An observational study of gastric contents in pediatric patients with long bone fracture using gastric ultrasound.

BACKGROUND: The retention of gastric contents at surgery presentation is a risk factor for perioperative aspiration. A preoperative fasting (nil per os; NPO) interval is widely used to reduce this risk, but this approach is based on assumptions about the prevalence of typical gastric emptying rates. We assessed NPO guidelines' reliability with ultrasound (US) imaging and suction in pediatric patients presenting for single long-bone fracture repair after appropriate NPO intervals, when nearly all should have had empty stomachs. AIMS AND METHODS: This prospective cross-sectional observational study comprised 200 pediatric surgical patients. As their NPO times varied by food/drink type, we defined "weighted NPO units" as the lowest multiple of elapsed recommended NPO times between consumption and surgery for each type of food or drink. We used US to image the stomach and its contents before anesthesia induction, followed by gastric suction. We evaluated the relationships between weighted NPO units, US gastric contents grade, opioid analgesic dosage and timing, and suctioned volume. RESULTS: Despite meeting typical NPO standards (median 14 h fasting), many patients retained nontrivial quantities of gastric contents at surgery. Weighted NPO units did not exhibit statistically-significant relationships with either suctioned volume or US grade. However, suctioned volume did correspond well to US grade. CONCLUSION: NPO status may be a less reliable predictor of gastric contents at anesthesia induction in this patient population than has been assumed. Bedside US screening appears to provide more useful information for the planning of airway management.

Use of Transparent Film Dressing to Facilitate Mask Ventilation in Bearded Patients.

BACKGROUND: Mask ventilation is a critical airway procedure made more difficult in the bearded patient. OBJECTIVE: We sought to objectively investigate whether application of transparent cling film (TegadermTM; 3M Healthcare, Maplewood, MN) over a beard in the operating room improves the quality of mask ventilation. METHODS: This was a randomized crossover trial of bearded adult patients undergoing surgery. Exclusions included emergency procedures, American Society of Anesthesiologists physical status classification > 3, a documented history of difficult mask ventilation, and body mass index (BMI) > 50. Transparent cling film was applied snuggly over the lower face with a 2- to 3-cm slit cut over the mouth after anesthesia induction. Mask ventilation performed by an anesthesiology resident, anesthesiology assistant, or anesthesiology assistant student and standardized to a thenar-eminence grip without use of airway adjuncts in a sniffing position. Standardized pressure-controlled ventilations were delivered via an anesthesia machine. A calibrated external pneumotachograph was used to measure delivered and returned tidal volumes from which raw and percent air leak were calculated. A clinically significant difference was determined a priori to be 15%, necessitating the enrollment of 25 patients. RESULTS: Of 25 subjects, 96% were men with a mean ± SD BMI of 29.3 ± 6. Seventeen (68%) had a full beard and 8 (32%) had a partial beard. The mean ± SD leakage was 48% ± 26% for transparent cling film vs. 46% ± 20% without its application, which was not significantly different (p = 0.67). CONCLUSIONS: The use of transparent cling film to cover the lower half of the bearded face did not have an impact on the ability or efficacy to perform mask ventilation in the operating room setting. CLINICALTRIALS: gov, Number NCT04274686.

Chargemaster Pricing Variation for Commonly Billed Procedures in Interventional Cardiology.

