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  • 1
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    Anti-diabetic agents for prevention of type 2 diabetes mellitus in people with pre-diabetes: a systematic review and network meta-analysis protocol
    BMJ ; 2019
    In:  BMJ Open Vol. 9, No. 10 ( 2019-10), p. e029073-
    Details
    In: BMJ Open, BMJ, Vol. 9, No. 10 ( 2019-10), p. e029073-
    Abstract: Type 2 diabetes mellitus (T2DM) is a substantial health problem worldwide. Pre-diabetic state is associated with increased risk for the development of diabetes. There are various pharmacological therapies with glucose-lowering activity for diabetes prevention. Of those, most are being compared with placebo instead of active agents. The relative effects and safety of different glucose-lowering drugs still remain uncertain. To address this gap, we will conduct a systematic review and network meta-analysis (NMA) to evaluate comparative efficacy and safety of glucose-lowering agents for T2DM prevention in patients with pre-diabetes. Methods and analysis PubMed, the Cochrane library and Embase will be searched from inception to December 2019 for relevant randomised controlled trials (RCTs) that examined anti-diabetic drugs for diabetes prevention in patients with pre-diabetes. Two reviewers working independently will screen titles, abstracts and full papers. Data extraction will also be completed by two independent authors. The primary outcome will be the incidence of T2DM in patients with pre-diabetes at baseline. Secondary outcomes will include the achievement of normoglycaemia, all-cause mortality, cardiovascular mortality and hypoglycaemic event. Pairwise meta-analysis and NMA will be conducted for each outcome using a frequentist random-effects model. Additionally, subgroup analyses will also be performed. The comparison-adjusted funnel plot will be used to assess publication bias. The overall quality of evidence will be rated with the Grading of Recommendations Assessment, Development and Evaluation framework. Data analysis will be conducted using Stata V.14.0. Ethics and dissemination Ethics approval is not required. We plan to submit the results of this study to a peer-review journal. PROSPERO registration number CRD42019119157.
    Type of Medium: Online Resource
    ISSN: 2044-6055 , 2044-6055
    URL: Article
    DOI: 10.1136/bmjopen-2019-029073
    Language: English
    Publisher: BMJ
    Publication Date: 2019
    detail.hit.zdb_id: 2599832-8
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  • 2
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    Association between same day discharge total knee and total hip arthroplasty and risks of cardiac/pulmonary complications and readmission: a population-based observational study
    BMJ ; 2019
    In:  BMJ Open Vol. 9, No. 12 ( 2019-12), p. e031260-
    Details
    In: BMJ Open, BMJ, Vol. 9, No. 12 ( 2019-12), p. e031260-
    Abstract: To determine if same-day discharge total knee arthroplasty (TKA) or total hip arthroplasty (THA) is not associated with increased risk of unplanned readmission and adverse outcomes within 30 days of surgery. Design This is a population-based observational study. Setting Patients from 708 participating institutions who underwent primary TKA or primary THA between 2011 and 2017 were divided into three groups by length of stay (LOS 0, 1 and 2–3 days). All patients with LOS 〉 3 days were excluded from the current study. Regression analysis and propensity score matching were performed. Data sources American College of Surgeons—National Surgical Quality Improvement Programme database. Main outcomes and measures Primary outcomes included unplanned readmission and cardiac/pulmonary complications within 30 days of surgery. Results We identified 226 481 TKA (LOS 0=3118, LOS 1=31 404, and LOS 2–3=1 91 959) and 140 557 THA patients (LOS 0=2652, LOS 1=29 617, and LOS 2–3=1 08 288). There were no differences in 30-day mortality. After adjusting for relevant covariates, LOS 0 (compared with LOS 1) was associated with higher odds of cardiac/pulmonary complications in both TKA (OR 1.95, 95% CI 1.20 to 3.16; 0.67% vs 0.37%) and THA (OR 1.96, 95% CI 1.05 to 3.64; 0.57% vs 0.26%). There were no statistical differences in unplanned readmissions between LOS 0 and LOS 1 groups in TKA (2.41% vs 2.31%) and THA (1.62% vs 2.04%). Conclusions LOS 0 discharge after TKA and THA was associated with higher odds of cardiac/pulmonary complications compared with LOS 1 discharge. While the overall burden of complications is relatively low, until future studies can confirm or challenge our findings, a measured approach is advisable when recommending discharge of patients on the same day of surgery.
