Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm.

Importance: Postoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume. Objective: To analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes. Design, Setting, and Participants: This cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]). Exposures: After V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1. Main Outcomes and Measures: Inpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses. Results: A total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P < .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P < .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P < .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P < .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups. Conclusions and Relevance: In this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.

Ancient peat and apple extracts supplementation may improve strength and power adaptations in resistance trained men.

BACKGROUND: Increased cellular ATP levels have the potential to enhance athletic performance. A proprietary blend of ancient peat and apple extracts has been supposed to increase ATP production. Therefore, the purpose of this investigation was to determine the effects of this supplement on athletic performance when used during 12 weeks of supervised, periodized resistance training. METHODS: Twenty-five healthy, resistance-trained, male subjects completed this study. Subjects supplemented once daily with either 1 serving (150 mg) of a proprietary blend of ancient peat and apple extract (TRT) or an equal-volume, visually-identical placebo (PLA) daily. Supervised resistance training consisted of 8 weeks of daily undulating periodized training followed by a 2 week overreach and a 2 week taper phase. Strength was determined using 1-repetition-maximum (1RM) testing in the barbell back squat, bench press (BP), and deadlift exercises. Peak power and peak velocity were determined during BP at 30 % 1RM and vertical jump tests as well as a 30s Wingate test, which also provided relative power (watt:mass) RESULTS: A group x time interaction was present for squat 1RM, deadlift 1RM, and vertical jump peak power and peak velocity. Squat and deadlift 1RM increased in TRT versus PLA from pre to post. Vertical jump peak velocity increased in TRT versus PLA from pre to week 10 as did vertical jump peak power, which also increased from pre to post. Wingate peak power and watt:mass tended to favor TRT. CONCLUSIONS: Supplementing with ancient peat and apple extract while participating in periodized resistance training may enhance performance adaptations. TRIAL REGISTRATION: ClinicalTrials.gov registration ID: NCT02819219 , retrospectively registered on 6/29/2016.

Twelve weeks supplementation with an extended-release caffeine and ATP-enhancing supplement may improve body composition without affecting hematology in resistance-trained men.

BACKGROUND: Increased ATP levels may enhance training-induced muscle accretion and fat loss, and caffeine is a known ergogenic aid. A novel supplement containing ancient peat and apple extracts has reported enhanced mitochondrial ATP production and it has been coupled with an extended-release caffeine. Therefore, the purpose of this investigation was to determine the effects of this supplement on body composition when used in conjunction with 12 weeks of resistance training. METHODS: Twenty-one resistance-trained subjects (27.2 ± 5.6y; 173.5 ± 5.7 cm; 82.8 ± 12.0 kg) completed this study. Subjects supplemented daily with either 1 serving of the supplement (TRT), which consisted of 150 mg ancient peat and apple extracts, 180 mg blend of caffeine anhydrous and pterostilbene-bound caffeine, and 38 mg B vitamins, or an equal-volume, visually-identical placebo (PLA) 45 min prior to training or at the same time of day on rest days. Supervised resistance training consisted of 8 weeks of daily undulating periodized training followed by a 2-week overreach and a 2-week taper phase. Body composition was assessed using DEXA and ultrasound at weeks 0, 4, 8, 10, and 12. Vital signs and blood markers were assessed at weeks 0, 8, and 12. RESULTS: Significant group x time (p < 0.05) interactions were present for cross-sectional area of the rectus femoris, which increased in TRT (+1.07 cm(2)) versus PLA (-0.08 cm(2)), as well as muscle thickness (TRT: +0.49 cm; PLA: +0.04 cm). A significant group x time (p < 0.05) interaction existed for creatinine (TRT: +0.00 mg/dL; PLA: +0.15 mg/dL) and estimated glomerular filtration rate (TRT: -0.70 mL/min/1.73; PLA: -14.6 mL/min/1.73), which remained within clinical ranges, but no other significant observations were observed. CONCLUSIONS: Supplementation with a combination of extended-release caffeine and ancient peat and apple extracts may enhance resistance training-induced skeletal muscle hypertrophy without adversely affecting blood chemistry.

Supplementation with a proprietary blend of ancient peat and apple extract may improve body composition without affecting hematology in resistance-trained men.

