Comparison between sedation room and operating room in central venous catheter positioning in children.

BACKGROUND: Placement of central venous access devices is a clinical procedure associated with some risk of adverse events and with a relevant cost. Careful choice of the device, appropriate insertion technique, and proper management of the device are well-known strategies commonly adopted to achieve an optimal clinical result. However, the environment where the procedure takes place may have an impact on the overall outcome in terms of safety and cost-effectiveness. METHODS: We carried out a retrospective analysis on pediatric patients scheduled for a major neurosurgical operation, who required a central venous access device in the perioperative period. We divided the patients in two groups: in group A the central venous access device was inserted in the operating room, while in group B the central venous access device was inserted in the sedation room of our Pediatric Intensive Care Unit. We compared the two groups in terms of safety and cost-effectiveness. RESULTS: We analyzed 47 central venous access devices in 42 children. There were no insertion-related complications. Only one catheter-related bloodstream infection was recorded, in group A. However, the costs related to central venous access device insertion were quite different: €330-€540 in group A versus €105-€135 in group B. CONCLUSION: In the pediatric patient candidate to a major neurosurgical operation, preoperative insertion of the central venous access device in the sedation room rather than in the operating room is less expensive and equally safe.

Preoperative nutrition-enhanced recovery after surgery protocol for thoracic neoplasms.

OBJECTIVES: Because patients' preoperative nutritional status influences the outcomes, we have used a preoperative nutrition program for surgical patients for a 2-year period and compared the results with those from a cohort treated in the previous 2 years. METHODS: We retrospectively reviewed curative thoracic neoplasm resections from July 15, 2016, to July 15, 2018, in patients who had received a preoperative nutritional-enhanced recovery after surgery (N-ERAS) protocol. The protocol consisted of 5 days of an oral immunonutrition drink 3 times daily, daily receipt of probiotics, and a carbohydrate-loading drink the night before surgery. The historical control cohort (standard group) included those patients who had undergone surgery by the same surgeon during the previous 24 months. We excluded patients who had undergone esophageal, diagnostic, benign, emergency, or palliative procedures. Nonparametric and parametric statistical tests were used to analyze the data. RESULTS: The data from 462 patients were analyzed: 229 N-ERAS patients and 233 standard patients. No significant demographic or caseload differences were found between the 2 groups. The major significant outcome differences included fewer postoperative complications (30 [13.1%] in the N-ERAS group vs 60 [25.8%] in the standard group; P < .001) and shorter hospital stays (3.8 ± 1.9 days for the N-ERAS group vs 4.4 ± 2.6 days for the standard group; P = .001). Use of the N-ERAS protocol resulted in a 16% reduction ($2198; P < .001) in the mean direct hospital costs/patient. Consequently, for the N-ERAS cohort, the hospital was likely saved $503,342 during the 2-year period for the 229 patients just by using the N-ERAS protocol. CONCLUSIONS: Thoracic surgeons should consider using the nontoxic, patient-compliant N-ERAS protocol for their patients, with an expectation of improved clinical results at lower hospital costs-an important consideration when exploring methods to decrease costs because hospitals are increasingly being paid by a negotiated prospective bundled payment reimbursement model.

Osteoarthritis Preoperative Package for care of Orthotics, Rehabilitation, Topical and oral agent Usage and Nutrition to Improve ouTcomes at a Year (OPPORTUNITY); a feasibility study protocol for a randomised controlled trial.

