Opioid use prior to total knee replacement: comparative analysis of trends in England and Sweden.

OBJECTIVES: To describe and compare trends in the frequency of opioid prescribing/dispensing in English and Swedish patients with osteoarthritis prior to total knee replacement (TKR). METHODS: 49,043 patients from an English national database (Clinical Practice Research Datalink) and 5,955 patients from the Swedish Skåne Healthcare register undergoing TKR between 2015 and 2019 were included, alongside 1:1 age-, sex-, and practice (residential area) matched controls. Annual prevalence and prevalence rates ratio (PRR) of opioid prescribing/dispensing (any, by strength) in the 10 years prior to TKR (or matched index date for controls) were estimated using Poisson regression. RESULTS: In England and Sweden, the prevalence of patients with osteoarthritis receiving any opioid prior to TKR increased towards the date of surgery from 24% to 44% in England and from 16% to 33% in Sweden. Prescribing in controls was stable, resulting in an increasing PRR (1.6-2.7) between 10 and 1 years prior to index date in both countries. No relevant cohort or period effect was observed in either country. Prevalence of opioid prescribing was higher in English cases and controls; weaker opioids were more commonly prescribed in England, stronger opioids in Sweden. CONCLUSIONS: Temporal prevalence patterns of opioid prescribing between cases and controls are similar in England and Sweden. Opioids are still commonly used in TKR cases in both countries highlighting the lack of valid alternatives for OA pain management.

Trends in gabapentinoid prescribing in patients with osteoarthritis: a United Kingdom national cohort study in primary care.

OBJECTIVE: To investigate trends in gabapentinoid prescribing in patients with osteoarthritis (OA). METHODS: Patients aged 40 years and over with a new OA diagnosis recorded between 1995 and 2015 were identified in the Clinical Practice Research Datalink (CPRD) and followed to first prescription of gabapentin or pregabalin, or other censoring event. We estimated the crude and age-standardised annual incidence rates of gabapentinoid prescribing, stratified by patient age, sex, geographical region, and time since OA diagnosis, and the proportion of prescriptions attributable to OA, or to other conditions representing licensed and unlicensed indications for a gabapentinoid prescription. RESULTS: Of 383,680 newly diagnosed OA cases, 35,031 were prescribed at least one gabapentinoid. Irrespective of indication, the annual age-standardised incidence rate of first gabapentinoid prescriptions rose from 1.6 [95% confidence interval (CI): 1.3, 2.0] per 1000 person-years in 2000, to 27.6 (26.7, 28.4) in 2015, a trend seen across all ages and not explained by length of follow-up. Rates were higher among women, younger patients, and in Northern Ireland, Scotland and the North of England. Approximately 9% of first prescriptions could be attributed to OA, a further 13% to comorbid licensed or unlicensed indications. CONCLUSION: Gabapentinoid prescribing in patients with OA increased dramatically between 1995 and 2015. In most cases, diagnostic codes for licensed or unlicensed indications were absent. Gabapentinoid prescribing may be attributable to OA in a significant proportion but evidence for their effectiveness in OA is lacking. Further research to investigate clinical decision making around prescribing these expensive and potentially harmful medicines is recommended.

Guidelines for the management of pelvic pain associated with endometriosis: a systematic appraisal of their quality.

BACKGROUND: Guidelines exist for the management of endometriosis. Validated and reliable appraisal tools exist to assess the quality of guidelines. OBJECTIVES: To systematically appraise the quality of guidelines for the management of pelvic pain associated with endometriosis. SEARCH STRATEGY: Guidelines were identified using a prospective protocol through a systematic search of MEDLINE (1951-2005), EMBASE (1974-2005), the Cochrane Library (2005, issue 2), known guideline websites and the World Wide Web. SELECTION CRITERIA: Type of document: guideline, consensus statement, care protocol or healthcare technology assessment produced by national or international professional organisations and societies or governmental agencies; subject: management of pelvic pain associated with endometriosis. DATA COLLECTION AND ANALYSIS: Two validated appraisal tools, Cluzeau and The Appraisal of Guidelines and Research and Evaluation (AGREE), were used to quantitatively assess the quality of guidelines. Areas evaluated included 'rigour of development', 'context and content' and 'application.' MAIN RESULTS: Eight of 596 potentially relevant citations identified met our inclusion criteria. The Cluzeau instrument quality score were the following: rigour of development, 53% (range 5-65%); context and content, 69% (range 29-79%) and application 20% (range 0-20%). The application dimension achieved significantly lower quality scores (P = 0.026 versus rigour of development and P = 0.017 versus context and content). The AGREE instrument quality scores were the following: scope and purpose, 68% (range 17-89%); stakeholder involvement, 33% (range 13-63%); rigour of development, 49% (range 10-81%); clarity of presentation, 55% (range 42-67%); applicability, 14% (range 0-28%) and editorial independence, 28% (range 8-67%). The applicability domain achieved significantly lower quality scores (P = 0.001 versus scope and purpose and P = 0.009 versus rigour of development). AUTHOR'S CONCLUSIONS: Guidelines for the management of pelvic pain associated with endometriosis do not comply with the recommendations for high-quality standards.

