The Standardization of Outpatient Procedure (STOP) Narcotics after anorectal surgery: a prospective non-inferiority study to reduce opioid use.

BACKGROUND: Prescription of opioid medication after ambulatory anorectal surgery may be excessive and lead to opioid misuse. The purpose of this study was to evaluate the efficacy of a multi-modality opioid-sparing approach to control postoperative pain and reduce opioid prescriptions after outpatient anorectal surgery. METHODS: A prospective non-inferiority pre- and post-intervention study was completed at three academic hospitals. Patients included were 18-75 years of age who had outpatient anorectal surgeries. The Standardization of Outpatient Procedure (STOP) Narcotics intervention was implemented, which is a multi-pronged analgesia bundle integrating patient education, health care provider education, and intra-/postoperative analgesia focused on multi-modal pain control strategies and opioid-reduced prescriptions. The primary outcome was patient-reported average pain in the first 7 postoperative days. Secondary outcomes included patient-reported quality of pain management, medication utilization, prescription refills and medication disposal. RESULTS: Ninety-three patients had outpatient anorectal surgery (42 pre-intervention and 51 post-intervention). No difference was seen in average postoperative pain in the pre- vs. post-intervention groups (2.8 vs. 2.6 on an 11-point scale, p = 0.33) or patient-reported quality of pain control (good/very good in 57% vs. 63%, p = 0.58). The median oral morphine equivalents (OME) prescribed was significantly less [112.5 (IQR 50-150) pre-intervention vs. 50 (IQR 50-50) post-intervention, p < 0.001]. In the post-intervention group, only 45% of patients filled their opioid prescription and median opioid use was 12.5 OME (2.5 pills). CONCLUSIONS: While pain control after anorectal surgery must consider the individual patient's needs, a standardized pain care bundle significantly decreased opioid prescribing without an increase in patient-reported postoperative pain.

Introduction of a mobile device based tertiary survey application reduces missed injuries: A multi-center prospective study.

BACKGROUND: Missed injuries during the initial assessment are a major cause of morbidity after trauma. The tertiary survey is a head-to-toe exam designed to identify any injuries missed after initial resuscitation. We designed a novel mobile device application (Physician Assist Trauma Software [PATS]) to standardize performance and documentation of the tertiary survey. This study was undertaken to assess the feasibility of introducing PATS into routine clinical practice, as well as its capacity to reduce missed injuries. METHODS: Prior to implementation of PATS, the missed injury rates at a higher-volume and a medium-volume level I trauma center were assessed. The PATS program was implemented simultaneously at both centers. Missed injuries were tracked during the study period. Compliance and tertiary survey completion rates were evaluated as a marker of feasibility. RESULTS: At the higher-volume trauma center, the missed injury rated decreased from 1% to 0% with the introduction of the PATS program (p = 0.04). At the medium-volume trauma center, the missed injury rate decreased from 9% to 1% (p < 0.001). Compliance and documentation increased from 68% to 100%, and from no formal documentation to 60% compliance at the higher- and medium-volume centers respectively. CONCLUSIONS: The implementation of a mobile tertiary survey application significantly reduced missed injuries at both a higher- and medium-volume trauma center. The use of this application resulted in a significant improvement in compliance with documentation of the tertiary survey.

Are retrievable vena cava filters placed in trauma patients really retrievable?

PURPOSE: Concerns have arisen regarding the use of retrievable inferior vena cava filters (rIVCFs) in trauma patients due to increasing reports of low retrieval rates. We hypothesized that complete follow-up with a dedicated trauma nurse practitioner would be associated with a higher rate of retrievability. This study was undertaken to determine the rate of retrievability of rIVCFs placed in a Canadian Lead Trauma Centre, and to compare the rate of retrievability in our trauma population to our non-trauma patients. METHODS: We performed a retrospective cohort study of all patients with rIVCF placed between Jan 1 2000 and June 30 2014. Data were collected on demographics, indication for filter placement, retrieval status, and reasons for non-retrieval. Comparison was made between trauma patients and non-trauma patients. RESULTS: A total of 374 rIVCFs were placed (61 in trauma patients and 313 in non-trauma patients) and follow-up was complete for the entire cohort. Filter retrieval was achieved in 86.9 % of trauma patients. Reasons for non-retrieval were technical in two patients, and death before retrieval in six patients. Retrieval was successful in 48.9 % of non-trauma patients. CONCLUSIONS: This study demonstrates that rIVCFs can be successfully retrieved amongst trauma patients. We demonstrated a higher rate of successful retrieval amongst trauma patients than non-trauma patients in our institution. Careful patient follow-up may play a role in successful retrieval of rIVCFs.

Non-operative management of blunt hepatic trauma: Does angioembolization have a major impact?

