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1.
Am J Health Syst Pharm ; 79(3): 147-164, 2022 01 24.
Article in English | MEDLINE | ID: covidwho-1429175

ABSTRACT

PURPOSE: To identify the proportion of patients with continued opioid use after total hip or knee arthroplasty. METHODS: This systematic review and meta-analysis searched Embase, MEDLINE, the Cochrane Central Register of Controlled Trials, and International Pharmaceutical Abstracts for articles published from January 1, 2009, to May 26, 2021. The search terms (opioid, postoperative, hospital discharge, total hip or knee arthroplasty, and treatment duration) were based on 5 key concepts. We included studies of adults who underwent total hip or knee arthroplasty, with at least 3 months postoperative follow-up. RESULTS: There were 30 studies included. Of these, 17 reported on outcomes of total hip arthroplasty and 19 reported on outcomes of total knee arthroplasty, with some reporting on outcomes of both procedures. In patients having total hip arthroplasty, rates of postoperative opioid use at various time points were as follows: at 3 months, 20% (95% CI, 13%-26%); at 6 months, 17% (95% CI, 12%-21%); at 9 months, 19% (95% CI, 13%-24%); and at 12 months, 16% (95% CI, 15%-16%). In patients who underwent total knee arthroplasty, rates of postoperative opioid use were as follows: at 3 months, 26% (95% CI, 19%-33%); at 6 months, 20% (95% CI, 17%-24%); at 9 months, 23% (95% CI, 17%-28%); and at 12 months, 21% (95% CI, 12%-29%). Opioid naïve patients were less likely to have continued postoperative opioid use than those who were opioid tolerant preoperatively. CONCLUSION: Over 1 in 5 patients continued opioid use for longer than 3 months after total hip or knee arthroplasty. Clinicians should be aware of this trajectory of opioid consumption after surgery.


Subject(s)
Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , Opioid-Related Disorders , Analgesics, Opioid/adverse effects , Arthroplasty, Replacement, Hip/adverse effects , Arthroplasty, Replacement, Knee/adverse effects , Humans , Opioid-Related Disorders/drug therapy , Pain, Postoperative/drug therapy , Pain, Postoperative/epidemiology
2.
Am J Health Syst Pharm ; 78(17): 1559-1567, 2021 08 30.
Article in English | MEDLINE | ID: covidwho-1233838

ABSTRACT

PURPOSE: Cost-avoidance studies of pharmacist interventions are common and often the first type of study conducted by investigators to quantify the economic impact of clinical pharmacy services. The purpose of this primer is to provide guidance for conducting cost-avoidance studies pertaining to clinical pharmacy practice. SUMMARY: Cost-avoidance studies represent a paradigm conceptually different from traditional pharmacoeconomic analysis. A cost-avoidance study reports on cost savings from a given intervention, where the savings is estimated based on a counterfactual scenario. Investigators need to determine what specifically would have happened to the patient if the intervention did not occur. This assessment can be fundamentally flawed, depending on underlying assumptions regarding the pharmacists' action and the patient trajectory. It requires careful identification of the potential consequence of nonaction, as well as probability and cost assessment. Given the uncertainty of assumptions, sensitivity analyses should be performed. A step-by-step methodology, formula for calculations, and best practice guidance is provided. CONCLUSIONS: Cost-avoidance studies focused on pharmacist interventions should be considered low-level evidence. These studies are acceptable to provide pilot data for the planning of future clinical trials. The guidance provided in this article should be followed to improve the quality and validity of such investigations.


Subject(s)
Pharmacies , Pharmacy Service, Hospital , Pharmacy , Cost Savings , Humans , Pharmacists
3.
BMC Med Educ ; 21(1): 175, 2021 Mar 20.
Article in English | MEDLINE | ID: covidwho-1143211

