Impact of an Electronic Health Record Pain Medication Prescribing Tool on Opioid Prescriptions for Postoperative Pain in Hand, Orthopedic, Plastic, and Spine Surgery Across a Health Care System.

PURPOSE: We hypothesized that a pain management prescribing tool embedded in the electronic health record system of a multihospital health care system would decrease prescription opioids for postoperative pain by hand, orthopedic, plastic, and spine surgeons. METHODS: A prescribing tool for postoperative pain was designed for hand, orthopedic, plastic, and spine surgeons and implemented into electronic discharge order sets in a 10-hospital health care system. Stakeholders were educated on tool use in person and/or by email on 2 occasions. A dashboard was created to monitor opioid pill quantities and morphine milligram equivalents (MMEs) prescribed. Overall compliance with the suggested opioid amounts was assessed for 20 months after tool implementation. A subgroup of 6 hand surgeons, one of whom was instrumental in designing the tool, were evaluated for MMEs prescribed, opioid refills, patient emergency room visits, and patient readmissions within 30 days after discharge. Comparisons in this subgroup were made from 12 months before to 15 months after tool implementation. RESULTS: The mean system-wide compliance with the suggested opioid pill quantities and MMEs prescribed in all 4 specialties improved by less than 5%. In the subgroup of hand surgeons, 5 of whom championed tool use, prescribed MMEs decreased by 10% during each of the 4 quarters before launching the tool and contracted an additional 26% in the first quarter after tool implementation. Opioid refills held steady at 5%, and there were no emergency room visits or readmissions within 30 days after discharge in this patient subgroup. CONCLUSIONS: The prescribing tool had a negligible impact on system-wide compliance with suggested prescription opioid pill quantities and MMEs. In a small group of surgeons who championed the use of the tool, there was a significant and sustained decline in MMEs prescribed without adversely impacting patient refills, emergency room visits, or readmissions. CLINICAL RELEVANCE: An electronic prescribing tool to assist surgeons in lowering opioid prescription pill quantities and MMEs may have a negligible impact on prescribing behavior in a multihospital health care system.

Patient-level meta-analysis of 999 claudicants undergoing primary femoropopliteal nitinol stent implantation.

CONDENSED ABSTRACT: The factors that impact the clinical effectiveness of bare nitinol stents in claudicants with symptomatic femoropopliteal atherosclerosis are incompletely known. The authors analyzed variables that may influence stent durability and provide a benchmark for their effectiveness. Data analyzed from six studies (999 patients) included baseline noninvasive hemodynamic tests, angiographic characteristics, ultrasound defined stent patency and target lesion revascularization through 12-months. Baseline ankle-brachial index and lesion length predicted stent patency and target lesion revascularization and when combined interacted significantly to better predict outcomes. This meta-analysis provides an important comparator against which emerging therapies that treat claudicants with femoropopliteal atherosclerosis can be assessed. SUBJECT CODE: Peripheral Artery Disease BACKGROUND: The performance of bare metal nitinol stents in patients with symptomatic femoropopliteal peripheral artery disease (PAD) is not well defined. METHODS: Patient-level data from six large prospective trials sponsored by medical device manufacturers was abstracted and analyzed to identify a cohort of patients with claudication and femoropopliteal artery occlusive disease. Twelve-month binary patency and target lesion revascularization (TLR) rates were primary outcomes. Stent patency was assessed by duplex ultrasonography (DUS) and TLR was a clinically driven intervention. To characterize the effects of patient characteristics on the outcomes, meta-regression was performed via mixed effects logistic regression models with patient-level covariates. RESULTS: About 999 patients were analyzed; the mean ABI was 0.68 ± 0.18, the mean lesion length was 84 ± 53 mm, the mean lesion stenosis was 78%, and nearly two thirds of patients had mild to severe calcification. The mean Rutherford clinical category was 2.7 ± 0.6 and ranged from 2.6 to 2.8 in all studies. The 12-month patency across all studies was 69.8% and TLR rates ranged from 9.2% to 19.7%. Multivariable analysis demonstrated that baseline ABI and baseline target lesion length predicted both primary patency and TLR. Further, these two variables interacted significantly to better predict TLR outcomes when used in combination. CONCLUSION: The 12-month clinical effectiveness of bare nitinol stents to treat patients with symptomatic femoropopliteal PAD is acceptable and is impacted by clinical and lesion-specific characteristics. These data provide an important and useful benchmark to compare the clinical benefit of emerging endovascular PAD therapies. © 2017 Wiley Periodicals, Inc.

An exploratory study to understand the relationship between diabetes and various pulpal conditions: An Indian perspective.

Aim: Diabetes mellitus (DM) affects an estimated 100 million Indians, ranking second globally in diabetic prevalence. Despite this, the correlation between DM and specific pulpal diagnoses remains underexplored. This study compares pulpal conditions in DM patients and nondiabetic controls. Designs: The study was started after taking ethical approval. Subjects and Methods: Two thousand and five hundred and sixty teeth were examined over 4 months at the institute, evenly distributed between diabetic and nondiabetic cases, we assessed diagnoses - normal pulp, reversible pulpitis (RP), symptomatic irreversible pulpitis, asymptomatic irreversible pulpitis, pulp necrosis (PN), missing teeth (MT), and root canal-treated teeth (RCT). Statistical analysis used the Chi-square test. Results: PN and MT prevalence in DM patients significantly exceeded the control group. Conversely, the control group showed higher RP prevalence in the older subgroup. Conclusions: PN prevalence was higher in diabetics, suggesting reduced pulp sensitivity in individuals over 60 years. This diminished sensitivity might lead to delayed dental treatment, increasing PN prevalence.

Choice of material for internal carotid artery bypass grafting: vein or prosthetic? Analysis of 44 procedures.