BACKGROUND: Patients' pre-operative health and physical function is known to influence their post-operative outcomes. In patients with knee osteoarthritis, pharmacological and non-pharmacological options are often not optimised prior to joint replacement. This results in some patients undergoing surgery when they are not as fit as they could be. The aim of this study is to assess the feasibility and acceptability of a pre-operative package of non-operative care versus standard care prior to joint replacement. METHODS/DESIGN: This is a multicentre, randomised controlled feasibility trial of patients undergoing primary total knee replacement for osteoarthritis. Sixty patients will be recruited and randomised (2:1) to intervention or standard care arms. Data will be collected at baseline (before the start of the intervention), around the end of the intervention period and a minimum of 90 days after the planned date of surgery. Adherence will be reviewed each week during the intervention period (by telephone or in person). Participants will be randomised to a pre-operative package of non-operative care or standard care. The non-operative care will consist of (1) a weight-loss programme, (2) a set of exercises, (3) provision of advice on analgesia use and (4) provision of insoles. The intervention will be started as soon as possible after patients have been added to the waiting list for joint replacement surgery to take advantage of the incentive for behavioural change that this will create. The primary outcomes of this study are feasibility outcomes which will indicate whether the intervention and study protocol is feasible and acceptable and whether a full-scale effectiveness trial is warranted. The following will be measured and used to inform study feasibility: rate of recruitment, rate of retention at 90-day follow-up review after planned surgery date, and adherence to the intervention estimated through review questionnaires and weight change (for those receiving the weight-loss aspect of intervention). In addition the following information will be assessed qualitatively: analysis of qualitative interviews exploring acceptability, feasibility, adherence and possible barriers to implementing the intervention, and acceptability of the different outcome measures. DISCUSSION: The aims of the study specifically relate to testing the feasibility and acceptability of the proposed effectiveness trial intervention and the feasibility of the trial methods. This study forms the important first step in developing and assessing whether the intervention has the potential to be assessed in a future fully powered effectiveness trial. The findings will also be used to refine the design of the effectiveness trial. TRIAL REGISTRATION: ISRCTN registry, ID: ISRCTN96684272. Registered on 18 April 2018.

Computed tomography for managing periprosthetic femoral fractures. A retrospective analysis.

BACKGROUND: Periprosthetic fractures (PPF) present a common cause for revision surgery after arthroplasty. The choice of performing either an osteosynthesis or revision arthroplasty depends on the orthopedic implant anchored and loosening. Standard diagnostics include x-ray imaging. CT is usually performed to confirm implant loosening in case of ambiguous diagnosis on standard x-ray imaging. This study aimed to examine the role of CT as a diagnostic modality and its implications for treatment planning and outcome. METHODS: Patients treated for PPF from January 2010 to February 2018 were included. X-ray and CT reports were analyzed to assess implant loosening. The planning for surgery and the final surgical treatment were evaluated. In addition, patient characteristics were analyzed and compared between patients with and without additional CT as a preoperative diagnostic procedure. RESULTS: Seventy-five patients were eligible for the study. X-ray imaging was performed in 90.7% of cases. CT was performed in 60% of the cases as part of the preoperative diagnostic. A clear statement on implant stability or loosening could not be made in 69.1% after X-ray imaging and in 84.4% following CT imaging. Revision arthroplasty for loosened femoral prosthesis components was necessary in 40% of cases. No difference could be determined comparing patients with X-ray imaging to those with X-ray and additional CT. In both groups, operative treatment did not deviate from the preoperative planning. DISCUSSION: In two thirds of the conventional radiographic findings, no reliable evaluation of implant loosening was possible in femoral PPFs. Intriguingly, additional CT did not improve the evaluation of implant loosening. Nonetheless, CT scans are often performed if loosening assessment is unclear on regular radiographs. This fact can explain the bias CT results in comparison to regular radiography. However, software-supported CT diagnosis could help to adequately answer the question of loosened implants in PPF in the near future. Since the diagnosis of fracture and their morphology assessment is currently adequately performed using X-rays, CT shall not be considered as the gold standard.

Preoperative ultrasound improves patency and cost effectiveness in arteriovenous fistula surgery.

