Prolonged Opioid Use Is Associated With Poor Pain Alleviation After Orthopaedic Surgery.

INTRODUCTION: Severe pain after orthopaedic surgery is common and often results in chronic postsurgical pain and chronic opioid use (COU). Poor pain alleviation (PPA) after surgery is a well-described modifiable risk factor of COU. Although PPA's role in inducing COU is recognized in other areas, it is not well defined in orthopaedic surgery. The aim of this study was to evaluate the influence of PPA on COU in the population who underwent orthopaedic surgery. METHODS: Medical records from a large academic medical center from 2015 to 2018 were available for analysis. Patients undergoing nononcologic surgical procedures by the orthopaedic surgery service that also required at least 24 hours of hospital stay for pain control were included in the study. Surgery type, body location, basic demographics, preoperative opioid use, comorbidities, medications administered in the hospital, opioid prescription after discharge, and length of stay were recorded. COU was defined as a continued opioid prescription at ≥ 3 months, ≥ 6 months, or ≥ 9 months after surgery. PPA was defined as having a recorded pain score of eight or more, between 4 and 12 hours apart, three times during the hospital stay. RESULTS: A total of 7,001 patients were identified. The overall rate of COU was 25.3% at 3 months after surgery. Charlson Comorbidity Index > 0 and PPA were statistically significant predictors of opioid use at all time points. Preoperative opioid naivety was associated with decreased COU. The type and location of surgical procedures were not associated with COU, after controlling for baseline variables. CONCLUSION: Our findings demonstrated an overall high rate of COU. The known risk factors of COU were evident in our study population, particularly the modifiable risk factor of acute postsurgical PPA. Better management of postsurgical pain in orthopaedic patients may lead to a decrease in the rates of COU in this group.

Modafinil Therapy and Mental Status Following Aneurysmal Subarachnoid Hemorrhage: Comprehensive Stroke Center Analysis.

BACKGROUND: Disorders of consciousness impair early recovery after aneurysmal subarachnoid hemorrhage (aSAH). Modafinil, a wakefulness-promoting agent, is efficacious for treating fatigue in stroke survivors, but data pertaining to its use in the acute setting are scarce. This study sought to assess the effects of modafinil use on mental status after aSAH. METHODS: Modafinil timing and dosage, neurological examination, intubation status, and physical and occupational therapy participation were documented. Repeated-measures paired tests were used for a before-after analysis of modafinil recipients. Propensity score matching (1:1 nearest neighbor) for modafinil and no-modafinil cohorts was used to compare outcomes. RESULTS: Modafinil (100-200 mg/day) was administered to 21% (88/422) of aSAH patients for a median (IQR) duration of 10.5 (4-16) days and initiated 14 (7-17) days after aSAH. Improvement in mentation (alertness, orientation, or Glasgow Coma Scale score) was documented in 87.5% (77/88) of modafinil recipients within 72 hours and 86.4% (76/88) at discharge. Of 37 intubated patients, 10 (27%) were extubated within 72 hours after modafinil initiation. Physical and occupational therapy teams noted increased alertness or participation in 47 of 56 modafinil patients (83.9%). After propensity score matching for baseline covariates, the modafinil cohort had a greater mean (SD) change in Glasgow Coma Scale score than the no-modafinil cohort at discharge (2.2 [4.0] vs. -0.2 [6.32], P = 0.003). CONCLUSIONS: A temporal relationship with improvement in mental status was noted for most patients administered modafinil after aSAH. These findings, a favorable adverse-effect profile, and implications for goals-of-care decisions favor a low threshold for modafinil initiation in aSAH patients in the acute-care setting.

Inpatient pain alleviation after orthopaedic trauma surgery-are we doing a good job?

