Prescribing and Consumption of Opioids After Primary, Unilateral Total Hip and Knee Arthroplasty in Opioid-Naive Patients

BACKGROUND

This cohort study was designed to determine the discrepancy between the quantity of opioid prescribed vs that which was consumed after total knee arthroplasty (TKA) and total hip arthroplasty (THA) in opioid-naive patients.

METHODS

Seven hundred twenty-three opioid-naive patients (426 TKAs and 297 THAs) from 7 hospitals in Michigan were contacted within 3 months of their surgery. Opioid prescribing and self-reported consumption was calculated in oral morphine equivalents (OMEs). Secondary outcomes included opioid refill in the first 90 days, pain in the first 7 days post-operatively, and satisfaction with pain care.

RESULTS

For TKA, the mean prescribing was 632 mg OME (±229), and the mean consumption was 416 mg (±279). For THA, the mean prescribing was 584 mg OME (±335), and the mean consumption was 285 mg (±301). There were no associations between the amount of opioid prescribed and the likelihood of refill, post-operative pain, or satisfaction with pain control. The amount of opioid prescribed was associated with increased consumption, such that each increase of 1 pill was associated with approximately an additional half pill consumed after adjusting for other covariates. Moreover, 48.2% felt that they received "More" or "Much more" opioid than they needed.

CONCLUSION

We recommend no more than 50 tablets of 5 mg oxycodone or its equivalent after TKA and 30 tablets after THA. Although dose reductions in other surgeries have not resulted in harm, continued assessment is needed to ensure that there are no unintended effects of opioid reduction, including worsened pain, decreased satisfaction, emergency department visits, or hospital readmissions.

LEVEL OF EVIDENCE

Level III; Retrospective, cohort study.

Elevated 1-Year Mortality Rate in Males Sustaining Low-Energy Proximal Femur Fractures and Subgroup Analysis Utilizing Age-Adjusted Charlson Comorbidity Index

INTRODUCTION

Low-energy proximal femur fractures are common in the aging population and the ability to identify patients at increased mortality risk provides surgeons information to improve informed decision-making with patients and families. We evaluated for gender differences in 1-year mortality after sustaining low-energy proximal femur fractures with subgroup analysis to identify the impact of fracture location, age, and comorbidities on mortality.

MATERIALS AND METHODS

Patients ≥40 years of age sustaining a low-energy proximal femur fracture identified at our institution between January 1, 2014, and December 31, 2017. International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes were used to identify comorbidities for calculation of the age-adjusted Charlson comorbidity index (ACCI). The county clerk database was searched to identify mortality within 1 year of injury. One-year mortality rates were calculated and multiple comparisons were made between genders controlling for age, fracture location, and/or ACCI.

RESULTS

Women presented with low-energy proximal femur fractures at a rate of almost 3:1 to men at our institution (P = .001). Men demonstrated a significantly increased ACCI at presentation (5.35 ± 2.55 vs 4.86 ± 1.77, P = .03). Men had an increased 1-year mortality rate for all (31.3% vs 21.5%, P = .004) and intertrochanteric (IT) fractures (36.2% vs 22.9%, P = .008). Controlling for ACCI, gender, and fracture location, men demonstrated increased mortality rate with IT fractures (P = .002) and trended toward but did not reach significance with femoral neck fractures (P = .07).

DISCUSSION

Men presenting with low-energy femur fractures are at an increased mortality risk compared to women. On average, men present with an overall worse health status as identified by ACCI, which could predispose these patients not only to fractures themselves but also impair their ability to recover from injury.

CONCLUSION

Men are at an increased 1-year mortality risk after sustaining proximal femur fractures.

Influence of Xe and Kr impurities on x-ray yield from debris-free plasma x-ray sources with an Ar supersonic gas jet irradiated by femtosecond near-infrared-wavelength laser pulses

Many aspects of physical phenomena occurring when an intense laser pulse with subpicosecond duration and an intensity of 10^{18}-10^{19}W/cm^{2} heats an underdense plasma in a supersonic clustered gas jet are studied to determine the relative contribution of thermal and nonthermal processes to soft- and hard-x-ray emission from debris-free plasmas. Experiments were performed at the University of Nevada, Reno (UNR) Leopard laser operated with a 15-J, 350-fs pulse and different pulse contrasts (10^{7} or 10^{5}). The supersonic linear (elongated) nozzle generated Xe cluster-monomer gas jets as well as jets with Kr-Ar or Xe-Kr-Ar mixtures with densities of 10^{18}-10^{19}cm^{-3}. Prior to laser heating experiments, all jets were probed with optical interferometry and Rayleigh scattering to measure jet density and cluster distribution parameters. The supersonic linear jet provides the capability to study the anisotropy of x-ray yield from laser plasma and also laser beam self-focusing in plasma, which leads to efficient x-ray generation. Plasma diagnostics included x-ray diodes, pinhole cameras, and spectrometers. Jet signatures of x-ray emission from pure Xe gas, as well as from a mixture with Ar and Kr, was found to be very different. The most intense x-ray emission in the 1-9 KeV spectral region was observed from gas mixtures rather than pure Xe. Also, this x-ray emission was strongly anisotropic with respect to the direction of laser beam polarization. Non-local thermodynamic equilibrium (Non-LTE) models have been implemented to analyze the x-ray spectra to determine the plasma temperature and election density. Evidence of electron beam generation in the supersonic jet plasma was found. The influence of the subpicosecond laser pulse contrast (a ratio between the laser peak intensity and pedestal pulse intensity) on the jets' x-ray emission characteristics is discussed. Surprisingly, it was found that the x-ray yield was not sensitive to the prepulse contrast ratio.

