Long-term analgesic use after low-risk surgery: a retrospective cohort study

BACKGROUND

This study evaluated the risk of long-term analgesic use after low-risk surgery in older adults not previously prescribed analgesics.

METHODS

We conducted a retrospective cohort study using linked, population-based administrative data in Ontario, Canada, from April 1, 1997, through December 31, 2008. We identified Ontario residents 66 years and older who were dispensed an opioid within 7 days of a short-stay surgery (cataract surgery, laparoscopic cholecystectomy, transurethral resection of the prostate, or varicose vein stripping) and assessed the risk of long-term opioid use, defined as a prescription for an opioid within 60 days of the 1-year anniversary of the surgery. In a secondary analysis, we examined the risk of long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs). We used multivariate logistic regression to examine the association between postsurgical use of analgesics and long-term use.

RESULTS

Among 391,139 opioid-naive patients undergoing short-stay surgery, opioids were newly prescribed to 27,636 patients (7.1%) within 7 days of being discharged from the hospital, and opioids were prescribed to 30,145 patients (7.7%) at 1 year from surgery. An increase in the use of oxycodone was found during this time (from 5.4% within 7 days to 15.9% at 1 year). In our primary analysis, patients receiving an opioid prescription within 7 days of surgery were 44% more likely to become long-term opioid users within 1 year compared with those who received no such prescription (adjusted odds ratio, 1.44; 95% CI, 1.39-1.50). In a secondary analysis, among 383,780 NSAID-naive patients undergoing short-stay surgery, NSAIDs were prescribed to 1169 patients (0.3%) within 7 days of discharge and to 30,080 patients (7.8%) at 1 year from surgery. Patients who began taking NSAIDs within 7 days of surgery were almost 4 times more likely to become long-term NSAID users compared with patients with no such prescription (adjusted odds ratio, 3.74; 95% CI, 3.27-4.28).

CONCLUSION

Prescription of analgesics immediately after ambulatory surgery occurs frequently in older adults and is associated with long-term use.

Computed tomography findings of bowel wall thickening: its significance and relationship to endoscopic abnormalities

INTRODUCTION

The aim of this study was to conduct retrospective analysis of abdominopelvic computed tomography (CT) reports, identifying those patients in whom bowel wall thickening (BWT) was observed, and to correlate these reports with subsequent endoscopic evaluation.

METHODS

Formal reports for all patients undergoing abdominopelvic CT between February 2007 and September 2009 were reviewed. Where patients were identified as having colorectal 'wall thickening', results of subsequent endoscopic evaluations were documented. Only those patients with a report of BWT who had follow-up endoscopy (colonoscopy, sigmoidoscopy) were included in the analysis.

RESULTS

A total of 165 patients were included. Abnormalities on endoscopy at the exact site of the BWT on CT were found in 95 patients (57.58%); in 36 cases (21.82%) this was a malignant lesion. BWT of the transverse colon was significantly more likely to correspond to an endoscopic finding of cancer than other sites (p=0.034). Rectal bleeding was reported significantly more often in patients with BWT and neoplastic disease on endoscopy compared with those with normal endoscopy (p=0.04). Excluding patients with inflammatory/diverticular lesions, 59.02% of Caucasians had a neoplastic lesion at the site of reported BWT, significantly higher than the other ethnic groups (p=0.008). There were 38 patients (23.03%) who did not present with bowel symptoms and, of these, 6 were diagnosed subsequently with colorectal cancer.

CONCLUSIONS

This study supports endoscopic evaluation to investigate patients with CT evidence of BWT, especially in cases involving the transverse colon, in Caucasian patients or in association with symptoms of rectal bleeding.

The characteristics of physicians disciplined by professional colleges in Canada

BACKGROUND

The identification of health care professionals who are incompetent, impaired, uncaring or have criminal intent has received increasing attention in recent years. These individuals are often subject to disciplinary action by professional licensing authorities. To date, no national data exist for Canadian physicians disciplined for professional misconduct. We sought to describe the characteristics of physicians disciplined by Canadian professional licensing authorities.

METHODS

We constructed a database of physicians disciplined by provincial licensing authorities during the years 2000 to 2009. Comparisons were made with the general population of physicians licensed in Canada. Data on demographic characteristics, type of misconduct and penalty imposed were collected for each disciplined physician.

