Continuous flow local anesthetic wound infusion for post-operative analgesia following kidney transplantation

BACKGROUND

Some patients with end stage renal disease are or will become narcotic-dependent. Chronic narcotic use is associated with increased graft loss and mortality following kidney transplantation. We aimed to compare the efficacy of continuous flow local anesthetic wound infusion pumps (CFLAP) with patient controlled analgesia pumps (PCA) in reducing inpatient narcotic consumption in patients undergoing kidney transplantation.

MATERIALS AND METHODS

In this single-center, retrospective analysis of patients undergoing kidney transplantation, we collected demographic and operative data, peri-operative outcomes, complications, and inpatient oral morphine milligram equivalent (OME) consumption.

RESULTS

Four hundred and ninety-eight patients underwent kidney transplantation from 2020 to 2022. 296 (59%) historical control patients received a PCA for postoperative pain control and the next 202 (41%) patients received a CFLAP. Median age [53.5 vs. 56.0 years, p = .08] and BMI [29.5 vs. 28.9 kg/m2, p = .17] were similar. Total OME requirement was lower in the CFLAP group [2.5 vs. 34 mg, p < .001]. Wound-related complications were higher in the CFLAP group [5.9% vs. 2.7%, p = .03]. Two (.9%) patients in the CFLAP group experienced cardiac arrhythmia due to local anesthetic toxicity and required lipid infusion.

CONCLUSIONS

Compared to PCA, CFLAP provided a 93% reduction in OME consumption with a small increase in the wound-related complication rate. The utility of local anesthetic pumps may also be applicable to patients undergoing any unilateral abdominal or pelvic incision.

State-level variation in distribution of oxycodone and opioid-related deaths from 2000 to 2021: an ecological study of ARCOS and CDC WONDER data in the USA

OBJECTIVES

This study aims to characterise oxycodone's distribution and opioid-related overdoses in the USA by state from 2000 to 2021.

DESIGN

This is an observational study.

SETTING

More than 80 000 Americans died of an opioid overdose in 2021 as the USA continues to struggle with an opioid crisis. Prescription opioids play a substantial role, introducing patients to opioids and providing a supply of drugs that can be redirected to those seeking to misuse them.

METHODS

The Drug Enforcement Administration annual summary reports from the Automation of Reports and Consolidated Orders System provided weights of oxycodone distributed per state by business type (pharmacies, hospitals and practitioners). Weights were converted to morphine milligram equivalents (MME) per capita and normalised for population. The Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research provided mortality data for heroin, other opioids, methadone, other synthetic narcotics and other/unspecified narcotics.

RESULTS

There was a sharp 280.13% increase in total MME/person of oxycodone from 2000 to 2010, followed by a slower 54.34% decrease from 2010 to 2021. Florida (2007-2011), Delaware (2003-2020) and Tennessee (2012-2021) displayed consistent and substantial elevations in combined MME/person compared with other states. In the peak year (2010), there was a 15-fold difference between the highest and lowest states. MME/person from only pharmacies, which constituted >94% of the total, showed similar results. Hospitals in Alaska (2000-2001, 2008, 2010-2021), Colorado (2008-2021) and DC (2000-2011) distributed substantially more MME/person over many years compared with other states. Florida stood out in practitioner-distributed oxycodone, with an elevation of almost 15-fold the average state from 2006 to 2010. Opioid-related deaths increased +806% from 2000 to 2021, largely driven by heroin, other opioids and other synthetic narcotics.

CONCLUSIONS

Oxycodone distribution across the USA showed marked differences between states and business types over time. Investigation of opioid policies in states of interest may provide insight for future actions to mitigate opioid misuse.

Assessment of opioid use following septorhinoplasty and its association with pain catastrophizing

PURPOSE

Anxiety towards pain is correlated with increased post-surgical pain and assessed with the "Pain Catastrophizing Scale" (PCS). We assess patient reported pain and opioid usage following septorhinoplasty and their association with the PCS.

METHODS

This prospective cohort study enrolled patients over 18 years of age undergoing open septorhinoplasty on an outpatient basis at a single academic institution. Participants completed the PCS preoperatively and recorded post-operative pain and analgesic use with a daily online based survey through post-operative day 5. Total opioid use and highest pain rating are assessed.

RESULTS

Postoperative pain was assessed in 34 patients with a median age of 37 years (Range: 22-62y). The average highest pain rating was 6.2/10 (σ = 2.03) and occurred on post-operative day 2. A median of 20 5-mg narcotic tablets (Range: 10-25) was prescribed to study participants though only an average of 7.25 (Range: 0-15) were reported as used. Medical comorbidities and surgical characteristics, including history of anxiety, cosmetic indication, surgical revision, use of osteotomies, Doyle splints, costal or conchal cartilage grafts, or inferior turbinate reduction, were not associated with increased pain or narcotic use. Those using >10 tablets scored higher on the PCS ([10.6] v. [4.8], p = 0.025).

CONCLUSION

Most patients require <10, 5 mg opioid tablets following septorhinoplasty. Surgeons should attempt to decrease opioid prescriptions while considering that patients with significant anxiety towards pain may report higher narcotic needs.

The Surgical Learning Curve for Cervical Disk Replacement

STUDY DESIGN

Retrospective study.

OBJECTIVE

To characterize an experienced single surgeon learning curve for cervical disk replacement (CDR).

SUMMARY OF BACKGROUND DATA

A single surgeon learning curve has not been established for CDR.

METHODS

Patients undergoing CDR were included. The cumulative sum of operative time was utilized to separate cases into 3 phases: learning, practicing, and mastery. Demographics, perioperative characteristics, complications, patient-reported outcomes (PROs), and radiographic outcomes were collected preoperatively and up to 1 year postoperatively. PROs included Patient-reported Outcomes Measurement Information System Physical Function, 12-item Short Form-12 Physical Component Score, 12-item Short Form-12 Mental Component Score, visual analog scale (VAS) arm, VAS neck, Neck Disability Index. Radiographic outcomes included segmental angle/segmental range of motion/C2-C7 range of motion. Minimum clinically important difference achievement was determined through a comparison of previously established values.

RESULTS

A total of 173 patients were identified, with 14 patients in the learning phase, 42 patients in the practicing phase, and 117 patients in the mastery phase. Mean operative time and mean postoperative day 0 narcotic consumption were significantly higher in the learning phase. The preoperative segmental angle was significantly lower for the learning phase, though these differences were eliminated at the final postoperative time point. Patients in the learning phase reported worse improvement to 6-week postoperative, final postoperative, and worse overall final postoperative VAS Arm scores compared with practicing and mastery phases.

CONCLUSIONS

For an experienced spine surgeon, the learning phase for CDR was estimated to span 14 patients. During this phase, patients demonstrated longer operative times, higher postoperative narcotic consumption, and worse postoperative VAS Arm scores. Radiographically, no postoperative differences were noted between different phases of mastery. This single surgeon learning curve demonstrates that CDR may be performed safely and with comparable outcomes by experienced spine surgeons despite decreased operative efficiency in the learning phase.

Does Anesthesiologist Experience Influence Early Postoperative Outcomes Following Orthognathic Surgery?

BACKGROUND

Anesthesia provider experience impacts nausea and vomiting in other surgical specialties but its influence within orthognathic surgery remains unclear.

PURPOSE

The study purpose was to evaluate whether anesthesiologist experience with orthognathic surgery impacts postoperative outcomes, including nausea, emesis, narcotic use, and perioperative adverse events, for patients undergoing orthognathic surgery.

STUDY DESIGN, SETTING, SAMPLE

This is a retrospective cohort study of subjects aged 12 to 35 years old who underwent orthognathic surgery, including Le Fort 1 osteotomy ± bilateral sagittal split osteotomy, at Boston Children's Hospital from August 2018 to January 2022. Subjects were excluded if they had incomplete medical records, a syndromic diagnosis, or a hospital stay of greater than 2 days.

PREDICTOR VARIABLE

The predictor variable was attending anesthesia provider experience with orthognathic surgery. Providers were classified as experienced or inexperienced, with experienced providers defined as having anesthetized ≥10 orthognathic operations during the study period.

MAIN OUTCOME VARIABLES

The primary outcome variable was postoperative nausea. Secondary outcome variables were emesis, narcotic use in the hospital, and perioperative adverse events within 30 days of their operation.

COVARIATES

Study covariates included age, sex, race, comorbidities (body mass index, history of psychiatric illness, cleft lip and/or palate, chronic pain, postoperative nausea/vomiting, gastrointestinal conditions), enhanced recovery after surgery protocol enrollment, and intraoperative factors (operation performed, anesthesia/procedure times, estimated blood loss, intravenous fluid and narcotic administration, and anesthesiologist's years in practice).

ANALYSES

χ2 and unpaired t-tests were used to compare primary predictor and covariates against outcome variables. A P-value <.05 was considered significant.

RESULTS

There were 118 subjects included in the study after 4 were excluded (51.7% female, mean age 19.1 ± 3.30 years). There were 71 operations performed by 5 experienced anesthesiologists (mean cases/provider 15.4 ± 5.95) and 47 cases by 22 different inexperienced providers (mean cases/provider 1.91 ± 1.16). The nausea rate was 52.1% for experienced providers and 53.2% for inexperienced providers (P = .909). There were no statistically significant associations between anesthesiologist experience and any outcome variable (P > .341).