Biphasic alterations in coronary smooth muscle Ca(2+) regulation in a repeat cross-sectional study of coronary artery disease severity in metabolic syndrome

BACKGROUND AND AIMS

Coronary artery disease (CAD) is progressive, classified by stages of severity. Alterations in Ca(2+) regulation within coronary smooth muscle (CSM) cells in metabolic syndrome (MetS) have been observed, but there is a lack of data in relatively early (mild) and late (severe) stages of CAD. The current study examined alterations in CSM Ca(2+) regulation at several time points during CAD progression.

METHODS

MetS was induced by feeding an excess calorie atherogenic diet for 6, 9, or 12 months and compared to age-matched lean controls. CAD was measured with intravascular ultrasound (IVUS). Intracellular Ca(2+) was assessed with fura-2.

RESULTS

IVUS revealed that the extent of atherosclerotic CAD correlated with the duration on atherogenic diet. Fura-2 imaging of intracellular Ca(2+) in CSM cells revealed heightened Ca(2+) signaling at 9 months on diet, compared to 6 and 12 months, and to age-matched lean controls. Isolated coronary artery rings from swine fed for 9 months followed the same pattern, developing greater tension to depolarization, compared to 6 and 12 months (6 months = 1.8 ± 0.6 g, 9 months = 5.0 ± 1.0 g, 12 months = 0.7 ± 0.1 g). CSM in severe atherosclerotic plaques showed dampened Ca(2+) regulation and decreased proliferation compared to CSM from the wall.

CONCLUSIONS

These CSM Ca(2+) regulation data from several time points in CAD progression and severity help to resolve the controversy regarding up-vs. down-regulation of CSM Ca(2+) regulation in previous reports. These data are consistent with the hypothesis that alterations in sarcoplasmic reticulum Ca(2+) contribute to progression of atherosclerotic CAD in MetS.

Repeat cross-sectional data on the progression of the metabolic syndrome in Ossabaw miniature swine

Ossabaw miniature swine were fed an excess calorie, atherogenic diet for 6, 9, or 12 months. Increased body weight, hypertension, and increased plasma cholesterol and triglycerides are described in Table 1. For more detailed interpretations and conclusions about the data, see our associated research study, “Biphasic alterations in coronary smooth muscle Ca²⁺ regulation during coronary artery disease progression in metabolic syndrome” McKenney-Drake, et al. (2016) [1].

Metabolic Syndrome Abolishes Glucagon-Like Peptide 1 Receptor Agonist Stimulation of SERCA in Coronary Smooth Muscle

Metabolic syndrome (MetS) doubles the risk of adverse cardiovascular events. Glucagon-like peptide 1 (GLP-1) receptor agonists induce weight loss, increase insulin secretion, and improve glucose tolerance. Studies in healthy animals suggest cardioprotective properties of GLP-1 receptor agonists, perhaps partially mediated by improved sarco-endoplasmic reticulum Ca(2+) ATPase (SERCA) activity. We examined the acute effect of GLP-1 receptor agonists on coronary smooth muscle cells (CSM) enzymatically isolated from lean, healthy Ossabaw miniature swine. Intracellular Ca(2+) handling was interrogated with fura-2. The GLP-1 receptor agonist exenatide activated SERCA but did not alter other Ca(2+) transporters. Further, we tested the hypothesis that chronic, in vivo treatment with GLP-1 receptor agonist AC3174 would attenuate coronary artery disease (CAD) in swine with MetS. MetS was induced in 20 swine by 6 months' feeding of a hypercaloric, atherogenic diet. Swine were then randomized (n = 10/group) into placebo or AC3174 treatment groups and continued the diet for an additional 6 months. AC3174 treatment attenuated weight gain, increased insulin secretion, and improved glucose tolerance. Intravascular ultrasound and histology showed no effect of AC3174 on CAD. MetS abolished SERCA activation by GLP-1 receptor agonists. We conclude that MetS confers vascular resistance to GLP-1 receptor agonists, partially through impaired cellular signaling steps involving SERCA.

Compact hohlraum configuration with parallel planar-wire-array x-ray sources at the 1.7-MA Zebra generator

A compact Z-pinch x-ray hohlraum design with parallel-driven x-ray sources is experimentally demonstrated in a configuration with a central target and tailored shine shields at a 1.7-MA Zebra generator. Driving in parallel two magnetically decoupled compact double-planar-wire Z pinches has demonstrated the generation of synchronized x-ray bursts that correlated well in time with x-ray emission from a central reemission target. Good agreement between simulated and measured hohlraum radiation temperature of the central target is shown. The advantages of compact hohlraum design applications for multi-MA facilities are discussed.