    Type of Medium: Online Resource
    ISSN: 2044-6055 , 2044-6055
    URL: Article
    DOI: 10.1136/bmjopen-2019-031260
    Language: English
    Publisher: BMJ
    Publication Date: 2019
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  • 3
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    Trends in total knee and hip arthroplasty recipients: a retrospective cohort study
    BMJ ; 2019
    In:  Regional Anesthesia & Pain Medicine Vol. 44, No. 9 ( 2019-09), p. 854-859
    Details
    In: Regional Anesthesia & Pain Medicine, BMJ, Vol. 44, No. 9 ( 2019-09), p. 854-859
    Abstract: Arthroplasty is one of the most commonly performed procedures in the USA with projections of continuous growth. As this field undergoes continuous changes, the goal of this study was to provide an analysis of patient-related and healthcare system-related trends. This is important as it allows practitioners, administrators and policy makers to allocate needed resources appropriately. Methods The study included total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures from 2006 to 2016. Demographic information, comorbidities and complications were extracted and analyzed from the Premier Healthcare database. Results The surgical volume increased annually over the observation period by an average of 5.54% for TKA and 7.02% for THA, respectively. The average age of the patient population and the types of anesthesia used remained relatively consistent over time. Comorbidity burden increased, especially for obesity (16.52% in 2006 and 29.77% in 2016 for TKA, 11.15% in 2006 and 20.92% in 2016 for THA), obstructive sleep apnea (OSA) (6.82% in 2006 and 17.03% in 2016 for TKA, 4.69% in 2006 and 12.72% in 2016 for THA) and renal insufficiency (2.81% in 2006 and 7.01% in 2016 for TKA, 2.78% in 2006 and 6.43% in 2016 for THA). Minor trends of increases were also observed in the prevalence of liver disease, depression and hypothyroidism. All postoperative complications were trending lower except for acute renal failure, where an increase was noted (4.39% in 2006 and 8.10% in 2016 for TKA, 4.99% in 2006 and 8.42% in 2016 for THA). Discussion Significant trends in the care of patients who undergo TKA and THA were identified. Individuals undergoing these procedures presented with a higher prevalence of comorbidities. Despite these trajectories, complications declined over time. These data can be used to inform future research and to allocate resources to address changes in populations cared for and complications encountered.
    Type of Medium: Online Resource
    ISSN: 1098-7339 , 1532-8651
    URL: Article
    URL: Article
    DOI: 10.1136/rapm-2019-100678
    DOI: 10.1136/rapm-2019-100678.supp1
    Language: English
    Publisher: BMJ
    Publication Date: 2019
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  • 4
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    Fascial plane blocks: a narrative review of the literature
    BMJ ; 2021
    In:  Regional Anesthesia & Pain Medicine Vol. 46, No. 7 ( 2021-07), p. 600-617
    Details
    In: Regional Anesthesia & Pain Medicine, BMJ, Vol. 46, No. 7 ( 2021-07), p. 600-617
    Abstract: Fascial plane blocks (FPBs) are increasingly numerous and are often touted as effective solutions to many perioperative challenges facing anesthesiologists. As ‘new’ FPBs are being described, questions regarding their effectiveness remain unanswered as appropriate studies are lacking and publications are often limited to case discussions or technical reports. It is often unclear if newly named FPBs truly represent a novel intervention with new indications, or if these new publications describe mere ultrasound facilitated modifications of existing techniques. Here, we present broad concepts and potential mechanisms of FPB. In addition, we discuss major FPBs of (1) the extremities (2) the posterior torso and (3) the anterior torso. The characteristics, indications and a brief summary of the literature on these blocks is included. Finally, we provide an estimate of the overall level of evidence currently supporting individual approaches as FPBs continue to rapidly evolve.
    Type of Medium: Online Resource
    ISSN: 1098-7339 , 1532-8651
    URL: Article
    DOI: 10.1136/rapm-2020-101909
    Language: English
    Publisher: BMJ
    Publication Date: 2021
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  • 5
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    Reply to ‘Can we trust the black box?’
