Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review.

BACKGROUND: Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area. METHODS: This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines. RESULTS: A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence. CONCLUSIONS: This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.

Trends of clinical outcomes in patients with a Traumatic Brain Injury (TBI) in Canada between 2006 and 2012.

BACKGROUND: Traumatic brain injuries (TBI) are the leading cause of death for people aged <40 years. In Canada, the structure of trauma care has evolved independently across provinces during the last decade. However, little is known about the evolution of clinical outcomes. We aimed to compare trends in hospital mortality, unplanned readmission, hospital length of stay (LOS) and intensive care unit (ICU) LOS for TBI between 2006 and 2012 across Canadian provinces. METHODS: We conducted a retrospective multicentre cohort study based on TBI admissions across Canadian level I and II trauma centres. Data were extracted from the National Trauma Registry linked to hospital discharge databases. All adults with an injury severity score ≥12 were included. Multilevel generalized linear models were used to evaluate trends in clinical outcomes. RESULTS: Between 2006 and 2012, we observed a decrease in mortality in Canada (odd ratio [OR] = 0.95; 95% confidence intervals [CI] = 0.92-0.98) mostly driven by Ontario (OR = 0.95; 95% CI = 0.93-0.98). We observed a significant decrease in hospital length of stay in Canada (hazard ratio [HR]: hazard of being discharged alive from hospital = 1.02; 95% CI = 1.01-1.02) mostly driven by a decrease in Quebec (HR = 1.03; 95% CI = 1.01-1.04). We observed a decrease in ICU Length of stay only in Alberta (HR = 1.05; 95% CI = 1.01-1.09). No trend was observed for hospital readmissions. CONCLUSION: We observed significant decreases in mortality, hospital and ICU length of stay for TBI in Canada between 2006 and 2012 but only in certain provinces. This study may represent the first step towards a better understanding of the influence of trauma system configuration on the burden of injuries in Canada.

The Ottawa SAH search algorithms: protocol for a multi- centre validation study of primary subarachnoid hemorrhage prediction models using health administrative data (the SAHepi prediction study protocol).

BACKGROUND: Conducting prospective epidemiological studies of hospitalized patients with rare diseases like primary subarachnoid hemorrhage (pSAH) are difficult due to time and budgetary constraints. Routinely collected administrative data could remove these barriers. We derived and validated 3 algorithms to identify hospitalized patients with a high probability of pSAH using administrative data. We aim to externally validate their performance in four hospitals across Canada. METHODS: Eligible patients include those ≥18 years of age admitted to these centres from January 1, 2012 to December 31, 2013. We will include patients whose discharge abstracts contain predictive variables identified in the models (ICD-10-CA diagnostic codes I60** (subarachnoid hemorrhage), I61** (intracranial hemorrhage), 162** (other nontrauma intracranial hemorrhage), I67** (other cerebrovascular disease), S06** (intracranial injury), G97 (other postprocedural nervous system disorder) and CCI procedural codes 1JW51 (occlusion of intracranial vessels), 1JE51 (carotid artery inclusion), 3JW10 (intracranial vessel imaging), 3FY20 (CT scan (soft tissue of neck)), and 3OT20 (CT scan (abdominal cavity)). The algorithms will be applied to each patient and the diagnosis confirmed via chart review. We will assess each model's sensitivity, specificity, negative and positive predictive value across the sites. DISCUSSION: Validating the Ottawa SAH Prediction Algorithms will provide a way to accurately identify large SAH cohorts, thereby furthering research and altering care.

Protocol adherence for continuously titrated interventions in randomized trials: an overview of the current methodology and case study.

BACKGROUND: The standard definition for protocol adherence is the proportion of all scheduled doses that are delivered. In clinical research, this definition has several limitations when evaluating protocol adherence in trials that study interventions requiring continuous titration. DISCUSSION: Building upon a specific case study, we analyzed a recent trial of a continuously titrated intervention to assess the impact of different definitions of protocol deviations on the interpretation of protocol adherence. The OVATION pilot trial was an open-label randomized controlled trial of higher (75-80 mmHg) versus lower (60-65 mmHg) mean arterial pressure (MAP) targets for vasopressor therapy in shock. In this trial, potential protocol deviations were defined as MAP values outside the targeted range for >4 consecutive hours during vasopressor therapy without synchronous and consistent adjustments of vasopressor doses. An adjudication committee reviewed each potential deviation to determine if it was clinically-justified or not. There are four reasons for this contextual measurement and reporting of protocol adherence. First, between-arm separation is a robust measure of adherence to complex protocols. Second, adherence assessed by protocol deviations varies in function of the definition of deviations and the frequency of measurements. Third, distinguishing clinically-justified vs. not clinically-justified protocol deviations acknowledges clinically sensible bedside decision-making and offers a clear terminology before the trial begins. Finally, multiple metrics exist to report protocol deviations, which provides different information but complementary information on protocol adherence. CONCLUSIONS: In trials of interventions requiring continuous titration, metrics used for defining protocol deviations have a considerable impact on the interpretation of protocol adherence. Definitions for protocol deviations should be prespecified and correlated with between-arm separation, if it can be measured.

