A Mobile App for Postoperative Pain Management Among Older Veterans Undergoing Total Knee Arthroplasty: Mixed Methods Feasibility and Acceptability Pilot Study.

BACKGROUND: Prescription opioid misuse risk is disproportionate among veterans; military veterans wounded in combat misuse prescription opioids at an even higher rate (46.2%). Opioid misuse is costly in terms of morbidity, mortality, and humanitarian and economic burden and costs the Civilian Health and Medical Program of the Department of Veterans Affairs more than US $1.13 billion annually. Preventing opioid misuse at the time of prescription is a critical component in the response to the opioid crisis. The CPMRx mobile app has been shown to decrease the odds of opioid misuse during the postoperative period. OBJECTIVE: The overarching purpose of this feasibility pilot study was to explore whether deploying a mobile app (CPMRx) to track postoperative pain and medication use is feasible in a Department of Veterans Affairs medical center. In support of this goal, we had four complementary specific aims: (1) determine the technological and logistical feasibility of the mobile app, (2) assess the acceptability of the mobile app to participants, (3) measure demand for and engagement with the mobile app, and (4) explore the potential use of the mobile app to patients and providers. METHODS: Participants (N=10) were veterans undergoing total knee arthroplasty within the Veterans Health Administration provided with the CPMRx app to self-manage their pain during their 7-day at-home recovery following surgery. CPMRx uses scientifically validated tools to help clinicians understand how a patient can use the least amount of medication while getting the most benefit. The suite of software includes a mobile app for patients that includes a behavioral health intervention and a clinical decision support tool for health care providers that provides feedback about pain and medication use trends. Patients filled out paper questionnaires regarding acceptability at their postoperative follow-up appointment. RESULTS: Overall, quantitative measures of acceptability were high. The average rating for the amount of time required to use the app was 4.9 of 5 (5="very little"), and the average rating for ease of use was 4.4 of 5 (5="very easy"). Open-ended questions also revealed that most participants found ease of use to be high. Demand and engagement were high as well with a mean number of mobile app entries of 34.1 (SD 20.1) during the postoperative period. There were no reported technological or logistical issues with the mobile app. Participants took an average of 25.13 (SD 14.37) opioid tablets to manage their postoperative pain. CONCLUSIONS: Results of this study revealed that the use of a mobile app for pain and medication management during postoperative recovery was both feasible and acceptable in older veterans undergoing total knee arthroplasty within the Veterans Health Administration. The wide variation in opioid consumption across participants revealed the potential use of the mobile app to provide actionable insights to clinicians if adopted more widely.

Z-osteotomy in hallux valgus: clinical and radiological outcome after Scarf osteotomy.

Correction osteotomies of the first metatarsal are common surgical approaches in treating hallux valgus deformities whereas the Scarf osteotomy has gained popularity. The purpose of this study was to analyze short- and mid-term results in hallux valgus patients who underwent a Scarf osteotomy. The subjective and radiological outcome of 131 Scarf osteotomies (106 hallux valgus patients, mean age: 57.5 years, range: 22-90 years) were retrospectively analyzed. Mean follow-up was 22.4 months (range: 6 months-5 years). Surgical indications were: intermetatarsal angle (IMA) of 12-23°; increased proximal articular angle (PAA>8°), and range of motion of the metatarsophalangeal joint in flexion and extension >40°. Exclusion criteria were severe osteoporosis and/or osteoarthritis. The mean subjective range of motion (ROM) of the great toe post-surgery was 0.8±1.73 points (0: full ROM, 10: total stiffness). The mean subjective cosmetic result was 2.7±2.7 points (0: excellent, 10: poor). The overall post-operative patient satisfaction with the result was high (2.1±2.5 points (0: excellent, 10: poor). The mean hallux valgus angle improvement was 16.6° (pre-operative mean value: 37.5°) which was statistically significant (p<0.01). The IMA improved by an average of 5.96° from a pre-operative mean value of 15.4° (p<0.01). Neither osteonecrosis of the distal fragment nor perioperative fractures were noted during the follow-up. In keeping with our follow-up results, the Scarf osteotomy approach shows potential in the therapy of hallux valgus.

Treatment patterns and costs associated with sessile colorectal polyps.

OBJECTIVES: Because of the paucity of existing literature on treatment and costs associated with sessile lesions, the objectives of this study were to perform a retrospective analysis on patients with sessile polyps to identify patient and polyp characteristics, to determine treatment patterns, and to estimate the cost of treating these patients. METHODS: We conducted a retrospective, observational cohort study of 280 patients who presented to a large teaching hospital between 1997 and 2000 with at least one sessile or broad-based pedunculated colorectal polyp of any size or histology, not including adenocarcinoma greater than stage T1. RESULTS: Mean polyp size was 1.3 cm, and two thirds of polyps were removed in a single procedure. The number of repeat procedures increased with polyp size (Kendall T-b = 0.47; 95% CI = 0.39-0.55). Patients with polyps > or = 2 cm were 5.88 times more likely than patients with smaller polyps to undergo a surgical procedure. Surgical procedures required 88.01 min longer than nonsurgical procedures (95% CI = 74.43-102.42). Mean total cost of treatment was $2,038 (range $153 to $14,838). Open resection ($6,165) was the most costly surgical procedure, and piecemeal polypectomy ($892) was the most costly nonsurgical therapeutic procedure. CONCLUSIONS: One third of polyps required more than one procedure. Surgical procedures accounted for the majority of resource use in this sample. Finally, patients with polyps > or = 2 cm incurred almost half the total costs while accounting for only 22% of the sample. The greatest economic gains could be made by improving efficiency of polyp removal for these patients.

Angiotensin-converting enzyme inhibitor angioedema of the intestine: a case report and review of the literature.

Visceral angioedema is a rare complication of angiotensin-converting enzyme (ACE) inhibitor use. To date, 15 cases have been reported in the literature. Common presentation is that of a middle-aged woman with abdominal pain, emesis, and diarrhea who has recently begun taking an ACE inhibitor. Signs include leukocytosis, ascites, and edematous small bowel seen on computed tomography. Diagnosis is elusive, and frequently invasive procedures, including surgery, are pursued. These can be avoided if the astute physician recognizes the association and withdraws the offending medication. We present the typical diagnostic dilemma faced in the evaluation of a patient with ACE inhibitor angioedema of the intestine, and review the current available literature.