OBJECTIVE: We aimed to compare routine preoperative color-coded duplex ultrasound (DUS) to clinical examination (CE) alone in surgery for arteriovenous fistula (AVF) with special emphasis on long-term outcomes and cost effectiveness. METHODS: All patients undergoing an AVF formation or revision between January 1, 2011, and December 31, 2016, at our tertiary referral center were subject to analysis. Routine DUS was performed in 114 patients and CE alone in 217 patients. Primary and secondary patency, the need for revision or reintervention to obtain patency, and individual as well as overall costs were analyzed. RESULTS: Primary patency rate was higher in AVF after DUS compared with CE alone at 62% vs 26% (P < .05), respectively. Patients receiving DUS had significantly lower rates of revision and revisions per patient when compared with CE (25.4% vs 59.4% [P < .0001]; 0.36 ± 0.71 vs 1.06 ± 1.55 [P < .0001], respectively). Costs per patient were significantly lower in the DUS group compared with CE at 4074€ vs 6078€ (P < .0001). CONCLUSIONS: We were able to show that patients receiving preoperative DUS showed higher patency rates and needed fewer revisions. Standard preoperative ultrasound examination is an easy tool to improve outcomes and cost effectiveness in AVF surgery.

Association Between Variation in Preoperative Care Before Arterial Switch Operation and Outcomes in Patients With Transposition of the Great Arteries.

BACKGROUND: The arterial switch operation (ASO) is the gold standard operative correction of neonates with transposition of the great arteries and intact ventricular septum, with excellent operative survival. The associations between patient and surgeon characteristics and outcomes are well understood, but the associations between variation in preoperative care and outcomes are less well studied. METHODS: A multicenter retrospective cohort study of infants undergoing neonatal ASO between January 2010 and September 2015 at hospitals contributing data to the Pediatric Health Information Systems database was performed. The association between preoperative care (timing of ASO, preoperative use of balloon atrial septostomy, prostaglandin infusion, mechanical ventilation, and vasoactive agents) and operative outcomes (mortality, length of stay, and cost) was studied with multivariable mixed-effects models. RESULTS: Over the study period, 2159 neonates at 40 hospitals were evaluated. Perioperative mortality was 2.8%. Between hospitals, the use of adjuvant therapies and timing of ASO varied broadly. At the subject level, older age at ASO was associated with higher mortality risk (age >6 days: odds ratio, 1.90; 95% CI, 1.11-3.26; P=0.02), cost, and length of stay. Receipt of a balloon atrial septostomy was associated with lower mortality risk (odds ratio, 0.32; 95% CI, 0.17-0.59; P<0.001), cost, and length of stay. Later hospital median age at ASO was associated with higher odds of mortality (odds ratio, 1.15 per day; 95% CI, 1.02-1.29; P=0.03), longer length of stay ( P<0.004), and higher cost ( P<0.001). Other hospital factors were not independently associated with the outcomes of interest. CONCLUSIONS: There was significant variation in preoperative care between hospitals. Some potentially modifiable aspects of perioperative care (timing of ASO and septostomy) were significantly associated with mortality, length of stay, and cost. Further research on the perioperative care of neonates is necessary to determine whether modifying practice on the basis of the observed associations translates into improved outcomes.

Preoperative risk assessment improves biomarker detection for predicting acute kidney injury after cardiac surgery.

BACKGROUND: Although urinary neutrophil gelatinase-associated lipocalin (NGAL) has emerged as a promising biomarker for the early detection of kidney injury, previous studies of adult patients who underwent cardiac surgery have reported only moderate discrimination. The age, creatinine, and ejection fraction (ACEF) score is a preoperative validated risk model with satisfactory accuracy for predicting AKI following cardiac surgery. It remains unknown whether combining preoperative risk assessment through ACEF scores followed by urinary NGAL test in a population of high-risk individuals is an optimal approach with improved predictive performance. MATERIAL AND METHODS: A total of 177 consecutive patients who underwent cardiac surgery were enrolled. Clinical characteristics, prognostic model scores, and outcomes were assessed. Urinary NGAL were examined within 6 hours after cardiac surgery. Patients were stratified according to preoperative ACEF scores, and comparisons were made using the area under the receiver operator characteristic curve (AUROC) for the prediction of AKI. RESULTS: A total of 45.8% (81/177) of the patients had AKI. As expected, patients with ACEF scores ≥ 1.1 were older and more likely to have class III or IV heart failure. They were also more likely to have diabetes mellitus, myocardial infarction, and peripheral arterial disease. Urinary NGAL alone moderately predicted AKI, with an AUROC of 0.732. Risk stratification by ACEF scores ≥ 1.1 substantially improved the AUROC of urinary NGAL to 0.873 (95% confidence interval, 0.784-0.961; P < .001). CONCLUSIONS: Risk stratification by preoperative ACEF scores ≥ 1.1, followed by postoperative urinary NGAL, provides more satisfactory risk discrimination than does urinary NGAL alone for the early detection of AKI after cardiac surgery. Future studies should investigate whether this strategy could improve the outcomes and cost-effectiveness of care in patients undergoing cardiac surgery.

