and formal training at individual institutions and highlights opportunities for improvement in opioid-prescribing practices within England.

Evolution and emergence of multidrug-resistant Mycobacterium tuberculosis in Chisinau, Moldova

The evolution and emergence of drug-resistant tuberculosis (TB) has been studied extensively in some contexts, but the ecological drivers of these two processes remain poorly understood. This study sought to describe the joint evolutionary and epidemiological histories of a novel multidrug-resistant Mycobacterium tuberculosis strain recently identified in the capital city of the Republic of Moldova (MDR Ural/4.2), where genomic surveillance of drug-resistant M. tuberculosis has been limited thus far. Using whole genome sequence data and Bayesian phylogenomic methods, we reconstruct the stepwise acquisition of drug resistance mutations in the MDR Ural/4.2 strain, estimate its historical bacterial population size over time, and infer the migration history of this strain between Eastern European countries. We infer that MDR Ural/4.2 likely evolved (via acquisition of rpoB S450L, which confers resistance to rifampin) in the early 1990s, during a period of social turmoil following Moldovan independence from the Soviet Union. This strain subsequently underwent substantial population size expansion in the early 2000s, at a time when national guidelines encouraged inpatient treatment of TB patients. We infer exportation of this strain and its isoniazid-resistant ancestral precursor from Moldova to neighbouring countries starting as early as 1985. Our findings suggest temporal and ecological associations between specific public health practices, including inpatient hospitalization of drug-resistant TB cases from the early 2000s until 2013, and the evolution of drug-resistant M. tuberculosis in Moldova. These findings underscore the need for regional coordination in TB control and expanded genomic surveillance efforts across Eastern Europe.

An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients

This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri-operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid-related harm, including persistent postoperative opioid use; opioid-induced ventilatory impairment; non-medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre-operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long-acting (modified-release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid-related harm in adults.

Regional anaesthesia in patients with diabetes

Diabetes is the most common metabolic condition worldwide and about 20% of surgical patients will have this condition. It is a major risk-factor for worse outcomes after surgery including mortality; infective and non-infective complications; and increased length of stay. However, diabetes is a modifiable risk-factor, and programs to improve medical management have the potential to reduce peri-operative complications and the risk of harm. Regional anaesthesia has well-documented benefits in promoting the restoration of function but there are legitimate concerns that the incidence of complications of regional anaesthesia in patients with diabetes is higher. The aim of this review is to explore in detail the various potential advantages and disadvantages of regional anaesthesia in patients with diabetes. This, in turn, will allow practitioners to undertake more informed shared decision-making and potentially modify their anaesthetic technique for patients with diabetes.

A New Point Mutation in the PMP22 Gene in a Family Suffering From Atypical HNPP

Hereditary neuropathy with liability to pressure palsies (HNPP) is an autosomal dominant inherited disorder commonly presenting with acute-onset, non-painful focal sensory and motor mono neuropathy. In 80% of cases, the genetic defect is a 1.5 Mb deletion on chromosome 17p11.2, including PMP22. Only few cases of partial deletion and point mutations in PMP22 are involved in HNPP. We investigated a 62-years-old man with lower limb plexopathy first considered as Garland’s syndrome. A month later, his 29 years old son also consulted for paresthesia on the peroneal nerve. Targeted sequencing of the PMP22 gene identified a c.370delT (p.Trp124Glyfs*31) in both affected patients. We report a new PMP22 point mutation associated with an atypical clinical phenotype of HNPP, a painful plexopathy of the lower limb worsenen by diabetes and a mere paresthesia, but a typical ENMG. This study illustrates the large spectrum of the disease, and emphasizes the importance of a complete ENMG and family history.

