The role of methadone in cardiac surgery for management of postoperative pain

Background

This retrospective study evaluated the efficacy and safety of intraoperative methadone compared with short-acting opioids.

Methods

Patients undergoing cardiac surgery with cardiopulmonary bypass (n=11 967) from 2018 to 2023 from a single health system were categorised into groups based on intraoperative opioid administration: no methadone (Group O), methadone plus other opioids (Group M+O), and methadone only (Group M).

Results

Patients in Groups M and M+O had lower mean pain scores until postoperative day (POD) 7 compared with Group O after adjusting for covariates (P<0.01). Both Groups M and M+O had lower total opioid administered compared with Group O for all days POD0-POD6 (all P<0.001). The median number of hours until initial postoperative opioid after surgery was 2.55 (inter-quartile range [IQR]=1.07-5.12), 6.82 (IQR=3.52-12.98), and 7.0 (IQR=3.82-12.95) for Group O, Group M+O, and Group M, respectively. The incidence of postoperative complications did not differ between groups.

Conclusions

Intraoperative administration of methadone was associated with better pain control without significant side-effects after cardiac surgery.

Patient Access of Their Radiology Reports Before and After Implementation of 21st Century Cures Act Information-Blocking Provisions at a Large Multicampus Health System

Background: To implement provisions of the 21st Century Cures Act addressing information blocking, federal regulations mandated that health systems provide patients with immediate access to elements of their electronic health information, including imaging results. Objective: To compare patient access of radiology reports before and after implementation of the information-blocking provisions of the 21st Century Cures Act. Method: This retrospective study included patients who underwent outpatient imaging examinations from January 1, 2021, to December 31, 2022 at three campuses within a large health system. The system implemented policies to comply with Cures Act information-blocking provisions on January 1, 2022. Imaging results were released in patient portals after a 36-hour embargo period before implementation, versus immediately upon report finalization after implementation. Data regarding patient report access in the portal and ordering provider report acknowledgment in the EMR were extracted and compared between periods. Results: The study included reports for 1,188,692 examinations in 388,921 patients (mean age, 58.5±16.6 years; 209,589 women, 179,290 men, 8 nonbinary, 34 missing sex information). A total of 77.5% of reports were accessed by the patient before implementation, versus 80.4% after implementation. Median time from report finalization to report release in the patient portal was 36.0 hours before implementation versus 0.4 hours after implementation. Median time from report release to first patient access in the portal was 8.7 hours before implementation versus 3.0 hours after implementation. Median time from report finalization to first patient access was 45.0 hours before implementation versus 5.5 hours after implementation. A total of 18.5% of reports were first accessed by the patient before the ordering provider before implementation, versus 44.0% after implementation. After implementation, median time from report release to first patient access was 1.8 hours for patients with age <60 years versus 4.3 hours for patients with age ≥60 years. Conclusion: After implementing institutional policies to comply with Cures Act information-blocking provisions, the time for patients to access imaging results decreased, and the proportion of patients who accessed their reports before the ordering provider increased. Clinical Impact: Radiologists should consider mechanisms to ensure timely and appropriate communication of important findings to ordering providers.

Expanding Liver Transplant Opportunities in Older Patients With Nonconventional Grafts

INTRODUCTION

Broader use of donation after circulatory death (DCD) and nonconventional grafts for liver transplant helps reduce disparities in organ availability. Limited data, however, exists on outcomes specific to nonconventional graft utilization in older patients. As such, this study aimed to investigate outcomes specific to conventional and nonconventional graft utilization in recipients > 70 y of age.

METHODS

1-to-3 matching based on recipient sex, Model for End-Stage Liver Disease score, and donor type was performed on patients ≥70 and <70 y of age who underwent liver transplant alone at Mayo Clinic Arizona between 2015 and 2020. Primary outcomes were posttransplant patient and liver allograft survival for recipients greater than or less than 70 y of age. Secondary outcomes included grafts utilization patterns, hospital length of stay, need for reoperation, biliary complications and disposition at time of hospital discharge.

