Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial

BACKGROUND

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.

OBJECTIVE

To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.

DESIGN

Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).

SETTING

46 U.S. and Canadian hospitals.

PARTICIPANTS

Patients aged 50 years or older undergoing hip fracture surgery.

INTERVENTION

Spinal or general anesthesia.

MEASUREMENTS

Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.

RESULTS

A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.

LIMITATION

Missing outcome data and multiple outcomes assessed.

CONCLUSION

Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

A novel embryo culture media supplement that improves pregnancy rates in mice

The preimplantation embryoinvivois exposed to numerous growth factors in the female reproductive tract, which are not recapitulated in embryo culture mediain vitro. The IGF2 and plasminogen activator systems facilitate blastocyst development. We hypothesized that the addition of IGF2 in combination with urokinase plasminogen activator (uPA) and plasminogen could improve rates of blastocyst hatching and implantation in mice. B6BcF1 and CBAB6F2 mouse embryos were divided into one of four supplemented culture media treatment groups: (1) control (media only); (2) 12.5 nM IGF2; (3) 10 µg/mL uPA and 5 µg/mL plasminogen; or (4) a combination of IGF2, uPA and plasminogen treatments. Embryo development to blastocyst stage and hatching were assessed before transfer to pseudopregnant recipient females and implantation, pregnancy rates and postnatal growth were assessed. After 90.5 h of culture, IGF2 + U + P treatment increased the percentage of B6BcF1 embryos that were hatching/hatched and percentage developing to blastocyst stage compared with controls (P < 0.02). Following B6BcF1 embryo transfer, IGF2 + U + P treatment increased implantation sites at day 8 of pregnancy compared with controls (P < 0.05). Replication in the CBAB6F2 mouse strain showed significant improvements in pregnancy rates at days 8 and 18 but not in blastocyst development. No adverse effects were seen on gestational age, litter size or birthweight, or the reproductive capacity of offspring of IGF2 + U + P treated embryos. For embryos susceptible to detrimental effects ofin vitroculture, IGF2, uPA and plasminogen supplementation of culture media can improve pregnancy success, but the effect of treatment is dependent on the mouse strain.

Ca(2+)-calmodulin can activate and inactivate cardiac ryanodine receptors

BACKGROUND AND PURPOSE

Ca(2+)-calmodulin (Ca(2+)CaM) is widely accepted as an inhibitor of cardiac ryanodine receptors (RyR2); however, the effects of physiologically relevant CaM concentrations have not been fully investigated.

EXPERIMENTAL APPROACH

We investigated the effects of low concentrations of Ca(2+)CaM (50-100 nmol.L(-1)) on the gating of native sheep RyR2, reconstituted into bilayers. Suramin displaces CaM from RyR2 and we have used a gel-shift assay to provide evidence of the mechanism underlying this effect. Finally, using suramin to displace endogenous CaM from RyR2 in permeabilized cardiac cells, we have investigated the effects of 50 nmol.L(-1) CaM on sarcoplasmic reticulum (SR) Ca(2+)-release.

KEY RESULTS

Ca(2+)CaM activated or inhibited single RyR2, but activation was much more likely at low (50-100 nmol.L(-1)) concentrations. Also, suramin displaced CaM from a peptide of the CaM binding domain of RyR2, indicating that, like the skeletal isoform (RyR1), suramin directly competes with CaM for its binding site on the channel. Pre-treatment of rat permeabilized ventricular myocytes with suramin to displace CaM, followed by addition of 50 nmol x L(-1) CaM to the mock cytoplasmic solution caused an increase in the frequency of spontaneous Ca(2+)-release events. Application of caffeine demonstrated that 50 nmol x L(-1) CaM reduced SR Ca(2+) content.

CONCLUSIONS AND IMPLICATIONS

We describe for the first time how Ca(2+)CaM is capable, not only of inactivating, but also of activating RyR2 channels in bilayers in a CaM kinase II-independent manner. Similarly, in cardiac cells, CaM stimulates SR Ca(2+)-release and the use of caffeine suggests that this is a RyR2-mediated effect.

The PRIME curriculum. Clinical research training during residency

AIM

The Primary Medical Education (PRIME) program is an outpatient-based, internal medicine residency track nested within the University of California, San Francisco (UCSF) categorical medicine program. Primary Medical Education is based at the San Francisco Veteran's Affairs Medical Center (VAMC), 1 of 3 teaching hospitals at UCSF. The program accepts 8 UCSF medicine residents annually, who differentiate into PRIME after internship. In 2000, we implemented a novel research methods curriculum with the dual purposes of teaching basic epidemiology skills and providing mentored opportunities for clinical research projects during residency.

