Cardiac Failure Associated with Medical Therapy of Benign Prostatic Hyperplasia: A Population Based Study.

PURPOSE: Increased risk of cardiac failure with α-blockers in hypertension studies and 5-alpha reductase inhibitors in prostate studies have raised safety concerns for long term management of benign prostatic hyperplasia. The objective of this study was to determine if these medications are associated with an increased risk of cardiac failure in routine care. MATERIALS AND METHODS: This population based study used administrative databases including all men over 66 with a diagnosis of benign prostatic hyperplasia between 2005 and 2015. Men were categorized based on 5-alpha reductase inhibitor exposure and/or α-blocker exposure with a primary outcome of new cardiac failure utilizing competing risk models. Explanatory variables examined included exposure thresholds, formulations, age, and comorbidities associated with cardiac disease. RESULTS: The data set included 175,201 men with a benign prostatic hyperplasia diagnosis with 8,339, 55,383, and 41,491 exposed to 5-alpha reductase inhibitor, α-blocker and combination therapy, respectively. Men treated with 5-alpha reductase inhibitor and α-blocker, alone or in combination, had a statistically increased risk of being diagnosed with cardiac failure compared to no medication use. Cardiac failure risk was highest for α-blockers alone (HR 1.22; 95% CI 1.18-1.26), intermediate for combination α-blockers/5-alpha reductase inhibitors (HR 1.16; 95% CI 1.12-1.21) and lowest for 5-alpha reductase inhibitors alone (HR 1.09; 95% CI 1.02-1.17). Nonselective α-blocker had a higher risk of cardiac failure than selective α-blockers (HR 1.08; 95% CI 1.00-1.17). CONCLUSIONS: In routine care, men with a benign prostatic hyperplasia diagnosis and exposed to both 5-alpha reductase inhibitor and α-blocker therapy had an increased association with cardiac failure, with the highest risk for men exposed to nonselective α-blockers.

Ten-year risk of complication and mortality after total hip arthroplasty in morbidly obese patients: a population study

Background: The relationship between morbid obesity and long-term patient outcomes after primary total hip arthroplasty (THA) has been understudied. The purpose of this study was to determine the association between morbid obesity and 10-year complications (revision surgery, reoperation, dislocation) and mortality in patients undergoing primary THA. Methods: We conducted a population-based cohort study of patients aged 45­74 years who underwent primary THA for osteoarthritis between 2002 and 2007 using Ontario administrative health care databases. Patients were followed for 10 years. We estimated risk ratios (RRs) of mortality, reoperation, revision and dislocation in patients with body mass index (BMI) greater than 45 kg/m2 (morbidly obese patients) compared with patients with a BMI of 45 kg/m2 or less (nonmorbidly obese patients). Results: There were 22 251 patients in the study cohort, of whom 726 (3.3%) were morbidly obese. Morbid obesity was associated with higher 10-year risk of death (RR 1.38, 95% confidence interval [CI] 1.18­1.62). Risks of revision (RR 1.43, 95% CI 0.96­2.13) and dislocation (RR 2.38, 95% CI 1.38­4.10) were higher in morbidly obese men than in nonmorbidly obese men; there were no associations between obesity and revision or dislocation in women. Risk of reoperation was higher in morbidly obese women than in nonmorbidly obese women (RR 1.59, 95% CI 1.05­2.40); there was no association between obesity and reoperation in men. Conclusion: Morbidly obese patients undergoing primary THA are at higher risk of long-term mortality and complications. There were differences in complication risk by sex. The results of this study should inform perioperative counselling of patients considering THA.

