Providing a post-vasectomy semen analysis cup at the time of vasectomy rather than post-operatively improves compliance

Background

Post-vasectomy semen analysis (PVSA) completion rates after vasectomy are poor, and minimizing the need for an additional in-person visit may improve compliance. We hypothesized that providing PVSA specimen cup at time of vasectomy instead of at a postoperative appointment might be associated with higher PVSA completion rates.

Methods

We performed a retrospective cohort study with historical control using medical records of all patients seen by a single provider for vasectomy consultation between October 2016 and June 2022. All patients who underwent vasectomy were included. Patients who underwent vasectomy prior to 05/01/2020 had PVSA specimen cup given at postoperative appointment two weeks following vasectomy, and those who underwent vasectomy after 05/01/2020 were given PVSA specimen cup at time of vasectomy. PVSA completion, demographic, and clinical outcomes data were collected. Logistic regressions were used to investigate associations between PVSA completion rates and timing of PVSA specimen cup provision.

Results

There were no significant differences among study cohorts across all patient demographics analyzed, including age, body mass index (BMI), age of primary partner, presence of children, and history of prior genitourinary infection. A total of 491 patients were seen for vasectomy consultation between October 2016 and June 2022; among these patients, 370 underwent vasectomy. Of these, 173 (46.8%) patients underwent vasectomy prior to 05/01/2020 and were given PVSA specimen cup at postoperative visit; 197 (53.2%) patients underwent vasectomy after 05/01/2020 and were given PVSA specimen cup at vasectomy. Providing PVSA specimen cup at time of vasectomy was associated with higher odds of PVSA completion than providing PVSA specimen cup at postoperative visit [62.4% vs. 49.7%; odds ratio (OR) =1.68; 95% confidence interval (CI): 1.11, 2.55]. Adjusting for all identified confounders excludes 35 (9.5%) patients without a primary partner and shows no statistically significant association in cup timing [adjusted OR (aOR) =1.53; 95% CI: 0.98, 2.39]. Adjusting for all identified confounders except age of primary partner revealed timing of specimen cup provision at time of vasectomy was associated with higher odds of PVSA completion (aOR =1.64; 95% CI: 1.08, 2.52).

Conclusions

PVSA specimen cup provision at time of vasectomy versus at postoperative appointment is associated with higher rates of PVSA completion in this retrospective cohort study.

Isotretinoin Use in Transmasculine Patients and Its Implication on Chest Masculinization Surgery: Scoping Review of the Literature

BACKGROUND

Acne often worsens in transmasculine patients who are on prolonged testosterone therapy. Isotretinoin is an oral retinoid used in the treatment of severe or refractory cases of acne, but it has the potential to cause delayed wound healing. Transmasculine patients may potentially be prescribed treatment for acne with isotretinoin while also planning to undergo chest masculinization surgery.

OBJECTIVE

This scoping review aims to determine whether isotretinoin has a negative impact on postoperative healing in transmasculine patients undergoing chest masculinization surgery.

METHODS

A scoping review was performed using the PubMed and Ovid databases. A total of 16 publications were selected for inclusion.

RESULTS

Acne tends to peak in transmasculine patients 6 months after initiation of testosterone treatment. Severe cases can be treated with isotretinoin; however, acne may recur once treatment is discontinued, given ongoing hormone therapy. There is little to no evidence in the medical literature regarding perioperative use of isotretinoin specifically among transmasculine patients undergoing chest masculinization surgery. In general, however, recent studies have found no evidence of increased hypertrophic scars or keloids in patients taking isotretinoin.

CONCLUSIONS

Further studies are required to strengthen the current evidence that suggests that isotretinoin does not need to be discontinued before or after incisional or excisional surgeries, including chest masculinization surgery in transmasculine patients.