SETTING

Single academic internal medicine program.

PROGRAM DESCRIPTION

The PRIME curriculum utilizes didactic lecture, frequent journal clubs, work-in-progress sessions, and active mentoring to enable residents to "try out" a clinical research project during residency.

PROGRAM EVALUATION

Among 32 residents in 4 years, 22 residents have produced 20 papers in peer-reviewed journals, 1 paper under review, and 2 book chapters. Their clinical evaluations are equivalent to other UCSF medicine residents.

DISCUSSION

While learning skills in evidence-based medicine, residents can conduct high-quality research. Utilizing a collaboration of General Internal Medicine researchers and educators, our curriculum affords residents the opportunity to "try-out" clinical research as a potential future career choice.

Utilization, patient satisfaction, and cost implications of acupuncture, massage, and naturopathic medicine offered as covered health benefits: a comparison of two delivery models

CONTEXT

Increasing numbers of health plans in the United States offer complementary and alternative medicine (CAM) benefits despite limited information.

OBJECTIVE

To determine the utilization rates and costs associated with providing CAM services in 2 benefit designs, and to determine the satisfaction of patients in both plans.

DESIGN

Two health plans were identified: a traditional indemnity plan offered through a defined preferred provider organization (PPO) of CAM providers and a health maintenance organization (HMO). Costs and utilization rates for CAM services were compared during a 1-year period of coverage beginning November 1, 1996.

SETTING AND PARTICIPANTS

1091 patients in both plans who used CAM services during the month of May 1997 in Washington state.

RESULTS

Only 1% of all patients covered for CAM accessed these services during the study period. A significantly higher percentage of patients in the PPO plan (1.2%) used CAM services compared to the HMO plan (0.6%) (P < .001). However, the average total cost of annual CAM services (plan benefit + user contribution) was similar ($347 in the HMO and $376 in the PPO), and the price per member per month was nearly identical ($0.20 in the HMO and $0.19 in the PPO). Most users perceived these services as helpful.

CONCLUSIONS

Utilization of CAM services and per member per month costs were lower than expected given the high interest in CAM services reported in consumer surveys. The high level of satisfaction with CAM services and self-reported decrease in the use of pain medications suggests the need for prospective studies examining the effect of CAM treatments.

[Decontamination of highly polychlorinated biphenyl contaminated indoor areas by complete removal of primary and secondary sources]

A new sanitization concept in a school highly contaminated with polychlorinated biphenyls (PCBs) is described. The maximum indoor air concentration was 13,100 ng/m3 PCB. Initially the average indoor PCB concentrations attained 6,000-7,000 ng/m3. A reduction to 226 +/- 89.1 ng/m3 (n = 24) was achieved. Ten months later the PCB concentration was 171 +/- 57.6 ng/m3 (n = 3). Primary sources were PCB-contaminated elastic sealants and the paint of radiators or heating elements. Also PCB-contaminated materials were walls, floors and ceilings. These secondary contaminations were also relevant for PCB indoor air concentrations. The primary sources were removed dust-free by manual procedures. Contrary to other sanitization concepts all secondary-contaminated PCB materials were also removed with a high-pressure water method specially developed for such cases. Because of the removal of all relevant primary and secondary PCB deposits, a lasting effect can be expected. By this sanitization concept, the use of new and less intensively explored products suppressing the diffusion of PCBs into the indoor air and whose toxicity is hardly known, may be prevented, thus avoiding the need for prolonged control measurements. Before using the above-mentioned new sanitization concept, another concept had been rejected for lack of efficiency, thus avoiding unnecessary costs. The companies performing sanitization should be compelled to accept a defined lowest PCB concentration.

An evidence-based review of the 10 most commonly used herbs

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Antibiotics in acute bronchitis: a meta-analysis

PURPOSE

Most patients with acute bronchitis who seek medical care are treated with antibiotics, although the effectiveness of this intervention is uncertain. We performed a meta-analysis of randomized, controlled trials to estimate the effectiveness of antibiotics in the treatment of acute bronchitis.

SUBJECTS AND METHODS

English-language studies published January 1966 to April 1998 were retrieved using MEDLINE, bibliographies, and consultation with experts. Only randomized trials that enrolled otherwise healthy patients with a diagnosis of acute bronchitis, used an antibiotic in the treatment group and a placebo in the control group, and provided sufficient data to calculate an effect size were included.