RESULTS

A total of 606 identifiable physicians were disciplined by their professional college during the years 2000 to 2009. The proportion of licensed physicians who were disciplined in a given year ranged from 0.06% to 0.11%. Fifty-one of the disciplined physicians committed 64 repeat offences, accounting for a total of 113 (19%) offences. Most of the disciplined physicians were independent practitioners (99%), male (92%) and trained in Canada (67%). The most common specialties of physicians subject to disciplinary action were family medicine (62%), psychiatry (14%) and surgery (9%). For disciplined physicians, the average number of years from medical school graduation to disciplinary action was 28.9 (standard deviation [SD] = 11.3). The 3 most frequent violations were sexual misconduct (20%), failure to meet a standard of care (19%) and unprofessional conduct (16%). The 3 most frequently imposed penalties were fines (27%), suspensions (19%) and formal reprimands (18%).

INTERPRETATION

A small proportion of registered physicians in Canada were disciplined by their medical licensing authorities. Sexual misconduct was the most common disciplined offence. The standardization of provincial reporting along with the creation of a national database of physician offenders would facilitate more comparable public reporting as well as further research and educational initiatives.

Magnetic Resonance Imaging in Evaluation of Periventricular Leukomalacia

BACKGROUND

Improvements in perinatal care have resulted in increased survival of infants born prematurely, however neurological damage due to ischaemic infarction of the periventricular white matter is a problem of enormous medical, social and economic importance. Such vascular insult leads to destruction of the periventricular white matter, termed periventricular leukomalacia (PVL). This abnormality is the leading cause of significant morbidity in the survivors of premature birth. Magnetic Resonance Imaging (MRI) is perhaps the only imaging modality, which can accurately detect and quantify periventricular leukomalacia.

METHODS

Magnetic Resonance Imaging was carried out in 45 children in the age group of 4 weeks to 8 years, with history of premature birth and perinatal hypoxia. These children had neurological deficits ranging from cortical blindness, spastic diplegia, spastic quadriplegia to severe mental retardation. The procedure was carried out on a 1.5 Tesla (Siemens Magnetom Avanto) MR system using available protocols for imaging the paediatric brain.

RESULT

The study revealed that MR imaging could accurately identify areas of ischaemic infarction of the periventricular white matter both in the early as well as in the late stages. The pattern of abnormalities detected on MRI of the brain in these patients can be considered specific for PVL in the clinical background of premature birth and perinatal hypoxia.

CONCLUSION

MRI is the ideal imaging modality to detect, quantify and accurately map the areas of brain affected by this hypoxic-ischaemic process. It is presently the gold standard for evaluating the neuroparenchyma in those with perinatal hypoxia. Advanced MR techniques like Diffusion Weighted Imaging (DWI), Proton MR Spectroscopy and DTI have shown great promise in our understanding of the pathophysiology and anatomic considerations of this disease process.

Three Dimensional Spiral CT Imaging of the Musculoskeletal System: Application and Advantages

BACKGROUND

Clinical applications of spiral computed tomography (CT) have increased extensively over the past decade and continue to widen rapidly. The introduction of three-dimensional(3-D) reconstruction in CT technology has revolutionized medical imaging. This advancement has been possible due to the combination of spiral computed tomography and various 3-D reconstruction protocols which have permitted rapid and comprehensive examination of all regions of the body. It has unequivocal advantages in the preoperative planning of craniofacial surgery, assessment of complex fractures of the skeletal system especially pelvis and in the surgical treatment of dysplastic hips in children.

METHODS

3-D spiral CT imaging of various parts of the musculoskeletal system was carried out in 60 cases using available protocols, at the CT scan center of a large tertiary care service hospital.

RESULTS

The study provided a new approach in the analysis of complex anatomic relationships of the musculoskeletal system. Therapeutic planning whether surgical or medical was to a great extent aided by the anatomic information available from these images.

CONCLUSION

3-D CT imaging is a rapid, non-invasive and accurate technique for diagnosis, pre-operative evaluation as well as post-operative assessment of a large number of musculoskeletal diseases. 3-D CT studies have come to stay and with continued improvement in CT technology it has now become an integral part of imaging studies of the musculoskeletal system.

