A randomized, pragmatic, pharmacist-led intervention reduced opioids following orthopedic surgery

OBJECTIVES

To determine whether a pharmacist-led, patient-directed intervention can reduce opioid use following total hip arthroplasty (THA) or total knee arthroplasty (TKA).

STUDY DESIGN

Randomized trial.

METHODS

Patients scheduled to undergo THA or TKA (during 2015 and 2016) were randomized to usual care or intervention. We ranked patients according to predicted risk of persistent opioid use and selected the top 60% for inclusion (n = 561); all contributed to the analysis. Intervention patients were mailed materials 2 weeks before and after surgery, plus they received telephone intervention from specially trained pharmacists if they filled opioid prescriptions in the 28 to 90 days following surgery. Our primary outcome was the dispensed morphine equivalents (DME) in the 90 days following surgery, modeled using a natural log transformation.

RESULTS

A total of 561 patients were randomized (286 usual care, 118 THA and 168 TKA; 275 intervention, 107 THA and 168 TKA); the mean age was 66 years, and 60% were female. Overall, we found no meaningful reduction in DME for intervention versus usual care (geometric mean ratio, 0.92 [95% CI, 0.69-1.21]). However, there was effect modification by whether the patient had TKA or THA (interaction P <.01). Those undergoing THA in the intervention group used significantly less DME than did those undergoing THA in the usual care group (geometric mean ratio, 0.52 [95% CI, 0.33-0.82]).

CONCLUSIONS

Our pharmacist-led, patient-directed intervention to reduce opioid use demonstrated a reduction in opioid dispensings in the 90 days following THA but not TKA.

A qualitative study to develop materials educating patients about opioid use before and after total hip or total knee arthroplasty

OBJECTIVE

The authors undertook a qualitative study with open-ended, structured interviews to understand patient)s educational needs for patients undergoing total hip and total knee arthroplasty (THA/TKA).

DESIGN

Provider interviews explored their approach with THA/TKA patients on: pain management; barriers to opioid tapering; and recommendations/changes on educational materials to support pain management and opioid reduction. Patient interviews explored their experience, understanding, beliefs surrounding opioids, and recommendations on important content. A qualitative methodologist conducted interviews and content analysis to identify key themes.

SETTING

Kaiser Permanente Northwest, community setting.

PATIENTS, PARTICIPANTS

A purposeful sampling method identified interviewees (surgeons, advice nurses, physical therapists, physician assistants, and patients). Patients were recent THA/TKA cases in the top third of opioid use after surgery.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURE(S)

Qualitative study.

RESULTS

Recommendations for patient educational content included: (1) clear descriptions of how opioids work in the body, how to taper, nonopioid pain management options, and problems from overuse; (2) messaging on how long to expect to use opioids and type of pain to expect; (3) visual timeline to illustrate opioid tapering and exercise expectations; (4) emphasize that pain management is multimodal, and stress the balance between opioids for recovery versus overuse; (5) provide educational messaging multiple times prior to and after surgery.

CONCLUSIONS

Patients and providers agreed that clearly stated verbal and written messaging is needed beyond what has typically been done regarding opioid expectations.

Regulatory T cells: tolerance induction in solid organ transplantation

The concept of regulatory T cell (T_reg ) therapy in transplantation is now a reality. Significant advances in science and technology have enabled us to isolate human T_regs , expand them to clinically relevant numbers and infuse them into human transplant recipients. With several Phase I/II trials under way investigating T_reg safety and efficacy it is now more crucial than ever to understand their complex biology. However, our journey is by no means complete; results from these trials will undoubtedly provoke both further knowledge and enquiry which, alongside evolving science, will continue to drive the optimization of T_reg therapy in the pursuit of transplantation tolerance. In this review we will summarize current knowledge of T_reg biology, explore novel technologies in the setting of T_reg immunotherapy and address key prerequisites surrounding the clinical application of T_regs in transplantation.

Mechanism of macromolecular structure evolution in self-assembled lipid nanoparticles for siRNA delivery

Lipid nanoparticles (LNPs) are a leading platform for therapeutic delivery of small interfering RNAs (siRNAs). Optimization of LNPs as therapeutic products is enabled by the development of structure-activity relationships (SAR) linking LNP physiochemical and macromolecular properties to bioperformance. Methods by which LNP properties can be rationally manipulated are thus critical enablers of this fundamental knowledge build. In this work, we present a mechanistic study of LNP self-assembly via a rapid antisolvent precipitation process and identify critical physiochemical and kinetic parameters governing the evolution of LNP three-dimensional macromolecular structure as a biorelevant SAR feature. Using small-angle X-ray scattering, LNPs are shown to undergo a temporal evolution in macromolecular structure during self-assembly, rearranging from initially disordered phases after precipitation into well-ordered structures following a necessary annealing stage of the assembly sequence. The ability of LNPs to undergo structural reorganization is shown to be effected by the chemical nature of the aqueous antisolvent used for precipitation. Antisolvents of varying buffering species differentially influence LNP macromolecular features, revealing a new participatory role of buffer ions in LNP self-assembly. Furthermore, the formation of macromolecular structure in LNPs is shown to improve the efficiency of siRNA encapsulation, thereby offering a simple, nonchemical route for preparation of high-payload LNPs that minimize the dose of lipid excipients. The developed LNP precipitation process and mechanistic understanding of self-assembly are shown to be generalizable, enabling the production of LNPs with a tunable range of macromolecular features, as evidenced by the cubic, hexagonal, and oligo-lamellar phase LNPs exemplarily generated.