PURPOSE: A paradigm shift toward non-operative management (NOM) of blunt hepatic trauma has occurred. With advances in percutaneous interventions, even severe liver injuries are being managed non-operatively. However, although overall mortality is decreased with NOM, liver-related morbidity remains high. This study was undertaken to explore the morbidity and mortality of blunt hepatic trauma in the era of angioembolization (AE). METHODS: A retrospective cohort of trauma patients with blunt hepatic injury who were assessed at our centre between 1999 and 2011 were identified. Logistic regression was undertaken to identify factors increasing the likelihood of operative management (OM) and mortality. RESULTS: We identified 396 patients with a mean ISS of 33 (± 14). Sixty-two (18%) patients had severe liver injuries (≥ AAST grade IV). OM occurred in 109 (27%) patients. Logistic regression revealed high ISS (OR 1.07; 95% CI 1.05-1.10), and lower systolic blood pressure on arrival (OR 0.98; 95% CI 0.97-0.99) to be associated with OM. The overall mortality was 17%. Older patients (OR 1.05; 95% CI 1.03-1.07), those with high ISS (OR 1.11; 95% CI 1.08-1.14) and those requiring OM (OR 2.89; 95% CI 1.47-5.69) were more likely to die. Liver-related morbidities occurred in equal frequency in the OM (23%) and AE (29%) groups (p = 0.32). Only 3% of those with NOM experienced morbidity. CONCLUSIONS: The majority of patients with blunt hepatic trauma can be successfully managed non-operatively. Morbidity associated with NOM was low. Patients requiring AE had morbidity similar to OM.

The use of trauma transfusion pathways for blood component transfusion in the civilian population: a systematic review and meta-analysis.

This study was undertaken to determine if, amongst civilian trauma patients requiring massive transfusion (MT), the use of a formal trauma transfusion pathway (TTP), in comparison with transfusion without a TTP, is associated with a reduction in mortality, or changes in indices of coagulation, blood product utilisation and complications. A systematic review of three bibliographic databases, reference lists and conference proceedings was conducted. Studies were included if comparisons were made between patients receiving transfusion with and without a TTP. Data were extracted by two independent reviewers on population characteristics, transfusion strategies, blood product utilisation, indices of coagulation, clinical outcomes and complications. Data were pooled using a random effects model and heterogeneity explored. Seven observational studies met all eligibility criteria. Amongst 1801 patients requiring MT, TTPs were associated with a significant reduction in mortality (RR 0·69, 95% CI 0·55, 0·87). No significant increase in the mean number of PRBC transfused between TTP and control patients was seen (MD -1·17 95% CI -2·70, 0·36). When studies assessing only trauma patients were considered, TTPs were associated with a reduction in the mean number of units of plasma transfused (MD -2·63, 95% CI -4·24, -1·01). In summary, the use of TTPs appears to be associated with a reduction in mortality amongst trauma patients requiring MT without a clinically significant increase in the number of PRBC transfused and a potential reduction in plasma transfusion. Effects of TTPs on platelet transfusion, indices of coagulation and complications remain unclear. A randomised controlled trial is warranted.

Renal effects of volume expansion in the renal-denervated nonhuman primate.

Experiments were performed to determine the role of renal nerves in mediating the renal excretory effects of volume expansion in the nonhuman primate. Male Macaca fascicularis monkeys underwent chronic bilateral renal denervation or sham surgery. After a 1- to 2-wk recovery period, each animal was anesthetized with pentobarbital sodium and volume expanded 20% of estimated blood volume. Two types of volume expansion were used, a hemodilutional expansion using 6% dextran in isotonic saline and an isohemic expansion using each monkey's own blood that had previously been withdrawn in exchange for dextran. Renal denervation did not attenuate the excretory responses to volume expansion in that similar increases in urine flow, sodium excretion, filtered load of sodium excreted, osmolar and free water clearances occurred in both the renal-denervated and sham-operated groups. The onset of the responses was not delayed by renal denervation. Furthermore, the results were the same with both volume expansions. These results suggest that, in the monkey, decreases in renal nerve activity that occur with volume expansion are not necessary for eliciting the excretory responses to this hypervolemic stimulus or that other factors compensate if the kidneys are chronically denervated. In addition, the failure of renal denervation to attenuate the excretory effects of a cell-free volume expansion is not related to any dilutional characteristics of the expansion.

Nutritional status and lymphocyte function in maintenance hemodialysis patients.

Nutritional status and lymphocyte transformation were examined in 30 clinically stable men who underwent maintenance hemodialysis for 1 to 141 months. The men displayed decreased relative body weight, triceps and subscapular skinfold thickness, midarm circumference, midarm muscle circumference, serum total protein, albumin, transferrin, IgG, IgA, IgM, and C3 concentrations. There were many abnormalities in the plasma amino acid pattern. Lymphocyte transformation stimulated by phytohemagglutin or pokeweed mitogen was reduced. Many nutritional parameters correlated with each other and with the rate of lymphocyte transformation. There was a tendency (p = 0.06) for higher mortality in the malnourished patients during a mean follow-up period of 43.3 months. These findings suggest that clinically stable men undergoing maintenance hemodialysis are typically malnourished. Poor nutritional status may be a cause of impaired lymphocyte function. Malnutrition or wasting may indicate that the patient is at risk for a higher mortality rate.

