Only 1% of Total Knee Arthroplasty Clinical Trials Report Patient Opioid Use Before or After Surgery: A Systematic Review.

OBJECTIVES: Many clinical trials report significant improvements in osteoarthritis-related pain and function after total knee arthroplasty (TKA). Opioids are commonly prescribed for pain management of knee osteoarthritis and also perioperative pain after surgery. The extent of persistent opioid use after TKA is unknown. Because up to 20% of individuals have poor outcomes after TKA and prior opioid use is a risk factor for future opioid use, treatment effects from TKA clinical trials would be better understood by assessing opioid use data from trial participants. The purpose of this review was to determine the proportion of participants in TKA trials with opioid use before surgery and persistent use after surgery and how well clinical trials capture and report these variables. MATERIALS AND METHODS: A systematic review of the literature (5 databases: CINAHL Cochrane CENTRAL, Embase, PubMed, and Web of Science) was conducted to assess the reporting of opioid use in TKA clinical trials. All opioid use was extracted, both prior and postoperatively. Long-term opioid use was determined using 4 different contemporary definitions to increase the sensitivity of the assessment. RESULTS: The search produced 24,252 titles and abstracts, and 324 met the final inclusion criteria. Only 4 of the 324 trials (1.2%) reported any type of opioid use; 1 identified prior opioid use, and none reported long-term opioid use after surgery. Only 1% of TKA clinical trials in the past 15 years reported any opioid use. DISCUSSION: Based on available research, it is not possible to determine if TKA is effective in reducing reliance on opioids for pain management. It also highlights the need to better track and report prior and long-term opioid use as a core outcome in future TKA trials.

Factors Associated With Myocardial Infarction Reoccurrence.

BACKGROUND: As recurrent myocardial infarctions (MIRs) constitute almost a third of the annual incidence of myocardial infarction, identifying the traditional and novel variables related to MIR is important. OBJECTIVE: The aim of this study was to examine modifiable cardiac risks, adiposity, symptoms associated with inflammation (fatigue, depression, sleep) and inflammatory cytokines, and MIR by sex and race. METHODS: Using a cross-sectional descriptive design, we recruited a convenience sample of adults (N = 156) discharged with first myocardial infarction or had MIR in the last 3 to 7 years. Surveys measured demographics, cardiac risk factors, depression, sleep, and fatigue. Anthropometric measures and cytokines tumor necrosis factor-α, interleukin-6, and high-sensitivity C-reactive protein (hsCRP) were obtained. A maximum likelihood regression was calculated to predict MIR. RESULTS: The sample included 57% male and 30% Black participants, and the mean (SD) age was 65 (12) years. The hsCRP was the only cytokine related to symptoms: fatigue ( r = 0.309, P < .001) and depression ( r = 0.255, P = .002). An MIR was not associated with race despite White participants reporting better sleep ( t146 = -3.25, P = .002), lower body mass index ( t154 = -3.49, P = .001), and fewer modifiable risk factors ( t152 = -2.05, P = .04). An MIR was associated with being male, higher hsCRP and tumor necrosis factor-α levels ( P < .001), and higher inflammatory symptoms of fatigue ( P = .04), depression ( P = .01), and poor sleep ( P < .001). CONCLUSION: Further examination of biomarkers to understand the mechanisms associated with inflammatory symptoms of fatigue, depression, and poor sleep and MIR is needed.

Effects of Tactile Desensitization on Postoperative Pain After Amputation Surgery.

PURPOSE: Pain in the acute setting after amputation is complex with multiple types of pain experienced, including somatic and neuropathic. No studies have measured multiple pain control modalities while using self-management techniques for acute amputation pain. Desensitization could provide a means of pain control for somatic and neuropathic pain. The purpose of this study was to test the efficacious use and effects of tactile desensitization in managing acute postoperative pain after lower limb amputation. DESIGN: This was a pre-experimental repeated measure study. METHODS: Pain description, intensity, anxiety, depression, and medication usage were measured during repeated time periods. Pain intensity was measured before and after each intervention along with efficacy. FINDINGS: Of the times the intervention was self-administered (n = 50) there was a statistically significant reduction in the pain level (P < .001) with large effect sizes for all paired comparisons. Participants found the intervention efficacious and feasible to use. CONCLUSIONS: The findings support a reduction in pain intensity scores using pain medication coupled with tactile desensitization.