CONCLUSIONS AND RELEVANCE

Anesthesia providers' experience with orthognathic surgery did not significantly influence postoperative nausea, emesis, narcotic use, or perioperative adverse events.

The need to monitor emerging issues in etomidate usage: the misuse or abuse potential

Since 2011, the misuse or abuse of etomidate has gradually increased when propofol was designated a controlled drug under the Narcotics Control Act in Korea. Accordingly, the Ministry of Food and Drug Safety announced that etomidate would be under the 'Regulation on the designation of drugs that may cause concerns of misuse or abuse' rule in June 2020, which is less stringent than the Narcotics Control Act. Therefore, this review investigates potential misuse or abuse cases of etomidate to consider strengthening its management. A literature search was conducted to compare etomidate with other sedatives in their efficacy and side effects, as well as identify the adverse health outcomes, abuse cases, and analytical methods of etomidate. Etomidate has an equal or higher sedative efficacy and lower risk of adverse cardiopulmonary events than propofol. However, major adverse effects of etomidate include adrenocortical suppression and unproven associated deaths, as well as myoclonus requiring pre-treatment. Although the issue of abuse and misuse of etomidate is emerging in recent years, there are few academic reports on these issues and analytical methods in the forensic field. In order to effectively manage the misuse or abuse of etomidate, it is necessary to continuously monitor related cases with great interest and to be more intensively studied on its abuse potential.

Poisoning in children and adolescents in Kermanshah city, Iran

BACKGROUND

Poisoning among children and adolescents is a public health problem worldwide. To take preventive measures, the pattern of this problem should be determined. This study aimed to describe the demographic characteristics of poisoning in children and to investigate the relationship between the types of poisoning and demographic factors in children in Kermanshah province.

METHODS

This cross-sectional, descriptive-analytical study was conducted on 250 children and adolescents under 18 years of age who were referred to Mohammad Kermanshahi Pediatric Hospital in Kermanshah province due to poisoning during 2019-2022. The demographic and epidemiological data of patients were extracted from their medical files and analyzed.

RESULTS

Out of 250 cases of poisoning, 173 (69.2%) cases were unintentional, 96 (55.5%) of whom were boys. Further, 77 (30.8%) cases of poisoning were intentional, of whom 49 (63.6%) were girls. There was a significant difference between gender and intentional and unintentional poisonings (p-value = 0.005). The median age of unintentional poisoning was 3 (IQR = 2.5) and that of intentional poisoning was 14 (IQR = 2). Most cases of poisoning were in cities, 145 (83.8%) of them were unintentional and 66 (85.7%) were intentional. Most cases of intentional and unintentional poisonings occurred in spring 2017 (35.1%) and autumn 2016 (34.6%), respectively. The most common causes of poisoning were narcotics (n = 36, 34.3%) and drugs (n = 35, 33.3%) in the age group 0-3 years and drugs (n = 46, 66.9) in the age group 11-18 years.

CONCLUSIONS

The most common causes of poisoning were narcotics and drugs in children and drugs in adolescents. To prevent poisoning in children, parents are required to increase their knowledge of the safe storage of narcotics and drugs, such as not storing methadone in a water bottle. Targeted evaluation and preventive measures are also needed in adolescent poisoning.

Impact of the Narcotics Information Management System on Opioid Use Among Outpatients With Musculoskeletal and Connective Tissue Disorders: Quasi-Experimental Study Using Interrupted Time Series

BACKGROUND

Opioids have traditionally been used to manage acute or terminal pain. However, their prolonged use has the potential for abuse, misuse, and addiction. South Korea introduced a new health care IT system named the Narcotics Information Management System (NIMS) with the objective of managing all aspects of opioid use, including manufacturing, distribution, sales, disposal, etc.

OBJECTIVE

This study aimed to assess the impact of NIMS on opioid use.

METHODS

We conducted an analysis using national claims data from 45,582 patients diagnosed with musculoskeletal and connective tissue disorders between 2016 and 2020. Our approach included using an interrupted time-series analysis and constructing segmented regression models. Within these models, we considered the primary intervention to be the implementation of NIMS, while we treated the COVID-19 outbreak as the secondary event. To comprehensively assess inappropriate opioid use, we examined 4 key indicators, as established in previous studies: (1) the proportion of patients on high-dose opioid treatment, (2) the proportion of patients receiving opioid prescriptions from multiple providers, (3) the overlap rate of opioid prescriptions per patient, and (4) the naloxone use rate among opioid users.

RESULTS

During the study period, there was a general trend of increasing opioid use. After the implementation of NIMS, significant increases were observed in the trend of the proportion of patients on high-dose opioid treatment (coefficient=0.0271; P=.01) and in the level of the proportion of patients receiving opioid prescriptions from multiple providers (coefficient=0.6252; P=.004). An abrupt decline was seen in the level of the naloxone use rate among opioid users (coefficient=-0.2968; P=.04). While these changes were statistically significant, their clinical significance appears to be minor. No significant changes were observed after both the implementation of NIMS and the COVID-19 outbreak.

CONCLUSIONS

This study suggests that, in its current form, the NIMS may not have brought significant improvements to the identified indicators of opioid overuse and misuse. Additionally, the COVID-19 outbreak exhibited no significant influence on opioid use patterns. The absence of real-time monitoring feature within the NIMS could be a key contributing factor. Further exploration and enhancements are needed to maximize the NIMS' impact on curbing inappropriate opioid use.

Anterior Cervical Discectomy and Fusion Versus Cervical Disc Replacement for a Workers' Compensation Population in an Ambulatory Surgical Center

STUDY DESIGN

Retrospective Cohort.

OBJECTIVE

To evaluate patient-reported outcome measures (PROM) and minimal clinically important difference (MCID) achievement outcomes between anterior cervical discectomy and fusion (ACDF) and cervical disk replacement (CDR) in the Workers' Compensation (WC) population.

SUMMARY OF BACKGROUND DATA

No studies to our knowledge have compared PROMs and MCID attainment between ACDF and CDR among patients with WC insurance undergoing surgery in an outpatient ambulatory surgical center (ASC).

METHODS

WC insurance patients undergoing primary, single/double-level ACDF/CDR in an ASC were identified. Patients were divided into ACDF versus CDR. PROMs were collected at preoperative/6-week/12-week/6-month/1-year timepoints, including PROMIS-PF, SF-12 PCS/MCS, VAS neck/arm, and NDI.

RESULTS

Seventy-nine patients were included, 51 ACDF/28 CDR. While operative time (56.4 vs. 54.4 min), estimated blood loss (29.2 vs. 25.9 mL), POD0 pain (4.9 vs. 3.8), and POD0 narcotic consumption (21.2 vs. 14.5 oral morphine equivalents) were higher in ACDF patients, none reached statistical significance ( P >0.050, all). One-year arthrodesis rate was 100.0% among ACDF recipients with available imaging (n=36). ACDF cohort improved from preoperative for PROMIS-PF from 12 weeks to 1 year, SF-12 PCS at 6 months, all timepoints for VAS neck/arm, and 12 weeks/6 months for NDI ( P ≤0.044, all). CDR cohort improved from preoperative for PROMIS-PF at 6 months, VAS neck/arm from 12 weeks to 1 year, and NDI at 12 weeks/6 months ( P ≤0.049, all). CDR cohort reported significantly lower VAS neck at 12 weeks/1 year and VAS arm at 12 weeks ( P ≤0.039, all). MCID achievement rates did not differ.

CONCLUSION

While operative duration/estimated blood loss/acute postoperative pain/narcotic consumption were, on average, higher among ACDF recipients, these were not statistically significant, possibly due to the limited sample size. ACDF and CDR ASC patients generally demonstrated comparable arm pain/disability/physical function/mental health, though neck pain was significantly lower at multiple timepoints among CDR patients. Clinically meaningful PROM improvements were comparable. Larger, multicentered studies are required to confirm our results.

Persistent long-term opioid use after trauma: Incidence and risk factors

BACKGROUND

The opioid epidemic in the United States continues to lead to a substantial number of preventable deaths and disability. The development of opioid dependence has been strongly linked to previous opioid exposure. Trauma patients are at particular risk since opioids are frequently required to control pain after injury. The purpose to this study was to examine the prevalence of opioid use before and after injury and to identify risk factors for persistent long-term opioid use after trauma.

METHODS

Records for all patients admitted to a Level 1 trauma center over a 1-year period were analyzed. Demographics, injury characteristics, and hospital course were recorded. A multistate Prescription Drug Monitoring Program database was queried to obtain records of all controlled substances prescribed from 6 months before the date of injury to 12 months after hospital discharge. Patients still receiving narcotics at 1 year were defined as persistent long-term users and were compared against those who were not.

RESULTS

A total of 2,992 patients were analyzed. Of all patients, 20.4% had filled a narcotic prescription within the 6 months before injury, 53.5% received opioids at hospital discharge, and 12.5% had persistent long-term use after trauma with the majority demonstrating preinjury use. Univariate risk factors for long-term use included female sex, longer length of stay, higher Injury Severity Score, anxiety, depression, orthopedic surgeries, spine injuries, multiple surgical locations, discharge to acute inpatient rehab, and preinjury opioid use. On multivariate analysis, the only significant predictors of persistent long-term prescription opioid use were preinjury use and a much smaller effect associated with use at discharge.