ABSTRACT

BACKGROUND: Point-of-care ultrasound is becoming a ubiquitous diagnostic tool, and there has been increasing interest to teach novice practitioners. One of the challenges is the scarcity of qualified instructors, and with COVID-19, another challenge is the difficulty with social distancing between learners and educators. The purpose of our study was to determine if ultrasound-naïve operators can learn ultrasound techniques and develop the psychomotor skills to acquire ultrasound images after reviewing SonoSim® online modules. METHODS: This was a prospective study evaluating first-year medical students. Medical students were asked to complete four SonoSim® online modules (aorta/IVC, cardiac, renal, and superficial). They were subsequently asked to perform ultrasound examinations on standardized patients utilizing the learned techniques/skills in the online modules. Emergency Ultrasound-trained physicians evaluated medical students' sonographic skills in image acquisition quality, image acquisition difficulty, and overall performance. Data are presented as means and percentages with standard deviation. All P values are based on 2-tailed tests of significance. RESULTS: Total of 44 medical students participated in the study. All (100%) students completed the hands-on skills evaluation with a median score of 83.7% (IQR 76.7-88.4%). Thirty-three medical students completed all the online modules and quizzes with median score of 87.5% (IQR 83.8-91.3%). There was a positive association between module quiz performance and the hands-on skills performance (R-squared = 0.45; p < 0.001). There was no statistically significant association between module performance and hands-on performance for any of the four categories individually. In all four categories, the evaluators' observation of the medical students' difficulty obtaining views correlated with hands-on performance scores. CONCLUSIONS: Our study findings suggest that ultrasound-naïve medical students can develop basic hands-on skills in image acquisition after reviewing online modules.


Subject(s)
Clinical Competence , Education, Distance/methods , Education, Medical, Undergraduate/methods , Point-of-Care Systems , Ultrasonography , COVID-19/epidemiology , Female , Humans , Male , Prospective Studies , SARS-CoV-2
4.
N Engl J Med ; 384(16): 1491-1502, 2021 04 22.
Article in English | MEDLINE | ID: covidwho-1101727

ABSTRACT

BACKGROUND: The efficacy of interleukin-6 receptor antagonists in critically ill patients with coronavirus disease 2019 (Covid-19) is unclear. METHODS: We evaluated tocilizumab and sarilumab in an ongoing international, multifactorial, adaptive platform trial. Adult patients with Covid-19, within 24 hours after starting organ support in the intensive care unit (ICU), were randomly assigned to receive tocilizumab (8 mg per kilogram of body weight), sarilumab (400 mg), or standard care (control). The primary outcome was respiratory and cardiovascular organ support-free days, on an ordinal scale combining in-hospital death (assigned a value of -1) and days free of organ support to day 21. The trial uses a Bayesian statistical model with predefined criteria for superiority, efficacy, equivalence, or futility. An odds ratio greater than 1 represented improved survival, more organ support-free days, or both. RESULTS: Both tocilizumab and sarilumab met the predefined criteria for efficacy. At that time, 353 patients had been assigned to tocilizumab, 48 to sarilumab, and 402 to control. The median number of organ support-free days was 10 (interquartile range, -1 to 16) in the tocilizumab group, 11 (interquartile range, 0 to 16) in the sarilumab group, and 0 (interquartile range, -1 to 15) in the control group. The median adjusted cumulative odds ratios were 1.64 (95% credible interval, 1.25 to 2.14) for tocilizumab and 1.76 (95% credible interval, 1.17 to 2.91) for sarilumab as compared with control, yielding posterior probabilities of superiority to control of more than 99.9% and of 99.5%, respectively. An analysis of 90-day survival showed improved survival in the pooled interleukin-6 receptor antagonist groups, yielding a hazard ratio for the comparison with the control group of 1.61 (95% credible interval, 1.25 to 2.08) and a posterior probability of superiority of more than 99.9%. All secondary analyses supported efficacy of these interleukin-6 receptor antagonists. CONCLUSIONS: In critically ill patients with Covid-19 receiving organ support in ICUs, treatment with the interleukin-6 receptor antagonists tocilizumab and sarilumab improved outcomes, including survival. (REMAP-CAP ClinicalTrials.gov number, NCT02735707.).


Subject(s)
Antibodies, Monoclonal, Humanized/therapeutic use , COVID-19/drug therapy , Receptors, Interleukin-6/antagonists & inhibitors , Adult , Aged , Antibodies, Monoclonal, Humanized/adverse effects , COVID-19/complications , COVID-19/mortality , COVID-19/therapy , Critical Illness , Female , Hospital Mortality , Humans , Intensive Care Units , Male , Middle Aged , Odds Ratio , Respiration, Artificial
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