Treating Anemia in the Preanesthesia Assessment Clinic: Results of a Retrospective Evaluation.

BACKGROUND: Perioperative anemia is challenging during hospital stay because anemia and red blood cell (RBC) transfusions are associated with an increased morbidity and mortality. With the implementation of patient blood management (PBM), a preanesthesia assessment clinic to screen and treat anemia before elective surgery was institutionalized at Muenster University Hospital, Germany. The main objective of this study was to evaluate the association between treating preoperative anemic patients with intravenous iron (IVI) and (primarily) presurgical hemoglobin levels and (secondarily) use of RBCs and mortality. METHODS: Between April 1, 2014, and July 4, 2016, patients scheduled for elective surgery with a risk for RBC transfusions >10% in 2013 were screened for preoperative anemia and, if indicated, treated with IVI. Patients' data, time span between visit in the anesthesia/PBM clinic and surgery, demographic data, type of surgery, the difference of hemoglobin levels between visit and surgery, RBC transfusion, infectious-related International Classification of Disease codes during hospital stay, and 1-year survival were determined retrospectively by screening electronic data files. In addition, patients were interviewed about adverse events, health-related events, and infections via telephone 30, 90, and 365 days after visiting the anesthesia/PBM clinic. RESULTS: A total of 1101 patients were seen in the anesthesia/PBM clinic between days -28 and -1 (median [Q1-Q3], -3 days [-1, -9 days]) before elective surgery. Approximately 29% of patients presented with anemia, 46.8% of these anemic patients were treated with ferric carboxymaltose (500-1000 mg).In the primary analysis, hemoglobin levels at median were associated with a reduction between the visit in the anesthesia/PBM clinic and the surgery in all nonanemic patients on beginning of medical treatment (nonanemic patients at median -2.8 g/dL [-4, -0.9 g/dL], while anemic patients without IVI presented with median differences of -0.8 g/dL [-2, 0 g/dL] and anemic patients with IVI of 0 g/dL [-1.0, 0.5 g/dL]). Hemoglobin levels raised best at substitution 22-28 days before surgery (0.95 g/dL [-0.35, 1.18 g/dL]). Due to the selection criteria, transfusion rates were high in the cohort. Overall, there was no association between IVI treatment and the use of RBC transfusions (odds ratio for use of RBCs in anemic patients, no IVI versus IVI: 1.14; 95% confidence interval, 0.72-1.82). Patients treated with or without IVI presented a comparable range of International Classification of Disease codes related to infections. Telephone interviews indicated similar adverse events, health-related events, and infections. Cox regression analysis showed an association between anemia and reduced survival, regardless of IVI. CONCLUSIONS: An anemia clinic within the preanesthesia assessment clinic is a feasible and effective approach to treat preoperative anemia. The IVI supplementation was safe but was associated with decreased RBC transfusions in gynecology/obstetric patients only. The conclusions from this retrospective analysis have to be tested in prospective, controlled trials.

Prognostic Impact of Bacterobilia on Morbidity and Postoperative Management After Pancreatoduodenectomy: A Systematic Review and Meta-analysis.