    BMJ ; 2022
    In:  Regional Anesthesia & Pain Medicine Vol. 47, No. 5 ( 2022-05), p. 338.2-339
    Details
    In: Regional Anesthesia & Pain Medicine, BMJ, Vol. 47, No. 5 ( 2022-05), p. 338.2-339
    Type of Medium: Online Resource
    ISSN: 1098-7339 , 1532-8651
    URL: Article
    DOI: 10.1136/rapm-2021-103336
    Language: English
    Publisher: BMJ
    Publication Date: 2022
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  • 6
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    Trends of liposomal bupivacaine utilization in major lower extremity total joint arthroplasty in the USA: a population-based study
    BMJ ; 2023
    In:  Regional Anesthesia & Pain Medicine
    Details
    In: Regional Anesthesia & Pain Medicine, BMJ
    Abstract: Liposomal bupivacaine has been marketed for the achievement of long-acting local or regional anesthesia after major lower extremity total joint arthroplasty. However, it is comparatively expensive and controversy remains regarding its ability to decrease healthcare costs. With mounting evidence suggesting non-superiority in efficacy, compared with plain bupivacaine, we sought to investigate trends in liposomal bupivacaine use and identify changes in practice. Methods We identified adult patients from the Premier Healthcare Database who underwent elective total joint arthroplasty between 2012 and 2021. Prevalence and trends of liposomal bupivacaine utilization were compared on the individual patient and hospital levels. Log-rank tests were performed to assess the influence of location, teaching status, or hospital size on time to hospital-level liposomal bupivacaine termination. Results Among 103,165 total joint arthroplasty cases, liposomal bupivacaine use increased between 2012 and 2015 (from 0.4% to 22.8%) and decreased by approximately 1%–3% annually thereafter (15.7% in 2021). Liposomal bupivacaine was ever used in approximately 60% of hospitals. Hospital-level initiation of liposomal bupivacaine use peaked in 2014 and decreased thereafter (from 32.8% in 2013 to 4.3% in 2021), while termination rates increased (from 1.4% in 2014 to 9.9% in 2019). Non-teaching hospitals and those located in the South and West regions were more likely to retain liposomal bupivacaine longer than teaching or Midwest/Northeast hospitals, respectively (p=0.023 and p=0.014). Discussion Liposomal bupivacaine use peaked around 2015 and has been declining thereafter on individual patient and hospital levels. How these trends correlate with health outcomes and expenditures would be a strategic target for future research.
    Type of Medium: Online Resource
    ISSN: 1098-7339 , 1532-8651
    URL: Article
    URL: Article
    URL: Article
    DOI: 10.1136/rapm-2023-104784
    DOI: 10.1136/rapm-2023-104784.supp2
    DOI: 10.1136/rapm-2023-104784.supp1
    Language: English
    Publisher: BMJ
    Publication Date: 2023
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  • 7
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    Effectiveness of intravenous acetaminophen for postoperative pain management in hip and knee arthroplasties: a population-based study
    BMJ ; 2019
    In:  Regional Anesthesia & Pain Medicine Vol. 44, No. 5 ( 2019-05), p. 565-572
    Details
    In: Regional Anesthesia & Pain Medicine, BMJ, Vol. 44, No. 5 ( 2019-05), p. 565-572
    Abstract: The significance of intravenous over oral acetaminophen (APAP) as part of multimodal analgesic protocols is contested, particularly when considering its relatively high price and use in a surgical cohort such as total hip or knee arthroplasty (THA/TKA), which generally tolerates oral medications. This study aims to elucidate APAP’s effectiveness in a large, population-based patient sample. Methods 1 039 647 THA/TKA procedures were sampled from the Premier Healthcare claims database 2011–2016. APAP use was categorized by intravenous/oral and use on the day of surgery, postoperative day 1 and thereafter. Outcomes were opioid utilization (in oral morphine equivalents), length and cost of hospitalization, and opioid-related adverse effects (respiratory, gastrointestinal, and naloxone use as a proxy). Mixed-effects models measured the associations between intravenous/oral APAP use and outcomes. Percent (%) change and 95% CIs are reported. Results Overall, 23.6% (n=245 454) of patients received intravenous APAP; of these, 56.3% (n=138 180) received just one dose on the day of surgery. After adjustment for relevant covariates, particularly use of 〉 1 dose of intravenous APAP (compared with no use) on postoperative day 1 was associated with −6.0% (CI −7.2% to −4.7%) reduced opioid utilization; this was −10.7% (CI −11.4% to -9.9%) for use of 〉 1 dose oral APAP on postoperative day 1. Further comparisons regarding other outcomes also favored oral (over intravenous) APAP. Conclusions These results do not support the routine use of intravenous APAP in patients undergoing lower joint arthroplasty, especially since oral APAP shows more beneficial outcome patterns.