CONCLUSION

During a sustained opioid epidemic, concerns and caution are warranted in the use of prescription narcotics for trauma patients. However, persistent long-term opioid use among opioid-naive patients is rare and difficult to predict after trauma.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

How to improve the surveillance of the Taliban ban's impact on European drug markets

In April 2023, the Taliban banned poppy cultivation and the trade of all narcotics. This caused a 95% reduction in opium production. Usually, that would be good news. But there is a substantial worry: synthetic opioids might fill the void left by heroin. This is concerning because these drugs have led to health emergencies in areas where they are prevalent. This paper highlights the limitations of the current drug surveillance system in Europe and proposes improvements. It argues that reliance on secondary data is insufficient. Instead, we need to interview a sentinel group of people who inject drugs and adjust city-level sentinel systems, such as wastewater analysis, to specifically track the spread of synthetic opioids. Without these proactive steps, we risk only noticing a transition from heroin to synthetic opioids after it has occurred, with its harmful impacts already in place.

Robotic versus open radical cystectomy for bladder cancer: evaluation of complications, survival, and opioid prescribing patterns

We aim to compare complications, readmission, survival, and prescribing patterns of opioids for post-operative pain management for Robotic-assisted laparoscopic radical cystectomy (RARC) as compared to open radical cystectomy (ORC). Patients that underwent RARC or ORC for bladder cancer at a tertiary care center from 2005 to 2021 were included. Recurrence-free survival (RFS) and overall survival (OS) were evaluated with Kaplan-Meier curves and multivariable Cox proportional hazards regression models. Comparisons of narcotic usage were completed with oral morphine equivalents (OMEQ). Multivariable linear regression was used to assess predictors of OMEQ utilization. A total of 128 RARC and 461 ORC patients were included. There was no difference in rates of Clavien-Dindo grade ≥ 3 complications between RARC and ORC (36.7 vs 30.1%, p = 0.16). After a mean follow up of 3.4 years, RFS (HR 0.96, 95%CI 0.58-1.56) and OS (HR 0.69, 95%CI 0.46-1.05) were comparable between RARC and ORC. There was no difference in the narcotic usage between patients in the RARC and ORC groups during the last 24 h of hospitalization (median OMEQ: 0 vs 0, p = 0.33) and upon discharge (median OMEQ: 178 vs 210, p = 0.36). Predictors of higher OMEQ discharge prescriptions included younger age [(- )3.46, 95%CI (-)5.5-(-)0.34], no epidural during hospitalization [- 95.85, 95%CI (- )144.95-(- )107.36], and early time-period of surgery [(- )151.04, 95%CI (- )194.72-(- )107.36]. RARC has comparable 90-day complication rates and early survival outcomes to ORC and remains a viable option for bladder cancer. RARC results in comparable levels of opioid utilization for pain management as ORC.

Disparities in alcohol- and substance-related hospitalizations and deaths across sexual orientations in Canada: a longitudinal study

OBJECTIVES

We aim to quantify disparities in substance-related acute events (i.e. hospitalizations and deaths for substances, including alcohol, cannabis, opioids, narcotics, and/or illicit drugs) across sexual orientations based on health administrative data.

STUDY DESIGN

This was a longitudinal analysis from six waves of the Canadian Community Health Survey (2009-2014) linked to hospitalization/mortality data in Ontario, Canada.

METHODS

The study sample consisted of survey respondents aged ≥15 (weighted n = 15,406,000) who provided a valid response to the question about sexual orientation. The primary outcome was substance-related acute events, including hospitalizations and deaths due to alcohol, cannabis, opioids, narcotics, and/or illicit drugs. Disparities in substance-related acute events across sexual orientation and gender were examined using flexible parametric survival analysis.

RESULTS

Bisexual women had hazard ratios of 2.46 (95% confidence interval: 1.46-4.15) for any substance-related acute event and 2.67 (95% confidence interval: 1.42-5.00) for non-alcohol substance acute events compared to heterosexual women. Lesbian women did not exhibit significant differences in acute event risk compared to heterosexual women. Gay and bisexual men demonstrated elevated but not statistically significant risks compared to heterosexual men.

CONCLUSIONS

Bisexual women face higher risks of substance-related acute events, potentially due to self-medication of unique stressors brought on by discrimination and isolation. Enhanced education and training for healthcare professionals are essential to increase awareness and sensitivity toward the heightened substance use risk among lesbian, gay, and bisexual individuals. Targeted interventions aimed at reducing substance use problems among bisexual individuals warrant increased funding and research.

Randomized Trial on Expectations and Pain Control Advancement in Surgery: The REPAIR Study

IMPORTANCE

Following standardized preoperative education and adoption of shared decision making positively affects postoperative narcotic practices.

OBJECTIVES

The aim of this study was to assess the impact of patient-centered preoperative education and shared decision making on the quantities of postoperative narcotics prescribed and consumed after urogynecologic surgery.

STUDY DESIGN

Women undergoing urogynecologic surgery were randomized to "standard" (standard preoperative education, standard narcotic quantities at discharge) or "patient-centered" (patient-informed preoperative education, choice of narcotic quantities at discharge) groups. At discharge, the "standard" group received 30 (major surgery) or 12 (minor surgery) pills of 5-mg oxycodone. The "patient-centered" group chose 0 to 30 (major surgery) or 0 to 12 (minor surgery) pills. Outcomes included postoperative narcotics consumed and unused. Other outcomes included patient satisfaction/preparedness, return to activity, and pain interference. An intention-to-treat analysis was performed.

RESULTS

The study enrolled 174 women; 154 were randomized and completed the major outcomes of interest (78 in the standard group, 76 in the patient-centered group). Narcotic consumption did not differ between groups (standard group: median of 3.5 pills, interquartile range [IQR] of [0, 8.25]; patient centered: median of 2, IQR of [0, 9.75]; P = 0.627). The patient-centered group had fewer narcotics prescribed ( P < 0.001) and unused ( P < 0.001), and chose a median of 20 pills (IQR [10, 30]) after a major surgical procedure and 12 pills (IQR [6, 12]) after a minor surgical procedure, with fewer unused narcotics (median difference, 9 pills; 95% confidence interval, 5-13; P < 0.001). There were no differences between groups' return to function, pain interference, and preparedness or satisfaction ( P > 0.05).

CONCLUSIONS

Patient-centered education did not decrease narcotic consumption. Shared decision making did decrease prescribed and unused narcotics. Shared decision making in narcotic prescribing is feasible and may improve postoperative prescribing practices.

Erector Spinae versus Surgically Placed Pain Catheters for Thoracic Outlet Decompression

BACKGROUND

Perioperative care after surgery for thoracic outlet syndrome (TOS) involves multimodal pain control. Pain catheters with bupivacaine infusion are a modality to minimize perioperative narcotic use. Our study aims to compare surgically placed pain catheters (SP) with erector spinae pain catheters (ESP) placed by the anesthesia pain service.

METHODS

Retrospective review of a prospectively maintained surgical TOS database identified patients undergoing transaxillary first rib resection (FRR) who had either SP or ESP placed for pain control. Patients were matched for age and gender. Data collected included demographics, operative details, and perioperative pain medication use. Narcotic pain medication doses were converted to milligram morphine equivalents (MMEs) for comparison between groups. Pain medications were collected for several time points: intraoperatively, for each postoperative day (POD) and for the entire hospital stay.

RESULTS

Eighty-eight total patients were selected for comparison: 44 patients in the SP and ESP groups. Patients in each group did not differ with regards to age, body mass index, gender, diagnosis, or comorbidities. There were no differences in preoperative narcotic use, preoperative pain score, or Quick Disabilities of Arm, Shoulder, and Hand score. All patients underwent FRR. Concurrent cervical rib resection was performed in 6.8% SP and 6.8% ESP patients (P = 1.00), pectoralis minor tenotomy in 34.1% SP and 29.5% ESP patients (P = 0.65), and venogram in 31.8% SP and 31.8% ESP patients (P = 1.00). Mean operating room time was 90.0 min in SP and 105.3 min in ESP cases (P = 0.15). Mean length of stay was 1.9 days for SP and 1.8 days for ESP patients (P = 0.56). There were no significant differences in intraoperative narcotics dosing in MME (SP: 22.1 versus ESP: 25.3, P = 0.018). On POD 0, there were no differences in total narcotics dosing (MME) (SP: 112.0 versus ESP: 100.7, P = 0.59), or in the use of acetaminophen, nonsteroidal anti-inflammatory drugs, or muscle relaxants. A similar trend in narcotics dosing was observed on POD 1 (SP: 58.6 versus ESP: 69.7, P = 0.43) and POD 2 (SP: 23.5 versus ESP: 71.3, P = 0.23). On POD 1, there was a higher percentage of SP patients taking nonsteroidal anti-inflammatory drugs (63.6% vs. 40.9%, P = 0.024); however, this difference was not observed on POD 2. There were no differences in acetaminophen or muscle relaxant use on POD 1 or 2. Total hospital stay MME was similar between groups (SP: 215.9 versus ESP: 250.9, P = 0.23).

CONCLUSIONS

Pain catheters with bupivacaine infusions are helpful adjuncts in postoperative pain control after FRR for TOS. This study compares SP to ESP and demonstrates no difference in narcotics use between SP and ESP groups. SP should be used for pain control in facilities which do not have an anesthesia pain service available for ESP placement.

The comparison of the analgesic efficacy of continuous paravertebral block alone compared with continuous paravertebral and intercostal nerve block for thoracotomy in adults: a randomized controlled trial

PURPOSE

The study aims to compare the analgesic efficacy of two analgesic interventions, continuous paravertebral (PVB) nerve block alone with continuous paravertebral and intercostal nerve block (PVB/ICB) in patients undergoing thoracotomy.