OBJECTIVES: A chargemaster is a database of all of the billable items offered by a hospital with their base price listings. A 2018 executive order required all American hospitals to publish their chargemasters to increase price transparency and reduce healthcare expenditures. Chargemaster listings, however, demonstrate marked variability and inconsistency and have not been associated with consumer benefit. The objective of this study was to analyze chargemasters for commonly billed interventional cardiology procedures across five diverse states to explore relationships between price listings and hospital characteristics, ownership, location, and hospital quality. METHODS: Chargemasters were downloaded from hospitals in five states selected to represent the nation's healthcare diversity. Price listings for five interventional cardiology procedures (percutaneous coronary angiography, coronary angiography, single-vessel angioplasty, single-vessel stent, and percutaneous coronary intervention of acute myocardial infarction) were extracted. Statistical analyses such as the Kruskal-Wallis test were performed to explore relationships between mean chargemaster price listings for each procedure and hospital characteristics, ownership, location, and quality ratings. RESULTS: The median mean chargemaster price of four of the five interventional cardiology procedures significantly differed across all states. Price listings were significantly higher in urban versus rural areas and in general acute care hospitals and state government-owned facilities. The highest prices were found with the highest hospital quality rating. CONCLUSIONS: Chargemaster price listings for common interventional cardiology procedures varied significantly across these five states. Urban and metropolitan hospital location, hospital type, and hospital ownership could be factors driving increased chargemaster procedure prices. Prices were highest at hospitals with the highest quality rating.

Chlorhexidine gluconate vs povidone-iodine vaginal antisepsis for urogynecologic surgery: a randomized controlled noninferiority trial.

BACKGROUND: Although povidone-iodine (iodine) is the only Food and Drug Administration-approved vaginal antiseptic solution, there is a lack of comparative data evaluating alternatives. Chlorhexidine gluconate is readily accessible, recommended by multiple societies as an alternative for patients with iodine allergy, and preliminary data indicate that it may provide superior antisepsis. OBJECTIVE: This study aimed to compare the effectiveness of chlorhexidine and iodine as presurgical vaginal antiseptic solutions in preventing the most common surgery-associated infection after gynecologic surgery, urinary tract infections. STUDY DESIGN: We conducted a randomized controlled noninferiority trial among women undergoing urogynecologic surgery. The primary outcome measure was symptomatic urinary tract infection within 2 weeks after surgery. The secondary outcomes included culture-proven urinary tract infection at 2 and 6 weeks after surgery, symptomatic urinary tract infections at 6 weeks after surgery, any surgical site infection at 2 weeks after surgery, and patient-reported vaginal irritation after surgery. We required 58 participants per arm to demonstrate noninferiority of chlorhexidine vs iodine (margin of relative risk of <1.5 for the upper limit of 95% confidence interval) between groups for the primary outcome. RESULTS: A total of 119 participants (61 in the chlorhexidine group and 58 in the iodine group) completed the primary outcome and were included in the analyses. There was no difference in the groups' demographic characteristics, medical history, operations performed, or perioperative factors. Chlorhexidine was not inferior to iodine concerning the primary outcome, symptomatic urinary tract infection at 2 weeks after surgery (10% vs 17%; relative risk, 0.6; 95% confidence interval [-∞, 1.3]). Furthermore, chlorhexidine was not inferior to iodine for the secondary urinary tract infection outcomes (culture-proven urinary tract infection at 2 and 6 weeks after surgery and symptomatic urinary tract infection at 6 weeks after surgery). Groups were similar in terms of surgical site infection (overall 3/119 [2.5%]) and presence of any vaginal irritation (4/54 [7.4%], for both groups). CONCLUSION: Chlorhexidine was not inferior to iodine for vaginal antisepsis before urogynecologic surgery concerning urinary tract infection. Given the similar postoperative urinary tract infection rates demonstrated in this study and the lack of difference in vaginal irritation, chlorhexidine seemed to be a safe and reasonable option for vaginal antisepsis before surgical procedures. Additional studies are needed to further examine surgical site infection.

Anesthetic concerns for pediatric patients in the era of COVID-19.

After a novel human coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was reported in China in December 2019, the disease quickly reached pandemic level. On January 30, 2020, the World Health Organization (WHO) declared that the SARS-CoV-2 outbreak constituted a Public Health Emergency of International Concern. The caseload has increased exponentially, with WHO reporting 182 000 global cases by March 17, 2020, and over 2.6 million by 23 April. The clinical situation is complex, with children presenting different clinical features compared to adults. Several articles with recommendations on the anesthetic management of adult patients with COVID-19 have been published, but no specific recommendations for pediatric anesthesiologists have been made yet. This article addresses specific concerns for the anesthetic management of the pediatric population with COVID-19.