RESULTS

In this cohort, 36.1% of grafts came from DCD donors, 17.4% were postcross clamp offers, and 20.8% were nationally allocated. Median recipient ages were 59 and 71 y (P < 0.01). Recipients had similar Intensive care unit (P = 0.82) and hospital (P = 0.14) lengths of stay, and there were no differences in patient (P = 0.68) or graft (P = 0.38) survival. When comparing donation after brain death and DCD grafts in those >70 y, there were no differences in patient (P = 0.89) or graft (P = 0.71) survival.

CONCLUSIONS

Excellent outcomes can be achieved in older recipients, even with use of nonconventional grafts. Expanded use of nonconventional grafts can help facilitate transplant opportunities in older patients.

Job Satisfaction Among Pain Medicine Physicians in the US

Purpose

Data are lacking on the factors that contribute to job satisfaction among pain medicine physicians. We sought to determine how sociodemographic and professional characteristics relate to job satisfaction among pain medicine physicians.

Methods

In this nationwide, multicenter, cross-sectional observational study, an electronic questionnaire related to job satisfaction was emailed in 2021 to pain medicine physicians who were members of the American Society of Anesthesiologists or the American Society of Pain and Neuroscience. The 28-item questionnaire asked physicians about sociodemographic and professional factors. Eight questions related to job satisfaction were based on a 10-point Likert scale, and 1 question was a binary (yes/no) variable. Differences in responses based on sociodemographic and professional factors were assessed with the Kruskal-Wallis rank sum test for Likert scale questions and with the Pearson χ² test for yes/no questions.

Results

We determined that several variables, including gender, parental status, geographic location, specialty, years of practice, and volume of patients, are associated with pain medicine physicians' outlook on job satisfaction. Overall, 74.9% of respondents surveyed would choose pain medicine as a specialty again.

Conclusion

High rates of poor job satisfaction persist among pain medicine physicians. This survey study identified several sociodemographic and professional factors that are associated with job satisfaction among pain medicine physicians. By identifying physicians at high risk for poor job satisfaction, healthcare leadership and occupational health agencies can aim to protect physicians' well-being, enhance working conditions, and raise awareness about burnout.

Effect of a Condensed NBA Season on Injury Risk: An Analysis of the 2020 Season and Player Safety

Background:

Health and safety concerns surrounding the coronavirus 2019 (COVID-19) pandemic led the National Basketball Association (NBA) to condense and accelerate the 2020 season. Although prior literature has suggested that inadequate rest may lead to an increased injury risk, the unique circumstances surrounding this season offer a unique opportunity to evaluate player safety in the setting of reduced interval rest.

Hypothesis:

We hypothesized that the condensed 2020 NBA season resulted in an increased overall injury risk as compared with the 2015 to 2018 seasons.

Study Design:

Descriptive epidemiology study.

Methods:

A publicly available database, Pro Sports Transactions, was queried for injuries that forced players to miss ≥1 game between the 2015 and 2020 seasons. Data from the 2019 season were omitted given the abrupt suspension of the league year. All injury incidences were calculated per 1000 game-exposures (GEs). The primary outcome was the overall injury proportion ratio (IPR) between the 2020 season and previous seasons. Secondary measures included injury incidences stratified by type, severity, age, position, and minutes per game.

Results:

A total of 4346 injuries occurred over a 5-season span among 2572 unique player-seasons. The overall incidence of injury during the 2020 season was 48.20 per 1000 GEs but decreased to 39.97 per 1000 GEs when excluding COVID-19. Despite this exclusion, the overall injury rate in 2020 remained significantly greater (IPR, 1.42 [95% CI, 1.32-1.52]) than that of the 2015 to 2018 seasons (28.20 per 1000 GEs). On closer evaluation, the most notable increases seen in the 2020 season occurred within minor injuries requiring only a 1-game absence (IPR, 1.53 [95% CI, 1.37-1.70]) and in players who were aged 25 to 29 years (IPR, 1.57 [95% CI, 1.40-2.63]), averaging ≥30.0 minutes per game (IPR, 1.67 [95% CI, 1.47-1.90]), and playing the point guard position (IPR, 1.67 [95% 1.44-1.95]).

Conclusion:

Players in the condensed 2020 NBA season had a significantly higher incidence of injuries when compared with the prior 4 seasons, even when excluding COVID-19–related absences. This rise is consistent with the other congested NBA seasons of 1998 and 2011. These findings suggest that condensing the NBA schedule is associated with an increased risk to player health and safety.