METHODS

A total of 70 patients undergoing thoracotomy were randomly enrolled in either continuous paravertebral nerve block (PVB) group or in continuous paravertebral and intercostal nerve block (PVB/ICB) group and received corresponding blocks. Analgesic efficacy measured by Visual Analog Scale (VAS) pain score, hemodynamic effects, total narcotic consumption, sedation score, patient's length of stay in hospital and patient's satisfaction with the analgesic technique were recorded.

RESULTS

Demographic characteristics of the patients were similar in both groups. The mean VAS pain score was not statistically significant in both groups at 24 h. The mean pulse rate and blood pressures were comparable in both groups for the first 24 h. Nalbuphine consumption was significantly higher in PVB group as compared to PVB/ICB group at 1 h (p = 0.01), 6 h (p = 0.03) and 12 h (p = 0.009) and 24 h (p = 0.03). The mean total nalbuphine consumption in the PVB group was higher (28.29 mg vs. 22.63 mg) and statistically significant then PVB/ICB group (p = 0.03). The total tramadol consumption as a rescue analgesic was higher in the PVB group (131.42 mg) as compared to PVB/ICB group (120 mg) after 24 h but not statistically significant (p = 0.17).

CONCLUSION

Continuous paravertebral nerve block with intercostal nerve block provides effective post-operative pain relief after thoracotomy with reduced narcotic consumption compared to continuous paravertebral nerve block alone.

CLINICAL TRIAL REGISTRATION NUMBER

Clinicaltrails.gov NCT04715880.

Surgical stabilization of rib fractures is associated with better return on investment for a health care institution than nonoperative management

BACKGROUND

Surgical stabilization of rib fractures (SSRFs) continues to gain popularity due to patient benefits. However, little has been produced regarding the economic benefits of SSRF and its impact on hospital metrics such as Vizient. The aim of this study was to explore these benefits hypothesizing SSRF will demonstrate positive return on investment (ROI) for a health care institution.

METHODS

This is a retrospective review of all rib fracture patients over 5 years at our Level I trauma center. Patients were grouped into SSRF versus nonoperative management. Basic demographics were obtained including case mix index (CMI). Outcomes included narcotic requirements in morphine milliequivalents prior to discharge, mortality, and discharge disposition. Furthermore, actual hospital length of stay (ALOS) versus Vizient expected length of stay were compared between cohorts. Contribution margin (CM) was also calculated. Independent t-test, paired t-test, and linear regression analysis were performed, and significance set at p < 0.05.

RESULTS

A total of 1,639 patients were included; 230 (14%) underwent SSRF. Age, gender, and Injury Severity Score were similar. Surgical stabilization of rib fracture patients had more ribs fractured (7 vs. 4; p < 0.001) and more patients with flail chest (43.5% vs. 6.7%; p < 0.001). Surgical stabilization of rib fracture patients also had a significantly higher CMI (4.33 vs. 2.78; p = 0.001). Narcotic requirements and mortality were less in the SSRF cohort; 155 versus 246 morphine milliequivalents ( p < 0.001) and 1.7% versus 7.1% ( p = 0.003), respectively. Surgical stabilization of rib fracture patients were more likely to be discharged home (70.4% vs. 63.7%; p = 0.006). Surgical stabilization of rib fracture patients demonstrated shorter ALOS where nonoperative management patients demonstrated longer ALOS compared with Vizient expected length of stay. Contribution margins for SSRF patients were significantly higher and linear regression analysis showed a CM $1,128.14 higher per patient undergoing SSRF ( p < 0.001).

CONCLUSION

Patients undergoing SSRF demonstrate a significant ROI for a health care organization. Despite SSRF patients having a higher CMI, they were able to be discharged sooner than expected by Vizient calculations resulting in better a CM.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Levomethadone Therapeutic Drug Monitoring to Aid Opioid Withdrawal Therapy: A Short Communication

BACKGROUND

Therapeutic drug monitoring (TDM) is recommended for opioid maintenance therapy with levomethadone. However, TDM has not yet been applied to monitor opioid withdrawal therapy clinically, although tools to improve it are required.

METHODS

In this observational cohort study, repeated TDM with levomethadone was performed according to a prospective opioid withdrawal study protocol. Objective and subjective opioid withdrawal symptoms were measured using validated rating scales and correlated to levomethadone plasma concentrations. Plasma levels were measured using high-pressure liquid chromatography with column switching and spectroscopic detection of methadone and its major metabolite.

RESULTS

This study included 31 opioid-dependent patients who participated in standardized opioid withdrawal therapy. The serum levels of levomethadone were found to be highly variable and below the recommended therapeutic reference range of 250 ng/mL for maintenance therapy. These serum levels were positively correlated with dosage (r = 0.632; P < 0.001) and inversely correlated with subjective (r = -0.29; P = 0.011) and objective (r = -0.28; P = 0.014) withdrawal symptoms.

CONCLUSIONS

The evidence provided sheds light on how to improve levomethadone withdrawal therapy in patients with opioid dependence. It seems likely that higher initial doses at the beginning and lower dose reductions would have been advantageous. TDM can enhance the safety of opioid withdrawal therapies, minimize withdrawal symptoms, and reduce dropout rates.

Predicting heroin potency from the analysis of paraphernalia: A tool for overdose prevention projects

In recent years, fatal and non-fatal heroin-related overdoses have increased in northeastern Italy, and the change in potency of heroin available at street level has been identified as a prominent factor associated with acute toxicity. Two very different products, high-potency and low-potency heroin were becoming available on the street, and no clear morphological characteristics could be used to easily distinguish them. A theoretical model for predicting heroin potency from rapid analysis of cigarette filters was developed as part of an overdose prevention project. The model was derived from the analysis of real heroin samples and exploits the common presence of caffeine in heroin as an adulterant. It was tested on laboratory prepared filters, real filters used to prepare heroin injections, and other paraphernalia. The model showed strong predictive ability and was used to implement a rapid alert system to inform drug users and healthcare institutions about the potency of heroin or other psychoactive substances circulating in the area. Cigarette filters were used as standard material, but other paraphernalia were successfully tested. The developed model is a dynamic tool whose parameters can be updated according to the market characteristics, so it can be useful for laboratories involved in drug analysis and similar prevention programs.

[Male infertility, environment and lifestyle]

BACKGROUND

Since the 1970s, there has been a quantitative and qualitative decline in sperm parameters. The main hypothesis to explain such a rapid evolution is the involvement of environmental and behavioral phenomena.

METHODS

A bibliographic search limited to English and French literature in men published before 7/2023 was carried out on the links between fertility and pollution, xenobiotics, tobacco, narcotics, cannabis, alcohol, weight, sport, sedentary lifestyle, sleep and anabolics.

RESULTS

Profound changes in lifestyle have occurred over the past 50 years: reduced sleep time, sedentary lifestyle, dietary changes, tobacco consumption, use of narcotics and anabolics. These changes have a proven impact on spermogram parameters, and should be corrected in an effort to optimize reproductive health. Other environmental parameters: pollution, exposure to heavy metals, exposure to xenobiotics, phthalates and pesticides… will be more difficult to exclude from patients' daily lives, but deserve to be taken more into account.

CONCLUSION

This review should help the urologist to assess and counsel patients in order to improve their reproductive health. These factors should be routinely investigated in infertile men.

Higher intra-operative narcotic requirements and weakness with quadratus lumborum compared to paravertebral nerve block for total hip arthroplasty

BACKGROUND

This was a prospective single-blinded study comparing the peri-operative opioid consumption and motor weakness for patients undergoing total hip arthroplasty (THA) with either a Quadratus Lumborum Type 3 Nerve Block (QLB) or a Paravertebral Nerve Block (PVB).

METHODS

A consecutive cohort of patients undergoing elective anterior approach (AA) THA by a single high-volume surgeon were randomly assigned an anesthesiologist by the charge anesthesiologist. One anesthesiologist performed all QLBs, and the other six anesthesiologists performed the PVBs. Pertinent data include prospectively collected qualitative surveys from blinded medical personnel, floor nurses, and physical therapists as well as demographic information and post-operative complications.

RESULTS

Overall, 160 patients were included in the study divided equally between the QLB and PVB groups. The QLB group had a statistically higher peri-operative narcotic use (p < 0.001), greater intra-operative peak systolic blood pressure (p < 0.001) and respiratory rate (p < 0.001), and higher incidence of post-operative lower extremity muscle weakness (p = 0.040). There were no statistical group differences for floor narcotic use, post-operative hemoglobin levels or hospital length of stay.

CONCLUSION

The QLB required greater intraoperative narcotic use and resulted in greater post-operative weakness, however provided nearly equal post-operative pain management and did not adversely affect rapid discharge success.

LEVEL OF EVIDENCE

III, Non-randomized controlled cohort/follow-up study.

Opioid prescription patterns in a children's hospital from 2012 to 2016

STUDY OBJECTIVE

Pain management is a widely discussed topic, especially in the setting of the current opioid epidemic. Previous studies have shown that the use of opioids increased in the adult population. We aimed to look at the use of narcotic and non-narcotic pain medications at a large pediatric hospital to discern if patterns of pediatric pain management changed over time.