Adenosine-5'-triphosphate (ATP) is primarily known as a cellular source of energy. Increased ATP levels may have the potential to enhance body composition. A novel, proprietary blend of ancient peat and apple extracts has been reported to increase ATP levels, potentially by enhancing mitochondrial ATP production. Therefore, the purpose of this investigation was to determine the supplement's effects on body composition when consumed during 12 weeks of resistance training. Twenty-five healthy, resistance-trained, male subjects (age, 27.7 ± 4.8 years; height, 176.0 ± 6.5 cm; body mass, 83.2 ± 12.1 kg) completed this study. Subjects supplemented once daily with either 1 serving (150 mg) of a proprietary blend of ancient peat and apple extracts (TRT) or placebo (PLA). Supervised resistance training consisted of 8 weeks of daily undulating periodized training followed by a 2-week overreach and a 2-week taper phase. Body composition was assessed using dual-energy X-ray absorptiometry and ultrasound at weeks 0, 4, 8, 10, and 12. Vital signs and blood markers were assessed at weeks 0, 8, and 12. Significant group × time (p < 0.05) interactions were present for ultrasound-determined cross-sectional area, which increased in TRT (+0.91 cm(2)) versus PLA (-0.08 cm(2)), as well as muscle thickness (TRT: +0.46; PLA: +0.04 cm). A significant group × time (p < 0.05) interaction existed for creatinine (TRT: +0.06; PLA: +0.15 mg/dL), triglycerides (TRT: +24.1; PLA: -20.2 mg/dL), and very-low-density lipoprotein (TRT: +4.9; PLA: -3.9 mg/dL), which remained within clinical ranges. Supplementation with a proprietary blend of ancient peat and apple extracts may enhance resistance training-induced skeletal muscle hypertrophy without affecting fat mass or blood chemistry in healthy males.

Subcutaneous and segmental fat loss with and without supportive supplements in conjunction with a low-calorie high protein diet in healthy women.

BACKGROUND: Weight loss benefits of multi-ingredient supplements in conjunction with a low-calorie, high-protein diet in young women are unknown. Therefore, the purpose of this study was to investigate the effects of a three-week low-calorie diet with and without supplementation on body composition. METHODS: Thirty-seven recreationally-trained women (n = 37; age = 27.1 ± 4.2; height = 165.1 ± 6.4; weight = 68.5 ± 10.1; BMI = 25.1 ± 3.4) completed one of the following three-week interventions: no change in diet (CON); a high-protein, low-calorie diet supplemented with a thermogenic, conjugated linoleic acid (CLA), a protein gel, and a multi-vitamin (SUP); or the high-protein diet with isocaloric placebo supplements (PLA). Before and after the three-week intervention, body weight, %Fat via dual X-ray absorptiometry (DXA), segmental fat mass via DXA, %Fat via skinfolds, and skinfold thicknesses at seven sites were measured. RESULTS: SUP and PLA significantly decreased body weight (SUP: PRE, 70.47 ± 8.01 kg to POST, 67.51 ± 8.10 kg; PLA: PRE, 67.88 ± 12.28 kg vs. POST, 66.38 ± 11.94 kg; p ≤ 0.05) with a greater (p ≤ 0.05) decrease in SUP than PLA or CON. SUP and PLA significantly decreased %Fat according to DXA (SUP: PRE, 34.98 ± 7.05% to POST, 32.99 ± 6.89%; PLA: PRE, 34.22 ± 6.36% vs. POST, 32.69 ± 5.84%; p ≤ 0.05), whereas only SUP significantly decreased %Fat according to skinfolds (SUP: PRE, 27.40 ± 4.09% to POST, 24.08 ± 4.31%; p ≤ 0.05). SUP significantly (p ≤ 0.05) decreased thicknesses at five skinfolds (chest, waist, hip, subscapular, and tricep) compared to PLA, but not at two skinfolds (axilla and thigh). CONCLUSIONS: The addition of a thermogenic, CLA, protein, and a multi-vitamin to a three-week low-calorie diet improved weight loss, total fat loss and subcutaneous fat loss, compared to diet alone.

An amino acid-electrolyte beverage may increase cellular rehydration relative to carbohydrate-electrolyte and flavored water beverages.

