The Financial Implications of a Single-Use Device Reprocessing Program at a Tertiary Referral Center Surgical Department.

The operating room has been identified as one of the primary contributors to waste and energy expenditure in the health care system. The primary objective of our study was to evaluate the efficacy of single-use device reprocessing and report the cost savings, waste diversion, and reduction in carbon emissions. Data was collected from January 2021 to April 2023. Medline collected the data for analysis and converted it from an Excel file format to SPSS (Version 27) for analysis. Descriptive frequencies were used for data analysis. We found a mean monthly cost savings of $16,051.68 and a mean 700.68 pounds of waste a month diverted, resulting in an estimated yearly saving of $2354.29 in disposal costs and a reduction of 1112.65 CO2e emissions per month. This program has made significant contributions to cost savings and environmental efforts.

Impact of BMI on Dyspnea and Need for Surgical Intervention in Bilateral Vocal Fold Immobility.

OBJECTIVE: Bilateral vocal fold paralysis (BVFP) and posterior glottic stenosis (PGS) are causes of bilateral vocal fold immobility (BVFI) and may cause shortness of breath, stridor, and need for surgical intervention. Although increased body mass index (BMI) is associated with restrictive breathing patterns in patients with normal upper airways, it is unclear how BMI impacts dyspnea and need for surgical intervention in BVFI patients. STUDY DESIGN: Retrospective cohort study. SETTING: Three tertiary academic centers in the United States. METHODS: Demographics, BMI, Dyspnea Index (DI), etiology, presence of tracheostomy and surgical intervention (dilation, tracheostomy, cordotomy, arytenoidectomy, open reconstruction) were collected. Primary outcomes included dyspnea measured by DI and need for surgery to improve airway. Linear regressions were performed to assess continuous outcomes. Mann-Whitney U-test was utilized to assess categorical outcomes. RESULTS: Among 121 patients, 52 presented with BVFP and 69 with PGS. Previous neck surgery was the most common cause of BVFI (40.2%). 44.3% of patients received a tracheostomy. Through multivariate linear regression, increased BMI was significantly associated with increased DI in the entire cohort (ß = .43, P = .016). Increased BMI was also associated with need for any surgical intervention (odds ratio [OR] = 1.07, 95% confidence interval [CI] = [1.01-1.13]) in the overall cohort. When stratifying our data, BMI was only significantly associated with DI in BVFP (ß = .496) and need for surgical intervention in PGS (OR = 1.11, 95% CI = [1.01-1.21]), although a positive trend was seen in all analyses. CONCLUSION: Increased BMI may correlate with worsening dyspnea symptoms and need for surgical intervention in patients with BVFI. Weight-loss-related counseling may benefit symptom management.

PPAR agonists as add-on treatment with metformin in management of type 2 diabetes: a systematic review and meta-analysis.

The combination of metformin and the peroxisome proliferator-activated receptors (PPAR) agonists offers a promising avenue for managing type 2 diabetes (T2D) through their potential complementary mechanisms of action. The results from randomized controlled trials (RCT) assessing the efficacy of PPAR agonists plus metformin versus metformin alone in T2D are inconsistent, which prompted the conduct of the systematic review and meta-analysis. We searched MEDLINE and EMBASE from inception (1966) to March 2023 to identify all RCTs comparing any PPAR agonists plus metformin versus metformin alone in T2D. Categorical variables were summarized as relative risk along with 95% confidence interval (CI). Twenty RCTs enrolling a total of 6058 patients met the inclusion criteria. The certainty of evidence ranged from moderate to very low. Pooled results show that using PPAR agonist plus metformin, as compared to metformin alone, results in lower concentrations of fasting glucose [MD = - 22.07 mg/dl (95% CI - 27.17, - 16.97), HbA1c [MD = - 0.53% (95% CI - 0.67, - 0.38)], HOMA-IR [MD = - 1.26 (95% CI - 2.16, - 0.37)], and fasting insulin [MD = - 19.83 pmol/L (95% CI - 29.54, - 10.13)] without significant increase in any adverse events. Thus, synthesized evidence from RCTs demonstrates the beneficial effects of PPAR agonist add-on treatment versus metformin alone in T2D patients. In particular, novel dual PPARα/γ agonist (tesaglitazar) demonstrate efficacy in improving glycaemic and lipid concentrations, so further RCTs should be performed to elucidate the long-term outcomes and safety profile of these novel combined and personalized therapeutic strategies in the management of T2D.PROSPERO registration no. CRD42023412603.

Changes in rate-pressure product associated with pregnancy.