METHODS

58,402 analgesic prescriptions of patients 0-21 years of age were analyzed from May 2012 to November 2016. A logistic regression model was fitted to examine the association of age, sex, primary diagnosis, and the length of hospital stay with probability of opioid prescription.

RESULTS

36,560 patients aged 0-21 years (mean: 10.5, median: 11.0, and standard deviation (SD): 7.42) received analgesic pain medications. 21,847 (59.8 percent) patients were prescribed more than one analgesic. There was a male predominance in patients <15 years of age; however, in adolescents >16 years, females constituted 57.1 percent of patients. Data also showed a statistically significant reduction of opioid prescriptions from 2012 to 2016 (p < 0.001). Age and length of hospital stay were directly associated with opioid prescription (p < 0.001).

CONCLUSION

Data show that there is a decrease in overall opioid prescriptions among pediatric patients, which may be secondary to new Food and Drug Administration regulations and increased awareness of morbidity associated with opioid use. Not surprisingly, increased hospital stay and increase in age lead to more analgesic prescriptions. Further investigation is needed to determine the differences within opioid prescription patterns.

Relapses in Illicit Drug Use Among Probationers: Results in a Risk Group of Public Health Services in Bavaria

Objective: We aimed to identify in this study time trends of relapses in the illicit consumption of narcotics in a special at-risk population of former drug users under a public health perspective. Methods: In a pooled dataset of 14 consecutive calendar years (2006-2019), the use of seven different narcotic substances was studied in 380 persons with a total of 2,928 urine samples which were analyzed using a valid marker system for narcotic residues. Results: During the entire observation period, the relapse rate for cannabinoids and opiates was the highest despite abstinence requirements. It was noticeable that the relapses across all narcotics groups occurred primarily during the first 3 years of the probation period (90%) with a decrease in illegal consumption during the following years of the observation period. Conclusion: Special attention should be paid to probationers at the beginning of the probation period to develop more effective prevention strategies for substance abstinence by all involved actors in public health services.

The Effect of Upper Extremity Tourniquet Time on Postoperative Pain and Opiate Consumption

BACKGROUND

There is widespread use of pneumatic tourniquet for both upper and lower extremity orthopedic surgeries. Tourniquet use improves visualization, decreases blood loss, and as a result, decreases operative time. Exceeding a certain amount of tourniquet time can cause lasting neuromuscular damage. Orthopedic procedures cause significant pain, and the perioperative narcotic prescriptions after orthopedic surgery have been identified as one of the major contributors to the opioid epidemic. Our aim was to determine whether increasing tourniquet time had a negative impact on immediate postoperative opiate usage in the upper extremity, and to determine other factors associated with increased immediate postoperative opiate usage.

METHODS

A retrospective medical record review was performed on patients who underwent volar pleading for fracture fixation between January 2014 and December 2019 at a single institution. Postoperative pain, morphine equivalent dose (MED) usage, and demographic variables were collected. Multivariable analysis was performed, with P < .05 considered significant.

RESULTS

Immediate postoperative MED consumed was not correlated with operative time, tourniquet time, preoperative substance usage, or sex. However, postoperative MED consumed was correlated with preoperative narcotic use, high body mass index (BMI), and fracture surgery complexity.

CONCLUSIONS

Tourniquet usage under current guidelines does not appear to have an effect on postoperative pain and narcotic usage. Preoperative narcotic usage, BMI, and surgery complexity are significant factors for postoperative opiate consumption.

Virtual reality for the treatment of postoperative pain after laparoscopic hysterectomy for benign Indications: A randomized controlled trial

OBJECTIVE

The primary objective of this study was to determine if immediate post-operative use of virtual reality impacts pain scores or opioid consumption following hysterectomy.

STUDY DESIGN

A randomized controlled trial was performed at a university associated tertiary referral hospital in the United States among patients undergoing laparoscopic hysterectomy for benign indications. Prior to surgery, participants were randomized to use a VR program versus routine care postoperatively in the post anesthesia care unit. Postoperative pain was measured using visual analogue scale, and morphine milligram equivalent to quantify narcotic usage. Patient satisfaction was assessed with a survey. A total of 15 patients were randomized to the virtual reality intervention and 15 to the standard care group. The test statistic was a one-sided T-test, with a significance level targeted of 0.05. Categorical variables were analyzed using chi-square analysis and t-test for continuous variables. Pain score differences between the virtual reality and standard care groups at each time assessment were compared using the Wilcoxon Rank Sum test.

RESULTS

The use of virtual reality did not significantly affect pain scores or postoperative narcotics required; however, it did have a positive impact on the subject's perception of their postoperative course. No adverse events were reported.

CONCLUSION

Although virtual reality use following hysterectomy did not improve pain scores or decrease narcotic usage, it was well received by patients.

[LEGAL BASIS FOR THE MOVEMENT OF MEDICINES ACROSS THE CUSTOMS BORDER OF THE EURASIAN ECONOMIC UNION BY LEGAL ENTITIES]

The issues of the movement of medicines across the customs border of the Eurasian Economic Union are timely and relevant, due to the increase in the turnover of medicines in the Russian Federation. The article deals with the issues of import and export through the customs border of the Eurasian Economic Union of both registered and unregistered medicines in the Russian Federation by legal entities. In addition, the authors investigated the regulatory and legal procedure for the movement of medicines across the customs border of the Eurasian Economic Union containing narcotic and psychotropic substances. Topical issues of falsification of medicines and criminal norms of the law on combating it are touched upon. The analysis carried out in the work allowed the authors to identify the existing problems of regulatory regulation of the issue under study and propose a solution.

Decreasing Post-Operative Narcotic Usage Following Total Knee Arthroplasty Requires More than Simple Education: A Blinded Randomized Controlled Trial

The purpose of this study was to understand if including a patient opioid education document would decrease opioid consumption following TKA. Patients were balanced between the control and intervention group based on age, sex, and date of surgery. At 5 weeks following surgery, there were significantly fewer patients driving in the education cohort as compared to the control cohort. There was not a significant difference in mean 2-week post-operative VAS pain score, mean 5 weeks post-operative VAS pain score, mean number of dispensed pills. Reducing post-operative narcotic usage likely requires a more comprehensive strategy.

Narcotic Utilization After Cleft Lip Repair: Does Local Anesthetic Choice Matter?

To analyze whether the choice of intraoperative local anesthetic for cleft lip repair is associated with the amount of perioperative narcotic utilization.

Retrospective cohort study.

Hospitals participating in the Pediatric Health Information System.

Primary cleft lip repairs performed in the United States from 2010 to 2020.

Local anesthesia injected-treatment with lidocaine alone, bupivacaine alone, or treatment with both agents.

Perioperative narcotic administration.

During the study interval, 8954 patients underwent primary cleft lip repair. Narcotic utilization for unilateral (P < .001) and bilateral (P = .004) cleft lip repair has decreased over the last 5 years. Overall, 21.8% (n = 1950) of infants were administered perioperative narcotics for cleft lip repair, such that 14.3% (n = 1282) required narcotics on POD 0, and 7.2% (n = 647) required narcotics on POD 1.In this study, 36.5% (n = 3269) patients received lidocaine, 22.0% (n = 1966) patients received bupivacaine, and 19.7% (n = 1762) patients received both local anesthetics. Administration of any perioperative narcotic was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only lidocaine (P = .001, 17.5% vs 21.7%) or only bupivacaine (P < .001, 17.5% vs 22.9%). Narcotic utilization on the day of surgery was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only lidocaine (P < .001, 11.5% vs 15.1%) or only bupivacaine (P = .004, 11.5% vs 14.6%). Narcotic utilization on the first postoperative day was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only bupivacaine (P = .009, 5.9% vs 8.1%).

CONCLUSIONS

In children undergoing cleft lip repair, local anesthetic combination of lidocaine and bupivacaine is associated with decreased perioperative narcotic use compared to lidocaine or bupivacaine alone.

An answered call for aid? Cannabinoid clinical framework for the opioid epidemic

BACKGROUND

The opioid crisis continues in full force, as physicians and caregivers are desperate for resources to help patients with opioid use and chronic pain disorders find safer and more accessible non-opioid tools.

MAIN BODY

The purpose of this article is to review the current state of the opioid epidemic; the shifting picture of cannabinoids; and the research, policy, and current events that make opioid risk reduction an urgent public health challenge. The provided table contains an evidence-based clinical framework for the utilization of cannabinoids to treat patients with chronic pain who are dependent on opioids, seeking alternatives to opioids, and tapering opioids.

CONCLUSION

Based on a comprehensive review of the literature and epidemiological evidence to date, cannabinoids stand to be one of the most interesting, safe, and accessible tools available to attenuate the devastation resulting from the misuse and abuse of opioid narcotics. Considering the urgency of the opioid epidemic and broadening of cannabinoid accessibility amidst absent prescribing guidelines, the authors recommend use of this clinical framework in the contexts of both clinical research continuity and patient care.

Assessment of efficacy of drug evaluation and classification program in Florida

OBJECTIVE

The present study aims to assess the effectiveness of the Drug Evaluation and Classification (DEC) program in Florida.

METHODS

Data from 236 completed DEC evaluations of central nervous system (CNS) depressants, CNS stimulants, narcotic analgesics, and cannabis were analyzed using a classification process comprising toxicology findings and corresponding Drug Recognition Expert (DRE) opinions. A series of standard measures (sensitivity, specificity, false-alarm rate, miss rate, corroboration, and accuracy) were calculated to assess the effectiveness of the DEC program.