BACKGROUND: Intraoperative bile analysis during pancreatoduodenectomy (PD) is performed routinely at specialized centers worldwide. However, it remains controversial if and how intraoperative bacterobilia during PD affects morbidity and its management. The aim of the study was a systematic review and meta-analysis of intraoperative bacterobilia and its impact on patient outcome after PD. METHODS: Five relevant outcomes of interest were defined, and a systematic review of the literature with meta-analysis was performed according to the PRISMA guidelines. RESULTS: A total of 28 studies (8523 patients) were included. The median incidence of bacterobilia was 58% (interquartile range 51-67%). The most frequently isolated bacteria were Enterococcus species (51%), Klebsiella species (28%), and Escherichia coli (27%). Preoperative biliary drainage was significantly associated with bacterobilia (86 vs. 25%; RR 3.27; 95% confidence interval (CI) 2.42-4.42; p < 0.001). The incidence of surgical site infections (SSI) was significantly increased in cases with bacterobilia (RR 2.84; 95% CI 2.17-3.73; p < 0.001). Postoperative pancreatic fistula, overall postoperative morbidity, and mortality were not significantly influenced. Identical bacteria in bile and the infectious sources were found in 48% (interquartile range 34-59%) of the cases. CONCLUSIONS: Bacterobilia is detected during almost every second PD and is associated with an increased rate of SSI. The microbiome from intraoperative bile and postoperative infectious sources match in ~50% of patients, providing the option of early administration of calculated antibiotics and the determination of resistance patterns.

Ulipristal acetate for pre-operative management of uterine fibroids: Modeling outcomes and costs.

OBJECTIVES: The aim of this study was to evaluate the pharmacoeconomic profile in Italy of preoperative treatment with ulipristal acetate at the dose of 5 mg/day for 13 weeks in comparison with placebo prior to surgical management of symptomatic uterine fibroids. STUDY DESIGN: The pharmacoeconomic analysis was based on the calculation of incremental cost-effectiveness ratio (ICER). Effectiveness data were derived from the randomized-controlled trial PEARL-1, whilst costs data were retrieved from the published literature. A Markov model was employed to simulate the pattern of costs and two univariate sensitivity analyses tested the robustness of the results. RESULTS: In comparison with placebo, ulipristal acetate 5 mg for presurgical therapy was estimated to be associated with an incremental cost of €351 per patient. Costs per patient were €3836 for ulipristal acetate vs €3485 for placebo. The incremental effectiveness was 0.01931 QALYs per patient (around 7 quality-adjusted days per patient). Hence, the cost effectiveness ratio was calculated to be €18,177 per QALY gained. CONCLUSIONS: Preoperative use of ulipristal acetate 5 mg in patients with uterine fibroids has a favourable pharmacoeconomic profile.

Preoperative geriatric assessment and tailored interventions in frail older patients with colorectal cancer: a randomized controlled trial.

AIM: Colorectal cancer (CRC) is prevalent in the older population, and surgery is the mainstay of curative treatment. A preoperative geriatric assessment (GA) can identify frail older patients at risk for developing postoperative complications. In this randomized controlled trial we wanted to investigate whether tailored interventions based on a preoperative GA could reduce the frequency of postoperative complications in frail patients operated on for CRC. METHOD: Patients > 65 years scheduled for elective CRC surgery and fulfilling predefined criteria for frailty were randomized to either a preoperative GA followed by a tailored intervention or care as usual. The primary end-point was Clavien-Dindo Grade II-V postoperative complications. Secondary end-points included complications of any grade, reoperation, length of stay, readmission and survival. RESULTS: One hundred and twenty-two patients with a mean age of 78.6 years were randomized. We found no statistically significant differences between the intervention group and the control group for Grade II-V complications (68% vs 75%, P = 0.43), reoperation (19% vs 11%, P = 0.24), length of stay (8 days in both groups), readmission (16% vs 6%, P = 0.12) or 30-day survival (4% vs 5%, P = 0.79). Grade I-V complications occurred in 76% of patients in the intervention group compared with 87% in the control group (P = 0.10). In secondary analyses adjusting for prespecified prognostic factors, there was a statistically significant difference in favour of the intervention for reducing the total number of Grade I-V complications (P = 0.05). CONCLUSION: A preoperative GA and tailored interventions did not reduce the rate of Grade II-V complications, reoperations, readmission or mortality in frail older patients electively operated on for CRC.