Contexte: Le lien entre l'obésité morbide et les issues à long terme des patients ayant subi une arthroplastie totale primaire de la hanche (ATH) est sous-étudié. Cette étude visait à caractériser l'association entre l'obésité morbide et les complications (chirurgie de révision, réintervention, dislocation) et la mortalité sur 10 ans chez les patients ayant subi une ATH. Méthodes: Nous avons mené une étude de cohorte basée sur la population auprès de patients de 45 à 74 ans atteints d'arthrose ayant subi une ATH primaire entre 2002 et 2007 en utilisant les bases de données administratives en santé de l'Ontario. Les patients ont été suivis pour une période de 10 ans. Nous avons estimé des rapports de risque (RR) pour la mortalité, la réintervention, la chirurgie de révision et la dislocation chez les patients ayant un indice de masse corporelle (IMC) de plus de 45 kg/m2 (obésité morbide) en comparaison avec les patients ayant un IMC de 45 kg/m2 ou moins. Résultats: L'étude de cohorte comptait 22 251 patients, dont 726 (3,3 %) étaient atteints d'obésité morbide. L'obésité morbide a été associée à un risque de mortalité sur 10 ans accru (RR 1,38; intervalle de confiance [IC] de 95 % 1,18­1,62). Le risque de chirurgie de révision (RR 1,43; IC de 95 % 0,96­2,13) et de dislocation (RR 2,38; IC de 95 % 1,38­4,10) était plus élevé chez les hommes atteints d'obésité morbide que chez les autres hommes; aucune association n'a été observée entre l'obésité et la chirurgie de révision ou la dislocation chez les femmes. Par contre, le risque de réintervention était accru chez les femmes atteintes d'obésité morbide (RR 1,59; IC de 95 % 1,05­2,40), mais aucune association n'a été établie entre l'obésité et la réintervention chez les hommes. Conclusion: Les patients atteints d'obésité morbide qui subissent une ATH primaire courent un risque plus élevé de complications et de mortalité à long terme. Des différences ont été observées dans les risques de complications selon le sexe. Les résultats de cette étude devraient guider l'offre de conseils aux patients qui envisagent l'ATH.

Ten-Year Mortality and Revision After Total Knee Arthroplasty in Morbidly Obese Patients.

BACKGROUND: Although morbid obesity has been associated with early surgical complications after total knee arthroplasty (TKA), evidence of long-term outcomes is limited. We conducted a population-based study to determine the association between morbid obesity and 10-year survival and revision surgery in patients undergoing primary TKA. METHODS: A cohort study of 9817 patients aged 18-60 years treated with primary TKA from April 1, 2002 to March 31, 2007 was conducted using Ontario administrative health-care databases of universal health-care coverage. Patients were followed up for 10 years after TKA. Risk ratios (RRs) of mortality and TKA revision surgery in patients with body mass index > 45 kg/m2 (morbidly obese patients) compared with body mass index ≤45 kg/m2 (nonmorbidly obese) were estimated adjusting for age, sex, socioeconomic status, and comorbidities. RESULTS: About 10.2% (1001) of the cohort was morbidly obese. Morbidly obese patients were more likely to be female than nonmorbidly obese patients (82.5% vs 63.7%, P < .001) but otherwise similar in characteristics. Morbidly obese patients had higher 10-year risk of death than nonmorbidly obese patients (adjusted RR 1.50, 95% confidence interval 1.22-1.85). About 8.5% (832) of the patients had at least 1 revision procedure in the 10 years after TKA; revision rates did not differ by obesity (adjusted RR 1.09, 95% confidence interval 0.88-1.34). CONCLUSION: Morbidly obese patients ≤60 years had a 50% higher 10-year risk of death but no difference in the risk of revision surgery. Results of this population-based study inform evidence-based perioperative counseling of morbidly obese patients considering TKA.

Emergency Caesarean Section in Obese Parturients: Is a 30-Minute Decision-to-Incision Interval Feasible?

OBJECTIVE: To determine the effect of obesity on decision-to-incision and decision-to-delivery time intervals in emergency Caesarean section. METHODS: We performed a retrospective study of emergency Caesarean sections performed between 2005 and 2009. Indications for emergency Caesarean section were defined as those posing an immediate threat to the life of the mother or fetus. The primary outcomes were the time intervals from decision for emergency delivery to skin incision, and decision to delivery of the infant. The secondary outcome was a composite of poor neonatal outcomes comprising umbilical cord artery pH lt; 7.20, Apgar score lt; 7 at five minutes, admission to NICU, or neonatal death. RESULTS: A total of 232 women underwent emergency Caesarean section, and 140 of these met the inclusion criteria. At the time of delivery, 78/140 (55.7%) patients were categorized as obese (BMI ≥ 30kg/m2). The median decision-to-incision and decision-to-delivery intervals were significantly longer in the obese group, with a median delay of 4.5 minutes in both time intervals. Time-to-event analysis demonstrated prolongation of the decision-to-incision interval in the obese group (hazard ratio 0.71, P lt; 0.05). There was no difference in the neonatal composite outcome, but there was a significant reduction in median five-minute Apgar score in the obese group (P = 0.02). CONCLUSION: Obesity is associated with prolonged decision-to-incision and decision-to-delivery intervals, without associated neonatal morbidity, in a tertiary hospital setting. Further studies are required to assess the specific factors limiting expedient delivery in this population.

