Increased Use and Large Variation in Strong Opioids and Metamizole (Dipyrone) for Minor and Major Musculoskeletal Injuries Between 2008 and 2018: An Analysis of a Representative Sample of Swiss Workers.

PURPOSE: Musculoskeletal (MSK) injuries are a major contributing factor for chronic pain. To date, little is known how pain medication use in MSK injuries has changed over time. We assessed pain medication prescription for MSK injuries in a representative sample of Swiss workers between 2008 and 2018. METHODS: Retrospective analysis of the Swiss Accident Insurance Fund (Suva) data. We calculated annual pain medication use, treatment days, and costs associated with pain medication use in minor and major MSK injuries. RESULTS: In total, 1,921,382 cases with MSK injuries with ≥ 1 pain medication were analyzed. Whereas MSK injuries with ≥ 1 pain medication increased by 9.4%, we observed a larger increase in metamizole (+ 254%), strong opioids (+ 88.4%), coxibs (+ 85.8%), and paracetamol (+ 28.1%). Strong opioids were increasingly used in minor (+ 91.4%) and major (+ 88.3%) injuries. The increase in metamizole (+ 390.6%) and coxibs (+ 115.5%) was larger in minor injuries compared to major injuries (+ 238.7% and + 80.6%, respectively). Medical expenses decreased in all medications except for strong opioids where a substantial increase was observed (+ 192.4% in minor; + 34% in major injuries). CONCLUSIONS: We observed a disproportionate increase in metamizole, strong opioids, coxibs, and paracetamol prescriptions even in minor MSK injuries between 2008 and 2018. Whereas treatment costs decreased for all pain medications, there was a substantial increase in strong opioids. A more liberal prescription practice of opioids conflict with current evidence-based practice recommendations and need to be addressed by physicians and policy makers.

Anterolateral Ligament Reconstruction and Modified Lemaire Lateral Extra-Articular Tenodesis Similarly Improve Knee Stability After Anterior Cruciate Ligament Reconstruction: A Biomechanical Study.

PURPOSE: To determine the stabilizing role of anterolateral ligament reconstruction (ALLR) and modified Lemaire lateral extra-articular tenodesis (LET) performed in combination with anterior cruciate ligament reconstruction (ACLR) and to determine whether either procedure was superior to the other. METHODS: Six nonpaired, human, fresh-frozen cadaveric knees were tested with a 6-df robotic system. Internal rotation and anterior translation of the knee were recorded from 0° to 90° of flexion after application of a 5-Nm internal rotation torque and a 134-N anterior load, respectively. A full kinematic assessment was performed in each of the following conditions: (1) intact knee, (2) after sectioning of the anterior cruciate ligament (ACL), (3) after sectioning of the ACL and anterolateral ligament, (4) after isolated ACLR, and (5) after combined ACLR and Lemaire LET and combined ACLR and ALLR. ALLR was performed using the gracilis tendon, whereas the modified Lemaire procedure was performed using the central strip of the iliotibial band. The different states were compared using a Tukey paired comparison test. RESULTS: In knees with combined deficiency of the ACL and anterolateral structures, anterior translation and internal rotation remained significantly increased after isolated ACLR compared with the intact knee (+2.33 ± 1.44 mm and +1.98° ± 1.06°, respectively; P < .01). On the other hand, the addition of ALLR or modified Lemaire LET to ACLR restored anterior translation and internal rotation to values similar to those in the intact knee. The 2 anterolateral procedures did not show statistically significantly different values for both tests. This difference was 0.67 ± 1.46 mm for anterior translation (P = .79) and 0.11° ± 1.11° for internal rotation (P = .99). CONCLUSIONS: In knees with ACL and anterolateral deficiency, combined ACLR and anterolateral reconstruction restored the native knee stability in anterior translation and internal rotation contrary to isolated ACLR. In addition, both types of extra-articular reconstruction-ALLR and modified Lemaire LET-were similar in terms of restoring knee kinematics, and neither overconstrained the knee. CLINICAL RELEVANCE: In knees with deficiency of the ACL and anterolateral structures, combined ACLR and anterolateral reconstruction increased knee stability at time zero after surgery. This biomechanical improvement could be responsible for the protective effect on ACL graft and meniscal repair reported in the literature after the combined procedure.

Factors influencing pain medication and opioid use in patients with musculoskeletal injuries: a retrospective insurance claims database study.

Opioid use is only recommended in selected cases of musculoskeletal (MSK) injuries. We assessed factors associated with increased opioid use in MSK injuries. In a retrospective analysis of over four million workers with MSK injuries using the Swiss National Accident Insurance Fund (Suva) database, we analyzed risk factors by multivariate logistic regression. Injury severity was associated with pain medication, opioid, and strong opioid use. Whereas fractures, contusions, and ruptures had higher odds for any pain medication use, increased odds for strong opioids were observed in fractures, superficial injuries, and other injuries. Injuries of the shoulders, elbow, chest, back/spine, thorax, and pelvis/hips showed high odds for opioid use (odds ratio (OR) > 2.0). Injuries of the shoulders had higher odds for strong opioid use (OR 1.136; 95% CI 1.040-1.241). The odds for using strong opioids increased from 2008 OR 0.843 (95% confidence interval (CI) 0.798-0.891) to 2018 OR 1.503 (95% CI 1.431-1.578), compared to 2013. Injury severity, type of injury, and injured body parts influenced the use of pain medication and overall opioid use in musculoskeletal injuries. Strong opioids were more often used in fractures but also in superficial and other minor injuries, which indicates that other factors play a role when prescribing strong opioids.

Biomechanical Comparison of Anterior Cruciate Ligament Reconstruction Using a Single-Bundle Round or Ribbon-like Hamstring Tendon Graft.