Preoperative Opioid Use is a Predictor of Poor Return to Work in Workers' Compensation Patients After Lumbar Diskectomy.

STUDY DESIGN: A retrospective cohort. OBJECTIVE: The aim of this study was to determine the impact of preoperative opioid use in workers' compensation (WC) patients undergoing lumbar diskectomy (LD). SUMMARY OF BACKGROUND DATA: The prevalence of back pain among opioid users approached 60%. Long-term opioid dependence in spine surgery patients is roughly 20%. Despite pervasive use, there is no evidence to support long-term opioid analgesic use for back pain. METHODS: Ten thousand five hundred ninety-two patients received compensation from the Ohio Bureau of Workers' Compensation for a lumbar disc herniation between 2005 and 2012. Patients with spine comorbidities, smoking history, or multilevel surgery were excluded. Preoperatively, 566 patients had no opioid use, 126 had short-term opioid use (STO), 315 had moderate opioid use (MTO), and 279 had long-term opioid use (LTO). The primary outcome was whether subjects returned to work (RTW). RESULTS: Seven hundred twelve (55.4%) patients met our RTW criteria. There was a significant difference in RTW rates among the no opioid (64.1%), MTO (52.7%), and LTO (36.9%) populations. Multivariate logistic regression analysis found several covariates to be independent negative predictors of RTW status: preoperative opioid use [P < 0.01; odds ratio (OR) = 0.54], time to surgery (P < 0.01; OR = 0.98 per month), legal representation (P < 0.01; OR = 0.57), and psychiatric comorbidity (P = 0.02; OR = 0.36). Patients in the LTO group had higher medical costs (P < 0.01), rates of psychiatric comorbidity (P < 0.01), incidence of failed back surgery syndrome (FBSS) (P < 0.01), and postoperative opioid use (P < 0.01) compared with the STO and no opioid groups. CONCLUSION: Preoperative opioid use was determined to be a negative predictor of RTW rates after LD in WC patients. In addition, long-term preoperative opioid use was associated with higher medical costs, psychiatric illness, FBSS, and postoperative opioid use. Even a short or moderate course of preoperative opioids was associated with worse outcomes compared with no use. For WC patients undergoing LD, judicious use of preoperative opioid analgesics may improve clinical outcomes and reduce the opioid burden. LEVEL OF EVIDENCE: 3.

The effect of pre- and post-operative physical activity on recovery after colorectal cancer surgery (PHYSSURG-C): study protocol for a randomised controlled trial.

BACKGROUND: Surgery for colorectal cancer is associated with a high risk of post-operative adverse events, re-operations and a prolonged post-operative recovery. Previously, the effect of prehabilitation (pre-operative physical activity) has been studied for different types of surgery, including colorectal surgery. However, the trials on colorectal surgery have been of limited methodological quality and size. The aim of this trial is to compare the effect of a combined pre- and post-operative intervention of moderate aerobic physical activity and inspiratory muscle training (IMT) with standard care on post-operative recovery after surgery for colorectal cancer. METHODS/DESIGN: We are conducting a randomised, controlled, parallel-group, open-label, multi-centre trial with physical recovery within 4 weeks after cancer surgery as the primary endpoint. Some 640 patients planned for surgery for colorectal cancer will be enrolled. The intervention consists of pre- and post-operative physical activity with increased daily aerobic activity of moderate intensity as well as IMT. In the control group, patients will be advised to continue their normal daily exercise routine. The primary outcome is patient-reported physical recovery 4 weeks post-operatively. Secondary outcomes are length of sick leave, complication rate and severity, length of hospital stay, re-admittances, re-operations, post-operative mental recovery, quality of life and mortality, as well as changes in insulin-like growth factor 1 and insulin-like growth factor-binding protein 3, perception of pain and a health economic analysis. DISCUSSION: An increase in moderate-intensity aerobic physical activity is a safe, cheap and feasible intervention that would be possible to implement in standard care for patients with colorectal cancer. If shown to be effective, this lifestyle intervention could be a clinical parallel to pre-operative smoke cessation that has already been implemented with good clinical results. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02299596 . Registered on 17 November 2014.