Objective : Déterminer l'effet de l'obésité sur les intervalles décision-incision et décision-accouchement en ce qui concerne la tenue d'une césarienne d'urgence. Méthodes : Nous avons mené une étude rétrospective portant sur les césariennes d'urgence menées entre 2005 et 2009. Les indications menant à la tenue d'une césarienne d'urgence ont été définies comme étant celles qui constituaient une menace immédiate pour la vie de la mère ou celle du fœtus. Les critères d'évaluation principaux ont été l'intervalle entre la décision de procéder à un accouchement d'urgence et l'exécution de l'incision cutanée, et l'intervalle entre cette décision et la naissance de l'enfant. Le critère d'évaluation secondaire était un composite de diverses mauvaises issues néonatales, dont un pH artériel (cordon ombilical) lt; 7,20, un indice d'Apgar lt; 7 à cinq minutes, l'admission à l'UNSI et le décès néonatal. Résultats : Au total, 232 femmes ont subi une césarienne d'urgence et 140 d'entre elles répondaient aux critères d'inclusion. Au moment de l'accouchement, 78/140 (55,7 %) patientes ont été catégorisées comme étant obèses (IMC ≥ 30kg/m2). Les intervalles décision-incision et décision-accouchement médians étaient considérablement plus longs dans le groupe des femmes obèses (délai médian de 4,5 minutes pour ce qui est de ces deux intervalles). L'analyse du délai avant la survenue de l'événement a démontré la prolongation de l'intervalle décision-incision au sein du groupe des femmes obèses (rapport de risque, 0,71; P lt; 0,05). Bien qu'aucune différence n'ait été constatée en ce qui concerne l'issue composite néonatale, une baisse significative de l'indice d'Apgar médian à cinq minutes a été observée au sein du groupe des femmes obèses (P = 0,02). Conclusion : L'obésité est associée à une prolongation des intervalles décision-incision et décision-accouchement, sans répercussions connexes sur la morbidité néonatale, en milieu hospitalier tertiaire. La tenue d'autres études s'avère requise pour l'évaluation des facteurs particuliers qui limitent la tenue d'un accouchement en temps opportun au sein de cette population.

Total hip arthroplasty versus hemiarthroplasty for treatment of femoral neck fractures : a population-based analysis of practice variation in Ontario, Canada.

AIMS: This study aimed to describe practice variation in the use of total hip arthroplasty (THA) for older patients with femoral neck fracture and to determine the association between patient, surgeon, and institution factors and treatment with THA. METHODS: We performed a cross-sectional analysis of 49,597 patients aged 60 years and older from Ontario, Canada, who underwent hemiarthroplasty or THA for femoral neck fracture between 2002 and 2017. This population-based study used routinely collected healthcare databases linked through ICES (formerly known as the Institute for Clinical Evaluative Sciences). Multilevel logistic regression modelling was used to quantify the association between patient, surgeon, and institution-level variables and whether patients were treated with THA. Variance partition coefficient and median odds ratios were used to estimate the variation attributable to higher-level variables and the magnitude of effect of higher-level variables, respectively. RESULTS: Over the study period, 9.4% of patients (n = 4,638) were treated with THA. Patient factors associated with higher likelihood of treatment by THA included: younger age, male sex, and diagnosis with rheumatoid arthritis. Long-term care residence, use of home care services prior to hip fracture, diagnosis of dementia, higher comorbidity burden, and the most marginalized group were negatively associated with treatment by THA. Treating surgeon and institution accounted for 54.2% and 17.8% of the total variation in treatment with THA, respectively. Surgeon volume of THA procedures in the 365 days prior to surgery was the strongest higher-level predictor of treatment with THA. Specific treating surgeons and institutions still accounted for significant proportions of the variability in treatment with THA (40.3% and 19.5% of total observed variation, respectively) after controlling for available patient, surgeon, and institution-level variables. CONCLUSION: The strongest predictors for treatment of patients with femoral neck fracture with THA were patient age, treating surgeon, and treating institution. This practice variation highlights differential access to care for patients.Cite this article: Bone Joint J 2023;105-B(2):180-189.

Total hip arthroplasty for displaced femoral neck fracture: Survey of orthopaedic surgeons in Ontario, Canada.

