Low Self-Reported Function Predicts Adverse Postoperative Course in Veterans Affairs Beneficiaries Undergoing Total Hip and Total Knee Replacement.

OBJECTIVES: To measure association between self-reported function and an adverse postoperative course and improvement in performance on the American College of Surgeons Universal Risk Calculator (ACS calculator) with inclusion of self-reported function available through the Veteran Rand-12 based Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. DESIGN: Cohort analysis. SETTING: Veteran Affairs health system. PARTICIPANTS: Surgeries (n = 3,503) for older male veterans undergoing hip and knee replacement from 2002 to 2009. MEASUREMENTS: Serious complication (per ACS definition), discharge to facility, readmission, and death within 30 days after surgery as a function of PCS and MCS; comparison of prediction of net reclassification index (NRI) for serious complication using a modified version of the ACS calculator with prediction using the ACS calculator with MCS and PCS added. RESULTS: Being in the lowest PCS quartile (vs highest quartile) predicted more than twice the risk of a serious complication (odds ratio (OR) = 2.27, 95% confidence interval (CI) = 1.44-3.58), twice the risk of discharge to facility (OR = 1.97, 95% CI = 1.39-2.79), and almost twice the risk of readmission (OR = 1.80, 95% CI = 1.37-2.36). The lowest quartile of MCS predicted each outcome, although to a lesser extent than PCS. The enhanced model had a NRI of 29.4% (95% CI = 15.4-43.3%), reflecting that 20.8% of events were appropriately upgraded and 8.6% of nonevents appropriately downgraded. CONCLUSION: Low PCS and MCS predicted an adverse postoperative course and enhanced the ACS calculator. Clinicians evaluating older adults undergoing orthopedic surgery could enhance the accuracy of their assessments by including self-reported functional status.

Management of opioid side effects in cancer-related and chronic noncancer pain: a systematic review.

Side effects can limit opioid dosage and reduce quality of life. The purpose of this systematic review was to assess the management of opioid side effects in the context of cancer pain management or, in the event that no evidence was available for cancer pain, for chronic noncancer pain. The side effects studied were constipation, pruritus, nausea and vomiting, myoclonus, sedation, respiratory depression, and delirium. Opioid rotation to manage side effects was also studied. For each side effect, we searched MEDLINE and the Cochrane Controlled Trials Register and identified 657 possible titles for inclusion. Of these, 67 studies met inclusion criteria for analysis. The lack of well-designed, randomized controlled trials and the heterogeneity of populations and study designs made the drawing of firm conclusions difficult and precluded performance of meta-analysis. The type, strength, and consistency of evidence for available interventions to manage opioid side effects vary from strong (eg, on the use of naloxone to reverse respiratory depression or constipation) to weak (eg, changing from the oral to epidural route of morphine administration to manage sedation). Well-designed trials in the specified populations are required to furnish clinicians with secure evidence on managing opioid side effects successfully.