PURPOSE: Although infrequent, reconstruction of the internal carotid artery due to recurrent or extensive disease, tumor, or difficulty in completing the endarterectomy, may be necessary. Few studies evaluate the type of material used as conduit in regard to outcome. In this report we detail our results using both prosthetic and vein bypass of the internal carotid artery for atherosclerotic bifurcation stenosis. METHODS AND MATERIALS: All patients undergoing carotid artery reconstruction over the last 10 years were retrieved from our vascular registry. Those patients requiring bypass of the internal carotid artery were included. Demographics, indication, complications, and long term follow-up were reviewed. Chi square and log rank analysis was used to compare bypass with PTFE to those with vein as conduit. RESULTS: Over the last 10 years, 44 reconstructions of the internal carotid artery were performed in 41 patients. Twenty-two procedures used prosthetic and 22 used vein. Asymptomatic carotid artery occlusive disease was identified in 14 of the 22 procedures with PTFE, and in 10 of 22 patients with vein. There was no operative mortality in the prosthetic group, and one patient died of a stroke (4.5%) in the vein graft group. There were no strokes or occlusions in the PTFE group. Two permanent neurologic deficits (9%) and one occlusion occurred in the vein bypass group. In follow-up, there have been no late occlusions in the PTFE group, and three in the vein group. CONCLUSION: While endarterectomy is the procedure of choice in carotid bifurcation stenosis, internal carotid artery bypass can be performed with reasonable outcomes whenever necessary. Prosthetic reconstruction of the internal carotid artery had acceptable results that was comparable to vein graft reconstruction.

Carotid-carotid crossover bypass: is it a durable procedure?

PURPOSE: Reconstruction of a diseased common carotid artery may necessitate direct repair via aortic artery-based revascularization. However, carotid-carotid artery crossover grafting is an alternative extra-anatomic option that obviates the need for median sternotomy. We analyzed our results with carotid-carotid artery crossover bypass surgery. METHODS: Data were analyzed for all patients undergoing carotid-carotid crossover bypass surgery from 1995 to 2000. Data on patient demographics, indications for surgery, perioperative morbidity and mortality, and graft patency were retrieved from a vascular surgery data base and hospital records. Stroke-free survival and graft patency were determined with life table methods. RESULTS: Over 5 years, 24 carotid-carotid artery crossover bypass procedures were performed to treat both symptomatic (n = 19, 79%) and asymptomatic (n = 5, 17%) disease. Nine procedures (38%) were performed in men, 3 (13%) in patients with diabetes, 12 (50%) in active smokers, and 2 in patients with a history of Takayasu arteritis. Patient mean age was 63 years (range, 38-79 years). Twenty-three patients (96%) received polytetrafluoroethylene conduit grafts, and the remaining patients received vein grafts. Ten (42%) patients underwent concomitant endarterectomy. There were no perioperative deaths. One patient (4%) had asymptomatic early occlusion, one had transient neurologic deficit (4%), one (4%) required additional surgery because of bleeding, and one (4%) had a perioperative cerebrovascular accident (stroke). Three (17%) asymptomatic late occlusions were identified at 11, 57, and 64 months, respectively. Mean follow-up was 30 months (range, 1-70 months). Primary patency was 88%, and secondary patency was 92% at 3 years. Stroke-free survival was 94% at 4 years. CONCLUSION: Carotid-carotid artery crossover bypass surgery is a safe and durable procedure. Its use precludes the need for median sternotomy and provides acceptable stroke-free survival.

Composite sequential arterial reconstruction for limb salvage.

OBJECTIVE: Autogenous vein is the conduit of choice in patients presenting for infrainguinal arterial reconstruction. Venous conduit may be limited because of inadequacy or prior utilization. Our group and others use prosthetics to maximize limb salvage with moderate results. However, in cases where patients present with an isolated popliteal segment that may extend below the knee, we have performed prosthetic bypasses to this above-knee segment and then used a venous reconstruction from the native arterial circulation to a more distal outflow tract. In this report, we will analyze our results using this type of reconstruction in patients who present for limb salvage with no all-autogenous option. METHOD: From 1992 to 2000, 27 patients presented for limb salvage with an isolated popliteal artery and inadequate vein for continuous bypass. There were 106 patients in this period without an isolated popliteal segment or adequate vein who underwent prosthetic bypass with distal vein cuff or arteriovenous fistula. The vascular registry and patient charts were reviewed for indication, demographics, and type of composite reconstruction. Outcomes were calculated with use of life table methods and compared by log rank analysis. RESULTS: Demographics revealed 16 (59%) men, 16 (59%) patients with diabetes, and 4 (15%) smokers with a mean age of 71 years (range, 51-87 years). The venous reconstructions had the inflow taken from the distal native popliteal artery in 26 (above knee in 8 and below knee in 18) and the peroneal artery in one. The outflow involved the below-knee popliteal in one (4%), a tibial in 23 (85%), and the dorsalis pedis artery in 3 (11%). Morbidity included bleeding (4%), wound infection (4%), and limb loss (4%). Mortality occurred in one patient (4%), and no revisions were required in follow-up. Six late failures were identified, one of which resulted in amputation. Primary patency and limb salvage were 80% and 88% at 1 year, respectively. For comparison, our results using prosthetic with vein cuff had a 1-year primary patency of 52% and limb salvage of 92% (P = NS), whereas prosthetic with an arteriovenous fistula was 73% and 84%, respectively (P = NS). CONCLUSIONS: Composite sequential reconstruction using an isolated popliteal segment as inflow for the distal reconstruction is an acceptable option in patients presenting for limb salvage reconstruction with limited venous conduit. This type of reconstruction, when available, may be a better option than pure prosthetic with or without a vein cuff or arteriovenous fistula.