Mild to moderate COVID-19 illness in adult outpatients: Characteristics, symptoms, and outcomes in the first 4 weeks of illness

Most patients with coronavirus disease 2019 (COVID-19) have mild to moderate illness not requiring hospitalization. However, no study has detailed the evolution of symptoms in the first month of illness.At our institution, we conducted remote (telephone and video) visits for all adult outpatients diagnosed with COVID-19 within 24 h of a positive nasopharyngeal polymerase chain test for SARS-CoV-2. We repeated regular video visits at 7, 14, and 28 days after the positive test, retrospectively reviewed the prospective data collected in the remote visits, and constructed a week by week profile of clinical illness, through week 4 of illness.We reviewed the courses of 458 symptomatic patients diagnosed between March 12, 2020, and June 22, 2020, and characterized their weekly courses. Common initial symptoms included fever, headache, cough, and chest pain, which frequently persisted through week 3 or longer. Upper respiratory or gastrointestinal symptoms were much shorter lived, present primarily in week 1. Anosmia/ageusia peaked in weeks 2 to 3. Emergency department visits were frequent, with 128 visits in the 423 patients who were not hospitalized and 48 visits among the 35 outpatients (7.6%) who were eventually hospitalized (2 subsequently died). By the fourth week, 28.9% said their illness had completely resolved. After the 4-week follow up, 20 (4.7%) of the 423 nonhospitalized patients had further medical evaluation and management for subacute or chronic COVID-19 symptoms.Mild to moderate outpatient COVID-19 is a prolonged illness, with evolving symptoms commonly lasting into the fourth week of illness.

Treatment Outcomes of Well-Differentiated High-Grade Neuroendocrine Tumors

INTRODUCTION

Recent classification of neuroendocrine neoplasms has defined well-differentiated high-grade neuroendocrine tumors (NET G3) as a distinct entity from poorly differentiated neuroendocrine carcinoma. The optimal treatment for NET G3 has not been well-described. This study aimed to evaluate metastatic NET G3 response to different treatment regimens.

MATERIALS AND METHODS

This was a retrospective study of patients with NET G3 within the Mayo Clinic database. Patients' demographics along with treatment characteristics, responses, and survival were assessed. Primary endpoints were progression-free survival (PFS) and overall survival. Secondary endpoints were objective response rate (ORR) and disease control rate (DCR).

RESULTS

Treatment data was available in 30 patients with median age of 59.5 years at diagnosis. The primary tumor was mostly pancreatic (73.3%). Ki-67 index was ≥55% in 26.7% of cases. Treatments included capecitabine + temozolomide (CAPTEM) (n = 20), lutetium 177 DOTATATE (PRRT; n = 10), Platinum-etoposide (EP; n = 8), FOLFOX (n = 7), and everolimus (n = 2). CAPTEM exhibited ORR 35%, DCR 65%, and median PFS 9.4 months (95% confidence interval, 2.96-16.07). Both EP and FOLFOX showed similar radiographic response rates with ORR 25.0% and 28.6%; however, median PFS durations were quite distinct at 2.94 and 13.04 months, respectively. PRRT had ORR of 20%, DCR of 70%, and median PFS of 9.13 months.

CONCLUSION

Among patients with NET G3, CAPTEM was the most commonly used treatment with clinically meaningful efficacy and disease control. FOLFOX or PRRT are other potentially active treatment options. EP has some activity in NET G3, but responses appear to be short-lived. Prospective studies evaluating different treatments effects in patients with NET G3 are needed to determine an optimal treatment strategy.

IMPLICATIONS FOR PRACTICE

High-grade well-differentiated neuroendocrine tumors (NET G3) are considered a different entity from low-grade NET and neuroendocrine carcinoma in terms of prognosis and management. The oral combination of capecitabine and temozolomide is considered a good option in the management of metastatic NET G3 and may be preferred. FOLFOX is another systemic option with reasonable efficacy. Similar to other well-differentiated neuroendocrine tumors, peptide receptor radionuclide therapy seems to have some efficacy in these tumors.