A comparison of postoperative respiratory complications associated with the use of desflurane and sevoflurane: a single-centre cohort study

Sevoflurane and desflurane are the most commonly used volatile anaesthetics for maintenance of anaesthesia. In this study, we aimed to evaluate the relationship between choice of volatile anaesthetic and early postoperative respiratory complications, and to address a critical knowledge gap in safety outcomes between these two commonly used agents. We performed a retrospective analysis of adult (non-cardiac surgery) patients who received sevoflurane or desflurane for the maintenance of general anaesthesia at our institution between 2005 and 2018. We evaluated the association between desflurane exposure (when compared with sevoflurane) and the primary outcome of postoperative respiratory complications, defined by early post-extubation desaturation (S_p O₂  < 90%) or re-intubation within 7 days postoperatively. Multivariable regression analyses were performed and adjusted for confounding factors, including patient, anaesthetic and surgical factors. Propensity matched, interaction and sub-group analyses were performed to assess outcomes in high-risk groups: morbidly obese (BMI > 35 kg.m^-2 ); elderly (age > 65 years); and high risk of respiratory complications as well as the primary outcome at 24 h. Desflurane was used for 23,830 patients and sevoflurane for 84,608 patients. Patients exposed to desflurane did not demonstrate a reduced risk of postoperative respiratory complications when compared with sevoflurane (adjusted odds ratio 0.99, 95%CI 0.94-1.04, p = 0.598). These findings were consistent across all sub-groups of high-risk patients and in the propensity score matched cohort. In summary, desflurane use was not associated with reduced postoperative respiratory complications when compared with sevoflurane. In the context of environmental and cost concerns with volatile anaesthetic agents, our study provides important data to support organisational decisions regarding the use of desflurane.

Barriers and Facilitators to the Implementation of a Mobile Insulin Titration Intervention for Patients With Uncontrolled Diabetes: A Qualitative Analysis

BACKGROUND

In 2016, a short message service text messaging intervention to titrate insulin in patients with uncontrolled type 2 diabetes was implemented at two health care facilities in New York City.

OBJECTIVE

This study aimed to conduct a qualitative evaluation assessing barriers to and the facilitators of the implementation of the Mobile Insulin Titration Intervention (MITI) program into usual care.

METHODS

We conducted in-depth interviews with 36 patients enrolled in the MITI program and the staff involved in MITI (n=19) in the two health care systems. Interviews were transcribed and iteratively coded by two study investigators, both inductively and deductively using a codebook guided by the Consolidated Framework for Implementation Research.

RESULTS

Multiple facilitator themes emerged: (1) MITI had strong relative advantages to in-person titration, including its convenience and time-saving design, (2) the free cost of MITI was important to the patients, (3) MITI was easy to use and the patients were confident in their ability to use it, (4) MITI was compatible with the patients' home routines and clinic workflow, (5) the patients and staff perceived MITI to have value beyond insulin titration by reminding and motivating the patients to engage in healthy behaviors and providing a source of patient support, and (6) implementation in clinics was made easy by having a strong implementation climate, communication networks to spread information about MITI, and a strong program champion. The barriers identified included the following: (1) language limitations, (2) initial nurse concerns about the scope of practice changes required to deliver MITI, (3) initial provider knowledge gaps about the program, and (4) provider perceptions that MITI might not be appropriate for some patients (eg, older or not tech-savvy). There was also a theme that emerged during the patient and staff interviews of an unmet need for long-term additional diabetes management support among this population, specifically diet, nutrition, and exercise support.

CONCLUSIONS

The patients and staff were overwhelmingly supportive of MITI and believed that it had many benefits and that it was compatible with the clinic workflow and patients' lives. Initial implementation efforts should address staff training and nurse concerns. Future research should explore options for integrating additional diabetes support for patients.

Clinical and radiographic findings in cats with aspiration pneumonia: retrospective evaluation of 28 cases

OBJECTIVES

To describe the clinical syndrome of aspiration pneumonia in cats and record potential predisposing factors.

MATERIALS AND METHODS

A retrospective medical records search for cats with a diagnosis of "aspiration pneumonia" or "bronchopneumonia" was performed. Cases were included if they had a complete medical record and three-view thoracic radiographs with pulmonary changes consistent with aspiration pneumonia and no other radiographic or physical examination findings suggestive of another cause of pulmonary or cardiac disease.