RESULTS

We identified eight randomized controlled trials that satisfied all inclusion criteria. These studies used one of three antibiotics (erythromycin, doxycycline, trimethoprim/sulfamethoxazole). The use of antibiotics decreased the duration of cough and sputum production by approximately one-half day (summary effect size 0.21; 95% CI, 0.05 to 0.36). For specific symptoms, there were nonsignificant trends favoring the use of antibiotics: a decrease of 0.4 days of purulent sputum (95% CI, -0.1 to 0.8), a decrease of 0.5 days of cough (95% CI, -0.1 to 1.1), and a decrease of 0.3 days lost from work (95% CI, -0.6 to 1.1).

CONCLUSION

This meta-analysis suggests a small benefit from the use of the antibiotics erythromycin, doxycycline, or trimethoprim/sulfamethoxazole in the treatment of acute bronchitis in otherwise healthy patients. As this small benefit must be weighed against the risk of side effects and the societal cost of increasing antibiotic resistance, we believe that the use of antibiotics is not justified in these patients.

[Solvent emissions in a school building after using a construction moisture protection substance]

A wall of a school building was treated with a moisture repellent containing a silicone resin and white spirit. In the temporal connection with this a child experienced an exacerbation of its bronchial asthma. Some weeks after the second application the users of the rooms complained about unpleasant odor and discomfort. As shown by analysis the white spirit containing aliphatic and aromatic hydrocarbons diffused through the 50 cm thick stone wall into the classrooms. Due to the considerable concentration of the pollutant a part of the building could not be used any longer. In Germany no guideline values exist for white spirit or any mixtures of hydrocarbons in indoor air for non-occupational workplaces. For the reopening of the rooms a target value of 300 micrograms VOC/m3 was set. The incident shows that building materials can cause health problems and discomfort even if instructions of application are followed.

[Copper-induced liver cirrhosis in a 13-month old boy]

A micronodular liver cirrhosis with a massive accumulation of copper in hepatocytes was found in a 13-months old boy. The causal factor was due to the increased copper concentration within the drinking water, which caused liver disease of the boy who had been completely weaned at the age of four weeks. The cooper concentration found in the drinking water exceeded 12 mg/l after a twelve hour stagnation time; after several days of stagnation the highest measured concentration was 28.6 mg/l. This increase is caused by the combined effect of copper pipes and acidulous well water.

Antibiotics in chronic obstructive pulmonary disease exacerbations. A meta-analysis

OBJECTIVE

A meta-analysis of randomized trials was performed to estimate the effectiveness of antibiotics in treating exacerbations of chronic obstructive pulmonary disease (COPD).

DATA SOURCES

English-language studies published from 1955 through 1994 were retrieved using MEDLINE, Index Medicus, bibliographies, and consultation with experts. MEDLINE search terms included "COPD," "chronic bronchitis," and "antibiotic(s)."

STUDY SELECTION

Only randomized trials that enrolled patients having an exacerbation of COPD, used an antibiotic in the treatment group and placebo in the control group, and provided sufficient data to calculate an effect size were included in the meta-analysis.

DATA EXTRACTION

Descriptive and outcome data from each study were independently in the meta-analysis.

DATA SYNTHESIS

Overall summary effect size of the nine trials satisfying all inclusion criteria was 0.22 (95% confidence interval [CI], 0.10 to 0.34), indicating a small benefit in the antibiotic-treated group. Similar analysis of the six studies that provided data on peak expiratory flow rate changes revealed a summary effect size of 0.19 (95% CI, 0.03 to 0.35) and a summary change in peak expiratory flow rate of 10.75 L/min (95% CI, 4.96 to 16.54 L/min) in favor of the antibiotic-treated group. Sensitivity analyses did not significantly affect these results.

CONCLUSIONS

These analyses suggest a small but statistically significant improvement due to antibiotic therapy in patients with exacerbations of COPD. This antibiotic-associated improvement may be clinically significant, especially in patients with low baseline flow rates.

[Management of indoor air pollution by polychlorinated biphenyl compounds exemplified by two Hagen schools]

An indoor pollution of polychlorinated biphenyls (PCB) of about 4000 ng/m3 could be reduced by an average amount of 68% by temporary sealing of the primary source in combination with intensive cleaning. The costs were around DM 100,000.- for the school building containing 12 classrooms. Due to this procedure a continued usage of the building is possible until a concept of decontamination is available. In another building the PCB indoor pollution was reduced by 73% in a representative trial restoration, whereas the stripping of the paint with a chemical caustic substance induced a significant reduction of the PCB concentration. The usage of special air conditioners--called "Luftwäscher"--in the classrooms did not reduce the PCB concentration. The realisation of disturbing factors such as the fluctuation of the temperature is of great importance for judging the efficiency of decontamination procedures. The possible misinterpretation regarding the results and the data of decontamination procedures can be excluded by parallel measurements in control rooms. Costs induced by these additional analyses will be reduced by the early realization of ineffective steps.

