Predictors of persistent postoperative opioid use following colectomy: a population-based cohort study from England.

This retrospective cohort study on adults undergoing colectomy from 2010 to 2019 used linked primary (Clinical Practice Research Datalink), and secondary (Hospital Episode Statistics) care data to determine the prevalence of persistent postoperative opioid use following colectomy, stratified by pre-admission opioid exposure, and identify associated predictors. Based on pre-admission opioid exposure, patients were categorised as opioid-naïve, currently exposed (opioid prescription 0-6 months before admission) and previously exposed (opioid prescription within 7-12 months before admission). Persistent postoperative opioid use was defined as requiring an opioid prescription within 90 days of discharge, along with one or more opioid prescriptions 91-180 days after hospital discharge. Multivariable logistic regression analyses were conducted to obtain odds ratios for predictors of persistent postoperative opioid use. Among the 93,262 patients, 15,081 (16.2%) were issued at least one opioid prescription within 90 days of discharge. Of these, 6791 (45.0%) were opioid-naïve, 7528 (49.9%) were currently exposed and 762 (5.0%) were previously exposed. From the whole cohort, 7540 (8.1%) developed persistent postoperative opioid use. Patients with pre-operative opioid exposure had the highest persistent use: 5317 (40.4%) from the currently exposed group; 305 (9.8%) from the previously exposed group; and 1918 (2.5%) from the opioid-naïve group. The odds of developing persistent opioid use were higher among individuals who used long-acting opioid formulations in the 180 days before colectomy than those who used short-acting formulations (odds ratio 3.41 (95%CI 3.07-3.77)). Predictors of persistent opioid use included: previous opioid exposure; high deprivation index; multiple comorbidities; use of long-acting opioids; white race; and open surgery. Minimally invasive surgical approaches were associated with lower odds of persistent opioid use and may represent a modifiable risk factor.

Supporting patients to get the best from their osteoporosis treatment: a rapid realist review of what works, for whom, and in what circumstance.

Systematic reviews that examine effectiveness of interventions to improve medicines optimisation do not explain how or why they work. This realist review identified that interventions which effectively optimise medicines use in osteoporosis include opportunities to address patients' perceptions of illness and treatment and/or support primary care clinician decision making. INTRODUCTION: In people with osteoporosis, adherence to medicines is poorer than other diseases and patients report follow-up is lacking, and multiple unmet information needs. We conducted a rapid realist review to understand what contextual conditions and mechanisms enable interventions to support osteoporosis medication optimisation. METHODS: A primary search identified observational or interventional studies which aimed to improve medicines adherence or optimisation; a supplementary second search identified research of any design to gain additional insights on emerging findings. Extracted data was interrogated for patterns of context-mechanism-outcome configurations, further discussed in team meetings, informed by background literature and the Practicalities and Perception Approach as an underpinning conceptual framework. RESULTS: We identified 5 contextual timepoints for the person with osteoporosis (identifying a problem; starting medicine; continuing medicine) and the practitioner and healthcare system (making a diagnosis and giving a treatment recommendation; reviewing medicine). Interventions which support patient-informed decision making appear to influence long-term commitment to treatment. Supporting patients' practical ability to adhere (e.g. by lowering treatment burden and issuing reminders) only appears to be helpful, when combined with other approaches to address patient beliefs and concerns. However, few studies explicitly addressed patients' perceptions of illness and treatment. Supporting primary care clinician decision making and integration of primary and secondary care services also appears to be important, in improving rates of treatment initiation and adherence. CONCLUSIONS: We identified a need for further research to identify a sustainable, integrated, patient-centred, and cost- and clinically effective model of long-term care for people with osteoporosis.

The association between incident vertebral deformities, health-related quality of life and functional impairment: a 10.7-year cohort study.