Sampling problems and nonparametric solutions in clinical neuropsychological research.

Research data in clinical neuropsychology frequently do not conform to the requirements for parametric statistical analysis. In some of these cases, data analysis by parametric techniques does not identify existing differences. The usefulness of nonparametric statistical tools in evaluating irregular data sets is demonstrated in three cases examples. Methodological considerations arising from these examples are discussed.

Head-up tilt in the nonhuman primate. Effects of renal denervation.

Experiments were performed to determine the role of the renal nerves in mediating the antinatriuresis of head-up tilt in the nonhuman primate. Male Macaca fascicularis monkeys underwent chronic bilateral renal denervation or sham surgery and were allowed a 1- to 2-week recovery period. After that time, each animal was anesthetized with sodium pentobarbital and subjected to 40 min of 35 degrees head-up tilt. Renal perfusion pressure was maintained constant throughout the experiment. Tilt caused significant decreases in urine flow, sodium excretion and osmolar clearance and increases in urine osmolality in both groups. Creatinine and para-aminohippurate clearances decreased in the sham-operated animals but were unchanged in the denervated animals. Although the pattern of the renal excretory responses showed some group differences in that a significant antidiuresis and antinatriuresis occurred after 10 min of tilt in the sham-operated group but not until 20 min in the denervated group, the magnitudes of these excretory responses were similar in both groups throughout the entire tilt procedure. These results suggest that, in this species, the renal nerves are not necessary for eliciting the overall antinatriuretic response to orthostasis but may have some minor involvement in the onset of the response.

Biphasic effects of ethanol on open-field activity: sensitivity and tolerance in C57BL/6N and DBA/2N mice.

Male C57BL/6N (C57) and DBA/2N (DBA) inbred mice were found to differ in open-field behavior after an acute ip injection of ethanol and in the development of tolerance to repeated injections. DBA mice showed only increased activity for 28 min after ethanol doses up to 2.67% g/kg when compared with saline-injected controls. Under the same conditions, C57 mice showed dose-related increases in activity during the first 4 min, followed by dose-related decreases in activity. The effects endured for at least 60 min after injection in both strains. In a third experiment, mice were injected daily with saline or 2.0 g/kg ethanol and tested on Days 1, 5, 9, and 13 for open-field activity. On the 17th day, all mice were tested after an ethanol injection. Neither strain showed tolerance to the activity-stimulating effect of ethanol. Some evidence for tolerance to the effect of ethanol to reduce activity in C57 mice was found. In a fourth experiment, twice-daily injections of ethanol for 10 days produced marked tolerance to the depressant effect of an injection on the 11th day in C57 mice, compared with those in a control group given ethanol for the first time on the 11th day. No tolerance to the stimulant effect of ethanol was seen in C57s. DBA mice were injected twice daily for 19 days but did not display tolerance when tested on Day 10 or on Day 20, Indeed, DBA mice chronically treated with ethanol exhibited more marked stimulation of activity after ethanol than mice treated chronically with saline. Differences in blood ethanol concentrations between the strains could not account for any of the observed differences. Implications for the genetic control of responses to ethanol are discussed.

In vitro determinants of plasma renin activity in serially-studied inbred dogs with neonatally induced coarctation hypertension: renin reactivity, renin substrate, and renin concentration.

Increased renin activity of plasma, suggesting an excess of circulating accelerators and/or deficit of inhibitors of the renin reaction, has been reported in a number of hypertensive states; however, its contribution to genesis and/or maintenance of hypertension is unknown. To longitudinally assess the evolution of plasma renin reactivity in relation to blood pressure in neonatally-induced coarctation hypertension, we have made serial observations in 6 coarcted dogs and in 7 littermate controls over 1-12 months post-aortic-banding during varied steady-state sodium intake. Measurements of renin activity (defined as the increment of angiotensin I-generation rate following addition of exogenous renin to plasma), renin substrate concentration (RS), and plasma renin activity (PRA), together with calculation of plasma renin concentration (PRC) (as PRC = PRA divided by renin reactivity) provided estimates of the three major determinants of PRA. RS values were adjusted for variability due to assay-control and to age via covariate analysis. Results indicate no difference in adjusted RS between coarcted and control dogs, thus obviating the influence of RS differences on renin reactivity results. Renin reactivity and PRC in coarcted dogs were also comparable to control values. Furthermore, responses of RS, renin reactivity and PRC to dietary sodium manipulation were similar in coarcted and control animals. We conclude that circulating modifiers of the renin reaction play no role in the genesis or in the first-year maintenance of neonatally-induced coarctation hypertension.

Corticotropin releasing factor (CRF) activity in rat plasma.

The ACTH-releasing activity of hypothalamic extract and rat plasma was examined with the dispersed rat pituitary cell technique of Swallow and Sayer (8). Although both plasma and serum caused ACTH release which was dose-related, stress did not enhance the ACTH releasing activity. Furthermore, separation studies of plasma using ultrafiltration and gel separation suggest that the CRF activity in plasma is associated with molecules of a molecular weight greater than 15,000.