Increased risk of atrial fibrillation among patients undergoing coronary artery bypass graft surgery while receiving nitrates and antiplatelet agents.

Background Postoperative atrial fibrillation (POAF) is a frequent complication of coronary artery bypass graft (CABG) surgery. This arrhythmia occurs more frequently among patients who receive perioperative inotropic therapy (PINOT). Administration of nitrates with antiplatelet agents reduces the conversion rate of cyclic guanosine monophosphate to guanosine monophosphate. This process is associated with increased concentrations of free radicals, catecholamines, and blood plasma volume. We hypothesized that patients undergoing CABG surgery who receive PINOT may be more susceptible to POAF when nitrates are administered with antiplatelet agents. Methods Clinical records were examined from a prospectively maintained cohort of 4,124 patients undergoing primary isolated CABG surgery to identify POAF-associated factors. Results POAF risk was increased among patients receiving PINOT, and the greatest effect was observed when nitrates were administered with antiplatelet therapy. Adjustment for comorbidities did not substantively change the study results. Conclusions Administration of nitrates with certain antiplatelet agents was associated with an increased POAF risk among patients undergoing CABG surgery. Additional studies are needed to determine whether preventive strategies such as administration of antioxidants will reduce this risk.

Treatment of axillary web syndrome using instrument assisted soft tissue mobilization and thoracic manipulation for associated thoracic rotation dysfunction.

PURPOSE: There is a paucity of research that investigates physical therapy management for patients with axillary web syndrome (AWS) and thoracic rotation dysfunction. The purpose of this case report is to describe the management of a patient with AWS and thoracic rotation dysfunction using an impairment-based approach that includes instrument assisted soft tissue mobilization (IASTM), thoracic manipulation, and stretching. CASE DESCRIPTION: The patient was a 48-year-old female with a past medical history of bilateral breast cancer with a bilateral latissimus dorsi flap reconstruction. The patient was referred to physical therapy with chief complaints of right shoulder pain with reaching and an inability to resume running due to right shoulder and scapula pain. The patient was seen in outpatient physical therapy for four visits over four weeks. Treatment consisted of IASTM, thoracic manipulation, stretching exercises, and home exercise program instruction. OUTCOMES: Upon discharge, the patient had improved right shoulder and thoracic range of motion, decreased pain, and improved function on the patient specific functional scale (PSFS). CONCLUSION: Utilization of an impairment-based physical therapy approach to treat a patient with AWS and thoracic dysfunction yielded positive outcomes. Further research on the efficacy of IASTM and physical therapy management of AWS is warranted.

Perioperative Inotrope Therapy and Atrial Fibrillation Following Coronary Artery Bypass Graft Surgery: Evidence of a Racial Disparity.

BACKGROUND AND OBJECTIVE: Following coronary artery bypass graft (CABG) surgery, mortality rates are significantly higher among black patients who experience postoperative atrial fibrillation (POAF). Perioperative inotropic therapy (PINOT) was associated with POAF in previous reports, but the extent to which race influences this association is unknown. In the present study, the relationship between PINOT, race, and POAF was examined in patients undergoing CABG surgery. METHODS AND SETTING: Clinical records were examined from a prospectively maintained cohort of 11,855 patients (median age 64 yrs; 70% male; 16% black) undergoing primary isolated CABG at a large cardiovascular institute in the southeastern region of the United States. Relative risk (RR) and 95% confidence intervals (CIs) were computed using log-binomial regression. MAIN RESULTS: The association between PINOT and POAF was significantly increased among black patients (adjusted RR 1.7, CI 1.4-2.0) compared with white patients (adjusted RR 1.3, CI 1.2-1.4) (pinteraction  = 0.013). CONCLUSIONS: These findings suggest that PINOT may be disproportionately associated with POAF among black patients undergoing CABG surgery. Additional studies are needed to examine further the potential underlying mechanisms of this association.