    Type of Medium: Online Resource
    ISSN: 1098-7339 , 1532-8651
    URL: Article
    URL: Article
    DOI: 10.1136/rapm-2018-100145
    DOI: 10.1136/rapm-2018-100145.supp1
    Language: English
    Publisher: BMJ
    Publication Date: 2019
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  • 8
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    Risk of chronic opioid use after simultaneous versus staged bilateral knee arthroplasty
    BMJ ; 2021
    In:  Regional Anesthesia & Pain Medicine Vol. 46, No. 5 ( 2021-05), p. 405-409
    Details
    In: Regional Anesthesia & Pain Medicine, BMJ, Vol. 46, No. 5 ( 2021-05), p. 405-409
    Abstract: Several studies have identified excess risk associated with undergoing simultaneous (compared with unilateral or staged) bilateral total knee arthroplasty (BTKA). However, few have addressed subsequent chronic opioid use. Given the substantial morbidity and mortality associated with prolonged opioid use, we evaluated the incidence of postoperative chronic opioid use following simultaneous versus staged BTKA, based on the different timing strategies of staged procedures. Methods In this retrospective cohort study, patients who underwent BTKA procedures (2012–2016; Truven Health MarketScan; n=14 407) were classified as having undergone simultaneous or staged BTKA ( 〈 3 months, 3–6 months or 6–12 months apart). Outcomes were postoperative chronic opioid use and oral morphine equivalents prescribed on discharge. Multivariable regression models measured associations between type/timing of BTKA and outcomes. ORs and 95% CIs were reported. Results Unadjusted frequency of chronic opioid use did not differ between groups, (Simultaneous: 11.3%, staged 〈 3 months: 10.7%, staged 3–6 months: 11.7%, staged 〉 6 months: 10.2%; p=0.247). In an adjusted model, there was no significant difference in the odds of becoming chronic opioid users between staged and simultaneous BTKA (staged 〈 3 months OR 1.03, 95% CI 0.88 to 1.21/staged 3–6 months OR 0.94, 95% CI 0.79 to 1.12/staged 〉 6 months OR 0.96, 95% CI 0.82 to 1.13; p=0.755). Patients undergoing staged BTKAs 〈 6 months apart (compared with simultaneous) were prescribed slightly greater oral morphine equivalents on hospital discharge (staged 〈 3 months 6% increase, 95% CI 3% to 10%; staged 3–6 months 4%, 95% CI 1% to 8%; p=0.002). Conclusion Although patients undergoing staged BTKA 〈 6 months apart were prescribed greater quantities of opioids on discharge, there was no significant difference in the odds of postoperative chronic opioid use compared with simultaneous BTKA. The timing of BTKA procedures does not appear to influence the likelihood of postoperative chronic opioid dependence.