Computer hardware for radiologists: Part I

Computers are an integral part of modern radiology practice. They are used in different radiology modalities to acquire, process, and postprocess imaging data. They have had a dramatic influence on contemporary radiology practice. Their impact has extended further with the emergence of Digital Imaging and Communications in Medicine (DICOM), Picture Archiving and Communication System (PACS), Radiology information system (RIS) technology, and Teleradiology. A basic overview of computer hardware relevant to radiology practice is presented here. The key hardware components in a computer are the motherboard, central processor unit (CPU), the chipset, the random access memory (RAM), the memory modules, bus, storage drives, and ports. The personnel computer (PC) has a rectangular case that contains important components called hardware, many of which are integrated circuits (ICs). The fiberglass motherboard is the main printed circuit board and has a variety of important hardware mounted on it, which are connected by electrical pathways called “buses”. The CPU is the largest IC on the motherboard and contains millions of transistors. Its principal function is to execute “programs”. A Pentium^® 4 CPU has transistors that execute a billion instructions per second. The chipset is completely different from the CPU in design and function; it controls data and interaction of buses between the motherboard and the CPU. Memory (RAM) is fundamentally semiconductor chips storing data and instructions for access by a CPU. RAM is classified by storage capacity, access speed, data rate, and configuration.

The fungicide ciclopirox inhibits lymphatic endothelial cell tube formation by suppressing VEGFR-3-mediated ERK signaling pathway

Ciclopirox olamine (CPX), an off-patent antifungal agent used to treat mycoses of skin and nails, has recently been demonstrated to be a potential anticancer agent. However, the underlying mechanism is not well understood. Here for the first time we show that CPX inhibited lymphangiogenesis in an in vitro model (tube formation). This effect was in part associated with inhibition of vascular endothelial growth factor receptor 3 (VEGFR-3) expression, as overexpression of VEGFR-3 conferred partial resistance to CPX inhibitory effect on tube formation in lymphatic endothelial cells (LECs), whereas downregulation of VEGFR-3 mimicked the effect of CPX, blocking the tube formation. Further study revealed that CPX did not alter mRNA level, but inhibited protein synthesis and promoted protein degradation of VEGFR-3. In addition, we found that CPX inhibited phosphorylation of the extracellular signal-related kinase 1/2 (ERK1/2), a downstream effector of VEGFR-3. Overexpression of VEGFR-3 attenuated CPX inhibition of ERK1/2 phosphorylation, whereas downregulation of VEGFR-3 inhibited extracellular signal-related kinase 1/2 (ERK1/2) phosphorylation in LECs. Ectopic expression of constitutively active mitogen -activated protein kinase kinase 1 (MKK1) resulted in activation of ERK1/2, and partially prevented CPX inhibition of LEC tube formation. The results suggest that CPX inhibits LEC tube formation at least in part through inhibiting VEGFR-3-mediated ERK signaling pathway.

Computer hardware for radiologists: Part 2

Computers are an integral part of modern radiology equipment. In the first half of this two-part article, we dwelt upon some fundamental concepts regarding computer hardware, covering components like motherboard, central processing unit (CPU), chipset, random access memory (RAM), and memory modules. In this article, we describe the remaining computer hardware components that are of relevance to radiology. “Storage drive” is a term describing a “memory” hardware used to store data for later retrieval. Commonly used storage drives are hard drives, floppy drives, optical drives, flash drives, and network drives. The capacity of a hard drive is dependent on many factors, including the number of disk sides, number of tracks per side, number of sectors on each track, and the amount of data that can be stored in each sector. “Drive interfaces” connect hard drives and optical drives to a computer. The connections of such drives require both a power cable and a data cable. The four most popular “input/output devices” used commonly with computers are the printer, monitor, mouse, and keyboard. The “bus” is a built-in electronic signal pathway in the motherboard to permit efficient and uninterrupted data transfer. A motherboard can have several buses, including the system bus, the PCI express bus, the PCI bus, the AGP bus, and the (outdated) ISA bus. “Ports” are the location at which external devices are connected to a computer motherboard. All commonly used peripheral devices, such as printers, scanners, and portable drives, need ports. A working knowledge of computers is necessary for the radiologist if the workflow is to realize its full potential and, besides, this knowledge will prepare the radiologist for the coming innovations in the ‘ever increasing’ digital future.

Lymphocytic variant of hypereosinophilic syndrome

Hypereosinophilia may be associated with any of several underlying diseases. Atopy or allergic drug reactions are the most common causes, but infections with bacteria and parasites should also be considered in the differential diagnosis. When thorough evaluation of a patient with chronic hypereosinophilia fails to reveal an underlying disease, the diagnosis of idiopathic hypereosinophilic syndrome (HES) should be considered. We report a patient with unexplained persistent hypereosinophilia associated with a chronic pruritic rash and an underlying diagnosis of HES (lymphocytic variant).