BACKGROUND: Total hip arthroplasty (THA) for displaced femoral neck fractures in older patients remains a controversial topic. This study describes patient and surgeon factors that are associated with surgeons' recommendation of THA for this patient population. Furthermore, this study explores surgeon perceptions on why most patients are treated with hemiarthroplasty over THA. METHODS: In October 2019, a cross-sectional survey was mailed to practicing orthopaedic surgeons in Ontario, Canada. The questionnaire included paper patient cases to capture surgical practice variation using a full factorial, vignette-based experimental design. Multilevel linear regression and multivariable linear regression were used to determine patient and surgeon factors that are associated with treatment recommendations. RESULTS: Of a target population of 494 practicing surgeons, 302 (61.1%) responded. Sixty percent of respondents worked in the community, and most respondents (89.4%) had fellowship training. Surgeon-level predictors of treatment with THA included higher volume of THA for fracture in the last 12 months, having an elective THA practice, and increasing years in practice. Pre-existing hip arthritis increased likelihood to recommend THA, while increasing patient age and comorbidity burden decreased likelihood to recommend THA. There are medical, institutional, financial, and historic reasons why most patients are treated with hemiarthroplasty over THA. INTERPRETATION: This survey identified several patient and surgeon-level factors that were associated with treatment recommendation for THA. Hemiarthroplasty remains the more common treatment for this patient population for multiple reasons. There is potential for differential access to care when the factors driving treatment decisions are unrelated to the patient.

Comparative Effectiveness of Total Hip Arthroplasty and Hemiarthroplasty for Femoral Neck Fracture: A Propensity-Score-Matched Cohort Study.

BACKGROUND: The optimal treatment of older patients with a displaced femoral neck fracture remains a controversial topic. This study aimed to compare clinical outcomes across a matched group of patients with a femoral neck fracture treated with either hemiarthroplasty or total hip arthroplasty (THA). METHODS: Routinely collected health-care databases were linked to create a population-based cohort of 49,597 patients ≥60 years old from Ontario, Canada, who underwent hemiarthroplasty or THA for a femoral neck fracture between 2002 and 2017. A propensity-score-matched cohort was created using relevant and available predictors of treatment assignment and outcomes of interest. Clinical outcomes consisting of hip dislocation, revision surgery, hospital readmission, and death were compared in the matched cohort using survival analysis. RESULTS: Over 99% of THA patients (4,612) were adequately matched 1:1 to hemiarthroplasty patients (total matched cohort = 9,224). Patients treated with THA were at higher risk for hip dislocation at 30 days and 1 and 2 years postoperatively (2-year risk, 1.8% for THA versus 0.8% for hemiarthroplasty; p < 0.001). There was no difference in the short-term (30-day) or long-term (up to 10-year) risk of revision surgery between treatment groups. There was no significant difference in the risk of 30-day hospital readmission between groups. The risk of death at 1 year and 2 years postoperatively was lower for patients treated with THA. CONCLUSIONS: For patients with a hip fracture, shared decision-making should involve discussion of the potential higher risk of short-term hip dislocation after THA compared with hemiarthroplasty. The risk of revision surgery was similar between treatment groups at up to 10 years of follow-up. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Association between pre-operative sagittal alignment and radiographic measures of decompression following cervical laminectomy: a retrospective cohort study.

BACKGROUND: The primary purpose of this study was to determine the association between pre-operative cervical sagittal alignment and the extent of cord decompression in the form of increased spinal cord width and cerebrospinal fluid (CSF) space in front of and behind the cord in patients undergoing laminectomy for cervical spondylotic myelopathy (CSM). Secondary objectives included an assessment of the correlation between increasing numbers of levels decompressed and the post-operative cervical spine sagittal alignment, the effect of laminectomy on the change in alignment, as well as effect of laminectomy on pre-existing spinal cord signal abnormality. METHODS: This retrospective cohort study included patients who underwent cervical laminectomies, without fusion, between 2015 and 2020. Chart review was used to collect baseline variables. Cervical sagittal alignment, width of the spinal cord, and the CSF space in-front and behind the cord was measured pre-operatively and post-operatively using magnetic resonance imaging (MRI) scans for each patient. The correlation between change in measured parameters and pre-operative cervical sagittal alignment was assessed using Spearman's correlation. RESULTS: Thirty-five patients were included. Average age was 65.29±10.98 years old. The majority of patients (80%) underwent laminectomies at 3-4 levels. Average pre-operative sagittal alignment determined by the Cobb angle was 6.05°±14.17°, while the average post-operative Cobb angle was 3.15°±16.64°. The change in Cobb angle was not statistically significant (P=0.998). Eleven patients (32%) had pre-operative kyphotic sagittal alignment. The average time from surgery to post-operative MRI scan was 20.44±13.18 months (range, 3-39; median, 18.5; IQR, 23.5). There was no statistically significant association between increasing levels of decompression and change in alignment (P=0.546). Cord signal abnormality persisted after decompression. There was a moderate correlation between lordotic pre-operative cervical sagittal alignment and change in space in-front of the cord (correlation coefficient 0.337, P=0.048) and change in cord width (correlation coefficient 0.388, P=0.021). CONCLUSIONS: Severity of pre-operative kyphotic sagittal alignment is associated with decreased spinal cord drift and extent of decompression. The pre-operative sagittal alignment is not significantly associated with the change in post-operative alignment. Increasing number of levels decompressed does not worsen a kyphotic cervical spine sagittal alignment.