Aneurysmal SubArachnoid Hemorrhage-Red Blood Cell Transfusion And Outcome (SAHaRA): a pilot randomised controlled trial protocol.

INTRODUCTION: Anaemia is common in aneurysmal subarachnoid haemorrhage (aSAH) and is a potential critical modifiable factor affecting secondary injury. Despite physiological evidence and management guidelines that support maintaining a higher haemoglobin level in patients with aSAH, current practice is one of a more restrictive approach to transfusion. The goal of this multicentre pilot trial is to determine the feasibility of successfully conducting a red blood cell (RBC) transfusion trial in adult patients with acute aSAH and anaemia (Hb ≤100 g/L), comparing a liberal transfusion strategy (Hb ≤100 g/L) with a restrictive strategy (Hb ≤80 g/L) on the combined rate of death and severe disability at 12 months. METHODS: Design This is a multicentre open-label randomised controlled pilot trial at 5 academic tertiary care centres. Population We are targeting adult aSAH patients within 14 days of their initial bleed and with anaemia (Hb ≤110 g/L). Randomisation Central computer-generated randomisation, stratified by centre, will be undertaken from the host centre. Randomisation into 1 of the 2 treatment arms will occur when the haemoglobin levels of eligible patients fall to ≤100 g/L. Intervention Patients will be randomly assigned to either a liberal (threshold: Hb ≤100 g/L) or a restrictive transfusion strategy (threshold: Hb ≤80 g/L). Outcome Primary: Centre randomisation rate over the study period. Secondary: (1) transfusion threshold adherence; (2) study RBC transfusion protocol adherence; and (3) outcome assessment including vital status at hospital discharge, modified Rankin Score at 6 and 12 months and Functional Independence Measure and EuroQOL Quality of Life Scale scores at 12 months. Outcome measures will be reported in aggregate. ETHICS AND DISSEMINATION: The study protocol has been approved by the host centre (OHSN-REB 20150433-01H). This study will determine the feasibility of conducting the large pragmatic RCT comparing 2 RBC transfusion strategies examining the effect of a liberal strategy on 12-month outcome following aSAH. TRIAL REGISTRATION NUMBER: NCT02483351; Pre-results.

Healthy worker effect and changes in respiratory symptoms and lung function in hairdressing apprentices.

AIMS: To compare the prevalence and incidence of respiratory symptoms and lung function values between hairdressing apprentices and office apprentices. METHODS: A total of 322 hairdressing apprentices and 277 office apprentices (controls) were studied. Two cross sectional surveys were conducted in 1994 and 1996/97 with longitudinal follow up for a subgroup of apprentices (191 hairdressing apprentices and 189 office apprentices). RESULTS: In the initial phase, the prevalence of respiratory symptoms was significantly lower among hairdressing apprentices than among office apprentices. Lung function test results showed significantly higher values for hairdressing apprentices. Non-specific bronchial reactivity was similar in the two groups. In the final phase, results for respiratory symptoms were similar. The incidence of respiratory symptoms was not significantly different between hairdressing apprentices and office apprentices. Subjects who dropped out had lower values for FVC and FEV1 in the initial phase than those who completed the final phase. There was a significant deterioration of FEV1 and FEF25-75% in hairdressing apprentices compared to office apprentices. There was a link between atopy and the incidence of most of the respiratory symptoms (day/night cough, wheezing, dyspnoea, mucosal hyperresponsiveness) and between smoking and the incidence of bronchial hyperreactivity. There was no significant correlation between change in lung function tests and specific hairdressing activities reported at the end of the apprenticeship or with environmental working conditions in hairdressing salons. CONCLUSIONS: Although a healthy worker effect can be suspected, results showed a significant deterioration of baseline values of lung function tests in the hairdressing apprentice group. However, no clear link was shown between change in lung function tests and specific parameters of occupational activities.