We aimed to describe longitudinal changes in health-related quality of life (HRQoL) measures associated with incident vertebral deformities (VDs) over 10.7 years. Incident VDs are associated with clinically significant functional impairment in men, and reduction in overall HRQoL in older women. Increasing severity and number of incident VDs are associated with clinically meaningful functional impairment in men, but not women. INTRODUCTION: To describe associations between incident VD and changes in HRQoL and functional ability in older adults over 10.7 years. METHODS: Participants (n = 780) underwent whole-body dual-energy X-ray absorptiometry (DXA) scans at baseline, 2.5, 5.1 and 10.7 years later. VD was defined as ≥ 25% reduction in anterior height relative to posterior height of vertebrae from T4 to L4. An incident VD was defined as a new VD at any follow-up visit. Assessment of Quality of Life (AQoL-4D) questionnaire and Health Assessment Questionnaire-Disability Index (HAQ-DI) were used to assess HRQoL and functional impairment. Changes in AQoL and HAQ-DI associated with incident VD were analysed using multilevel mixed-effects linear regression. Log binomial regression was used to examine clinically relevant changes and effects of severity and number of VD. RESULTS: The incidence of VD was 37% over 10.7 years. In women, incident VDs were associated with annual reduction in AQoL utility score (ß = -0.005, 95% CI -0.008 to -0.002). Men had increased risk of clinically significant reduction in HAQ-DI (IRR = 1.76, 95% CI 1.07-2.89). Men had increased risk of clinically important functional impairment with increasing severity (IRR 1.76, 95% CI 1.04-2.95 for mild vs IRR 1.98, 95% CI 1.13-3.47 for moderate to severe VD) as well as number of incident VD (IRR 1.85, 95% CI 1.17-2.93 for one vs IRR 1.88, 95% CI 0.94-3.78 for ≥ 2 VDs). Such associations were not observed in women. CONCLUSIONS: Incident VDs are associated with clinically significant functional impairment in men, and reduction in overall HRQoL in older women. Increasing severity and number of incident VDs are associated with clinically meaningful functional impairment in men, but not women.

Radiological retrograde ureteric stent exchange in women: a single-centre review.

AIM: To evaluate the safety and efficacy of modified wire loop technique for retrograde stent exchange. MATERIALS AND METHODS: All patients were from the KK Women and Children's Hospital where there is no on-site urology service. Patients were identified retrospectively from the institutional radiological information system (RIS) database. In total, 270 stents were removed and 238 replaced for 79 patients between January 2012 to December 2016. Success rates for stent removal and exchange as well as skin dose and fluoroscopy time were assessed. RESULTS: Stent exchange was successful in 234/238 (98%) of cases. Failure was due to loss of access (one case), inability to snare stent due to distorted anatomy (two cases), and extensive encrustation of stent (one case). In 252/270 (93%) cases, stent was removed using modified snare while in 18 (7%) cases, other snare devices were used. Average fluoroscopy time per stent for stent exchange was 573 seconds and average skin dose was 12,494 DAP/mGy•cm2. CONCLUSION: Fluoroscopy-guided retrograde ureteric stent exchange using the modified snare loop technique is effective, quick, and can be performed easily with equipment used in daily intervention practice. It may also be coupled with ureteroplasty, which may help the patient achieve eventual stent-free status.

Initial data from an experiment to implement a safe procedure to perform PA erect chest radiographs for COVID-19 patients with a mobile radiographic system in a "clean" zone of the hospital ward.

INTRODUCTION: With the current Covid-19 pandemic, general wards have been converted into cohort wards for Covid-19 patients who are stable and ambulant. A 2-radiographer mobile radiography team is required to perform bedside Chest X-rays (CXR) for these patients. Hospital guidelines require both radiographers to be in full Personal Protective Equipment (PPE) throughout the image acquisition process and the mobile radiographic unit needs to be disinfected twice after each case. This affects the efficiency of the procedure and an increase usage of limited PPE resources. This study aims to explore the feasibility of performing mobile chest radiography with the mobile radiographic unit in a "clean" zone of the hospital ward. METHODS: An anthropomorphic body phantom was used during the test. With the mobile radiographic unit placed in a "clean" zone, the phantom and the mobile radiographic unit was segregated by the room door with a clear glass panel. The test was carried out with the room door open and closed. Integrated radiation level and patient dose were measured. A consultant radiologist was invited to review and score all the images acquired using a Barco Medical Grade workstation. The Absolute Visual Grading Analysis (VGA) scoring system was used to score these images. RESULTS: A VGA score of 4 was given to all the 40 test images, suggesting that there is no significant differences in the image quality of the images acquired using the 2 different methods. Radiation exposure received by the patient at the highest kV setting through the glass is comparable to the regular CXR on patient without glass panel at 90 kV, suggesting that there is no significant increase in patient dose. CONCLUSION: The result suggests that acquiring CXR with the X-ray beam attenuating through a glass panel is a safe and feasible way of performing CXR for COVID-19 patients in the newly converted COVID wards. This will allow the mobile radiographic unit as well as one radiographer to be completely segregated from the patient. IMPLICATIONS FOR PRACTICE: This new method of acquiring CXR in an isolation facility set up requires a 2-Radiographer mobile radiography team, and is applicable only for patients who are generally well and not presented with any mobility issues. It is also important to note that a clear glass panel must be present in the barriers set up for segregation between the "clean" zone and patient zone in order to use this new method of acquiring CXR.

Nitrated type III collagen as a biological marker of nitric oxide-mediated synovial tissue metabolism in osteoarthritis.