Impact of Isolyte Versus 0.9% Saline on Postoperative Event of Acute Kidney Injury Assayed by Urinary [TIMP-2] × [IGFBP7] in Patients Undergoing Cardiac Surgery.

OBJECTIVE: Administration of excess chloride in 0.9% normal saline (NS) decreases renal perfusion and glomerular filtration rate, thereby increasing the risk for acute kidney injury (AKI). In this study, the effect of NS versus Isolyte use during cardiac surgery on urinary levels of tissue inhibitor of metalloproteinase 2 and insulin-like growth factor-binding protein 7 [TIMP-2] × [IGFBP7] and postoperative risk of AKI were examined. DESIGN: Prospective, randomized, and single-blinded trial. SETTING: Single university medical center. PARTICIPANTS: Thirty patients over 18 years without chronic renal insufficiency or recent AKI undergoing elective cardiac surgery. INTERVENTIONS: Subjects were randomized to receive either NS or Isolyte during the intraoperative period. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the change in urinary levels of [TIMP2] × [IGFBP7] from before surgery to 24 hours postoperatively. Secondary outcomes included serum creatinine pre- and postoperatively at 24 and 48 hours, serum chloride pre- and postoperatively at 24 and 48 hours, need for dialysis prior to discharge, and arterial pH measured 24 hours postoperatively. Sixteen patients received NS and 14 patients received Isolyte. Three patients developed AKI within the first 3 postoperative days, all in the NS group. The authors found increases in [TIMP-2] × [IGFBP7] in both groups. However, the difference in this increase between study arms was not significant (p = 0.92; -0.097 to 0.107). CONCLUSION: The authors observed no change in urinary [TIMP-] × [IGFBP7] levels in patients receiving NS versus Isolyte during cardiac surgery. Future larger studies in patients at higher risk for AKI are recommended to evaluate the impact of high- versus lower-chloride solutions on the risk of postoperative AKI after cardiac surgery.

Apneic nasal oxygenation and safe apnea time during pediatric intubations by learners.

BACKGROUND: Apneic nasal oxygenation (ApOx) prolongs the time to desaturation during intubation of adult patients, but there is limited prospective evidence for apneic oxygenation in pediatric patients. AIMS: We hypothesized that ApOx during operating room intubation of pediatric patients by inexperienced learners would prolong the interval before desaturation. METHODS: This prospective observational study compared intubation data for 196 pediatric surgical patients intubated by learners under baseline practice (no nasal cannula), to 160 patients enrolled after adoption of routine apneic nasal cannula oxygenation at 5 L/min. The primary outcome was elapsed time between anesthetic induction and pulse oximetry (SpO2 ) falling to 95, if ever. RESULTS: Nasal cannula oxygenation during intubation by learners delayed desaturation to SpO2 95 (risk ratio for this event before intubation 0.05, 95% CI 0.03-0.09; P < 0.0001). CONCLUSIONS: Apneic oxygenation via nasal cannula during intubation of pediatric surgical patients prolongs time before desaturation, thus extending the safe interval for airway management by learners.