RESULTS

DREs provided 172 correct opinions and 23 missed opinions, resulting in an accuracy rate of 88%, sensitivity rate of 97%, specificity rate of 23%, false alarm rate of 77%, miss rate of 3%, and corroboration rate of 91%. The 12-step DRE protocol of the DEC program therefore has the desired effect of DREs formulating correct opinions. The specificity and false alarm rate were influenced by the restricted testing procedures in the state of Florida. In general, law enforcement officers certified in the DEC program with specialized training can identify drugged drivers and the correct drug category of the drug causing impairment at the time of operating a vehicle. The DEC program goals are met through rigorous training and a curriculum establishing the 12-step DRE protocol.

CONCLUSIONS

DRE drug classification opinions identify drugged drivers. The limitations of Florida's biological sample testing procedures have an impact on the specificity of DRE opinions. Addressing these limitations could increase the confirmation rates of the presence of drugs in the individual's biological samples, which would directly impact the conviction rates in DUI-related criminal cases. Further Florida's testing procedures need to be further studied and updated to improve the DEC program in Florida.

Initial learning curve after switching to uniportal endoscopic discectomy for lumbar disc herniations

PURPOSE

The purpose was to investigate the learning curve for elective endoscopic discectomy performed by a single surgeon who made a complete switch to uniportal endoscopic surgery for lumbar disc herniations in an ambulatory surgery center and determine the minimum case number required to safely overcome the initial learning curve.

METHODS

Electronic medical records (EMR) of the first 90 patients receiving endoscopic discectomy by the senior author in an ambulatory surgery center were reviewed. Cases were divided by approach, transforaminal (46) versus interlaminar (44). Patient-reported outcome measures (visual-analog-score (VAS) and the Oswestry disability index (ODI)) were recorded preoperatively and at 2-week, 6-week, 3-month, and 6-month appointments. Operative times, complications, time to discharge from PACU, postoperative narcotic use, return to work, and reoperations were compiled.

RESULTS

Median operative time decreased approximately 50% for the first 50 patients then plateaued for both approaches (mean: 65 min). No difference in reoperation rate observed during the learning curve. Mean time to reoperation was 10 weeks, with 7(7.8%) reoperations. The interlaminar and transforaminal median operative times were 52 versus 73 min, respectively (p = 0.03). Median time to discharge from PACU was 80 min for interlaminar approaches and 60 min for transforaminal (p < 0.001). Mean VAS and ODI scores 6 weeks and 6 months postoperatively were statistically and clinically improved from preoperatively. The duration of postoperative narcotic use and narcotics need significantly decreased during the learning curve as the senior author realized that narcotics were not needed. No differences were apparent between groups in other metrics.

CONCLUSIONS

Endoscopic discectomy was shown to be safe and effective for symptomatic disc herniations in an ambulatory setting. Median operative time decreases by half over the first 50 patients in our learning curve, while reoperation rates remained similar without the need for hospital transfer or conversion to an open procedure in an ambulatory setting.

LEVEL OF EVIDENCE

Level III, prospective cohort.

Simplifying Retroperitoneal Robotic Single-port Surgery: Novel Supine Anterior Retroperitoneal Access

BACKGROUND

Multiport robotic surgery in the retroperitoneum is limited by the bulky robotic frame and clashing of instruments. Moreover, patients are placed in the lateral decubitus position, which has been linked to complications.

OBJECTIVE

To assess the feasibility and safety of a supine anterior retroperitoneal access (SARA) technique with the da Vinci Single-Port (SP) robotic platform.

DESIGN, SETTING, AND PARTICIPANTS

Between October 2022 and January 2023, 18 patients underwent surgery using the SARA technique for renal cancer, urothelial cancer, or ureteral stenosis. Perioperative variables were prospectively collected and outcomes were assessed.

SURGICAL PROCEDURE

With the patient in a supine position, a 3-cm incision is made at the McBurney point and the abdominal muscles are dissected. Finger dissection is used to develop the retroperitoneal space for the da Vinci SP access port. After docking, the first step is to dissect retroperitoneal tissue to reveal the psoas muscle. This allows identification of the ureter, the inferior renal pole, and the hilum.

MEASUREMENTS

A descriptive statistical analysis was performed. Data collected included demographics, operative time, warm ischemia time (WIT), surgical margin status, complications, length of hospital stay, 30-d Clavien-Dindo complications, and postoperative narcotic use.

RESULTS AND LIMITATIONS

Twelve patients underwent partial nephrectomy (PN) and two each underwent pyeloplasty, radical nephroureterectomy, and radical nephrectomy. In the PN group, mean age was 57 yr (interquartile range [IQR] 30-73), median body mass index was 32 kg/m2 (IQR 17-58), and 25% had stage ≥3 chronic kidney disease. The median Charlson comorbidity index was 3 (IQR 0-7) and 75% of PN patients had an American Society of Anesthesiologists score ≥3. The median RENAL score was 5 (IQR 4-7). The median WIT was 25 min (IQR 16-48) and the median tumor size was 35 mm (IQR 16-50). The median estimated blood loss was 105 ml (IQR 20-400) and the median operative time was 160 min (IQR 110-200). Positive surgical margins were found in one patient. In the overall cohort, one patient was readmitted and managed conservatively; 83% of the PN group were discharged on the same day as their surgery, with the remainder discharged the next day. At 7 d after surgery, no patients reported narcotic use.

CONCLUSIONS

The SARA approach is feasible and safe. Larger studies are needed to confirm this approach as a one-step solution for upper urinary tract surgery.

PATIENT SUMMARY

We assessed initial outcomes of a novel approach for accessing the retroperitoneum (the space behind the abdominal cavity and in front of the back muscles and spine) during robot-assisted surgery in the upper urinary tract. The patient is placed on their back and surgery is performed with a single-port robot. Our results show that this approach was feasible and safe, with low complication rates, less postoperative pain, and earlier discharge. This is a promising start, but larger studies are needed to confirm our findings.

Augmented Reality for Perioperative Anxiety in Patients Undergoing Surgery: A Randomized Clinical Trial

Importance

Both augmented reality (AR) and virtual reality (VR) have had increasing applications in medicine, including medical training, psychology, physical medicine, rehabilitation, and surgical specialties, such as neurosurgery and orthopedic surgery. There are little data on AR's effect on patients' anxiety and experiences.

Objective

To determine whether the use of an AR walkthrough effects patient perioperative anxiety.

Design, Setting, and Participants

This randomized clinical trial was conducted at an outpatient surgery center in 2021 to 2022. All patients undergoing elective orthopedic surgery with the senior author were randomized to the treatment or control group. Analyses were conducted per protocol. Data analysis was performed in November 2022.

Intervention

AR experience explaining to patients what to expect on their day of surgery and walking them through the surgery space. The control group received the standard educational packet.

Main Outcomes and Measures

The main outcome was change in State-Trait Anxiety Inventory (STAI) from the screening survey to the preoperative survey.

Results

A total of 140 patients were eligible, and 45 patients either declined or were excluded. Therefore, 95 patients (63 [66.3%] male; mean [SD] age, 38 [16] years) were recruited for the study and included in the final analysis; 46 patients received the AR intervention, and 49 patients received standard instructions. The AR group experienced a decrease in anxiety from the screening to preoperative survey (mean score change, -2.4 [95% CI, -4.6 to -0.3]), while the standard care group experienced an increase (mean score change, 2.6 [95% CI, 0.2 to 4.9]; P = .01). All patients postoperatively experienced a mean decrease in anxiety score compared with both the screening survey (mean change: AR, -5.4 [95% CI, -7.9 to -2.9]; standard care, -6.9 [95% CI, -11.5 to -2.2]; P = .32) and preoperative survey (mean change: AR, -8.0 [95% CI, -10.3 to -5.7]; standard care, -4.2 [95% CI, -8.6 to 0.2]; P = .19). Of 42 patients in the AR group who completed the postoperative follow-up survey, 30 (71.4%) agreed or strongly agreed that they enjoyed the experience, 29 (69.0%) agreed or strongly agreed that they would recommend the experience, and 28 (66.7%) agreed or strongly agreed that they would use the experience again. No differences were observed in postoperative pain levels or narcotic use.

Conclusions and Relevance

In this randomized clinical trial, the use of AR decreased preoperative anxiety compared with traditional perioperative education and handouts, but there was no significant effect on postoperative anxiety, pain levels, or narcotic use. These findings suggest that AR may serve as an effective means of decreasing preoperative patient anxiety.

Trial Registration

ClinicalTrials.gov Identifier: NCT04727697.

Detection & identification of hazardous narcotics and new psychoactive substances using Fourier transform infrared spectroscopy (FTIR)

According to the latest World Drug Report, released by the United Nations Office on Drugs and Crime (UNODC), drug use is up 30% over the past decade and there are more drugs, and more types of drugs, than ever. Herein we use Fourier Transform Infrared Spectroscopy (FTIR) for the rapid ID of narcotics in a range of concentrations - from pure forms (as it is likely to be smuggled & transported) to street forms, often mixed with conventional cutting agents. Using FTIR, 75% of "street sample" narcotics were rapidly identified, and the effects of cutting agents on identification (ID) were also investigated. The limit of detection of MDMA was assessed, with a correct ID shown from 25% w/v. Concentration was correlated with Hit Quality Index, showing the capability of FTIR use in concentration estimation.