PURPOSE: Poor pain alleviation (PPA) after orthopaedic surgery is known to increase recovery time, readmissions, patient dissatisfaction, and lead to chronic postsurgical pain. This study's goal was to identify the magnitude of PPA and its risk factors in the orthopaedic trauma patient population. METHODS: A single-institution's electronic medical records from 2015 to 2018 were available for retrospective analysis. Inclusion criteria included orthopaedic fracture surgery patients admitted to the hospital for 24 h or more. Collected variables included surgery type, basic demographics, comorbidities, inpatient medications, pain scores, and length of stay. PPA was defined as a pain score of ≥ 8 on at least three occasions 4-12 h apart. Associations between collected variables and PPA were derived using a multivariable logistic regression model and expressed in adjusted odds ratios. RESULTS: A total of 1663 patients underwent fracture surgeries from 2015 to 2018, and 25% of them reported PPA. Female sex, previous use of narcotics, increased ASA, increased baseline pain score, and younger age without comorbidities were identified as significant risk factors for PPA. Spine procedures were associated with increased risk of PPA, while procedures in the hip, shoulder, and knee had reduced risk. Patients experiencing PPA were less likely to receive NSAIDs compared to other pain medications. CONCLUSIONS: This study found an unacceptably high rate of PPA after fracture surgery. While the identified risk factors for PPA were all non-modifiable, our results highlight the necessity to improve application of current multimodal approaches to pain alleviation including a more personalized approach to pain alleviation.

Socioeconomic Drivers of Outcomes After Aneurysmal Subarachnoid Hemorrhage Treatment at a Large Comprehensive Stroke Center.

BACKGROUND: Sparse data exist on socioeconomic disparities among patients treated for aneurysmal subarachnoid hemorrhage (aSAH). The authors analyzed factors possibly influencing patient outcomes, including having a primary care physician (PCP) at admission, family/caregiver support, a foreign language barrier, primary payer status, and race. METHODS: Socioeconomic data were abstracted for patients treated endovascularly or microsurgically for aSAH at a single center (January 1, 2014-July 31, 2019). Binary logistic regression analyses were used to identify independent predictors of an unfavorable outcome (modified Rankin Scale [mRS] score >2) and for predictive modeling. RESULTS: Among 422 patients, the median (interquartile range) follow-up was 2 (1-23) months. Lack of caregiver support was the only socioeconomic factor associated with an unfavorable outcome at discharge. Independent predictors of mRS score >2 at last follow-up included baseline markers of disease severity (P ≤ 0.03), nonwhite race (OR, 1.69; P = 0.047), lack of caregiver support (OR, 5.55; P = 0.007), and lack of a PCP (OR, 1.96; P = 0.007). Adjusting for follow-up mediated the effects of race and PCP, although caregiver support remained significant and PCP was associated with a lower mortality risk independent of follow-up (OR, 0.51; P = 0.047). Predischarge socioeconomic factors, alongside disease severity, predicted a follow-up mRS score >2 with excellent discrimination (area under the receiver operating curve, 0.81; 95% CI, 0.77-0.86). CONCLUSIONS: At a large, urban, comprehensive stroke center, patients with PCPs, caregiver support, and white race had significantly better long-term outcomes after aSAH. These results reflect disparities in access to healthcare after aSAH for vulnerable populations with extensive lifetime needs.

Point-of-Care Lung Ultrasound Predicts Severe Disease and Death Due to COVID-19: A Prospective Cohort Study.

The clinical utility of point-of-care lung ultrasound (LUS) among hospitalized patients with COVID-19 is unclear. DESIGN: Prospective cohort study. SETTING: A large tertiary care center in Maryland, between April 2020 and September 2021. PATIENTS: Hospitalized adults (≥ 18 yr old) with positive severe acute respiratory syndrome coronavirus 2 reverse transcriptase-polymerase chain reaction results. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All patients were scanned using a standardized protocol including 12 lung zones and followed to determine clinical outcomes until hospital discharge and vital status at 28 days. Ultrasounds were independently reviewed for lung and pleural line artifacts and abnormalities, and the mean LUS Score (mLUSS) (ranging from 0 to 3) across lung zones was determined. The primary outcome was time to ICU-level care, defined as high-flow oxygen, noninvasive, or invasive mechanical ventilation, within 28 days of the initial ultrasound. Cox proportional hazards regression models adjusted for age and sex were fit for mLUSS and each ultrasound covariate. A total of 264 participants were enrolled in the study; the median age was 61 years and 114 participants (43.2%) were female. The median mLUSS was 1.0 (interquartile range, 0.5-1.3). Following enrollment, 27 participants (10.0%) went on to require ICU-level care, and 14 (5.3%) subsequently died by 28 days. Each increase in mLUSS at enrollment was associated with disease progression to ICU-level care (adjusted hazard ratio [aHR], 3.61; 95% CI, 1.27-10.2) and 28-day mortality (aHR, 3.10; 95% CI, 1.29-7.50). Pleural line abnormalities were independently associated with disease progression to death (aHR, 20.93; CI, 3.33-131.30). CONCLUSIONS: Participants with a mLUSS greater than or equal to 1 or pleural line changes on LUS had an increased likelihood of subsequent requirement of high-flow oxygen or greater. LUS is a promising tool for assessing risk of COVID-19 progression at the bedside.