A Program to Reduce Post-Operative Opioid Prescribing at a Veteran's Affairs Hospital

Variability in surgeon prescribing patterns is common in the post-operative period and can be the nidus for dependence and addiction. This project aims to reduce opioid overprescribing at the Veteran’s Affairs Pittsburgh Healthcare System (VAPHS). The VAPHS Opioid Stewardship Committee collaborated to create prescribing guidelines for inpatient and outpatient general, thoracic, and vascular surgery procedures. We incorporated bundled order sets into the provider workflow in the electronic medical system and performed a retrospective cohort study comparing opioid prescription patterns for Veterans who underwent any surgical procedure for a three-month period pre- and post- guideline implementation. After implementation of opioid prescribing guidelines, morphine milligram equivalents (MME), quantity of pills prescribed, and days prescribed were statistically significantly reduced for procedures with associated guidelines, including cholecystectomy (MME 140.8 vs. 57.5, p = 0.002; quantity 18.8 vs. 8, p = 0.002; days 5.1 vs. 2.8, p = 0.021), inguinal hernia repair (MME 129.9 vs. 45.3, p = 0.002; quantity 17.3 vs. 6.1, p = 0.002; days 5.0 vs. 2.4, p = 0.002), and umbilical hernia repair (MME 128.8 vs. 53.8, p = 0.002; quantity 17.1 vs. 7.8, p = 0.002; days 5.1 vs. 2.5, p = 0.022). Procedures without associated recommendations also preceded a decrease in overall opioid prescribing. Post-operative opioid prescribing guidelines can steer clinicians toward more conscientious opioid disbursement. There may also be reductions in prescribing opioids for procedures without guidelines as an indirect effect of practice change.

Impact of Bariatric Surgery on Renal Function

Introduction

Bariatric surgery offers superior benefits for weight loss, quality of life and a spectrum of metabolic diseases. Despite these benefits, studies so far have shown varying results on its effect on renal function.

Aim

In this study, we aim to look at bariatric surgery’s effect on renal function at one, two and three year post operation (post-op).

Methods

This is a retrospective cross-sectional single-center study of patients who underwent bariatric surgery between 11/2008 and 06/2018. Renal function was calculated by using Cockroft-Gault equation, expressed as Creatinine Clearance (CrCl). Statistical analysis used was one-way ANOVA (Welch’s) with Games-Howell Post-Hoc Test.

Results

From 307 patients who underwent bariatric surgery within the time period, 145 were studied. 30.3% (n=44) were male. The average age and body mass index (BMI) at referral were 48.1±8.6 years and 47.96±7.9 kgm^-2 respectively, while the average age and BMI at surgery were 49.1±8.8 years and 40.62±4.2 kgm^-2 respectively. Mean CrCl at surgery, year 1, year 2, and year 3 post-op were 172.35±53.29 mL/min, 179.20±57.87 mL/min, 142.35±46.05 mL/min, and 119.56±42.46 mL/min. Marginal improvement of CrCl at year one post-op (172.35±53.29mL/min to 179.20±57.87mL/min) was statistically insignificant (p=0.731). Meanwhile, there was statistically significant CrCl decline observed from year 1 to year 3 post-op (p<0.001).

Conclusion

Statistically insignificant marginal improvement in CrCl at year one post-op was noted. Beyond this, there was steady CrCl decline, albeit remained higher than the lower limit for respective gender. We recommend for further studies that take into account additional factors affecting renal function.

Surgicel-Induced Anaphylaxis Post Permacath Placement

This case report details the resulting anaphylaxis and angioedema following placement of Surgicel hemostatic agent in a 38-year-old male postoperatively. Our patient experienced minor postoperative bleeding at the placement site of a dialysis catheter, which was controlled using Surgicel. Within minutes of the placement of Surgicel in the incision, the patient experienced an anaphylactic reaction with facial angioedema resulting in a Rapid Response being called to intervene. Incidences of Surgicel-induced anaphylaxis and hypersensitivity reactions are rare, but this report aims to bring awareness to this potential complication, as well as to assist with guiding management of future adverse reactions and surveillance of patients afterward.

A longitudinal study to evaluate the bleeding pattern of patients on low dose aspirin therapy following dental extraction

Background and Aims:

Antiplatelet dugs are often interrupted preceding invasive dental extraction because of concern of bleeding complications. The fear of uncontrolled bleeding often prompts medical and dental practitioners to stop aspirin intake for 7 to 10 days before any surgical procedure, which puts the patient at risk from adverse thrombotic events. The aim of the study conducted was to evaluate the bleeding pattern after routine dental extraction among patients on low dose long term aspirin therapy.