Complications in Pediatric Regional Anesthesia: An Analysis of More than 100,000 Blocks from the Pediatric Regional Anesthesia Network.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Complications in pediatric regional anesthesia are rare, so a large sample size is necessary to quantify risk. The Pediatric Regional Anesthesia Network contains data on more than 100,000 blocks administered at more than 20 children's hospitals. This study analyzed the risk of major complications associated with regional anesthesia in children. METHODS: This is a prospective, observational study of routine clinical practice. Data were collected on every regional block placed by an anesthesiologist at participating institutions and were uploaded to a secure database. The data were audited at multiple points for accuracy. RESULTS: There were no permanent neurologic deficits reported (95% CI, 0 to 0.4:10,000). The risk of transient neurologic deficit was 2.4:10,000 (95% CI, 1.6 to 3.6:10,000) and was not different between peripheral and neuraxial blocks. The risk of severe local anesthetic systemic toxicity was 0.76:10,000 (95% CI, 0.3 to 1.6:10,000); the majority of cases occurred in infants. There was one epidural abscess reported (0.76:10,000, 95% CI, 0 to 4.8:10,000). The incidence of cutaneous infections was 0.5% (53:10,000, 95% CI, 43 to 64:10,000). There were no hematomas associated with neuraxial catheters (95% CI, 0 to 3.5:10,000), but one epidural hematoma occurred with a paravertebral catheter. No additional risk was observed with placing blocks under general anesthesia. The most common adverse events were benign catheter-related failures (4%). CONCLUSIONS: The data from this study demonstrate a level of safety in pediatric regional anesthesia that is comparable to adult practice and confirms the safety of placing blocks under general anesthesia in children.

Preliminary Report: Comparing Aspiration Rates between Prehospital Patients Managed with Extraglottic Airway Devices and Endotracheal Intubation.

INTRODUCTION: There has been a shift from endotracheal intubation (ETI) toward extraglottic devices (EGDs) for prehospital airway management. A concern exists that this may lead to more frequent cases of aspiration. METHODS: This was a retrospective study using a prehospital quality assurance database. Patients were assigned to groups based on the method that ultimately managed their airways (EGD or ETI). Cases with documented blood/emesis obscuring the airway were considered inevitable aspiration cases and excluded. Aspiration was defined by the radiology report within 48 hours. RESULTS: A total of 104 EGD and 152 ETI patients were identified. Aspiration data were available for 67 EGD and 94 ETI cases. Of those, 8 EGD and 3 ETI cases had blood/emesis obscuring the airway and were excluded as planned. After exclusions, there were 5 EGD and 11 ETI cases in which aspiration was later diagnosed (EGD aspiration rate = 8%, ETI aspiration rate = 12%; χ2: P = .359; relative risk = .841; 95% confidence interval, .329-2.152). CONCLUSION: In this small quality assurance database, aspiration rates were not significantly different for prehospital patients managed with an EGD versus ETI.

Prenatal alcohol exposure potentiates chronic neuropathic pain, spinal glial and immune cell activation and alters sciatic nerve and DRG cytokine levels.

A growing body of evidence indicates that prenatal alcohol exposure (PAE) may predispose individuals to secondary medical disabilities later in life. Animal models of PAE reveal neuroimmune sequelae such as elevated brain astrocyte and microglial activation with corresponding region-specific changes in immune signaling molecules such as cytokines and chemokines. The aim of this study was to evaluate the effects of moderate PAE on the development and maintenance of allodynia induced by chronic constriction injury (CCI) of the sciatic nerve in adult male rat offspring. Because CCI allodynia requires the actions of glial cytokines, we analyzed lumbar spinal cord glial and immune cell surface markers indicative of their activation levels, as well as sciatic nerve and dorsal root ganglia (DRG) cytokines in PAE offspring in adulthood. While PAE did not alter basal sensory thresholds before or after sham manipulations, PAE significantly potentiated adult onset and maintenance of allodynia. Microscopic analysis revealed exaggerated astrocyte and microglial activation, while flow cytometry data demonstrated increased proportions of immune cells with cell surface major histocompatibility complex II (MHCII) and ß-integrin adhesion molecules, which are indicative of PAE-induced immune cell activation. Sciatic nerves from CCI rats revealed that PAE potentiated the proinflammatory cytokines interleukin (IL)-1ß, IL-6 and tumor necrosis factor-alpha (TNFα) protein levels with a simultaneous robust suppression of the anti-inflammatory cytokine, IL-10. A profound reduction in IL-10 expression in the DRG of PAE neuropathic rats was also observed. Taken together, our results provide novel insights into the vulnerability that PAE produces for adult-onset central nervous system (CNS) pathological conditions from peripheral nerve injury.

Chronic Sciatic Neuropathy in Rat Reduces Voluntary Wheel-Running Activity With Concurrent Chronic Mechanical Allodynia.

