Postoperative cognitive dysfunction is rare after fast-track hip- and knee arthroplasty - But potentially related to opioid use.

STUDY OBJECTIVE: Postoperative cognitive dysfunction (POCD) remains a frequent postoperative complication in non-fast-track surgeries, with negative implications for return to daily activities and work. In fast-track total hip and -knee arthroplasty (THA/TKA) an 8-9% incidence of POCD after 3 months has been reported, but without details on specific perioperative risk factors. Thus, we re-investigated the incidence and role of suggested factors for POCD in a well-controlled patient cohort, to guide future preventive interventions. DESIGN: A subanalysis of a prospective study. SETTING: Hospital ward, patients own home. PATIENTS: One-hundred-and-four patients undergoing elective THA/TKA. INTERVENTIONS: A full contextual and validated cognitive test battery pre- and 2-3 weeks postoperatively by interview by research nurse. MEASUREMENTS: Results from the cognitive test battery were corrected for learning effect by normative data from an age-matched unoperated control group. Potential perioperative risk factors (age, procedure, gender, inflammation, blood-percentage, opioids etc.) associated with POCD was investigated by univariate and multivariate logistic analysis, with a 5% significance level. MAIN RESULTS: Four patients (3.9%) developed POCD. POCD-positive patients consumed higher dose of opioids in the acute postoperative period (postoperative days 0-3: median 214 mg), vs. POCD-negative patients (postoperative days 0-3: median 98 mg, p = 0.008), and during the 2-3-week study period (POCD-positive vs. POCD-negative patients, median 739 mg vs. 208 mg, respectively). Other pre and postoperative factors were non-significant but associated with the development of POCD. CONCLUSION: POCD is rare in fast-track THA/TKA patients and may be related to postoperative opioid consumption, supporting the ongoing focus on opioid-sparing analgesia.

Objectively measured early physical activity after total hip or knee arthroplasty.

Although reduced early physical function after total hip- and knee arthroplasty (THA/TKA) is well-described, the underlying reasons have not been clarified with detailed studies on pathophysiological mechanisms related to recovery, thereby prohibiting advances in rehabilitation. Thus, we aimed to describe early post-THA/TKA physical activity measured by actigraphy and potential underlying pathophysiological mechanisms related to recovery in a well-defined cohort of THA and TKA patients. Daytime-activity was measured from 2 days before until 13 (THA) or 20 (TKA) days after surgery. The primary outcome was individualized recovery in activity, with secondary analyses of activity-intensities and association to the perioperative factors: sex, age, BMI, hemoglobin (hgb), C-reactive protein and postoperative pain. Eighty-one THA/TKA-patients were examined. A large inter-individual variation in early physical activity was found. On a group level, activity was significantly reduced compared to preoperatively the first 2 (THA) or 3 (TKA) weeks after surgery (mean-difference - 64 counts × 103/day, p < 0.001 and - 78 counts × 103/day, p < 0.001, respectively). All activity-intensities were affected with the largest decline in high intense activity. A slight overall improvement in activity was seen during the postoperative phase [THA: 1%/day (SD 2.15); TKA: 0.7%/day (SD 1.04)], but approximately 30% of THA and 20% of TKA patients had reduced and declining activity. Hgb, CRP, BMI (THA) and postoperative pain (TKA) were only weakly associated with impaired physical activity. Physical activity was reduced the first weeks following THA/TKA, but with large inter-individual variations in recovery profiles. No single pathogenic factor was associated with a poor recovery. Early risk stratified interventions are needed in patients on a suboptimal course.

Individualized assessment of post-arthroplasty recovery by actigraphy: a methodology study.

Previous studies using actigraphy to monitor recovery after total knee arthroplasty (TKA) have reported activity as maximum and average count/min, but not utilized the full potential of the data by stratifying activity into various intensities or analysed the individual development in activity over time. The aim of this study was to describe a novel methodology using actigraphy data to describe specific activity-intensities potentially affected by surgery and patients with poor rehabilitation trajectories. Actigraphy data from 10 patients scheduled for primary unilateral TKA were recorded preoperatively and for 3 weeks postoperatively. Data were individualized by comparing pre- and post-operative values, and activity intensities stratified by division into 5 percentiles (10th, 25th, 50th, 75th and 90th). Changes in activity were assessed visually and by non-parametric testing. Individualized recovery trajectories were described by the gradient of the regression line of post- versus pre-operative physical activity over the study period. TKA had a negative impact on all activity intensities with gradual improvement towards preoperative values during the study period. The inter-individual variation increased with intensified activity. Identification of individual patients with positive, neutral or negative activity trajectories was possible. The methodology should be considered in future interventional studies to improve rehabilitation strategies.

Somatostatin-Immunoreactive Pancreaticoduodenal Neuroendocrine Neoplasms: Twenty-Three Cases Evaluated according to the WHO 2010 Classification.

BACKGROUND/OBJECTIVE: Neuroendocrine neoplasms of the pancreas and duodenum with predominant or exclusive immunoreactivity for somatostatin (pdSOMs) are rare, and knowledge about tumour biology, treatment, survival and prognostic factors is limited. This study aims to describe clinical, pathological and biochemical features as well as treatment and prognosis of pdSOMs. DESIGN: Twenty-three patients with pdSOM (9 duodenal, 12 pancreatic and 2 unknown primary tumours) were identified from our prospective neuroendocrine tumour database, and data according to the study aims were recorded. RESULTS: Among the 9 patients with duodenal SOM, the male/female ratio was 4/5. All males and 1 female had neurofibromatosis type 1. Seven patients had stage 1A/B and 2 had stage 2B disease. The Ki-67 index was 1-5% (median 2%). Plasma somatostatin was elevated in the patients with 2B disease. Of the 14 patients with pancreatic SOM or an unknown primary tumour, the male/female ratio was 2/12. One male had multiple endocrine neoplasia type 1. Five had stage 1A/2B and 9 had stage 4. The Ki-67 index was 1-40% (median 7%). Plasma somatostatin was elevated in 7 patients. Patients reported symptoms related to the somatostatinoma syndrome, but none fulfilled the criteria for a full syndrome. Primary tumour in the pancreas, metastatic disease at diagnosis and higher tumour grade were all associated with significantly poorer survival. CONCLUSION: None of the patients with pdSOM presented with the full somatostatinoma syndrome. Prognostic factors are localisation of the primary tumour, dissemination and tumour grade. A Ki-67 index of 5% may discriminate the course of the disease.