The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery.

OBJECTIVE Lumbar epidural steroid injections (LESIs) are performed for both diagnostic and therapeutic purposes for a variety of indications, including low-back pain, the leading cause of disability and expense due to work-related conditions in the US. The steroid agent used in epidural injections is reported to relieve nerve root inflammation, local ischemia, and resultant pain, but the injection may also have an adverse impact on spinal surgery performed thereafter. In particular, the possibility that preoperative epidural injections may increase the risk of surgical site infection after lumbar spinal fusion has been reported but has not been studied in detail. The goal of the present study was to use a large national insurance database to analyze the association of preoperative LESIs with surgical site infection after lumbar spinal fusion. METHODS A nationwide insurance database of patient records was used for this retrospective analysis. Current Procedural Terminology codes were used to query the database for patients who had undergone LESI and 1- or 2-level lumbar posterior spinal fusion procedures. The rate of postoperative infection after 1- or 2-level posterior spinal fusion was analyzed. These study patients were then divided into 3 separate cohorts: 1) lumbar spinal fusion performed within 1 month after LESI, 2) fusion performed between 1 and 3 months after LESI, and 3) fusion performed between 3 and 6 months after LESI. The study patients were compared with a control cohort of patients who underwent lumbar fusion without previous LESI. RESULTS The overall 3-month infection rate after lumbar spinal fusion procedure was 1.6% (1411 of 88,540 patients). The infection risk increased in patients who received LESI within 1 month (OR 2.6, p < 0.0001) or 1-3 months (OR 1.4, p = 0.0002) prior to surgery compared with controls. The infection risk was not significantly different from controls in patients who underwent lumbar fusion more than 3 months after LESI. CONCLUSIONS Lumbar spinal fusion performed within 3 months after LESI may be associated with an increased rate of postoperative infection. This association was not found when lumbar fusion was performed more than 3 months after LESI.

Prolonged Preoperative Opioid Therapy in Patients With Degenerative Lumbar Stenosis in a Workers' Compensation Setting.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To investigate the impact of prolonged opioid use in the preoperative treatment plan of degenerative lumbar stenosis (DLS). SUMMARY OF BACKGROUND DATA: Patients undergoing operative treatment for DLS with concomitant opioid use represent a clinically challenging population. The relative paucity of data on the relationship between preoperative opioid use and clinical outcomes in the workers' compensation (WC) population necessitates further study of this unique population. METHODS: We identified 140 Ohio WC patients who underwent lumbar decompression and had received preoperative opioid prescriptions between 1993 and 2013. Our study cohorts were formed based on opioid use duration, which included short-term use (<3 months) and long-term use (>3 months). Our primary outcome was if patients were able to make a stable return to work (RTW). A multivariate regression analysis was used to determine the impact of the duration of preoperative opioid use on return to work rates. We also compared many secondary outcomes after surgery between both groups. RESULTS: Patients on opioids less than 3 months had a significantly higher RTW rate compared with those who used opioids longer than 3 months [25/60 (42%) vs. 18/80 (23%); P = 0.01]. A logistic regression was performed to examine the effect of preoperative opioid therapy duration on RTW status. Our regression model showed that opioid use greater than 3 months remained a significant negative predictor of RTW (OR: 0.35, 95% CI: 0.13-0.89; P = 0.02). Patients who remained on opioid therapy longer than 3 months cost the Ohio Bureau of Workers' Compensation $70,979 more than patients who were on opioid therapy for less than 3 months (P < 0.01). CONCLUSION: Prolonged preoperative opioid use was associated with poor clinical outcomes after lumbar decompression. These results suggest that a shorter course of opioid therapy and earlier surgical intervention may improve outcomes and lower postoperative morbidity in patients with DLS. LEVEL OF EVIDENCE: 3.