BACKGROUND: In nonpregnant individuals, the rate-pressure product, the product of heart rate and systolic blood pressure, is used as a noninvasive surrogate of myocardial O2 consumption during cardiac stress testing. Pregnancy is considered a physiological cardiovascular stress test. Evidence describing the impact of pregnancy on myocardial O2 demand, as assessed by the rate-pressure product, is limited. OBJECTIVE: This study aimed to describe changes in the rate-pressure product for each pregnancy trimester, during labor and delivery, and the postpartum period among low-risk pregnancies. STUDY DESIGN: This was a retrospective cohort study that assessed uncomplicated pregnancies delivered vaginally at term. We collected rate-pressure product (heart rate × systolic blood pressure) values preconception, during pregnancy for each trimester (at ≤13 weeks + 6/7 days, at 14 weeks + 0/7 days through 27 weeks + 6/7 days, and at ≥28 weeks + 0/7 days), during the labor and delivery encounter (hospital admission until complete cervical dilation, complete cervical dilation until placental delivery, and after placental delivery until hospital discharge), and during the outpatient postpartum visit at 2 to 6 weeks after delivery. We calculated the percentage change at each time point from the preconception rate-pressure product (delta rate-pressure product). We used a mixed-linear model to analyze differences in the mean delta rate-pressure product over time and the influence of prepregnancy age, prepregnancy body mass index, and neuraxial anesthesia status during labor and delivery on these estimates. RESULTS: Our cohort comprised 316 patients. The mean rate-pressure product increased significantly from preconception starting at the third trimester of pregnancy and during labor and delivery (P≤.05). The mean delta rate-pressure product peaked at 12% and 38% in the third trimester and during labor and delivery, respectively. Prepregnancy body mass index was inversely correlated with the mean delta rate-pressure product changes (estimate, -0.308; 95% confidence interval, -0.536 to -0.80; P=.008). In contrast, neither the prepregnancy age, nor neuraxial anesthesia status during labor had a significant influence on this parameter. CONCLUSION: This study validates the transient but significant increase in the rate-pressure product, a clinical estimate of myocardial O2 demand, during uncomplicated pregnancies delivered vaginally at term. Pregnant individuals with lower prepregnancy body mass index experienced a sharper increase in this parameter. Patients who receive neuraxial anesthesia during labor and delivery experience similar changes in the rate-pressure product as those who did not.

Does Head Positioning After Percutaneous Glycerol Rhizotomy for Trigeminal Neuralgia Matter?

BACKGROUND: Percutaneous glycerol rhizotomy (PGR) is a minimally invasive procedure for patients with trigeminal neuralgia who are not candidates for microvascular decompression. PGR has widely varying success rates. It has been postulated that differences in post-injection head positioning might account for the various success rates. METHODS: By comparing glycerol dispersion after injection at various head positions, we provide the first evidence supporting post-injection head flexion positioning. Furthermore, we study the clival-Meckel cave (CMC) angle as a predictor of beneficial glycerol flow, measured on computed tomography images. Twenty-two dissected cadaveric specimens were injected with dyed glycerol through the Hartel approach. The glycerol dispersion was measured at prespecified intervals for 1 hour. The Mann-Whitney U and χ2 tests were used to determine the most ideal angle of head flexion to avoid posterior glycerol dispersion and ensure V1-V3 branch glycerol submersion. RESULTS: We found that 30° of anterior head flexion provided optimal trigeminal nerve glycerol submersion (81.82%) in comparison to neutral (27.27%) and 15° (68.18%), P < 0.001. There was minimal unfavorable dispersion beyond 30 minutes at all angles. More obtuse CMC angles were associated with higher rates of unfavorable BC dispersion (U = 6.0; P = 0.001). For specimens with CMC angles >75°, unfavorable BC dispersion was prevented by head flexion (U = 4.5; P = 0.021). We show that 30° of lateral head tilt achieves V1 submersion in all specimens by 30 minutes [X2(1,N = 44) = 22.759; P < 0.001]. CONCLUSIONS: We found that 30° anterior head flexion for >30 minutes provides ideal conditions for PGR to avoid BC dispersion and ensure V1-V3 branches achieve glycerol submersion. For patients with V1 symptoms, contralateral head flexion might help optimize treatment effects.

Association of pharmacist intervention counseling with medication adherence and quality of life: A systematic review and meta-analysis of randomized trials.

OBJECTIVE(S): To assess the association between pharmacist intervention counseling with medication adherence and quality of life. Also, to assess if these associations vary by the focus, structure, training, or robustness of the counseling. METHODS: The initial search identified 1805 references, of which 62 randomized trials (RCTs) met inclusion criteria for the systematic review. Of the 62 RCTs, 60 (with 62 results) had extractable data for the meta-analysis. Data were pooled using a random-effects model. RESULTS: Most study patients were older and taking multiple prescription drugs. The pooled results showed a statistically significant increase in the odds of medication adherence with the pharmacist counseling intervention versus no counseling (pooled odds ratio [OR] = 4.41; 95% confidence interval [CI] 2.46-7.91; P < 0.01). The results of a subgroup analysis suggest the primary disease, counseling focus, location, and robustness may modify the effect of pharmacist counseling on medication adherence. There was a statistically significant improvement in the quality of life with pharmacist counseling versus no pharmacist counseling (pooled standardized mean difference [SMD] = 0.69; 95% CI 0.41-0.96; P < 0.01). The results of a subgroup analysis suggest that counseling focus, location, training, robustness, and the measurement method, but not the disease category, may modify the effect of pharmacist counseling on quality of life. CONCLUSION: The evidence supports pharmacist intervention counseling to increase mediation adherence and quality of life. The counseling location and structure may be significant factors in improving medication adherence. The overall methodological quality of evidence was very low.