Methods:

A total of 104 subjects in the age group of 30-65 years, who continued to have aspirin intake during extraction were included in the study. Dental extraction was performed without stopping aspirin therapy under local anesthesia. The post-operative blood loss was quantified by weighing the gauze pre and post operatively and adding total volume of fluid in the suction jar.

Results:

Of these 104 patients treated, 87% of patients had mild bleeding (<20 ml) and 13% of patients had moderate bleeding (20-30 ml). The total study population showed a mean blood loss of 16.15 ± 3.5 ml.

Conclusion:

Within in the limitations, our study concluded that the routine dental extraction in patients under low dose aspirin therapy did not cause clinically significant post extraction hemorrhage. Aspirin intake can be continued during routine dental extraction as post extraction bleeding encountered will be negligible.

Pre-specified Weight Loss Before Bariatric Surgery and Postoperative Outcomes

Bariatric surgery is increasing exponentially to address the steep rise in the prevalence of severe obesity. Most centers require pre-specified preoperative weight loss before allowing patients to receive surgery. We examined the current evidence surrounding the potential benefits of this requirement on postoperative outcomes. We reviewed the current literature by conducting a multistage advance electronic search in Ovid®/MEDLINE® and PubMed for publications indexed after 2008 reporting preoperative weight loss and postoperative outcomes. Thirteen original publications, three randomized control trials (RCT), and five systematic reviews that met inclusion criteria were included. These were analyzed with regards to weight loss before surgery and postoperative outcomes. There were varied reports regarding the significant effect of preoperative weight loss. Six of the original articles (50%) did not identify a significant difference in the outcome while two of the RCT (essentially the same patient population, started in 2007 and reanalyzed in 2009) demonstrated some advantage. A later RCT (2012) did not show any advantage, albeit in the short term. The results of the systematic reviews, some with heterogenic designs, show no conclusive evidence that weight loss before surgery conferred improved postoperative outcomes. There is not enough high-quality evidence to back up the requirement of pre-specified preoperative weight loss before receiving surgery. Further validation of the possible benefits of pre-specified preoperative weight loss may need to be carried out.

Comparison of palanosetron with ondansetron for postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy under general anesthesia

BACKGROUND:

Post-operative nausea and vomiting (PONV) is a ‘big little’ problem especially after laparoscopic surgeries. Palanosetron is a new potent 5 hydroxy tryptamine 3 antagonists. In this randomized double blind clinical study we compared the effects of i.v. ondansetron and palanosetron administered at the end of surgery in preventing post-operative nausea and vomiting in patients undergoing laparoscopic cholecystectomy under general anesthesia.

MATERIALS AND METHODS:

A total of 100 subjects between 18–60 years with Apfel score ≥2, were randomly assigned into one of the two groups, containing 50 patients each. Group A received ondansetron 4 mg i.v. and Group B received palanosetron 0.07 5mg i.v. both as bolus before induction. The incidence of nausea, retching and vomiting, incidence of total PONV, requirement of rescue antiemetics and adverse effects were evaluated during the first 24 h following end of surgery.

RESULTS:

The incidence of nausea was significantly lower in patients who had received palanosetron (16%) as compared to ondansetron (24%). Need of rescue antiemetics was significantly higher in patients receiving ondansetron (32%) as compared to palanosetron (16%). The incidence of total PONV was also significantly lower in group receiving palanosetron (20%) as compared to ondansetron (50%). Among the side effects, headache was noted significantly higher with ondansetron (20%) as compared to palanosetron (6%).

CONCLUSION:

Palanosetron has got better anti-nausea effect, less need of rescue antiemetics, favourable side effect profile and a decrease in the incidence of total PONV as compared to ondansetron in 24 h post operative period in patients undergoing laproscopic cholecystectomy under general anesthesia.

Post operative temporary epicardial pacing: When, how and why?

Temporary epicardial pacing is commonly used for the diagnosis and treatment of arrhythmias in the acute post operative period after surgery for congenital heart disease. Temporary epicardial pacemakers have become increasingly sophisticated over the years and have evolved from simple single chamber devices with few programmable parameters to complex dual chamber devices capable of adjustable parameters similar to permanent pacemakers. This review will describe the various indications for temporary pacing, technical considerations for both the choice of pacing wires and pacemaker modes, complications with temporary pacing and our current practice with temporary pacing.