The clinical impact of an early decline in kidney function in patients following heart transplantation

Renal dysfunction is a well-known complication following heart transplantation. We examined an early decline in kidney function as a predictor of progression to end-stage renal disease and mortality in heart transplant recipients. We performed a retrospective cohort study of 233 patients who received a heart transplant between July 1985 and July 2004, and who survived >1 month. The decline in estimated creatinine clearance (CrCl) was used to predict the outcomes of need for chronic dialysis or mortality >1-year posttransplant. The earliest time to chronic dialysis was 484 days. A 30% decline in CrCl between 1 month and 12 months predicted the need for chronic dialysis (p = 0.01), all-cause mortality (p < 0.0001) and time to first CrCl </=30 mL/min at >1-year posttransplant (p = 0.02). A 30% decline in CrCl between 1 month and 3 months also independently predicted the need for chronic dialysis (p = 0.04) and time to first CrCl </= 30 mL/min at >1-year posttransplant (p = 0.01). In conclusion, an early drop in CrCl within the first year is a strong predictor of chronic dialysis and death >1-year postheart transplantation. Future studies should focus on kidney function preservation in those identified at high risk for progression to end-stage kidney disease and mortality.

Formulation and evaluation of pharmaceutically equivalent parenteral depot suspension of methyl prednisolone acetate

The aim of the present study was to formulate and evaluate pharmaceutically equivalent injectable aqueous suspension for parenteral depot of methyl prednisolone acetate. Various aqueous suspensions were prepared by rapid stirring and colloid milling method. The prepared aqueous suspensions were subjected to particle size determination, sedimentation study, in vitro release studies (pH dependent dissolution study), and stability studies. The optimized formulation consisted of 4% w/w of methyl prednisolone acetate, 2.91% w/w of PEG-3350, 0.19% w/v of injection grade Tween-80, 0.68% w/w of monobasic sodium phosphate, 0.15% w/w of di-basic sodium phosphate, 0.91% w/v of benzyl alcohol, 0.32% w/w sodium meta bisulphate. The f(2) value was calculated for innovator (DepoMedrol( ((R)) ), Batch No. MPH-0254) and optimized formulation at pH 6.8 and pH 7.4 phosphate buffers. The f(2) values of 62.94 and 54.37 were obtained at pH 6.8 and pH 7.4 phosphate buffers respectively. The particle size ranged 23-27 mum at D value of 0.9 for both test and innovator product.

Occurrence, distribution and possible sources of organochlorine pesticide residues in tropical coastal environment of India: an overview

Organochlorine pesticides (OCPs) are an important potential component of chemical pollutants used extensively for agriculture and sanitation purposes in India as these are comparatively cheap and effective. These persistent organic compounds such as HCH isomers, DDT and its metabolites are the predominant chemical contaminants found along the Indian coast and thus constitute both alluring and grave areas of scientific research. Our objective in the paper is to provide a comprehensive account of the distribution of organochlorine pesticides in biotic and abiotic compartments of the Indian coastal environment, make some comments on their environmental sources, their movement through the food chain and possible ecotoxicological risk of health in biota including humans. The prevalent HCH, DDT and HCB concentrations differ markedly in eastern and western coast of India reflecting differing agricultural and other usage and their ultimate input into the coastal environment by several rivers and the bioturbation activities of macrozoobenthos (bivalve mollusks, polychaetous annelids, etc.). In several cases, the DDT levels exceeded the effects range-low (ER-L) and could thus cause acute biological impairments, in comparison with the sediment quality guidelines. Contributions of DDT metabolites (DDT, DDD and DDE residues) vary in different Indian coastal regions predominated by pp'-DDT and pp'-DDD. Measured concentrations of HCHs were lower than DDTs that might be due to higher water solubility, vapor pressure and biodegradability of the latter. HCH and DDT residues in fish in India were lower than those in the temperate countries indicating a lower accumulation in tropical fish, which might be related to rapid volatilization of this insecticide in the tropical environment. The concentrations of other chlorinated pesticides (aldrin, dieldrin, eldrin, methoxychlor, endosulfan sulphate) were lower and not generally of great concern.