RESULTS

We identified 28 cases. Potential predisposing conditions included: vomiting (12 of 28; 43%), anaesthesia (five of 28; 18%), enteral nutrition (five of 28; 18%), preexisting oesophageal disease (four of 28; 14%), neurologic disease (two of 28; 7%) and laryngeal disease (one of 28; 3.6%); 15 of 28 (53%) had more than one potentially predisposing condition. The most common lung lobe affected was the right middle (18 of 28; 64%), followed by the left cranial (16 of 28; 57%); multiple lung lobes were affected in 16 of 28 (57%) cases. Most cats (25 of 28; 89%) survived to discharge, with a median hospitalisation of 3 days.

CLINICAL SIGNIFICANCE

Potential predisposing factors for developing aspiration pneumonia in cats are similar to those recorded in dogs and people. Aspiration pneumonia occurred in cats following vomiting, anaesthesia or after receiving enteral nutrition. Survival rates are high following treatment with antibiotics and supportive care, with 89% of cats in this study surviving to discharge.

Pre-operative optimisation of the surgical patient with diagnosed and undiagnosed diabetes: a practical review

Peri-operative hyperglycaemia, whether the cause is known diabetes, undiagnosed diabetes or stress hyperglycaemia, is a risk factor for harm, increased length of stay and death. There is increasing evidence that peri-operative hyperglycaemia is a modifiable risk factor, and many of the interventions required to improve the outcome of surgery must be instituted before the actual surgical admission. These interventions depend on communication and collaboration within the multidisciplinary team along each stage of the patient journey to ensure that integration of care occurs across the whole of the patient-centred care pathway.

Protocol for the CHORD project (community health outreach to reduce diabetes): a cluster-randomized community health worker trial to prevent diabetes

BACKGROUND

Type 2 diabetes mellitus (DM) affects 9.4% of US adults and children, while another 33.9% of Americans are at risk of DM. Health care institutions face many barriers to systematically delivering the preventive care needed to decrease DM incidence. Community health workers (CHWs) may, as frontline public health workers bridging clinic and community, help overcome these challenges. This paper presents the protocol for a pragmatic, cluster-randomized trial integrating CHWs into two primary care clinics to support DM prevention for at-risk patients.

METHODS

The trial will randomize 15 care teams, stratified by practice site (Bellevue Hospital and Manhattan VA), totaling 56 primary care physicians. The study cohort will consist of ~ 2000 patients who are 18-75 years of age, actively enrolled in a primary care team, able to speak English or Spanish, and have at least one glycosylated hemoglobin (HbA1c) result in the prediabetic range (5.7-6.4%) since 2012. Those with a current DM diagnosis or DM medication prescription (other than metformin) are ineligible. The intervention consists of four core activities - setting health goals, health education, activation for doctor's appointments, and referrals to DM prevention programs - adjustable according to the patient's needs and readiness. The primary outcome is DM incidence. Secondary outcomes include weight loss, HbA1C, and self-reported health behaviors. Clinical variables and health behaviors will be obtained through electronic medical records and surveys, respectively. Implementation outcomes, namely implementation fidelity and physicians' perspectives about CHW integration into the clinic, will be assessed using interviews and CHW activity logs and analyzed for the influence of moderating organizational factors.

DISCUSSION

This is the first rigorous, pragmatic trial to test the effectiveness of integrating CHWs into primary care for DM prevention reaching a population-based sample. Our study's limitations include language-based eligibility and the use of HbA1c as a measure of DM risk. It will measure both clinical and implementation outcomes and potentially broaden the evidence base for CHWs and patient-centered medical home implementation. Further, the intervention's unique features, notably patient-level personalization and referral to existing programs, may offer a scalable model to benefit patients at-risk of DM.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03006666 (Received 12/27/2016).