Safety and comparative costs of preoperative assessments for cataract surgery: traditional mandatory assessment versus a novel graded assessment system.

PURPOSE: We conducted this study to evaluate the safety and costs of traditional mandatory preoperative assessment for cataract surgery patients compared with a novel graded preoperative assessment system. METHODS: Patients were recruited at a high-volume surgical centre from May to November 2013. Patients completed a health-related questionnaire which allowed for a graded preoperative assessment of all participants. Based on responses to the questionnaire, patients were classified preoperatively into a) low-risk patients not requiring a preoperative assessment and b) high-risk patients requiring this assessment. Anesthesiologists still assessed all patients immediately before surgery but with staff blinded to preoperative assessment information for low-risk patients. Observed complication rates and costs were compared with those expected in the mandatory assessment system. RESULTS: We examined 3,347 cataract surgeries on 2,766 patients and categorized 59.9% of patients as low risk. In the graded system cohort, there were no major complications and a low rate of minor complications occurred. Wherever a complication occurred in a low-risk patient, the anesthesiologist doubted that the preoperative assessment information would have prevented the complication. If implemented, the graded system would save approximately 4,414 preoperative assessments per year in our region, with an associated cost of approximately $40.00 per surgery, or $359,000 in total. The cost to prevent a single minor complication with the mandatory system was approximately $8,976, with a number needed to treat of 223. CONCLUSION: The graded system resulted in no major complications and a low rate of minor complications. The information obtained from the mandatory assessment is unlikely to prevent complications. Additionally, the cost effectiveness of the mandatory system was poor. This novel graded preoperative assessment system for cataract surgery patients can save time and resources by eliminating unnecessary patient visits.

Preoperative Mapping in Unicompartmental Knee Arthroplasty Using Computed Tomography Scans Is Associated with Radiation Exposure and Carries High Cost.

Robotic-assisted knee arthroplasty with some systems requires the use of computed tomography (CT) scans. The associated radiation dose has not been studied. The effective dose (ED, mSv) of radiation was calculated for 236 preoperative CT scans used for planning of robotic assisted surgery. The mean ED was 4.8±3.0 mSv. There was a 3-fold difference in ED between institutions. One or more additional CT scans were obtained in 25% of patients, amounting to a cumulative ED per patient up to 103 mSv. Preoperative CT is a disadvantage of some robotic-assisted knee arthroplasty systems due to additional cost and radiation exposure. Newer image-free robotic technologies are an alternative to CT-dependent surgery if accuracy and safety are not compromised.

The epidemiology and outcomes of percutaneous coronary intervention before high-risk noncardiac surgery in contemporary practice: insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) Registry.

BACKGROUND: Percutaneous coronary intervention (PCI) is sometimes performed with the intent to lower cardiovascular risk before high-risk noncardiac surgery (HRNCS). There are limited data on the frequency and outcome of PCIs performed in this setting. METHODS AND RESULTS: We assessed the frequency, characteristics, and in-hospital outcomes of patients undergoing PCI as part of the preoperative workup for HRNCS among all 61 145 elective PCIs performed between 2002 and 2009 at 14 hospitals in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Propensity matching was performed to compare outcomes of patients undergoing PCI before HRNCS with all other elective PCI patients. The frequency of PCI before HRNCS was low (4.2%). Patients undergoing PCI before HRNCS were older (67.3 versus 64.9 years, P<0.0001) and had a greater burden of comorbidity. Patients undergoing PCI before HRNCS had an increase in unadjusted major adverse cardiovascular events, postprocedure transfusion, contrast-induced nephropathy, nephropathy requiring dialysis, and same-admission coronary artery bypass graft surgery, but there was no difference in mortality (0.27% versus 0.14%, P=0.11). However, in propensity score-matched samples, there was a significant difference only in nephropathy requiring dialysis. CONCLUSIONS: The incidence of PCI performed in preparation for high-risk noncardiac surgery is low, and these procedures are currently being performed on a highly selected high-risk patient population.