BACKGROUND: In cases of dehydration exceeding a 2% loss of body weight, athletic performance can be significantly compromised. Carbohydrate and/or electrolyte containing beverages have been effective for rehydration and recovery of performance, yet amino acid containing beverages remain unexamined. Therefore, the purpose of this study is to compare the rehydration capabilities of an electrolyte-carbohydrate (EC), electrolyte-branched chain amino acid (EA), and flavored water (FW) beverages. METHODS: Twenty men (n = 10; 26.7 ± 4.8 years; 174.3 ± 6.4 cm; 74.2 ± 10.9 kg) and women (n = 10; 27.1 ± 4.7 years; 175.3 ± 7.9 cm; 71.0 ± 6.5 kg) participated in this crossover study. For each trial, subjects were dehydrated, provided one of three random beverages, and monitored for the following three hours. Measurements were collected prior to and immediately after dehydration and 4 hours after dehydration (3 hours after rehydration) (AE = -2.5 ± 0.55%; CE = -2.2 ± 0.43%; FW = -2.5 ± 0.62%). Measurements collected at each time point were urine volume, urine specific gravity, drink volume, and fluid retention. RESULTS: No significant differences (p > 0.05) existed between beverages for urine volume, drink volume, or fluid retention for any time-point. Treatment x time interactions existed for urine specific gravity (USG) (p < 0.05). Post hoc analysis revealed differences occurred between the FW and EA beverages (p = 0.003) and between the EC and EA beverages (p = 0.007) at 4 hours after rehydration. Wherein, EA USG returned to baseline at 4 hours post-dehydration (mean difference from pre to 4 hours post-dehydration = -0.0002; p > 0.05) while both EC (-0.0067) and FW (-0.0051) continued to produce dilute urine and failed to return to baseline at the same time-point (p < 0.05). CONCLUSION: Because no differences existed for fluid retention, urine or drink volume at any time point, yet USG returned to baseline during the EA trial, an EA supplement may enhance cellular rehydration rate compared to an EC or FW beverage in healthy men and women after acute dehydration of around 2% body mass loss.

Ingesting a preworkout supplement containing caffeine, creatine, ß-alanine, amino acids, and B vitamins for 28 days is both safe and efficacious in recreationally active men.

The purpose of this study was to determine the safety and efficacy of consuming a preworkout supplement (SUP) containing caffeine, creatine, ß-alanine, amino acids, and B vitamins for 28 days. We hypothesized that little to no changes in kidney and liver clinical blood markers or resting heart rate and blood pressure (BP) would be observed. In addition, we hypothesized that body composition and performance would improve in recreationally active males after 28 days of supplementation. In a double-blind, placebo-controlled study, participants were randomly assigned to ingest one scoop of either the SUP or placebo every day for 28 days, either 20 minutes before exercise or ad libitum on nonexercise days. Resting heart rate and BP, body composition, and fasting blood samples were collected before and after supplementation. Aerobic capacity as well as muscular strength and endurance were also measured. Significant (P < .05) main effects for time were observed for resting heart rate (presupplementation, 67.59 ± 7.90 beats per minute; postsupplementation, 66.18 ± 7.63 beats per minute), systolic BP (presupplementation, 122.41 ± 11.25 mm Hg; postsupplementation, 118.35 ± 11.58 mm Hg), blood urea nitrogen (presupplementation, 13.12 ± 2.55 mg/dL; postsupplementation, 15.24 ± 4.47 mg/dL), aspartate aminotransferase (presupplementation, 34.29 ± 16.48 IU/L; postsupplementation, 24.76 ± 4.71 IU/L), and alanine aminotransferase (presupplementation, 32.76 ± 19.72 IU/L; postsupplementation, 24.88 ± 9.68 IU/L). Significant main effects for time were observed for body fat percentage (presupplementation, 15.55% ± 5.79%; postsupplementation, 14.21% ± 5.38%; P = .004) and fat-free mass (presupplementation, 70.80 ± 9.21 kg; postsupplementation, 71.98 ± 9.27 kg; P = .006). A significant decrease in maximal oxygen consumption (presupplementation, 47.28 ± 2.69 mL/kg per minute; postsupplementation, 45.60 ± 2.81 mL/kg per minute) and a significant increase in percentage of oxygen consumption per unit time at which ventilatory threshold occurred (presupplementation, 64.38% ± 6.63%; postsupplementation, 70.63% ± 6.39%) and leg press one-repetition maximum (presupplementation, 218.75 ± 38.43 kg; postsupplementation, 228.75 ± 44.79 kg) were observed in the SUP only. No adverse effects were noted for renal and hepatic clinical blood markers, resting heart rate, or BP. Supplements containing similar ingredients and doses should be safe for ingestion periods lasting up to 28 days in healthy, recreationally trained, college-aged men.