BACKGROUND: Animal models of peripheral neuropathy produced by a number of manipulations are assessed for the presence of pathologic pain states such as allodynia. Although stimulus-induced behavioral assays are frequently used and important to examine allodynia (ie, sensitivity to light mechanical touch; von Frey fiber test), other measures of behavior that reflect overall function are not only complementary to stimulus-induced responsive measures, but are also critical to gain a complete understanding of the effects of the pain model on quality of life, a clinically relevant aspect of pain on general function. Voluntary wheel-running activity in rodent models of inflammatory and muscle pain is emerging as a reliable index of general function that extends beyond stimulus-induced behavioral assays. Clinically, reports of increased pain intensity occur at night, a period typically characterized with reduced activity during the diurnal cycle. We therefore examined in rats whether alterations in wheel-running activity were more robust during the inactive phase compared with the active phase of their diurnal cycle in a widely used rodent model of chronic peripheral neuropathic pain, the sciatic nerve chronic constriction injury (CCI) model. METHODS: In adult male Sprague Dawley rats, baseline (BL) hindpaw threshold responses to light mechanical touch were assessed using the von Frey test before measuring BL activity levels using freely accessible running wheels (1 hour/day for 7 sequential days) to quantify the distance traveled. Running wheel activity BL values are expressed as total distance traveled (m). The overall experimental design was after BL measures, rats underwent either sham or CCI surgery followed by repeated behavioral reassessment of hindpaw thresholds and wheel-running activity levels for up to 18 days after surgery. Specifically, separate groups of rats were assessed for wheel-running activity levels (1 hour total/trial) during the onset (within first 2 hours) of either the (1) inactive (n = 8/group) or (2) active (n = 8/group) phase of the diurnal cycle. An additional group of CCI-treated rats (n = 8/group) was exposed to a locked running wheel to control for the potential effects of wheel-running exercise on allodynia. The 1-hour running wheel trial period was further examined at discrete 20-minute intervals to identify possible pattern differences in activity during the first, middle, and last portions of the 1-hour trial. The effect of neuropathy on activity levels was assessed by measuring the change from their respective BLs to distance traveled in the running wheels. RESULTS: Although wheel-running distances between groups were not different at BL from rats examined during either the inactive phase of the diurnal cycle or active phase of the diurnal cycle, sciatic nerve CCI reduced running wheel activity levels compared with sham-operated controls during the inactive phase. In addition, compared with sham controls, bilateral low-threshold mechanical allodynia was observed at all time points after surgical induction of neuropathy in rats with free-wheel and locked-wheel access. Allodynia in CCI compared with shams was replicated in rats whose running wheel activity was examined during the active phase of the diurnal cycle. Conversely, no significant reduction in wheel-running activity was observed in CCI-treated rats compared with sham controls at any time point when activity levels were examined during the active diurnal phase. Finally, running wheel activity patterns within the 1-hour trial period during the inactive phase of the diurnal cycle were relatively consistent throughout each 20-minute phase. CONCLUSIONS: Compared with nonneuropathic sham controls, a profound and stable reduction of running wheel activity was observed in CCI rats during the inactive phase of the diurnal cycle. A concurrent robust allodynia persisted in all rats regardless of when wheel-running activity was examined or whether they ran on wheels, suggesting that acute wheel-running activity does not alter chronic low-intensity mechanical allodynia as measured using the von Frey fiber test. Overall, these data support that acute wheel-running exercise with limited repeated exposures does not itself alter allodynia and offers a behavioral assay complementary to stimulus-induced measures of neuropathic pain.

A Randomized Double-Blinded Trial on the Effects of Ultrasound Transducer Orientation on Teaching and Learning Ultrasound-Guided Regional Anesthesia.