OBJECTIVES: Nitric oxide (NO) is a major mediator of joint tissue inflammation and damage in osteoarthritis (OA) and mediates the nitration of tyrosine (Y*) residues in proteins. We investigated the nitration of type III collagen, a major constituent of synovial membrane, in knee OA. METHODS: A polyclonal antibody directed against the nitrated QY*DSY*DVKSG sequence from type III collagen N-telopeptide was generated. Synovial tissues from patients with knee OA (n=4) and rheumatoid arthritis (RA, n=4) were analyzed by immunohistochemistry for IIINys. Serum IIINys levels were measured by enzyme-linked immunosorbent assay in 87 patients with painful knee OA (mean age: 63.0+/-8.0 years, Kellgren-Lawrence score II-III) and in 40 sex and age-matched healthy controls. RESULTS: Competition experiments using various nitrated and un-nitrated type III collagen and derived sequences, showed that the antibody was highly specific for the nitrated IIINys sequence. High IIINys immunoreactivity was detected in the synovial tissues from all patients with OA and RA with a preferential localization in the intimal layer. Serum IIINys levels were on average 1.5-fold higher (P<0.0001) in patients with knee OA than in healthy controls and significantly correlated with C-reactive protein values (r=0.40, P<0.005). CONCLUSIONS: Nitration of tyrosine residues of type III collagen N-telopeptide is increased in the synovial tissue of patients with knee OA. Measurements of serum IIINys level may be useful for the clinical investigation of oxidative-related alterations of synovial tissue metabolism in OA.

Exploring the current and future role of the pharmacists in osteoporosis screening and management in Malaysia.

Background Several studies have found that pharmacists can assist in screening and prevention of osteoporosis by referring patients for bone mineral density scans and counselling on lifestyle changes. In Malaysia, screening osteoporosis in all elderly women is not mandatory due to its cost. One approach to address this gap is to develop a pharmacist-led osteoporosis screening and prevention program. However, there is a paucity of data on the perspectives of Malaysian pharmacists in this area. Objective To explore the perspective of stakeholders (policy makers, doctors, pharmacists, nurses and patients) towards the role of pharmacists in osteoporosis screening and management. Setting A primary care clinic located within a teaching hospital in Kuala Lumpur, Malaysia. Method Patients (n = 20), nurses (n = 10), pharmacists (n = 11), doctors (n = 10) and policy makers (n = 5) were individually interviewed using a semi-structured topic guide. Purposive sampling was used. Interviews were transcribed verbatim and analysed using thematic analysis. Main outcome measure Perspective of stakeholders on the current and future role of pharmacists. Results All participants perceived pharmacists to be suppliers of medication, although there was some recognition of roles in providing medication advice. Nonetheless, these stakeholders were eager for pharmacists to expand their non-dispensing roles towards counselling, creating awareness and screening of osteoporosis. Interviewed pharmacists referred to their current role as 'robotic dispensers' and unanimously agreed to spread out to osteoporosis management role. Conclusion Under stakeholders there is a willingness to expand the role of pharmacists in Malaysia to non-dispensing roles, particularly in osteoporosis screening and management.

An analysis of inter-professional collaboration in osteoporosis screening at a primary care level using the D'Amour model.

OBJECTIVES: This study describes the perspective of patients, nurses, pharmacists, doctors and policy makers to identify the level of collaboration and the areas for improvement to achieve inter-professional collaboration between doctors, nurses, pharmacists and policy makers in a primary care clinic. METHODS: Patients (n = 20), Nurses (n = 10), pharmacists (n = 11), doctors (n = 10) and policy makers (n = 5) from a primary care were individually interviewed using a semi-structured topic guide. Purposive sampling was used. Interviews were transcribed verbatim and analysed using thematic analysis informed by constant comparison. RESULTS: Patients, doctors, nurses, pharmacists and policy makers were eager for pharmacists to be more proactive in creating health awareness and conducting osteoporosis screening at the primary care clinic via inter-professional collaboration. These findings were further examined using the D'Amour's structural model of collaboration which encompasses four main themes: shared goals and visions, internalization, formalization and governance. This model supports our data which highlights a lack of understanding of the pharmacists' role among the doctors, nurses, policy makers and pharmacists themselves. There is also a lack of governance and formalization, that fosters consensus, leadership, protocol and information exchange. Nonetheless, the stakeholders trust that pharmacists have sufficient knowledge to contribute to the screening of osteoporosis. Our primary care clinic can be described as developing towards an inter-professional collaboration in managing osteoporosis but is still in its early stages. CONCLUSIONS: Inter-professional collaboration in osteoporosis management at the primary care level is beginning to be practised. Efforts extending to awareness and acceptance towards the pharmacists' role will be crucial for a successful change.

