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Sensational Senses
Exploring take-home opioid stewardship (ETHOS) in UK postoperative patients.
BACKGROUND: Surgery is one of the most common indications for a patient's first opioid prescription, with some patients progressing to unintended long-term use. There is no current data from the United Kingdom on how much patients use of the opioid medication dispensed at discharge from hospital. This study investigates discharge opioid prescribing and usage following common surgical procedures. METHODS: This cohort study was conducted at the Oxford University Hospitals NHS Foundation Trust and involved 20 of the most commonly performed adult surgical procedures. At least 20 patients per procedure were surveyed using a standardised telephone questionnaire 6-8 days after discharge to establish the amount of used and unused opioids. Opioid doses were converted to oral morphine equivalent (OME) for analysis. RESULTS: The amount of opioid given to patients after all types of surgery far exceeded requirement, with often large variations in prescribing practices for the same procedures, most notably in trauma and orthopaedics.For the cohort of 426 patients, a total of 55 080 mg OME was dispensed on discharge, with only 34.4% actually used by patients, leaving a total of 36 108.5 mg OME unused in the community, risking inappropriate opioid use, overdose, or diversion. CONCLUSIONS: Opioid overprescribing is common after surgery and represents waste, expense, and risk to patients. There is a clear need to develop a procedure-specific evidence-base for discharge opioid prescribing, adopting an "enough but not too much" approach to ensure that patients have adequate analgesia to facilitate functional surgical recovery, but not more than is needed.
Five-year outcomes for patients with a displaced fracture of the distal tibia
Aims To report the outcomes of patients with a fracture of the distal tibia who were treated with intramedullary nail versus locking plate in the five years after participating in the Fixation of Distal Tibia fracture (FixDT) trial. Methods The FixDT trial reported the results for 321 patients randomized to nail or locking plate fixation in the first 12 months after their injury. In this follow-up study, we report the results of 170 of the original participants who agreed to be followed up until five years. Participants reported their Disability Rating Index (DRI) and health-related quality of life (EuroQol five-dimension three-level questionnaire) annually by self-reported questionnaire. Further surgical interventions related to the fracture were also recorded. Results There was no evidence of a difference in patient-reported disability, health-related quality of life, or the need for further surgery between participants treated with either type of fixation at five years. Considering the combined results for all participants, there was no significant change in DRI scores after the first 12 months of follow-up (difference between 12 and 24 months, 3.3 (95% confidence interval -1.8 to 8.5); p = 0.203), with patients reporting around 20% disability at five years. Conclusion This study shows that the moderate levels of disability and reduced quality of life reported by participants 12 months after a fracture of the distal tibia persist in the medium term, with little evidence of improvement after the first year.
The impact of complications on quality of life and mortality after hip fracture
Aims: Complications are to be key drivers of poorer outcome but there is limited information on how they influence quality of life (QoL) after hip fracture. The aim of this study was to investigate the relationship between complications, QoL, and mortality after hip fracture. Methods: The World Hip Trauma Evaluation (WHiTE) study is a multi-centre, prospective cohort study that collected data from patients ≥60 years who received operative treatment for their hip fracture. Patients were followed up for 120 days after surgery. The primary and secondary outcomes were health-related QoL (EQ-5D-5L) and mortality, respectively. Linear and logistic regression models were fitted to assess the relationship between complications, EQ-5D-5L, and mortality. Results: Among 24,523 patients with a hip fracture, the mean differences in EQ-5D-5L in patients who had surgery-specific complications were: prosthesis dislocation -0.14 (95% CI: - 0.20 to -0.08); fixation failure 0.00 (95% CI: -0.15 to 0.14); peri-prosthetic or peri-implant fracture -0.08 (95% CI: -0.18 to 0.02); re-operation for any indication -0.09 (95% CI: -0.14 to -0.05); surgical site infection (SSI) -0.06 (95% CI: -0.10 to -0.01); and deep SSI -0.13 (95% CI: -0.20 to -0.07). The mean differences in EQ-5D-5L for the general complications were: acute kidney injury -0.05 (95% CI: -0.07 to -0.02); blood transfusion -0.01 (95% CI: -0.03 to 0.01); lower respiratory tract infection -0.07 (95% CI: -0.09 to -0.05); urinary tract infection 0.01 (95% CI: -0.01 to 0.03); cerebrovascular accident (CVA) -0.17 (95% CI: -0.25 to -0.09); myocardial infarction (MI) -0.14 (95% CI: -0.20 to -0.08); and venous thromboembolism 0.03 (95% CI: -0.02 to 0.08). Conclusions: We observed worse health-related QoL in patients who had a complication after hip fracture. Those who underwent revision surgery or had a prosthesis dislocation or deep SSI experienced similar levels of disability to those with a CVA or MI.
Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK
Background The most common fractures in children are torus (buckle) fractures of the wrist. Controversy exists over treatment, which ranges from splint immobilisation and discharge to cast immobilisation, follow-up, and repeat imaging. This study compared pain and function in affected children offered a soft bandage and immediate discharge with those receiving rigid immobilisation and follow-up as per treating centre protocol. Methods In this randomised controlled equivalence trial we included 965 children (aged 4–15 years) with a distal radius torus fracture from 23 hospitals in the UK. Children were randomly allocated in a 1:1 ratio to the offer of bandage group or rigid immobilisation group using bespoke web-based randomisation software. Treating clinicians, participants, and their families could not be masked to treatment allocation. Exclusion criteria included multiple injuries, diagnosis at more than 36 h after injury, and inability to complete follow-up. The primary outcome was pain at 3-days post-randomisation measured using Wong-Baker FACES Pain Rating Scale. We performed a modified intention-to-treat and per protocol analysis. The trial was registered with ISRCTN registry, ISRCTN13955395. Findings Between Jan 16, 2019, and July 13, 2020, 965 children were randomly allocated to a group, 489 to the offer of a bandage group and 476 to the rigid immobilisation group, 379 (39%) were girls and 586 (61%) were boys. Primary outcome data was collected for 908 (94%) of participants, all of whom were included in the modified intention-to-treat analysis. Pain was equivalent at 3 days with 3·21 points (SD 2·08) in the offer of bandage group versus 3·14 points (2·11) in the rigid immobilisation group. With reference to a prespecified equivalence margin of 1·0, the adjusted difference in the intention-to-treat population was –0·10 (95% CI –0·37 to 0·17) and–0·06 (95% CI –0·34 to 0·21) in the per-protocol population. Interpretation This trial found equivalence in pain at 3 days in children with a torus fracture of the distal radius assigned to the offer of a bandage group or the rigid immobilisation group, with no between-group differences in pain or function during the 6 weeks of follow-up. Funding UK National Institute for Health and Care Research.
Clinical-grade whole genome sequencing-based haplarithmisis enables all forms of preimplantation genetic testing.
High-throughput sequencing technologies have increasingly led to discovery of disease-causing genetic variants, primarily in postnatal multi-cell DNA samples. However, applying these technologies to preimplantation genetic testing (PGT) in nuclear or mitochondrial DNA from single or few-cells biopsied from in vitro fertilised (IVF) embryos is challenging. PGT aims to select IVF embryos without genetic abnormalities. Although genotyping-by-sequencing (GBS)-based haplotyping methods enabled PGT for monogenic disorders (PGT-M), structural rearrangements (PGT-SR), and aneuploidies (PGT-A), they are labour intensive, only partially cover the genome and are troublesome for difficult loci and consanguineous couples. Here, we devise a simple, scalable and universal whole genome sequencing haplarithmisis-based approach enabling all forms of PGT in a single assay. In a comparison to state-of-the-art GBS-based PGT for nuclear DNA, shallow sequencing-based PGT, and PCR-based PGT for mitochondrial DNA, our approach alleviates technical limitations by decreasing whole genome amplification artifacts by 68.4%, increasing breadth of coverage by at least 4-fold, and reducing wet-lab turn-around-time by ~2.5-fold. Importantly, this method enables trio-based PGT-A for aneuploidy origin, an approach we coin PGT-AO, detects translocation breakpoints, and nuclear and mitochondrial single nucleotide variants and indels in base-resolution.
Self-management behaviour after a physiotherapist guided blended self-management intervention in patients with chronic low back pain: A qualitative study.
BACKGROUND: Self-management support is considered an important component in the physiotherapeutic treatment of people with chronic low back pain. The stratified blended physiotherapy intervention e-Exercise Low Back Pain is an example of a self-management intervention. More insight may contribute to improving blended interventions to stimulate self-management after treatment and thus hopefully prevent chronicity and/or relapses in patients with chronic low back pain. OBJECTIVES: The aim of this study was to gain an in-depth understanding of the self-management behaviour after a physiotherapist guided blended self-management intervention in people with chronic low back pain. DESIGN: A qualitative study with semi-structured interviews nested within a randomized controlled trial on the (cost-)effectiveness of e-Exercise Low Back Pain was conducted. METHOD: Thematic analysis was used to analyse the transcriptions. A hybrid process of both deductive and inductive approaches was used. RESULTS: After 12 interviews, data saturation was reached. Analysis of the data yielded six themes related to self-management behaviour: illness beliefs, coping, cognitions, social support and resource utilization, physiotherapeutic involvement and motivation. CONCLUSIONS: In our study the majority of the participants seemed to show adequate self-management behaviour when experiencing low back pain. Most participants first try to gain control over their low back pain themselves when experiencing a relapse before contacting the physiotherapist. Participants struggle in continuing health behaviour in pain free periods between relapses of low back pain. Physiotherapists are recommended to encourage long-term behaviour change. Additionally, better facilitation by the physiotherapist or additional functionalities in the app to stimulate social support might have a useful contribution.