    Type of Medium: Online Resource
    ISSN: 1098-7339 , 1532-8651
    URL: Article
    URL: Article
    DOI: 10.1136/rapm-2020-102060
    DOI: 10.1136/rapm-2020-102060.supp1
    Language: English
    Publisher: BMJ
    Publication Date: 2021
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  • 9
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    Tranexamic acid administration during total joint arthroplasty surgery is not associated with an increased risk of perioperative seizures: a national database analysis
    BMJ ; 2020
    In:  Regional Anesthesia & Pain Medicine Vol. 45, No. 7 ( 2020-07), p. 505-508
    Details
    In: Regional Anesthesia & Pain Medicine, BMJ, Vol. 45, No. 7 ( 2020-07), p. 505-508
    Abstract: Tranexamic acid (TXA) has been used extensively to minimize blood loss in cardiac surgery and more recently in orthopedic surgery. Despite a generally good safety profile, an increased risk of seizures has been observed in patients with cardiac disease. However, this issue has not been adequately addressed in the orthopedic literature. Methods After institutional review board approval, we queried a large national database to identify patients who had undergone total hip and total knee arthroplasties (2012–2016). Patients were divided based on their exposure to TXA and history of seizures. The main outcome of interest was a perioperative seizure. We conducted univariable comparisons and a multivariable regression analysis to elucidate a potential independent association between TXA administration and seizures in the perioperative period (with or without a history of seizures). Results TXA was used overall in 45.9% (n=4 21 890) of joint arthroplasty recipients (n=9 18 918), with more frequent use over time. Utilization rates did not differ between those with and without a history of seizures; 42.2% (3487/8252) of patients with a seizure history received TXA. Rates of perioperative seizure were low and did not differ between those who did and did not receive TXA (0.01% vs 0.02%, p=0.11); when subgrouping patients by history of seizures, we found no difference in incidence of perioperative seizures between groups (0.06% vs 0.02%, p=0.39). Our adjusted analysis further confirmed these results. Conclusion Despite increasing TXA utilization in total joint arthroplasty, we found an overall low seizure incidence. TXA use was not associated with elevated odds of perioperative seizure, even in patients with history of seizure.
    Type of Medium: Online Resource
    ISSN: 1098-7339 , 1532-8651
    URL: Article
    URL: Article
    DOI: 10.1136/rapm-2020-101301
    DOI: 10.1136/rapm-2020-101301.supp1
    Language: English
    Publisher: BMJ
    Publication Date: 2020
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  • 10
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    Tramadol prescribed at discharge is associated with lower odds of chronic opioid use after elective total joint arthroplasty
    BMJ ; 2022
    In:  Regional Anesthesia & Pain Medicine Vol. 47, No. 9 ( 2022-09), p. 560-565
    Details
    In: Regional Anesthesia & Pain Medicine, BMJ, Vol. 47, No. 9 ( 2022-09), p. 560-565
    Abstract: We aimed to study the association between tramadol prescribed at discharge (after elective total hip and knee arthroplasty (THA/TKA) surgery) and chronic opioid use postoperatively. Methods This retrospective cohort study queried the Truven MarketScan database and identified patients who underwent an elective THA/TKA surgery between 2016 and 2018 and were prescribed opioids at discharge (n=81 049). Multivariable analysis was conducted to study the association between tramadol prescription at discharge and chronic opioid use, with additional analysis adjusting for the amount of opioids prescribed in oral morphine equivalents. Chronic opioid use was defined as filling ≥10 opioid prescriptions or prescriptions for ≥120 pills within the period from 90 days to 1 year after surgery. Results Overall, tramadol was prescribed at discharge in 11.0% of all THA/TKA cases. Of those, 26.9% and 73.1% received tramadol only or tramadol with another opioid, respectively. Chronic opioid use was observed in 5.4% of cases. After adjustment for relevant covariates, prescription of tramadol combined with another opioid at discharge was associated with lower odds of chronic opioid use comparing to prescription of other opioids (OR 0.69 CI 0.61 to 0.78). Discussion Among patients undergoing elective THA/TKA surgery and discharged with a prescription of opioids, we found that prescription of tramadol combined with another opioid was associated with lower odds of chronic opioid use. This finding must be considered in the context of the tramadol’s pharmacology, as well-described genetic differences in metabolism that can make it ineffective in many patients, while for patients with ultrarapid metabolism can cause drug–drug interactions and adverse events, including feelings of high and seizures.
    Type of Medium: Online Resource
    ISSN: 1098-7339 , 1532-8651
    URL: Article
    URL: Article
    URL: Article
    DOI: 10.1136/rapm-2022-103486
    DOI: 10.1136/rapm-2022-103486.supp1
    DOI: 10.1136/rapm-2022-103486.supp2
    Language: English
    Publisher: BMJ
    Publication Date: 2022
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