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.     

RWMAs in critically ill patients with non-obstructed coronary arteries

Introduction

Left ventricular (LV) dysfunction is estimated to occur in 10%–25% of the general intensive care unit (ICU) population and is frequently seen as regional wall motion abnormalities (RWMAs). Although RWMA is mostly attributed to myocardial ischemia or infarction, some studies have suggested that nonischemic RWMA might also be prevalent. We sought to establish that RWMA can be seen in critically ill patients with normal coronary arteries and to explore reasons for RWMA in this population.

Methods

In this retrospective study, data from the hospital angiography register and the ICU register were collated between 2012 and 2019. Patients were identified who underwent angiography in conjunction with their ICU stay and had RWMA on echocardiography. Patients were divided into either those with non-obstructed or those with obstructed coronary arteries. Cardiac magnetic resonance imaging (cMRI) examinations were reviewed if they had been performed on patients with non-obstructed coronaries.

Results

We identified 53 patients with RWMA and non-obstructed coronary arteries and 204 patients with RWMA and obstructed coronary arteries. Patients with non-obstructed coronary arteries were more often female, younger, and had fewer cardiovascular risk factors. They less commonly had ST elevation, but more frequently had T-wave inversion or serious arrhythmias. Troponin levels were higher in patients with obstructed coronary arteries, but NT-proBNP was similar between the groups. There were no differences in risk-adjusted 90-day mortality between patients with non-obstructed versus obstructed coronary arteries (OR 1.21, [95% CI 0.56–2.64], p = .628). In those with non-obstructed coronary arteries, follow-up echocardiography was available for 38 patients, of whom 30 showed normalization of cardiac function. Of the 14 patients with non-obstructed coronary arteries on whom cMRI was performed, 7 had a tentative diagnosis of Takotsubo syndrome or myocardial stunning; 4 had a myocardial infarction (preexisting in 3 cases); 1 patient had acute myocarditis; 1 patient had post-myocarditis; and 1 patient was diagnosed with dilated cardiomyopathy.

Conclusion

RWMA can be seen to occur in critically ill patients in the absence of coronary artery obstruction. Several conditions can cause regional hypokinesia, and cMRI is useful to evaluate the underlying etiology.     

Effect of pneumatic leg compression on post-induction hypotension in elderly patients undergoing robot-assisted laparoscopic prostatectomy: a double-blind randomised controlled trial

Post-induction hypotension is common and associated with postoperative complications. We hypothesised that pneumatic leg compression reduces post-induction hypotension in elderly patients undergoing robot-assisted laparoscopic prostatectomy. In this double-blind randomised study, patients were allocated randomly to the pneumatic leg compression group (n = 50) or control (n = 50). In the intervention group, pneumatic leg compression was initiated before induction of anaesthesia. In the control group, pneumatic leg compression was initiated 20 min after anaesthesia induction. The primary outcome was the incidence of post-induction hypotension in these groups. Post-induction hypotension was defined as systolic blood pressure < 90 mmHg during the first 20 min after induction. Haemodynamic variables and area under the curve of post-induction systolic blood pressure over time were assessed. Complications associated with pneumatic leg compression were recorded, including: peripheral neuropathy; compartment syndrome; extensive bullae beneath the leg sleeves; and pulmonary thromboembolism. The incidence of post-induction hypotension decreased in the pneumatic leg compression group compared with that in the control group; 5 (10%) vs. 29 (58%), respectively, p < 0.001. In the pneumatic leg compression group, the lowest systolic, diastolic and mean blood pressures 20 min after induction of anaesthesia were significantly greater than the control group. Pneumatic leg compression resulted in an increased area under the curve of systolic blood pressure in the first 20 min after induction, p = 0.001. There were no pneumatic leg compression-related complications. Pneumatic leg compression reduced post-induction hypotension in elderly patients undergoing robot-assisted laparoscopic prostatectomy, suggesting that it is an effective and safe intervention to prevent post-induction hypotension among elderly patients undergoing general anaesthesia.     