OBJECTIVES: Learning ultrasound-guided regional anesthesia skills, especially needle/ beam alignment, can be especially difficulty for trainees, who can often become frustrated. We hypothesized that teaching novices to orient the transducer and needle perpendicular to their shoulders will improve performance on a standardized task, compared to holding the transducer and needle parallel to the shoulders. METHODS: This study compared the effects of transducer orientation on trainees' ability to complete a standardized ultrasound-guided nerve block simulation. The time to task completion and percentage of the attempt time without adequate needle visualization were measured. Participants were right-handed healthy adults with no previous ultrasound experience and were randomly assigned to training in either transducer and needle alignment in a coronal plane, parallel to the shoulders (parallel group) or transducer and needle alignment in a sagittal plane, perpendicular to the shoulders (perpendicular group). Participants used ultrasound to direct a needle to 3 targets in a standardized gelatin phantom and repeated this task 3 times. Their efforts were timed and evaluated by an assessor, who was blinded to group assignment. RESULTS: Data were analyzed on 28 participants. The perpendicular group was able to complete the task more quickly (P < .001) and with a smaller proportion of time lost to inadequate needle visualization (P < .001). CONCLUSIONS: Ultrasound-guided regional anesthesia trainees complete a standardized task more quickly and efficiently when instructed to hold the transducer and needle in an orientation perpendicular to their shoulders.

A Randomized Controlled Trial Evaluating the See, Tilt, Align, and Rotate (STAR) Maneuver on Skill Acquisition for Simulated Ultrasound-Guided Interventional Procedures.

OBJECTIVES: Achieving the best view of the needle and target anatomy when performing ultrasound-guided interventional procedures requires technical skill, which novices may find difficult to learn. We hypothesized that teaching novice performers to use 4 sequential steps (see, tilt, align, and rotate [STAR] method) to identify the needle under ultrasound guidance is more efficient than training with the commonly described probe movements of align, rotate, and tilt (ART). METHODS: This study compared 2 instructional methods for transducer manipulation including alignment of a probe and needle by novices during a simulated ultrasound-guided nerve block. Right-handed volunteers between the ages of 18 and 55 years who had no previous ultrasound experience were recruited and randomized to 1 of 2 groups; one group was trained to troubleshoot misalignment with the ART method, and the other was trained with the new STAR maneuver. Participants performed the task, consisting of directing a needle in plane to 3 targets in a standardized gelatin phantom 3 times. The performance assessor and data analyst were blinded to group assignment. RESULTS: Thirty-five participants were recruited. The STAR group was able to complete the task more quickly (P < .001) and visualized the needle in a greater proportion of the procedure time (P = .004) compared to the ART group. All STAR participants were able to complete the task, whereas 41% of ART participants abandoned the task (P = .003). CONCLUSIONS: Novices are able to complete a simulated ultrasound-guided nerve block more quickly and efficiently when trained with the 4-step STAR maneuver compared to the ART method.

A randomized clinical trial comparing the effectiveness of ultrasound guidance versus nerve stimulation for lateral popliteal-sciatic nerve blocks in obese patients.

OBJECTIVES: Ultrasound guidance may decrease the procedural time for many peripheral nerve blocks compared to nerve stimulation, but these studies have generally excluded obese patients. This single-blinded randomized clinical trial was designed to compare procedural times and related outcomes for ultrasound- versus nerve stimulation-guided lateral popliteal-sciatic nerve blockade specifically in obese patients. METHODS: With Institutional Review Board approval and informed consent, patients with a body mass index greater than 30 kg/m(2) who were scheduled for foot/ankle surgery and desiring a peripheral nerve block were offered enrollment. Study patients were randomly assigned to receive a lateral popliteal-sciatic nerve block under either ultrasound or nerve stimulation guidance. The patient and assessor were blinded to group assignment. The primary outcome was procedural time in seconds. Secondary outcomes included number of needle redirections, procedure-related pain, patient satisfaction with the block, success rate, sensory and motor onset times, block duration, and complication rates. RESULTS: Twenty-four patients were enrolled and completed the study. All patients had successful nerve blocks. The mean procedural times (SD) were 577 (57) seconds under nerve stimulation and 206 (40) seconds with ultrasound guidance (P< .001; 95% confidence interval for difference, 329-412 seconds). Patients in the ultrasound group had fewer needle redirections and less procedure-related pain, required less opioids, and were more satisfied with their block procedures. There were no statistically significant differences in other outcomes. CONCLUSIONS: The results of this study show that, for obese patients undergoing lateral popliteal-sciatic nerve blocks, ultrasound guidance reduces the procedural time and procedure-related pain and increases patient satisfaction compared to nerve stimulation while providing similar block characteristics.

