Treatment of Acute Pain in Adults With Sickle Cell Disease in an Infusion Center Versus the Emergency Department: A Multicenter Prospective Cohort Study: Annals of Internal Medicine: Vol 174, No 9

Background: Patients with sickle cell disease (SCD) have vaso-occlusive crises (VOCs). Infusion centers (ICs) are alternatives to emergency department (ED) care and may improve patient outcomes. Objective: To assess whether care in ICs or EDs leads to better outcomes for the treatment of uncomplicated VOCs. Design: Prospective cohort. (ClinicalTrials.gov: NCT02411396) Setting: 4 U.S. sites, with recruitment between April 2015 and December 2016. Participants: Adults with SCD living within 60 miles of a study site. Measurements: Participants were followed for 18 months after enrollment. Outcomes of interest were time to first dose of parenteral pain medication, whether pain reassessment was completed within 30 minutes after the first dose, and patient disposition on discharge from the acute care visit. Treatment effects for ICs versus EDs were estimated using a time-varying propensity score adjustment. Results: Researchers enrolled 483 participants; the 269 who had acute care visits on weekdays are included in this report. With inverse probability of treatment–weighted adjustment, the mean time to first dose was 62 minutes in ICs and 132 minutes in EDs; the difference was 70 minutes (95% CI, 54 to 98 minutes; E-value, 2.8). The probability of pain reassessment within 30 minutes of the first dose of parenteral pain medication was 3.8 times greater (CI, 2.63 to 5.64 times greater; E-value, 4.7) in the IC than the ED. The probability that a participant’s visit would end in admission to the hospital was smaller by a factor of 4 (0.25 [CI, 0.18 to 0.33]) with treatment in an IC versus an ED. Limitation: The study was restricted to participants with uncomplicated VOCs. Conclusion: In adults with SCD having a VOC, treatment in an IC is associated with substantially better outcomes than treatment in an ED. Primary Funding Source: Patient-Centered Outcomes Research Institute.

Stepped Exercise Program for Patients With Knee Osteoarthritis: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 174, No 3

Background: Evidence-based models are needed to deliver exercise-related services for knee osteoarthritis efficiently and according to patient needs. Objective: To examine a stepped exercise program for patients with knee osteoarthritis (STEP-KOA). Design: Randomized controlled trial. (ClinicalTrials.gov: NCT02653768) Setting: 2 U.S. Department of Veterans Affairs sites. Participants: 345 patients (mean age, 60 years; 15% female; 67% people of color) with symptomatic knee osteoarthritis. Intervention: Participants were randomly assigned in a 2:1 ratio to STEP-KOA or an arthritis education (AE) control group, respectively. The STEP-KOA intervention began with 3 months of an internet-based exercise program (step 1). Participants who did not meet response criteria for improvement in pain and function after step 1 progressed to step 2, which involved 3 months of biweekly physical activity coaching calls. Participants who did not meet response criteria after step 2 went on to in-person physical therapy visits (step 3). The AE group received educational materials via mail every 2 weeks. Measurements: Primary outcome was Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Scores for the STEP-KOA and AE groups at 9 months were compared by using linear mixed models. Results: In the STEP-KOA group, 65% of participants (150 of 230) progressed to step 2 and 35% (81 of 230) to step 3. The estimated baseline WOMAC score for the full sample was 47.5 (95% CI, 45.7 to 49.2). At 9-month follow-up, the estimated mean WOMAC score was 6.8 points (CI, −10.5 to −3.2 points) lower in the STEP-KOA than the AE group, indicating greater improvement. Limitation: Participants were mostly male veterans, and follow-up was limited. Conclusion: Veterans in STEP-KOA reported modest improvements in knee osteoarthritis symptoms compared with the control group. The STEP-KOA strategy may be efficient for delivering exercise therapies for knee osteoarthritis. Primary Funding Source: Department of Veterans Affairs, Health Services Research and Development Service.

Opportunities to Address First Opioid Prescriptions to Reduce Incident Long-Term Opioid Use

Fool Me Twice? The Reemergence of Rofecoxib and the Orphan Drug Act

Possibilities Beyond Analyses of a Fee-for-Service Database and Clinician Mindset

Changing the Conversation About Opioid Tapering

Low-Dose Intravenous Immunoglobulin Treatment for Long-Standing Complex Regional Pain Syndrome: A Randomized Trial: Annals of Internal Medicine: Vol 167, No 7

Background: Two small trials suggest that low-dose intravenous immunoglobulin (IVIg) may improve the symptoms of complex regional pain syndrome (CRPS), a rare posttraumatic pain condition. Objective: To confirm the efficacy of low-dose IVIg compared with placebo in reducing pain during a 6-week period in adult patients who had CRPS from 1 to 5 years. Design: 1:1 parallel, randomized, placebo-controlled, multicenter trial for 6 weeks, with an optional 6-week open extension. Patients were randomly assigned to 1 of 2 study groups between 27 August 2013 and 28 October 2015; the last patient completed follow-up on 21 March 2016. Patients, providers, researchers, and outcome assessors were blinded to treatment assignment. (ISRCTN42179756) Setting: 7 secondary and tertiary care pain management centers in the United Kingdom. Participants: 111 patients with moderate or severe CRPS of 1 to 5 years' duration. Intervention: IVIg, 0.5 g/kg of body weight, or visually indistinguishable placebo of 0.1% albumin in saline on days 1 and 22 after randomization. Measurements: The primary outcome was 24-hour average pain intensity, measured daily between days 6 and 42, on an 11-point (0- to 10-point) rating scale. Secondary outcomes were pain interference and quality of life. Results: The primary analysis sample consisted of 108 eligible patients, 103 of whom had outcome data. Mean (average) pain scores were 6.9 points (SD, 1.5) for placebo and 7.2 points (SD, 1.3) for IVIg. The adjusted difference in means was 0.27 (95% CI, −0.25 to 0.80; P = 0.30), which excluded the prespecified, clinically important difference of −1.2. No statistically significant differences in secondary outcomes were found between the groups. In the open extension, 12 of the 67 patients (18%) who received 2 IVIg infusions had pain reduction of at least 2 points compared with their baseline score. Two patients in the blinded phase (1 in the placebo and 1 in the IVIg group) and 4 in the open IVIg phase had serious events. Limitations: Results do not apply to patients who have had CRPS for less than 1 year or more than 5 years and do not extend to full-dose treatment (for example, 2 g/kg). The study was inadequately powered to detect subgroup effects. Conclusion: Low-dose immunoglobulin treatment for 6 weeks was not effective in relieving pain in patients with moderate to severe CRPS of 1 to 5 years' duration. Primary Funding Source: Medical Research Council/National Institute for Health Research Efficacy and Mechanism Evaluation Program, Pain Relief Foundation, and Biotest United Kingdom.

With the Merit-Based Incentive Payment System, Pay for Performance Is Now National Policy

Frailty and Surgical Decision Making

In symptomatic adults undergoing high-resolution manometry, long-term opioid use was linked to esophageal dysmotility

Source Citation Niu C, Zhang J, Bapaye J, et al. Systematic review with meta-analysis: chronic opioid use is associated with esophageal dysmotility in symptomatic patients. Am J Gastroenterol. 18 Aug 2023. [Epub ahead of print]. 37463432