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.

Morbidity and in-hospital mortality after hip fracture surgery on weekends versus weekdays.

PURPOSE: To compare morbidity and in-hospital mortality in patients who underwent surgery for femoral neck fracture on weekends versus on weekdays. METHODS: Records of 90 men and 225 women (mean age, 80.5 years) who underwent surgery for femoral neck fractures on weekends or public holidays (n=110) or on weekdays (n=205) were retrospectively reviewed. The morbidity and in-hospital mortality of the 2 groups were compared. RESULTS: The 2 groups were comparable in terms of age, sex, and time to surgery, but more hemiarthroplasties were performed on weekdays (35.0% vs. 25.0%, p=0.036). Compared with surgery on weekdays, surgery on weekends was associated with increased in-hospital mortality (3.4% vs. 9.1%, p=0.04). None of the potential confounders (age, type of surgery, presenting hospital, and time to surgery) had a significant effect on in-hospital mortality. CONCLUSION: In patients with femoral neck fractures, surgery on weekends was associated with increased in-hospital mortality but not with increased morbidity after adjusting for confounders, compared with surgery on weekdays.

Asunaprevir plus daclatasvir for the treatment of chronic hepatitis C virus infection.

Daclatasvir is a nonstructural protein 5A inhibitor of hepatitis C virus (HCV) replication. Asunaprevir is an NS3/4A complex inhibitor of HCV replication. The combination of daclatasvir and asunaprevir has been approved in Japan for the treatment of genotype 1 chronic HCV infection. In vitro studies have documented potent activity of these drugs, individually and in combination, against genotype 1 HCV. Results from completed and ongoing clinical studies have confirmed this potent activity in patients, with better responses noted in genotype 1b patients compared to patients with genotype 1a HCV. Response rates are also better in treatment-naive patients compared to those who are treatment-experienced; in these cases, the addition of interferon and ribavirin appears to enhance the treatment response. The combination of daclatasvir and asunaprevir is, in general, well tolerated. Daclatasvir and asunaprevir are substrates for cytochrome P450 3A4 enzymatic pathway; thus, there is a substantial potential for drug interactions.

Practice variation in common fracture presentations: a survey of orthopaedic surgeons.

BACKGROUND: Practice variation may indicate a lack of clear evidence to guide treatment. This study aims to quantify practice variation for common orthopaedic fractures, and to explore possible predictors of the variation. MATERIALS AND METHODS: A nationwide electronic survey of Australian orthopaedic surgeons was performed. Five common fractures (ankle, scaphoid, distal radius, neck of humerus, and clavicle) were presented. Data on management preferences and surgeon background were gathered. Potential predictors of operative (vs. non-operative) treatment were explored. RESULTS: 358 of 760 (47%) surgeons responded. For the ankle, undisplaced scaphoid, distal radius, neck of humerus and clavicle fractures, operative treatment was chosen in 40%, 44%, 77%, 26% and 38%, respectively. Operative treatment was significantly more likely to be chosen by more junior surgeons, and by surgeons specialising in the affected area (i.e., shoulder surgeons for clavicle and neck of humerus fractures, and hand surgeons for scaphoid and distal radius fractures). CONCLUSIONS: Variations exist in the management of common fractures. Variation may represent legitimate improvisation for varying clinical scenarios, but it may reflect clinician bias, which in turn, may contribute to varying standards of care for the management of common conditions.

Endorsing single-unit transfusion combined with a restrictive haemoglobin transfusion threshold after knee arthroplasty.

PROBLEM: The utility of single-unit transfusions in the presence of restrictive haemoglobin transfusion thresholds is unknown. DESIGN: A prospective, pre-post intervention study was undertaken to evaluate a new transfusion strategy designed to reduce the rate of allogeneic transfusion and promote single-unit transfusion. SETTING: Joint replacement centre within a public hospital. PARTICIPANTS: Patients undergoing primary unilateral knee arthroplasty (baseline, n=93; postintervention, n=347). OBJECTIVES OF THE INTERVENTION: Decrease the use of donor blood by (1) reducing the rate of donor transfusion and (2) endorsing the use of single-unit transfusion. STRATEGIES FOR CHANGE: A restrictive transfusion protocol was introduced, which included assessment of the need for transfusion based on haemoglobin value, and presence of signs, symptoms and comorbidity. Single or multiple units of blood were endorsed depending on the indication. KEY MEASURES FOR IMPROVEMENT: Primary outcomes were transfusion rate; frequencies of attempted and successful single-unit transfusions. Secondary outcomes included 6-week haemoglobin and complications within 6 months postsurgery. EFFECTS OF CHANGE: Transfusion rate significantly improved (41% (38/93) to 18% (64/347), chi(2) 21.3, p<0.001). The prescription of single units of blood (24% (9/38) to 33% (21/64), chi(2) 1, p=0.33) and successful single-unit transfusion (24% (9/38) vs 24% (15/64), chi(2)<0.01, p=1.0) were unchanged as were most secondary outcomes. LESSONS LEARNT: Restrictive haemoglobin thresholds are a safe, potent frontline strategy for decreasing the rate of blood transfusion. Judicious endorsement of single units is a secondary strategy for reducing the consumption of donor blood when the transfusion haemoglobin trigger is strict.