Lumbar Erector Spinae Plane Block for Dega Pelvic Osteotomy in a Pediatric Patient With Complex Neurological Issues: A Case Report.

The erector spinae plane (ESP) block, initially designed for thoracic analgesia, has evolved into a versatile regional anesthesia technique with literature support for success in numerous contexts. In this case report, we highlight the successful application of ESP to provide postoperative analgesia for pediatric Dega osteotomy involving both the femoral head and acetabulum, in a patient with numerous neurological comorbidities that would have weighed against some more traditional regional anesthesia techniques. This case further highlights the versatility of ESP, demonstrating its use in blocking lumbar nerve roots in a pediatric patient with complex neurological challenges.

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.

The Association Between Well-Being and Empathy in Medical Residents: A Cross-Sectional Survey.

Objective: To evaluate the extent to which personal well-being may be associated with empathy, while controlling for potential confounders. Settings/Location: Residency programs throughout the United States. Subjects: A total of 407 medical residents from residencies including general medicine, surgery, specialized and diagnostic medicine participated in this study. Outcome Measures: Well-being was measured using the modified existential well-being subscale of the spiritual well-being scale. Empathy was measured using the Jefferson Scale of Empathy. Results: Well-being was found to be positively correlated with empathy when adjusted for possible confounders (p < 0.001). In addition to well-being, other factors noted to be statistically significant contributors to higher empathy scores while controlling for the others included age, gender, year in residency, specialty, and work-hours (p < 0.05 for each). After controlling for these factors, a resident's year in residency was not found to be a statistically significant contributor to empathy score. Conclusions: In this study, well-being was associated with empathy in medical and surgical residents. Empathy is a fundamental component of physician competency, and its development is an essential aspect of medical training. These findings suggest that efforts to increase well-being may promote empathy among medical residents.

The Variation of Chargemaster Price Listings for Urogynecologic Procedures.

IMPORTANCE: A 2018 Executive Order calling for price transparency required hospitals to publicly provide chargemasters, which are detailed lists of standard price listings for billable medical procedures. OBJECTIVES: The objective of this study was to evaluate price listing variations in common urogynecology procedures. STUDY DESIGN: This was a cross-sectional study of chargemasters obtained between February and April 2020 from hospitals across 5 states chosen to reflect the diversity of health systems in the United States. Hospital characteristic and quality metric data were obtained from the Homeland Infrastructure Foundation, U.S. Department of Agriculture, and U.S. Centers for Medicare & Medicaid Services websites. Current Procedural Terminology codes and procedure names for 9 urogynecologic procedures were used to search each chargemaster and extract price listings. Price listings were compared with data on quality, population demographics, and hospital characteristics to determine if any significant relationships existed. RESULTS: Eight hundred thirty-four chargemasters were identified. Price listings for most procedures differed significantly across the 5 states, including colpocleisis, cystoscopy with chemodenervation, diagnostic cystoscopy, diverticulectomy, sacral neuromodulation, midurethral sling, and sacrospinous ligament fixation. Price listings were significantly higher in urban hospitals than rural hospitals for 6 procedures. No significant association was seen with price listing and quality measures for most procedures. CONCLUSIONS: Listed prices varied for several urogynecologic procedures. Some of this variation is associated with hospital characteristics such as urban setting. However, notably, price listing was not associated with quality. Further investigation of chargemaster price listings with hospital characteristics and quality metrics and with what is actually paid by patients is imperative for patients to navigate charges.