Reduction of ventricular arrhythmias with synchronized LV pacing—fact,fiction, or fortuitous

Journal of Interventional Cardiac Electrophysiology -     

腹腔镜与开腹手术治疗长径5~10 cm中危原发性胃间质瘤的安全性和有效性比较

目的　比较腹腔镜和开腹手术治疗长径5~10 cm的中危胃间质瘤的安全性和有效性，并评估患者术后使用伊马替尼辅助治疗是否有明显益处。方法　回顾性分析2010年1月—2020年7月在南京大学医学院附属鼓楼医院接受手术治疗的72例长径在5~10 cm的中危胃间质瘤患者资料。其中腹腔镜手术组28例，开腹手术组44例。比较两组患者基本资料、病理特征、围手术期结果、住院总费用。对比术后使用和不使用伊马替尼辅助治疗的生存率。结果　开腹组和腹腔镜组临床病理特征差异无统计学意义（P>0.05）。腹腔镜组术后并发症发生率为32.1%（9/28），开腹组为52.3%（23/44），两组比较差异无统计学意义（P=0.094）。与开腹组相比，腹腔镜组总住院时间明显缩短［（12.5±3.2） d比（15.0±3.5） d，P=0.004］；术后中位住院天数明显缩短（7.5 d 比 9.0 d，P=0.006）；首次排气时间明显缩短（P=0.003）。中位随访时间58个月（13~129个月），期间未出现与肿瘤相关的死亡病例。开腹组有2例死亡，分别因乳腺癌和心脏病；腹腔镜组有1例死亡，死亡原因与胃间质瘤无关。72例患者中，40例术后接受伊马替尼辅助治疗，开腹组22例（50.0%），腹腔镜组18例（64.3%），两组接受伊马替尼辅助治疗的患者例数占比差异无统计学意义（χ2=1.414，P=0.234）。术后使用伊马替尼辅助治疗组总体生存率与未使用伊马替尼辅助治疗组相比差异有统计学意义 （P=0.015）。结论　与开腹手术相比，腹腔镜治疗长径在5~10 cm的中危胃间质瘤是一种安全有效的方法。实现R0切除的长径在5~10 cm的中危胃间质瘤患者术后使用伊马替尼辅助治疗未增加生存率，且未使用伊马替尼者未出现与肿瘤相关的死亡、复发及转移。     

以宫腔积液为首发症状的胃型宫颈腺癌1例报道并文献复习

宫腔积液指宫腔内液体积存(积水、积血或积脓),是绝经后女性常见体征之一,常于超声检查时发现。持续宫腔积液患者,需宫腔镜检查寻找病因。本文报道1例以宫腔积液为首发症状,经宫腔镜检查确诊为胃型宫颈腺癌的患者。通过病例回顾并文献复习,以期为更多绝经后宫腔积液及宫颈病变的诊断提供参考,避免漏诊及误诊。1病例资料患者67岁,女,主因"绝经18年,不规则阴道出血2月"于2020年5月就诊于首都医科大学附属北京妇产医院妇科微创中心。     

Synthesis and automated fluorine-18 radiolabeling of new PSMA-617 derivatives with a CuAAC radiosynthetic approach

In the last decade, the development of new radiopharmaceuticals for the imaging and therapy of prostate cancer has been a highly active and important area of research, especially focusing on the prostate-specific membrane antigen (PSMA), an antigen which is upregulated in prostate, as well as in other tumor cells. A large variety of PSMA ligands have been radiolabeled, to date. Among the various derivatives, PSMA-617 resulted to be one of the most interesting in terms of interaction with the antigen and clinical properties, and its lutetium-177 labeled version has recently been approved by regulatory agencies for therapeutic purposes. For this reasons, the radiolabeling with fluorine-18 of a PSMA-617 derivative might be of interest. Beside other methodologies to radiolabel macromolecules with fluorine-18, the “click-chemistry” approach resulted to be very useful, and the copper-catalyzed azide-alkyne cycloaddition (CuAAC) is considered one of most efficient and reliable. This paper proposes the synthesis of a suitable precursor for the radiolabeling with fluorine-18 of a new PSMA-617 derivative. The whole radiosynthetic procedure has been fully automated, and the final product, which proved to be stable in plasma, has been obtained with radiochemical yield and purity suitable for subsequent preclinical studies.