The influence of H1-, H2- and H3-receptors on the spontaneous and ConA induced histamine release from human adenoidal mast cells

The effects of the H3-agonist R-alpha-methylhistamine (R-alpha-MeHA) and the H3-antagonist thioperamide on the spontaneous and concanavalin A (ConA) induced histamine release from human mast cells were tested and compared with the effect of some H1- and H2-receptor active substances. R-alpha-MeHA (10(-9)-10(-7) M) exerted no effect on histamine release whereas thioperamide increased the spontaneous release at 10(-6)-10(-4) M but inhibited the ConA induced release in a narrow concentration range (10(-6)-10(-5) M). This enhancement might be taken as an indication of the existence of H3-receptor dependent autoregulation although presently other mechanism cannot be excluded.

Comparison of dermal and systemic application of glucocorticoids on the RM 3/1+ macrophage in human blood

Dermal administration of either hydrocortisone or fluprednidene to healthy skin causes only a weak and short-lasting increase of the proportion of the anti-inflammatory macrophage RM 3/1 in the blood compared to the effect of the systemic application of glucocorticoids on this cell subtype. On the other hand, a rather permanent increase of these macrophages could be observed in untreated patients suffering from certain skin diseases, e.g. urticaria, atopic dermatitis, psoriasis.

Effects of calmodulin antagonists on human adenoidal mast cells

N-(6-aminohexyl)-1-naphthalenesulfonamide (W5), N-(6-aminohexyl)-5-chloro-1-naphthalenesulfonamide (W7) and Triflupromazine (TFPr) are substances with calmodulin antagonistic properties. All of these compounds inhibited the Con A-induced histamine release from human adenoidal mast cells. Maximal inhibition for W5 was observed at 200 microM, for W7 at 50 microM and for TFPr at 20 microM. Higher concentrations of each substance induced a marked histamine release. The kinetics of the mediator release were found to be different for Con A and W7 only after 5 mins incubation. The kinetics of TFPr were found to be biphasic: a slow onset was followed by a fast release reaction.

Glucocorticoid-induced appearance of the macrophage subtype RM 3/1 in peripheral blood of man

The effect of intravenous administration of the glucocorticoid prednylidene on the macrophage subtype RM 3/1 in the peripheral blood of man was studied. Injection of 60 mg steroid resulted in an increase in the proportion of RM 3/1 positive monocytes 12 h after application from the basic level to about 80%. After 24 h the number of RM 3/1 positive cells decreased but remained elevated over the basis rate for a period of at least 15 days. Similar results were obtained after administration of 30 or 6 mg prednylidene even if the peak value occurred with a delay of 12 h after 6 mg. A dose- and time-dependent induction of the RM 3/1 positive subtype could also be demonstrated in vitro by the addition of prednylidene or dexamethasone to cultured purified human monocytes/macrophages. Deoxycortone or indomethacin had no effects. These results suggest that glucocorticoids exert their influence on cells of the mononuclear phagocytic lineage by inducing a distinct monocyte/macrophage subpopulation which seems to be associated with anti-inflammatory functions.

Evaluation of acute bioassays for assessing toxicity of polychlorinated biphenyl-contaminated soils

Proposed State of California regulations use fish toxicity information as one criterion in municipal or industrial waste hazard evaluation. Static 96-hr bioassays were performed using fathead minnows (Pimephales promelas), blacksmith (Chromis punctipinnis), and glass shrimp (Palaemonetes kadiakensis) exposed to soil experimentally contaminated with up to 500 ppm polychlorinated biphenyl (PCB) capacitor fluid added at a concentration of 500 mg liter-1. Other bioassays were conducted with a 6-day mixing period prior to the bioassay or with acetone added to solubilize the PCBs. No mortality attributable to PCB toxicity was observed in definitive bioassays using the two fish and one invertebrate species. PCB levels leached from soil containing 500 ppm Aroclor 1242 ranged from less than 0.6 to 3.4 ppb in freshwater tests to 3.5 ppb in seawater bioassays. Using these data as the basis for waste classification, soils contaminated with up to 500 ppb PCBs during capacitor spills would be designated nonhazardous. PCBs are known to be environmentally persistent and to bioaccumulate. Acute toxicity tests, therefore, do not adequately evaluate the general toxicity of PCB-contaminated soils. Hazardous waste regulations for hydrophobic compounds such as PCBs should instead be based upon chronic toxicity data and should also consider bioaccumulation potential.