The development of an in vitro assay to screen lipid based nanoparticles for siRNA delivery

In order to rapidly screen and select lead candidates for in vivo evaluation of lipid nanoparticles (LNPs) for systemic small interfering RNA (siRNA) delivery, an in vitro assay amenable to high-throughput screening (HTS) is developed. The strategy is to mimic the in vivo experience of LNPs after systemic administration, such as interactions with serum components, exposure to endosomal pH environments, and interactions with endosomal membrane lipids. It is postulated that the amount of siRNA released from LNPs after going through these treatments can be used as a screening tool to rank order the effectiveness of siRNA delivery by lipid nanoparticles in vivo. LNPs were incubated with 50% serum from different species (i.e. mouse, rat, or rhesus) at 37°C. The resulting samples were then reacted with anionic, endosomal-mimicking lipids at different pHs. The amount of siRNA released from LNPs was determined using spectrophotometry employing the fluorescent indicator SYBR Gold. Our results indicated that the amount of siRNA liberated was highly dependent upon the species of serum used and the pH to which it was exposed. LNPs treated with mouse serum showed higher levels of siRNA release, as did those subjected to endosomal pH (6.0), compared to physiological pH. Most interestingly, a good correlation between the amount of siRNA released and the in vivo efficacy was observed. In conclusion, an in vitro siRNA release assay was developed to screen and rank order LNPs for in vivo evaluation.

The validation of synthetic spectra used in the performance evaluation of radionuclide identifiers

This work has evaluated synthetic gamma-ray spectra created by the RASE sampler using experimental data. The RASE sampler resamples experimental data to create large data libraries which are subsequently available for use in evaluation of radionuclide identification algorithms. A statistical evaluation of the synthetic energy bins has shown the variation to follow a Poisson distribution identical to experimental data. The minimum amount of statistics required in each base spectrum to ensure the subsequent use of the base spectrum in the generation of statistically robust synthetic data was determined. A requirement that the simulated acquisition time of the synthetic spectra was not more than 4% of the acquisition time of the base spectrum was also determined. Further validation of RASE was undertaken using two different radionuclide identification algorithms.

Incidence and demography of femur fractures with and without atypical features

The case definition, community incidence, and characteristics of atypical femoral shaft fractures (FSFs) are poorly understood. This retrospective study utilized electronic medical records and radiograph review among women ≥50 years of age and men ≥65 years of age from January 1996 to June 2009 at Kaiser Permanente Northwest to describe the incidence rates and characteristics of subgroups of femur fractures. Fractures were categorized based on the American Society for Bone and Mineral Research (ASBMR) as atypical fracture major features (AFMs) (low force, shaft location, transverse or short oblique, noncomminuted) and AFMs with additional minor radiograph features (AFMms) (beaking, cortical thickening, or stress fracture). There were 5034 fractures in the study. The incidence rates of FSFs (without atypical features) and AFMs appeared flat (cumulative incidence: 18.2 per 100,000 person-years, 95% CI = 16.0-20.7; 5.9 per 100,000 person-years, 95% CI = 4.6-7.4; respectively) with 1,271,575 person-years observed. The proportion of AFMs that were AFMms increased over time. Thirty percent of AFMs had any dispensing of a bisphosphonate prior to the fracture, compared to 15.8% of the non-atypical FSFs. Years of oral glucocorticosteroid dispensing appeared highest in AFM and AFMm fractures. Those with AFMs only were older and had a lower frequency of bisphosphonate dispensing compared to those with AFMms. We conclude that rates of FSFs, with and without atypia, were low and stable over 13.5 years. Patients with only AFMs appear to be different from those with AFMms; it may be that only the latter group is atypical. There appear to be multiple associated risk factors for AFMm fractures.

Strength of fixation with transosseous sutures in rotator cuff repair

The effect of various configurations of placement of transosseous sutures on the immediate strength of fixation was studied in forty-five fresh-frozen humeri from cadavera of older individuals (mean age at the time of death, sixty-three years). The ultimate strength (the strength to failure) was significantly greater (p < 0.05) when the sutures were placed at sites more distal to the tip of the greater tuberosity or when the sutures were tied over a wider bone bridge. Cortical augmentation with use of a plastic button through which the transosseous sutures were tied increased the ultimate strength approximately 1.9-fold. The increase in the ultimate strength of the transosseous repair corresponded significantly with the increasing mean thickness of the cortical bone as the sutures were placed more distally along the lateral aspect of the humerus. We concluded that the strength of the fixation of a rotator cuff repair can be increased by placing the transosseous sutures at least ten millimeters distal to the tip of the greater tuberosity and by tying them over a bone bridge that is at least ten millimeters wide. When bone is very osteoporotic, cortical augmentation with a readily available plastic button strengthens the repair.