Oxycodone withdrawal induces HDAC1/HDAC2-dependent transcriptional maladaptations in the reward pathway in a mouse model of peripheral nerve injury

The development of physical dependence and addiction disorders due to misuse of opioid analgesics is a major concern with pain therapeutics. We developed a mouse model of oxycodone exposure and subsequent withdrawal in the presence or absence of chronic neuropathic pain. Oxycodone withdrawal alone triggered robust gene expression adaptations in the nucleus accumbens, medial prefrontal cortex and ventral tegmental area, with numerous genes and pathways selectively affected by oxycodone withdrawal in mice with peripheral nerve injury. Pathway analysis predicted that histone deacetylase (HDAC) 1 is a top upstream regulator in opioid withdrawal in nucleus accumbens and medial prefrontal cortex. The novel HDAC1/HDAC2 inhibitor, Regenacy Brain Class I HDAC Inhibitor (RBC1HI), attenuated behavioral manifestations of oxycodone withdrawal, especially in mice with neuropathic pain. These findings suggest that inhibition of HDAC1/HDAC2 may provide an avenue for patients with chronic pain who are dependent on opioids to transition to non-opioid analgesics.

Advances in the characterization of negative affect caused by acute and protracted opioid withdrawal using animal models

Opioid use disorder (OUD) is a chronic brain disease which originates from long-term neuroadaptations that develop after repeated opioid consumption and withdrawal episodes. These neuroadaptations lead among other things to the development of a negative affect, which includes loss of motivation for natural rewards, higher anxiety, social deficits, heightened stress reactivity, an inability to identify and describe emotions, physical and/or emotional pain, malaise, dysphoria, sleep disorders and chronic irritability. The urge for relief from this negative affect is one of major causes of relapse, and thus represents a critical challenge for treatment and relapse prevention. Animal models of negative affect induced by opioid withdrawal have recapitulated the development of a negative emotional state with signs such as anhedonia, increased anxiety responses, increased despair-like behaviour and deficits in social interaction. This research has been critical to determine neurocircuitry adaptations during chronic opioid administration or upon withdrawal. In this review, we summarize the recent literature of rodent models of (i) acute withdrawal, (ii) protracted abstinence from passive administration of opioids, (iii) withdrawal or protracted abstinence from opioid self-administration. Finally, we describe neurocircuitry involved in acute withdrawal and protracted abstinence. This article is part of the Special Issue on "Opioid-induced changes in addiction and pain circuits".

Association of Urine Fentanyl Concentration With Severity of Opioid Withdrawal Among Patients Presenting to the Emergency Department

BACKGROUND AND AIMS

Fentanyl is involved in most US drug overdose deaths and its use can complicate opioid withdrawal management. Clinical applications of quantitative urine fentanyl testing have not been demonstrated previously. The aim of this study was to determine whether urine fentanyl concentration is associated with severity of opioid withdrawal.

DESIGN

This is a retrospective cross-sectional study.

SETTING

This study was conducted in 3 emergency departments in an urban, academic health system from January 1, 2020, to December 31, 2021.

PARTICIPANTS

This study included patients with opioid use disorder, detectable urine fentanyl or norfentanyl, and Clinical Opiate Withdrawal Scale (COWS) recorded within 6 hours of urine drug testing.

MEASUREMENTS

The primary exposure was urine fentanyl concentration stratified as high (>400 ng/mL), medium (40-399 ng/mL), or low (<40 ng/mL). The primary outcome was opioid withdrawal severity measured with COWS within 6 hours before or after urine specimen collection. We used a generalized linear model with γ distribution and log-link function to estimate the adjusted association between COWS and the exposures.

FINDINGS

For the 1127 patients in our sample, the mean age (SD) was 40.0 (10.7), 384 (34.1%) identified as female, 332 (29.5%) reported their race/ethnicity as non-Hispanic Black, and 658 (58.4%) reported their race/ethnicity as non-Hispanic White. For patients with high urine fentanyl concentrations, the adjusted mean COWS (95% confidence interval) was 4.4 (3.9-4.8) compared with 5.5 (5.1-6.0) among those with medium and 7.7 (6.8-8.7) among those with low fentanyl concentrations.

CONCLUSIONS

Lower urine fentanyl concentration was associated with more severe opioid withdrawal, suggesting potential clinical applications for quantitative urine measurements in evolving approaches to fentanyl withdrawal management.

Minimalistic approach to enhanced recovery after pediatric scoliosis surgery

PURPOSE

Prior studies of enhanced recovery protocols (ERP) have been conducted at large institutions with abundant resources. These results may not apply at institutions with less resources directed to quality improvement efforts. The purpose of this study was to assess the value of a minimalistic enhanced recovery protocol in reducing length of stay (LOS) following PSF for adolescent idiopathic scoliosis. We hypothesized that accelerated transition to oral pain medications and mobilization alone could shorten hospital length of stay in the absence of a formal multimodal pain regimen.

METHODS

AIS patients aged 10-18 who underwent PSF at a tertiary pediatric hospital between January 1, 2014 and December 31, 2017 were reviewed. The study population was further narrowed to consecutive patients from a single surgeon's practice that piloted the modified ERP. Reservation from key stakeholders regarding the feasibility of implementing widespread protocol change led to the minimal alterations made to the postoperative protocol following PSF. Patients were divided into either the Standard Recovery Protocol (SRP) or Enhanced Recovery Protocol (ERP). Primary variables analyzed were hospital LOS, complications, readmissions, and total narcotic requirement.

RESULTS

A total of 92 patients met inclusion criteria. SRP and ERP groups consisted of 44 (47.8%) and 48 (52.2%) patients. There was no difference between the two groups with regard to age, sex, and ASA score (p > 0.05). Fusion levels and EBL did not differ between treatment groups (p > 0.05). PCA pumps were discontinued later in the SRP group (39.5 ± 4.3 h) compared to the ERP group (17.4 ± 4.1 h, p < 0.0001). Narcotic requirement was similar between groups (p = 0.94) Patients in the SRP group had longer hospital stays than patients in the ERP group (p < 0.0001). 83% of the ERP group had LOS ≤ 3 days compared to 0% in the SRP group, whose mean LOS was 4.2 days. There was no difference in complications between the groups (2.2% vs 6.0%, p = 0.62). Readmission to the hospital within 30 days of surgery was rare in either group (2 SRP patients: 1 superior mesenteric artery syndrome, 1 bowel obstruction vs 0 ERP patients, p = 0.23).

CONCLUSION

In this cohort, minor changes to the postoperative protocol following surgery for AIS led to a significant decrease in hospital length of stay. This minimalistic approach may ease implementation of an ERP in the setting of stakeholder apprehension.

Does Facial Fracture Management Require Opioids? A Pilot Trial of a Narcotic-Minimizing Analgesia Protocol for Operative Facial Trauma

Opioid minimization in the acute postoperative phase is timely in the era of the opioid epidemic. The authors hypothesize that patients with facial trauma receiving multimodal, narcotic-minimizing pain management in the perioperative period will consume fewer morphine milligram equivalents (MMEs) while maintaining adequate pain control compared with a traditional analgesia protocol. An IRB-approved pilot study evaluating isolated facial trauma patients compared 10 consecutive prospective patients of a narcotic-minimizing pain protocol beginning in August 2020 with a retrospective, chart-reviewed cohort of 10 consecutive patients before protocol implementation. The protocol was comprised of multimodal nonopioid pharmacotherapy given preoperatively (acetaminophen, celecoxib, and pregabalin). Postoperatively, patients received intravenous (IV) ketorolac, scheduled acetaminophen, ibuprofen, and gabapentin. Oxycodone was reserved for severe uncontrolled pain. The control group had no standardized protocol, though opioids were ad libitum. Consumed MMEs and verbal Numeric Rating Scale (vNRS) pain scores (0-10) were prospectively tracked and compared with retrospective data. Descriptive and inferential statistics were run. At all recorded postoperative intervals, narcotic-minimizing subjects consumed significantly fewer MMEs than controls [0-8 h, 21.5 versus 63.5 ( P = 0.002); 8-16 h, 4.9 versus 20.6 ( P = 0.02); 16-24 h, 3.3 versus 13.9 ( P = 0.03); total 29.5 versus 98.0 ( P = 0.003)]. At all recorded postoperative intervals, narcotic-minimizing subjects reported less pain (vNRS) than controls (0-8 h, 7.7 versus 8.1; 8-16 h, 4.4 versus 8.0; 16-24 h 4.3 versus 6.9); significance was achieved at the 8 to 16-hour time point ( P = 0.006). A multimodal, opioid-sparing analgesia protocol significantly reduces opioid use in perioperative facial trauma management without sacrificing satisfactory pain control for patients.

Utility of Removable Rigid Dressings in Decreasing Discharge Narcotic Use and Improving Ambulation Following Below-Knee Amputation

BACKGROUND

Lower extremity amputations are often associated with limited postoperative functionality and postoperative complications. Removable rigid dressings (RRDs) have been used following below-knee amputation (BKA) to improve limb maturation, decrease postoperative complications, reduce time to prosthesis casting, and limit conversion rates to above-knee amputation (AKA). We hypothesized that usage of RRD following BKA will correlate with decreased prescription narcotics required at discharge and improved ambulatory status at follow-up.

METHODS

A retrospective chart review was conducted to identify all patients who underwent BKA performed by the vascular surgery service at a large, acute care hospital between July 2016 and July 2021. Data collected included age, sex, body mass index, conversion to AKA, narcotic prescriptions at discharge, and ambulatory status at follow-up.