Plasma Catecholamine Levels on the Morning of Surgery Predict Post-Operative Atrial Fibrillation.

OBJECTIVES: This study sought to determine whether plasma catecholamines and monoamine oxidase-B (MOA-B) are associated with post-operative atrial fibrillation (POAF) in patients undergoing elective cardiac surgery. BACKGROUND: Although intra- and post-operative adrenergic tone has been demonstrated to be an causative factor for POAF, the role and association of pre-operative plasma catecholamines remains unclear. METHODS: Prior to administration of anesthesia on the morning of surgery, blood samples were obtained from 324 patients undergoing nonemergent coronary artery bypass graft and/or aortic valve surgery with cardiopulmonary bypass at East Carolina Heart Institute. The concentrations of norepinephrine (NE), dopamine (DA), epinephrine (EPI), and enzyme MAO-B were assessed in platelet-rich plasma. A log-binomial regression model was used to determine the association between quartiles of these variables and POAF. RESULTS: Levels of NE (p = 0.0006) and EPI (p = 0.047) in the 4th quartile [Formula: see text] were positively associated with POAF, whereas DA (p = 0.0034) levels in the 4th quartile [Formula: see text] were inversely associated with POAF. Adjusting for age, heart failure (HF), and history of atrial fibrillation, the composite pre-operative (adrenergic) plasma marker [Formula: see text] was associated with a 4-fold increased occurrence of POAF (adjusted p = 0.0001). No association between plasma MAO-B and POAF was observed. CONCLUSIONS: Our results suggest that pre-operative adrenergic tone is an important factor underlying POAF. This information provides evidence that assessment of plasma catecholamines may be a low-cost method that is easy to implement for predicting which patients are likely to develop POAF. More investigation in a multicentric setting is needed to validate our results.

Long-Term Survival after Cardiac Surgery in Patients with Chronic Obstructive Pulmonary Disease.

BACKGROUND: Although many patients with chronic obstructive pulmonary disease (COPD) require a prolonged length of stay (PLOS) following coronary artery bypass grafting (CABG), the impact of PLOS on long-term survival has not been examined in this population. OBJECTIVES: To determine the association between PLOS and long-term survival among COPD and non-COPD patients after CABG and to examine consequent policy and practice-based implications. METHODS: A retrospective cohort study of CABG patients was conducted between 2002 and 2011. Long-term survival was compared in patients with and without COPD and stratified by PLOS. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. RESULTS: A total of 203 patients (4.2%) had PLOS after nonemergent CABG (N = 4801). PLOS was an important independent predictor of decreased long-term survival (no COPD, no PLOS: HR = 1.0; COPD, no PLOS: adjusted HR [95% CI], 1.8 [1.5-2.1]; no COPD, PLOS: 3.3 [2.5-4.4]; COPD, PLOS: 6.0 [4.4-8.2]; PTrend < .001). CONCLUSIONS: COPD and PLOS are 2 of many factors that affect long-term mortality in postoperative CABG patients. Aggressive treatment strategies aimed at early weaning off of mechanical ventilation and prevention of reintubation among COPD patients must be considered carefully as a means to reduce length of stay after CABG. Our results also have important implications for the long-term management of these patients and strategies for containing costs over the life course of the patient.

Seasonal Incidence of Emergent Coronary Artery Bypass Grafting Surgery.