The association of new-onset diabetes mellitus and medical therapy for benign prostatic hyperplasia: A population-based study.

INTRODUCTION: Benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms are highly prevalent in the aging male. Similarly, the prevalence of metabolic syndrome is increasing worldwide, with mounting evidence that these two common conditions share more than age as a predisposing factor. The objective of this study was to determine if medical management of BPH is associated with an increased risk of new-onset diabetes mellitus (DM) in routine care. METHODS: This population-based, retrospective cohort study expands on a parent study of linked administrative databases identifying patients diagnosed and treated for BPH between 2005 and 2015. The primary outcome of this secondary analysis was a new diagnosis of DM after the index date of BPH diagnosis. Covariates included age, dyslipidemia, hypertension, and vascular diseases. A Cox proportional hazards regression model was used for inferential statistical analysis. RESULTS: A total 129 223 men were identified with a BPH diagnosis and no prior history of DM. Of those men, 6390 (5%) were exposed to 5-alpha-reductase inhibitor (5-ARI), 39 592 (31%) exposed to alpha-blocker (AB), and 30 545 (24%) exposed to combination therapy. Compared to those men with no BPH medication use, those exposed to drugs had an increased risk of new DM. Men treated with combination therapy of 5-ARI and AB (hazard ratio [HR] 1.30, 95% confidence interval [CI] 1.25-1.35), 5-ARI monotherapy (HR 1.25, 95% CI 1.17-1.34), or AB monotherapy (HR 1.17, 95% CI 1.13-1.22) all were at higher risk of new DM diagnosis after adjusting for important covariates. When calculating the risk of a new diabetes diagnosis measured from the start of drug exposure, men treated with 5-ARIs had an increased risk of DM compared to AB monotherapy as the reference, with HR 1.12 (95% CI 1.03-1.21) for 5-ARI monotherapy and HR 1.20 (95% CI 1.14-1.25) for combination therapy. CONCLUSIONS: In this large, long-term, retrospective study of men with a BPH diagnosis in routine practice, the risk of a new diagnosis of DM was greater in patients receiving medical management compared to controls. This modest but significant increased risk was highest in men treated with any 5-ARIs, in combination as well as monotherapy, compared to the ABs.

Routine perioperative practices and postoperative outcomes for elective lumbar laminectomies.

BACKGROUND: Routine investigations for asymptomatic patients undergoing low-risk surgery contribute little value to perioperative care, but these tests are still ordered in many centres. The primary purpose of this retrospective cohort study was to determine the prevalence of preoperative bloodwork for elective lumbar laminectomy and its association with intraoperative and postoperative complications. Secondary objectives were to determine the prevalence of intraoperative tranexamic acid administration, length of stay, and 30-day readmission. METHODS: Retrospective electronic chart reviews were conducted on all patients 18+ years old who underwent elective lumbar laminectomy by one orthopaedic spine surgeon between July 01, 2013 and June 30, 2017. All procedures were performed at the University Health Sciences Centre. RESULTS: Two hundred fifty-six patients underwent lumbar laminectomy at one or more levels during the study period. Among these patients, 89.5% underwent at least one preoperative blood test. The intraoperative complication rate was 2.34%. Intraoperative intravenous tranexamic acid was administered in <2% of surgeries; there were no postoperative blood transfusions. The 30-day hospital readmission rate was zero. CONCLUSIONS: Hospital policies should be re-evaluated to address the overuse of unnecessary preoperative investigations for elective lumbar laminectomies, which have low perioperative transfusion and complication rates.