BACKGROUND: Persistent instability of the knee is reported in up to 30% of patients after anterior cruciate ligament (ACL) reconstruction. Based on anatomic findings showing that ACL is a flat ribbon-like structure that twists during knee flexion, a new surgical ACL reconstruction technique using a ribbon-like graft has been developed. However the effect of this surgical technique on knee kinematics has not yet been evaluated. PURPOSE: To compare the anteroposterior and rotational stability of the knee after ACL reconstruction using single-bundle (SB) round and ribbon-like grafts in anterolateral-intact/deficient knees. STUDY DESIGN: Controlled laboratory study. METHODS: Twelve human fresh-frozen cadaveric knees were tested with a 6 degrees of freedom robotic system. Internal rotation and anterior translation of the knee were recorded from 0° to 90° of flexion. A full kinematic assessment was performed in each of the following conditions: (1) intact knee, (2) after sectioning of the ACL, (3) after ACL reconstruction using a SB hamstring tendon graft in a round configuration and a ribbon-like configuration, and (4) after sectioning of the anterolateral structures. One-way analysis of variance and post hoc Tukey tests were used for statistical analyses. RESULTS: When compared with the intact knee, the ACL-deficient knee demonstrated a mean ± SD increase in anterior translation and internal rotation of 6.3 ± 2.5 mm (P < .01) and 5.8°± 2.3° (P < .01), respectively. After ACL reconstruction using a SB ribbon-like graft, the mean difference in anterior translation and internal rotation as compared with the intact knee was -0.1 ± 1.5 mm (P = .842) and 0.0°± 1.1° (P = .999). These differences from the intact knee were also not significant after ACL reconstruction using a round graft (-0.1 ± 1.3 mm, P = .999; -0.5°± 1.5°, P = .401). In the ACL-reconstructed knee using either a ribbon-like or round graft, sectioning of the anterolateral structures did not induce a significant increase of anterior translation and internal rotation of the knee. CONCLUSION: ACL reconstruction using a SB ribbon-like or round graft restored the kinematics of the intact knee at time zero. Secondary sectioning of the anterolateral structures in the ACL-reconstructed knee using both types of graft did not significantly affect the anterior translation and internal rotation of the knee. CLINICAL RELEVANCE: This is the first biomechanical study on the new ACL reconstruction technique using a ribbon-like graft.

Frailty to predict unplanned hospitalization, stroke, bleeding, and death in atrial fibrillation.

AIMS: Atrial fibrillation (AF) and frailty are common, and the prevalence is expected to rise further. We aimed to investigate the prevalence of frailty and the ability of a frailty index (FI) to predict unplanned hospitalizations, stroke, bleeding, and death in patients with AF. METHODS AND RESULTS: Patients with known AF were enrolled in a prospective cohort study in Switzerland. Information on medical history, lifestyle factors, and clinical measurements were obtained. The primary outcome was unplanned hospitalization; secondary outcomes were all-cause mortality, bleeding, and stroke. The FI was measured using a cumulative deficit approach, constructed according to previously published criteria and divided into three groups (non-frail, pre-frail, and frail). The association between frailty and outcomes was assessed using multivariable-adjusted Cox regression models. Of the 2369 included patients, prevalence of pre-frailty and frailty was 60.7% and 10.6%, respectively. Pre-frailty and frailty were associated with a higher risk of unplanned hospitalizations [adjusted hazard ratio (aHR) 1.82, 95% confidence interval (CI) 1.49-2.22; P < 0.001; and aHR 3.59, 95% CI 2.78-4.63, P < 0.001], all-cause mortality (aHR 5.07, 95% CI 2.43-10.59; P < 0.001; and aHR 16.72, 95% CI 7.75-36.05; P < 0.001), and bleeding (aHR 1.53, 95% CI 1.11-2.13; P = 0.01; and aHR 2.46, 95% CI 1.61-3.77; P < 0.001). Frailty, but not pre-frailty, was associated with a higher risk of stroke (aHR 3.29, 95% CI 1.2-8.39; P = 0.01). CONCLUSION: Over two-thirds of patients with AF are pre-frail or frail. These patients have a high risk for unplanned hospitalizations and other adverse events. These findings emphasize the need to carefully evaluate these patients. However, whether screening for pre-frailty and frailty and targeted prevention strategies improve outcomes needs to be shown in future studies. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov identifier number: NCT02105844.

No fever, no malaria ? A diagnostic challenge in an immunocompromised patient.

We describe the case of an immunosuppressed women with proven malaria tropicana. Fever was not reported with this patient. We conclude that the concept of using fever as a primary surrogate indicator for the presence of malaria should be used with caution in patients with complex immunosuppression.

Is correction for age necessary in neuroimaging studies of the central serotonin transporter?

The central neurotransmitter serotonin plays a major role in a number of neuropsychiatric disorders. However, results from post-mortem and in vivo neuroimaging studies of the influence of age on the number of presynaptic serotonin transporters (SERT) are controversial. To provide further evidence of relevance for this ongoing discussion, SERT were imaged in 22 persons without neuropsychiatric impairment using [(123)I]2beta-carbomethoxy-3beta-(iodophenyl)tropane ([(123)I]beta-CIT) and high-resolution single-photon emission tomography (SPET). The SPET analysis method was based on magnetic resonance image co-registration in order to quantify SERT with acceptable inter- and intra-observer variability. Using this technique, we found a significant age-related decline in the thalamic/hypothalamic and midbrain/upper brainstem SERT density, which was more pronounced than that previously reported in the literature. From these results we conclude that age-related changes in SERT density need to be considered in future clinical studies.