BACKGROUND: Emergent coronary artery bypass grafting (CABG) surgery is often required in the case of severe coronary artery disease, which is refractory to traditional management. The objective of our study was to test the hypothesis that there is seasonal variation in the incidence of emergent CABG. METHODS: A sinusoidal logistic regression model was used to analyze operative data at our cardiovascular institute of 270 cases spanning 5939 calendar days. RESULTS: A cyclic peak risk for emergent CABG was observed for late winter (calendar day 66; P = .036). The odds ratios for the 1-, 2- and 3-month window surrounding this peak were 1.8 (95% CI = 0.94-3.5, P = .072), 1.6 (95% CI = 1.06-2.5, P = .024) and 1.4 (95% CI = 0.9-1.8, P = .066), respectively. CONCLUSION: Our results suggest that a seasonal variation may exist in the incidence of patients presenting with severe coronary artery disease requiring emergent CABG. This information is useful in the scheduling of hospital resources and staff. It also provides important etiology clues underlying coronary artery disease that may lead to future interventions or targeted therapies.

Comparison of Risk of Atrial Fibrillation in Black Versus White Patients After Coronary Artery Bypass Grafting.

Obesity has been identified as a risk factor for postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG). However, no studies have addressed the influence of race on this association. A total of 13,594 patients undergoing first-time, isolated CABG without preoperative AF between 1992 and 2011 were included in our study. The association between body mass index and POAF was compared by race. Relative risk and 95% CIs were computed using maximum likelihood log-binomial regression. Increasing levels of body mass index were associated with higher POAF risk after CABG in black but not white patients (pinteraction = 0.0009).

Predicting Heart Failure Readmissions.

OBJECTIVES: In this study, the effects of sociodemographic and clinical factors on heart failure (HF) readmission risk were examined. BACKGROUND: Hospitals now incur financial penalties for excessive HF readmission rates; therefore, identifying factors associated with risk is essential for designing risk-reduction strategies. METHODS: A retrospective cohort study using chart reviews compared HF inpatients (N = 245) who were readmitted with those who were not readmitted. RESULTS: The sample included mostly white (64%) elderly (mean [SD] age, 69.8 [15.1] years) men (49%) and women (51%). Using Cox regression, the number of comorbidities (3-4 or 5-8) and type of comorbidities, specifically renal insufficiency (readmission ratio [RR], 1.7; P = .003), atrial fibrillation (RR, 1.7; P = .005), cardiomyopathy (RR, 1.5; P = .020), followed by a history of myocardial infarction/coronary artery disease (RR, 1.4; P = .055), were the predictors of HF readmission. CONCLUSIONS: Targeting those with high-risk comorbidities is important in designing measures to prevent or delay readmission of HF patients.

Conditional long-term survival following minimally invasive robotic mitral valve repair: a health services perspective.

BACKGROUND: Conditional survival is defined as the probability of surviving an additional number of years beyond that already survived. The aim of this study was to compute conditional survival in patients who received a robotically assisted, minimally invasive mitral valve repair procedure (RMVP). METHODS: Patients who received RMVP with annuloplasty band from May 2000 through April 2011 were included. A 5- and 10-year conditional survival model was computed using a multivariable product-limit method. RESULTS: Non-smoking men (≤65 years) who presented in sinus rhythm had a 96% probability of surviving at least 10 years if they survived their first year following surgery. In contrast, recent female smokers (>65 years) with preoperative atrial fibrillation only had an 11% probability of surviving beyond 10 years if alive after one year post-surgery. CONCLUSIONS: In the context of an increasingly managed healthcare environment, conditional survival provides useful information for patients needing to make important treatment decisions, physicians seeking to select patients most likely to benefit long-term following RMVP, and hospital administrators needing to comparatively assess the life-course economic value of high-tech surgical procedures.

Increased Long-Term Mortality among Black CABG Patients Receiving Preoperative Inotropic Agents.

The aim of this study was to examine racial differences in long-term mortality after coronary artery bypass grafting (CABG), stratified by preoperative use of inotropic agents. Black and white patients who required preoperative inotropic support prior to undergoing CABG procedures between 1992 and 2011 were compared. Mortality probabilities were computed using the Kaplan-Meier product-limit method. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. A total of 15,765 patients underwent CABG, of whom 211 received preoperative inotropic agents within 48 hours of surgery. Long-term mortality differed by race (black versus white) among preoperative inotropic category (inotropes: adjusted HR = 1.6, 95% CI = 1.009-2.4; no inotropes: adjusted HR = 1.15, 95% CI = 1.08-1.2; P(interaction) < 0.0001). Our study identified an independent preoperative risk-factor for long-term mortality among blacks receiving CABG. This outcome provides information that may be useful for surgeons, primary care providers, and their patients.