Epicardial adipose excision slows the progression of porcine coronary atherosclerosis

Background

In humans there is a positive association between epicardial adipose tissue (EAT) volume and coronary atherosclerosis (CAD) burden. We tested the hypothesis that EAT contributes locally to CAD in a pig model.

Methods

Ossabaw miniature swine (n = 9) were fed an atherogenic diet for 6 months to produce CAD. A 15 mm length by 3–5 mm width coronary EAT (cEAT) resection was performed over the middle segment of the left anterior descending artery (LAD) 15 mm distal to the left main bifurcation. Pigs recovered for 3 months on atherogenic diet. Intravascular ultrasound (IVUS) was performed in the LAD to quantify atheroma immediately after adipectomy and was repeated after recovery before sacrifice. Coronary wall biopsies were stained immunohistochemically for atherosclerosis markers and cytokines and cEAT was assayed for atherosclerosis-related genes by RT-PCR. Total EAT volume was measured by non-contrast CT before each IVUS.

Results

Circumferential plaque length increased (p < 0.05) in the proximal and distal LAD segments from baseline until sacrifice whereas plaque length in the middle LAD segment underneath the adipectomy site did not increase. T-cadherin, scavenger receptor A and adiponectin were reduced in the intramural middle LAD. Relative to control pigs without CAD, 11β-hydroxysteroid dehydrogenase (11βHSD-1), CCL19, CCL21, prostaglandin D₂ synthase, gp91phox [NADPH oxidase], VEGF, VEGFGR1, and angiotensinogen mRNAs were up-regulated in cEAT. EAT volume increased over 3 months.

Conclusion

In pigs used as their own controls, resection of cEAT decreased the progression of CAD, suggesting that cEAT may exacerbate coronary atherosclerosis.

The role of CCR5 and CCR2 polymorphisms in HIV-1 transmission and disease progression

Entry of human immunodeficiency virus type 1 (HIV-1) into target cells requires both CD4 (ref. 1, 2) and one of a growing number of G-protein-coupled seven-transmembrane receptors. Viruses predominantly use one, or occasionally both, of the major co-receptors CCR5 or CXCR4, although other receptors, including CCR2B and CCR3, function as minor co-receptors. CCR3 appears critical in central nervous system infection. A 32-base pair inactivating deletion in CCR5 (delta 32) common to Northern European populations has been associated with reduced, but not absolute, HIV-1 transmission risk and delayed disease progression. A more commonly distributed transition causing a valine to isoleucine switch in transmembrane domain I of CCR2B (64I) with unknown functional consequences was recently shown to delay disease progression but not reduce infection risk. Although we confirm the lack of association of CCR2B 64I with transmission, we cannot confirm the association with delayed progression. Although subjects with CCR5 delta 32 defects had significantly reduced median viral load at study entry, providing a plausible explanation for the association with delayed progression, this association was not seen with CCR2B 64I. Further studies are needed to define the role of CCR2B64I in HIV pathogenesis.

One trial conditioning with apomorphine is blocked by cycloheximide

Rats with unilateral 6-hydroxydopamine lesions of substantia nigra were treated with 0.05 mg/kg apomorphine and observation of their circling behavior was made. Twenty minutes after the apomorphine treatment they were injected with saline or 2 mg/kg cycloheximide. Two weeks after drug treatment, control animals exhibited rapid contralateral rotation in response to being placed in the rotation environment. This conditioned rotation was not observed in cycloheximide-treated animals. After the first test trial animals received a second apomorphine administration, this time followed by saline injection in both groups. Subsequent to the second apomorphine treatment both groups showed conditioned rotation.

The expression and genomic organization of randomly selected cloned Drosophila melanogaster genes

A lambda recombinant DNA library containing Drosophila melanogaster nuclear DNA inserts was screened with cDNA made from oocyte and gastrula poly(A)+ RNA. 124 clones were isolated which represented sequences complementary to a distribution of abundancies of their RNAs. The clone set was then used as probes to identify those whose RNA abundancies changed during embryonic development. The vast majority of clones showed little difference during development. Four different clones were identified whose poly(A)+ RNAs were quantitatively regulated; two were oocyte-specific, and two were embryonic-specific. 44 clones were chosen for in situ hybridization to salivary gland polytene chromosomes. The location and distribution of their sites are described. A class of clones, identified by in situ hybridization to the nucleolus, is further described. These clones contain a scrambled array of ribosomal intervening sequences.

Endoscopic removal of an intragastric Angelchik antireflux prosthesis

Four months after insertion of an Angelchik esophageal antireflux prosthesis, a 60-year-old man was seen with epigastric pain and vomiting. Upper gastrointestinal studies demonstrated intragastric migration of the prosthesis. The prosthesis was intact and the straps were untied , and gastroscopic removal was accomplished by pulling out the prosthesis. Surgeons using this prosthesis should be aware of this unique potential complication of erosion into a viscus.