RESULTS

Between July 2016 and 2021, rate of conversion to AKA was significantly lower in patients who received an RRD (9.3%), as opposed to those who did not (41.5%) (P = 0.0002). Narcotic prescriptions at discharge, compared following conversion to morphine equivalents, were also significantly lower in the rigid dressing group compared to patients who did not receive the dressing (50.5 vs. 108.9 morphine eq/24 h, P = 0.0019). Furthermore, use of rigid dressing significantly improved ambulatory status at follow-up to 75.9% in RRD patients compared to 29.3% in patients with conventional dressing (P < 0.0001). This statistical significance persisted after all patients who were converted to AKA were removed from analysis (79.6% vs. 39.3% ambulatory, P = 0.000363). Multivariate analysis revealed that ambulatory status at follow-up was only associated with age more than 80 years (P = 0.042) and use of postoperative RRD (P = 0.001).

CONCLUSIONS

These findings support the utility of an RRD following BKA to reduce conversion to AKA, reduce narcotic dosages required at discharge, and improve ambulatory status at follow-up.

Endomorphin analog ZH853 shows low reward, tolerance, and affective-motivational signs of withdrawal, while inhibiting opioid withdrawal and seeking

Currently available μ-opioid receptor agonist pharmacotherapies for opioid use disorder possess adverse effects limiting their use and, despite treatment, rates of relapse remain high. We previously showed that endomorphin analog ZH853 had no effect in rodent models that predict abuse liability in humans. Here we extended these findings by examining dependence liability and reinforcing properties in female rats and male rats with previous opioid exposure. The potential use of ZH853 in managing opioid use disorder was evaluated by examining its effect on opioid-seeking behavior and withdrawal. We found that ZH853 did not induce locomotor activation in male and female mice and was not self-administered by female rats. Relative to morphine, ZH853 led to similar somatic signs of withdrawal, but low affective-motivational signs of withdrawal, and absent changes in ventral tegmental area K(+)-Cl(-) co-transporter expression associated with reward dysregulation. The low abuse liability of ZH853 was further supported in oxycodone self-administering male rats, where ZH853 substitution extinguished opioid-seeking behavior. ZH853 priming also did not reinstate morphine conditioned place preference. Lastly, ZH853 inhibited oxycodone-seeking behavior during relapse after forced abstinence and decreased the expression of morphine withdrawal. These findings suggest the potential use of ZH853 as a safer opioid medication for long-term treatment of pain and opioid use disorder.

Modeling spontaneous opioid withdrawal in male and female outbred mice using traditional endpoints and hyperalgesia

Opioid withdrawal significantly impacts drug dependence cycles as hyperalgesia associated with withdrawal is often a reason for continued drug use. Animal models of addiction are important tools for studying how drug dependence and withdrawal impact not only normal neurocircuitry but also the effectiveness of potential treatments for dependence and withdrawal. We conducted a study of the time course of spontaneous morphine withdrawal in outbred male and female mice that can be used to examine sex differences in male and female mice using both traditional somatic endpoints and mechanical hyperalgesia as an endpoint of withdrawal. Male and female national institute of health (NIH) Swiss mice were made dependent upon morphine using an escalating dosing schedule. Injections were stopped after 5 days. Withdrawal behavior was assessed at time intervals up to 106 h after the final injection. Numbers of forepaw tremors, wet-dog shakes, jumps and other behaviors were scored to create a global score. Paw pressure readings were then also taken to track changes in sensitivity to a painful stimulus over time. Male and female mice had approximately similar withdrawal severity peaking at 24 h after the final injection as measured by composite global scores. Females did exhibit an earlier and greater frequency of tremors than males. Although males and females showed similar hyperalgesia during withdrawal, females recovered faster. Spontaneous opioid withdrawal peaking at 24 h was demonstrated in male and female NIH Swiss mice. We also successfully demonstrated that hyperalgesia is an endpoint that varies over the course of withdrawal.

Clinical Outcomes of Liposomal Bupivacaine Erector Spinae Block in Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery

BACKGROUND

Postoperative pain is a barrier to early mobility and discharge after lumbar surgery. Liposomal bupivacaine (LB) has been shown to decrease postoperative pain and narcotic consumption after transforaminal lumbar interbody fusions (TLIFs) when injected into the marginal suprafascial/subfascial plane-liposomal bupivacaine (MSSP-LB). Erector spinae plane (ESP) infiltration is a relatively new analgesic technique that may offer additional benefits when performed in addition to MSSP-LB.

OBJECTIVE

To evaluate postoperative outcomes of combining ESP-LB with MSSP-LB compared with MSSP-LB alone after single-level TLIF.

METHODS

A retrospective analysis was performed for patients undergoing single-level TLIFs under spinal anesthesia, 25 receiving combined ESP-LB and MSSP-LB and 25 receiving MSSP-LB alone. The primary outcome was length of hospitalization. Secondary outcomes included postoperative pain score, time to ambulation, and narcotics usage.

RESULTS

Baseline demographics and length of surgery were similar between groups. Hospitalization was significantly decreased in the ESP-LB + MSSP-LB cohort (2.56 days vs 3.36 days, P = .007), as were days to ambulation (0.96 days vs 1.29 days, P = .026). Postoperative pain area under the curve was significantly decreased for ESP-LB + MSSP-LB at 12 to 24 hours (39.37 ± 21.02 vs 53.38 ± 22.11, P = .03) and total (44.46 ± 19.89 vs 50.51 ± 22.15, P = .025). Postoperative narcotic use was significantly less in the ESP-LB + MSSP-LB group at 12 to 24 hours (13.18 ± 4.65 vs 14.78 ± 4.44, P = .03) and for total hospitalization (137.3 ± 96.3 vs 194.7 ± 110.2, P = .04).

CONCLUSION

Combining ESP-LB with MSSP-LB is superior to MSSP-LB alone for single-level TLIFs in decreasing length of hospital stay, time to ambulation, postoperative pain, and narcotic use.

Does the American College of Surgeons New Level I Children's Surgery Center Verification Affect Treatment Efficiency and Narcotic Administration in Treating Pediatric Trauma Patients with Femur Fracture?

BACKGROUND

In 2015, the American College of Surgeons (ACS) created a new hospital improvement program to enhance the performance of pediatric care in US hospitals. The Children's Surgery Verification (CSV) Quality Improvement Program is predicated on the idea that pediatric surgical patients have improved outcomes when treated at children's hospitals with optimal resources. Achieving ACS level I CSV designation at pediatric trauma centers may lead to greater benefits for pediatric trauma patients; however, the specific benefits have yet to be identified. We hypothesize that achieving the additional designation of ACS level I CSV is associated with decreased narcotic use perioperatively and improved efficiency when managing pediatric patients with femur fractures.

STUDY DESIGN

This study is a retrospective analysis of traumatic pediatric orthopaedic femur fractures treated at a verified level I pediatric trauma center before and after CSV designation (2010 to 2014 vs 2015 to 2019). Efficiency parameters, defined as time from admission to surgery, duration of surgery, and duration of hospital stay, and narcotic administration in oral morphine equivalents (OMEs) were compared.

RESULTS

Of 185 traumatic femur fractures analyzed, 80 occurred before meeting ACS level I CSV criteria, and 105 occurred after. Post-CSV, there was a significant decrease in mean wait time from admission to surgery (16.64 hours pre-CSV, 12.52 hours post-CSV [p < 0.01]) and duration of hospital stay (103.49 hours pre-CSV, 71.61 hours post-CSV [p < 0.01]). Narcotic usage was significantly decreased in both the preoperative period (40.61 OMEs pre-CSV, 23.77 OMEs post-CSV [p < 0.01]) and postoperative period (126.67 OMEs pre-CSV, 45.72 OMEs post-CSV [p < 0.01]).

CONCLUSIONS

Achieving ACS level I CSV designation is associated with increased efficiency and decreased preoperative and postoperative narcotic use when treating pediatric trauma patients.

Effects of a Prescription Drug Monitoring Program on Opioid Prescriptions Following Total Joint Arthroplasty in the State of California

In an attempt to reduce opioid prescriptions, the state of California mandated physician participation in the Controlled Substance Utilization Review and Evaluation System (CURES). The goal of this study is to assess whether this intervention led to a change in prescribing habits after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). The 90-day postoperative narcotic use was retrospectively reviewed for 13,382 patients undergoing primary THA and TKA. Patients were divided into pre-CURES and post-CURES cohorts based on date of surgery. Narcotic use was measured in morphine milligram equivalents (MME). There was a 21.3% decrease in postoperative MME post-CURES for patients undergoing THA (756.5±759.5 MME vs 962.00±864.4 MME, P<.0001) and a 19.9% decrease in postoperative MME post-CURES for patients undergoing TKA (1274.3±2707.1 MME vs 1590.6±1725.3 MME, P<.0001). Patients post-CURES required an additional prescription at 2 weeks more frequently compared with patients pre-CURES after THA (27.5% vs 20.5%, P<.001) and TKA (54.2% vs 44.2%, P<.001). Patients undergoing THA had 40.5% and 40.6% less narcotic prescribed compared with patients undergoing TKA pre-CURES and post-CURES (P<.001), respectively. Government guidelines led to a substantial decrease in postoperative MME prescribed after TKA and THA. Patients undergoing THA had a substantially smaller amount of narcotic prescribed than patients undergoing TKA. [Orthopedics. 2023;46(2):70-75.].