Predictors of depression in black women with hypertension.

Black women have the highest prevalence of hypertension in the world, and depression is associated with both hypertension and lack of health promoting behaviors. Thus, it is important to identify factors that may contribute to depression in hypertensive women. This cross-sectional study was conducted with a convenience sample of 80 black women ages 18-60 who were prescribed anti-hypertensive medication. Data were collected using self-report instruments. The study showed that lower income level, greater number of comorbidities, lower active coping scores, and poorer medication adherence were significantly associated with higher depression scores. These findings have important implications for the development of screening protocols and interventions for black women.

Exploring polypharmacy in elderly women after myocardial infarction.

The aims of the study were to: (a) examine the number, absolute volume, and type of daily medications older women were taking 6 to 12 months post-myocardial infarction (MI); (b) describe the financial burden of cardiac medications; and (c) examine the relationship of age, education, and income to the number of medications. An analysis of a cross-sectional descriptive study of women >or= 65 years of age who were post-MI was used. Most (89%; N = 83) were taking at least one cardiac medication, costs per day varied ($0.13-$6.75), and total number of pills taken per day was 1 to 19. Age, education, and income did not explain the number of medications. Consideration of the financial burden of medications is important to increase compliance and foster secondary prevention in older women.

Cardiovascular risks and physical activity in middle-aged and elderly African American women.

Cardiovascular disease rates are higher in African American women and they have more cardiovascular risk factors than other groups. Although one of the most important cardiovascular risk reduction behaviors is physical activity, few studies have focused on African American women's cardiovascular risk and physical activity. Therefore, the aims of this descriptive pilot study were to describe modifiable cardiovascular risks and to explore physical activity, as measured by pedometer steps, in younger (n = 22; aged 21-45 years) and older (n = 22; aged 46-75 years) community-dwelling African American women. The total number of pedometer steps recorded in 3 days ranged from 1,153 to 52,742. Day 1 steps were significantly different than day 2 and day 3 steps across the sample (F = 5.30, df = 1, P < .05). Risk factors were similar across the age groups. There was no relationship between the 3-day total or average number of daily steps and cardiovascular risks. Thus, interventions may be used in both age groups, with modifications for cohort effects of approach and health status. Given the disparities in cardiovascular disease and the Healthy People 2010 national health objectives, it is important to continue a variety of efforts to assist adult women of all ages to increase their physical activity and to decrease other CVD risks.

Inclusion of women in nursing research: 1995-2001.

BACKGROUND: Although the inclusion of women in research has been examined in medical publications, little is known about how federal mandates have influenced the inclusion of women in research published in nursing journals. OBJECTIVE: This study aimed to examine the inclusion of women in published nursing research from 1995 to 2001, with a focus on the leading causes of mortality. METHOD: All the articles in each journal were reviewed, and all the research articles that focused on the top 10 causes of death were sampled to measure the inclusion of women, the characteristics of the women included, the funding source, and the topic. RESULTS: Of the 1,149 studies reviewed, 139 met the inclusion criteria, and 117 of these studies included women. Only 15 of the studies reported the age of the women in their samples, and 10 of these included women between the ages of 35 and 64 years. The most frequently reported race was White (n = 21), followed by African American (n = 17), Hispanic (n = 6), and Asian (n = 2). There were no associations among year of publication (p =.62), federal funding (p =.30), and inclusion of women. Among the studies including women, heart disease was the most frequent topic (n = 52), followed by Alzheimer's disease (n = 21), cancer (n = 14), respiratory illness (n = 14), and diabetes (n = 8). DISCUSSION: Although the majority of the research included women, continuing efforts must be made to include sufficient numbers of women.