A case of cystic schwannoma of the lesser sac.

INTRODUCTION: Benign cystic schwannoma of the lesser sac is an extremely rare condition and only 3 reports were found in our review of the English literature. CLINICAL PICTURE: We describe a 58-year-old man with a large (5.2 x 6.7 x 7.6 cm) epigastric mass with solid and cystic components detected on sonography and computed tomography. Close association with the pancreas, stomach and liver led to a mistaken diagnosis of pancreatic cystadenoma/cystadenocarcinoma. TREATMENT AND OUTCOME: The mass was surgically resected and our patient has been well since. CONCLUSION: This case draws the reader's attention to a rare condition that may mimic other sinister lesions, and highlights the pitfalls of diagnosis. Depending on the size and extent of the lesion, imaging may assist in characterisation of a schwannoma of the lesser sac. Surgical resection would still be the end point of management, especially when mass effect causes debilitating symptoms. Surgery is usually associated with good outcome, and tumour recurrence is unusual, provided adequate margins are resected.

Measurement of intracellular cytokines in MS patients treated with beta-interferon and association of a beta-interferon induced exacerbation with increased expression of gamma-interferon by monocytes.

The effects that immunomodulatory agents such as beta-Interferon (IFN-beta) exert upon cytokine production in autoimmune disease such as multiple sclerosis remain incompletely understood. The recent development of techniques to directly assess cytokine production within peripheral blood leucocytes promises to advance this field. beta-Interferon treatment occasionally causes short-lived exacerbations of neurological dysfunction, often associated with systemic flu-like symptoms. Whereas these side effects usually occur and remit within the first few months of therapy, we have identified several patients who have developed symptoms many months after the onset of treatment. To begin to investigate the cause of these late onset exacerbations, we assessed the intracellular cytokine profiles of two patients, one stable on IFN-beta treatment and another experiencing side effects. The latter patient exhibited an increase in the percentage of monocytes that expressed g-Interferon after IFN-beta administration, whereas no such modulation was seen in the patient without side effects.

Novel insight into the inflammatory and cellular responses following experimental glaucoma surgery: a roadmap for inhibiting fibrosis.

Failure after glaucoma filtration surgery is attributed to fibrosis at the operated site. To understand the wound healing process after glaucoma filtration surgery, we have developed a mouse model for glaucoma filtration surgery which closely mimics the clinical response. In this study, we describe a systematic analysis of the wound healing response in vivo. Our data revealed that the post-surgical tissue response was separable into two distinguishable phases. The early "acute inflammatory" phase was characterized by significantly increased transcript expression of Vegfa, Cxcl1, Cxcl5, Ccl2, Ccl3, Ccl4, Gmcsf and specific Mmps as well as greater infiltration of monocytes/macrophages and T cells. The late "fibrotic" phase was characterized by an increased expression of Tgfb2 and extracellular matrix genes as well as a notable reduction of infiltrating inflammatory cells. Significantly, more mitotic cells were observed at both time points post-surgery. Subconjunctival fibroblasts may be involved in both phases since they have the capacity to reiterate the in vivo gene expression profiles upon either pro-inflammatory or pro-fibrotic cytokine stimulation. Given that the cellular and molecular targets that govern the early and late phases of wound healing are distinct and time sensitive, a multi-targeted therapeutic approach to sequentially inhibit inflammation and fibrogenesis at the critical time point may lead to improved surgical outcomes in glaucoma filtration surgery.

Endovascular revascularisation of popliteal artery occlusions: two complex cases.

Peripheral vascular disease-related occlusions of the arteries are complex lesions that can be treated surgically or through endovascular means in symptomatic patients. In this case report, we describe two interesting cases of popliteal occlusion that were revascularised using advanced endovascular techniques to salvage the limb. The first case was a chronic popliteal artery occlusion that required atypical arterial access along with embolisation due to earlier attempted intervention to revascularise the artery. The second case was an acute embolic occlusion that was excluded from the circulation primarily rather than through the typical approach of thrombolysis or mechanical thrombectomy.

Prelabor uterine rupture after laparoscopic repair of uterine perforation.

Uterine rupture is an established risk of previous uterine trauma. Conventionally this has been considered most likely following prior classical or midline hysterotomies at cesarean section or subsequent to abdominal myomectomy in which the uterine cavity was breached. Although there are reports of such cases after laparoscopic procedures such as myomectomy the incidence is believed to be very small. We present an extreme case of uterine rupture at 27 weeks with a previous laparoscopically repaired uterine perforation.