Health-Related QOL and Economic Burden of Chronic Pruritus.

Chronic pruritus (CP) has considerable implications for QOL. However, its impact on health-related QOL and economic burden is not fully characterized. We administered a cross-sectional survey on 132 patients with CP using the Health Utilities Index Mark 3 instrument. Normative data from healthy adults (n = 4,187) were obtained from the Joint Canada/US Survey of Health. Quality-adjusted life-year loss and economic costs were estimated on the basis of Health Utilities Index Mark 3 scores of patients with CP versus controls. Patients with CP had lower overall health performance than the control (0.56 ± 0.03 vs. 0.86 ± 0.003, P < 0.001). In multivariable regression, CP was associated with worse overall health performance (coefficient = -0.30, 95% confidence interval = -0.33 to -0.27), most accentuated in the domains of pain (coefficient = -0.24, confidence interval = -0.28 to -0.21) and emotion (coefficient = -0.11, confidence interval = -0.13 to -0.10). The reduced Health Utilities Index Mark 3 score correlated with 5.5 average lifetime quality-adjusted life-years lost per patient. Using conservative estimates for willingness to pay, the quality-adjusted life-year loss translated to an individual lifetime economic burden of $274,921 and a societal burden of $88.8 billion. CP is associated with significant QOL impairment. The economic burden of CP highlights the necessity for further research into management options.

Comorbidities in Mycosis Fungoides and Racial Differences in Co-Existent Lymphomatoid Papulosis: A Cross-Sectional Study of 580 Patients in an Urban Tertiary Care Center.

Background: Mycosis fungoides (MF) is a cutaneous T-cell lymphoma. Previous reports have suggested MF is associated with inflammatory conditions such as psoriasis, increased cardiovascular risk factors as well as secondary neoplasms. Methods: A cross-sectional study of MF patients seen from 2013 to 2019 was performed. Comorbidities were selected based on the 2015 Medicare report highlighting the most common chronic medical illnesses in the United States. Lifetime comorbidity occurrence in patients with MF were compared with that in patients with atopic dermatitis, psoriasis and patients without MF. Additional analyses were performed with patients sub-stratified by race. Results: Compared to control groups, MF was strongly associated with lymphomatoid papulosis and Hodgkin's disease, but not significantly associated with lung, breast or colon cancer. Interestingly, the association with lymphomatoid papulosis was observed in Caucasians (CI 1062-4338; p < 0.001) and not African Americans (p = 0.9). Patients with MF had a greater association with congestive heart failure, hypertension (HT) and hyperlipidemia (HLD) compared with the general population. However, they were significantly less likely to have HT and HLD when compared with psoriasis patients (HT CI: 0.6-0.9; p < 0.001, and HLD CI: 0.05-0.07; p < 0.001). MF patients were also significantly less likely to have concomitant vitamin D deficiency compared with atopic dermatitis (AD) and psoriasis (p < 0.001). Conclusions: Our results suggest that the association of MF with lymphomatoid papulosis varies by race. Compared to the general population, hypertension and hyperlipidemia were positively associated with MF, however, these were significantly less likely on comparison to psoriasis. Unlike previously described, vitamin D deficiency was found to be significantly less in patients with MF.