The role of laparoscopy to evaluate candidates for complete cytoreduction of peritoneal carcinomatosis and hyperthermic intraperitoneal chemotherapy.

AIM: The aim of this study was to evaluate the role of explorative laparoscopy to evaluate candidates for complete resection of peritoneal carcinomatosis (PC) combined with hyperthermic intraperitoneal chemotherapy (HIPC). METHODS: The database of the surgical department of the Institut Gustave Roussy was used to select 113 patients planned to undergo a maximal cytoreductive surgery combined with HIPC for PC between April 2001 and July 2003. Among them, 11 underwent an explorative laparoscopy because extent of the PC was insufficiently documented to evaluate its resectability. Patient records were retrospectively reviewed. RESULTS: Laparoscopic evaluation was successful in all 11 patients. The median operating time was 38 min (range 23-75 min). The laparoscopic examinations were well tolerated in all cases. The median length of hospital stay was 1.7 days. For three patients, the PC was as judge as unresectable. A complete resection of the PC combined with HIPC was performed in seven out of the eight patients with PC considered resectable at laparoscopy. One patient was diagnosed with more extensive disease than that as assessed by the evaluative laparoscopy. Of note, for 20% of the patients with straight away laparotomy, the complete cytoreduction was not possible. CONCLUSION: Laparoscopic scoring of peritoneal carcinomatosis is accurate to assess the complete resectability of PC in patients for which there is inadequate or contradictory information concerning disease extent.

Immune-mediated reactions to althesin (alphaxalone).

Measurements of complement conversion and white cell variations were made on sequential blood samples obtained from a single volunteer following repeated administration of Althesin. The results suggest a mechanism by which a clinically significant hypersensitivity reaction to the drug might be mediated. Studies of patients receiving routine anaesthesia revealed a very high incidence of subclinical "hypersensitivity" reaction, some of which appear to be immune-mediated. These reactions occurred irrespective of whether the patients were induced with Althesin, methohexitone or propanidid.

Identification and quantitation of hypersensitivity reactions to intravenous anaesthetic agents.

It is not possible to distinguish between direct pharmacological effects and immune-mediated hypersensitivity reactions by clinical observation alone and errors may occur in the absence of laboratory tests. A convenient and simple test is the measurement of plasma complement C3 consumption and conversion in sequential blood samples taken at intervals over the 24 h following an adverse response.

Malignant hyperpyrexia: Investigation of a family after a fatal case.

The relatives of a patient who died from malignant hyperpyrexia were examined clinically and biochemically. One fo the deceased's children, an identical twin, undergoing an anesthetic, was found to develop malignant hyperpyrexia on exposure to nitrous oxide. The creatine phosphokinase concentrations in this family were unhelpful as a method of identifying susceptible individuals.

Bupivacaine carbonate and bupivacaine hydrochloride: a comparison of blood concentrations during epidural blockade for vaginal surgery.

Carbonated bupivacaine, plain bupivacaine hydrochloride, and bupivacaine hydrochloride with adrenaline were used to provide epidural analgesia for patients undergoing vaginal hysterectomy. Following injection to the blood concentrations of bupivacaine were measured at intervals over a period of 30 minutes. All three preparations produced satisfactory analgesia at a bupivacaine dose of 1.5 mg/kg body weight. The highest group mean blood concentrations were just outside the toxic dose range. Carbonated bupivacaine was absorbed most rapidly producing significantly higher blood concentrations up to 12 minutes after injection.