The Effect of Scheduled Intravenous Acetaminophen in an Enhanced Recovery Protocol Pathway in Patients Undergoing Major Abdominal Procedures: A Prospective, Randomized, and Placebo-Controlled Clinical Trial.

OBJECTIVE: Enhanced recovery protocols (ERPs) utilize multi-modal analgesia regimens. Individual regimen components should be evaluated for their analgesic efficacy. We evaluated the effect of scheduled intravenous (IV) acetaminophen within an ERP on analgesia and recovery after a major abdominal surgery. DESIGN: This study is a prospective, randomized, double-blinded clinical trial. SETTING: The study setting was a tertiary care, academic medical center. SUBJECTS: Adult patients scheduled for elective major abdominal surgical procedures. METHODS: Patients in group A received 1 g IV acetaminophen, while patients in group P received IV placebo every six hours for 48 hours postoperatively within an ERP. Pain scores, opioid requirements, nausea and vomiting, time to oral intake and mobilization, length of stay, and patient satisfaction scores were measured and compared. RESULTS: From 412 patients screened, 154 patients completed the study (Group A: 76, Group P: 78). Primary outcome was the number of patients with unsatisfactory pain relief, defined as a composite of average Numeric Rating Scale (NRS) scores above 5 and requirement of IV patient-controlled analgesia for pain relief during the first 48 hours postoperatively, and was not significantly different between the two groups (33 (43.4%) in group A versus 42 (53.8%) patients in group P, P = .20). Opioid consumption was comparable between two groups. Group A utilized significantly less postoperative rescue antiemetics compared to group P (41% vs. 58%, P = .02). CONCLUSIONS: Scheduled administration of IV acetaminophen did not improve postoperative analgesia or characteristics of postoperative recovery in patients undergoing major abdominal surgery within an ERP pathway.

Dexamethasone implant improves anatomic response to anti-VEGF therapy in treatment-resistant polypoidal choroidal vasculopathy.

BACKGROUND: A significant proportion of eyes with polypoidal choroidal vasculopathy (PCV) can be resistant to anti-vascular endothelial growth factor (VEGF) injections. We evaluated the efficacy of a combination of dexamethasone intravitreal implant (DXI) and anti-VEGF therapy in eyes resistant to anti-VEGF monotherapy. METHODS: In this retrospective study, patients with PCV resistant to anti-VEGF injections were additionally injected with a DXI along with an anti-VEGF agent. Best-corrected visual acuity (BCVA), slit-lamp examination, fundus evaluation, and optical coherence tomography (OCT) data were analyzed. Anatomical response on OCT was the primary outcome measure. Change in visual acuity and injection-free interval after DXI were evaluated as secondary outcome measures. RESULTS: Twelve eyes of 11 patients were included in the study. Mean age of patients at presentation was 64.7 ± 9.5 years (range, 49-78.8 years), and there were seven females (63.6%). Median number of anti-VEGF injections prior to DXI was 4 (interquartile range IQR, 3-7). Median follow-up duration after DXI was 32.2 months (IQR, 6.6-41.6 months). Median logMAR BCVA immediately prior to DXI was 0.41 (IQR, 0.30-0.88) and after injection was 0.40 (IQR, 0.30-1.05), which was not significantly different (p = 0.85). Median Central Retinal Thickness (CRT) after DXI was 305.5 µm (IQR, 249-409 µm), which was significantly (p = 0.003) lesser than pre-injection thickness of 547 µm (IQR, 431-771 µm). Median injection-free interval in these eyes after DXI was 5 months (IQR, 2.8-6.4 months). Kaplan-Meier estimates of first injection after DXI were 27.3% at 3 months, 67.3% at 6 months, and 89.1% at 12 months. CONCLUSIONS: Dexamethasone implant combined with anti-VEGF treatment can prolong the treatment-free interval in eyes with PCV resistant to anti-VEGF injection while maintaining visual acuity.

Comparing clinical outcomes of macular hole surgeries performed by trainee surgeons using a 3D heads-up display viewing system versus a standard operating microscope.

PURPOSE: To compare the surgical outcomes of macular hole (MH) surgery performed by trainee surgeons using a three-dimensional heads-up display (3D HUD) versus a standard operating microscope (SOM). MATERIALS AND METHODS: A retrospective review of all consecutive medical records patients operated on for MHs by a trainee surgeon between 2017 and 2020 using either 3D HUD or SOM was performed. Minimum hole diameter, maximum hole diameter, total surgical time, and MH closure rates were compared between the two groups. MH retinal detachments, traumatic MHs, and MHs for which inverted internal limiting membrane flaps were used were excluded from the study. RESULTS: Trainee surgeons operated on 51 patients using 3D HUD and 63 patients using SOM. Age at presentation, intraocular pressure (IOP) at diagnosis, maximum hole diameter, minimum hole diameter, surgical time, duration between diagnosis and surgery were comparable between both groups. MH closure rate was significantly (p < 0.004) higher in the 3D HUD group (n = 44, 86.3%) than that of the SOM group (n = 38, 60.3%). There were no postoperative adverse events such as glaucoma or retinal detachment in either group. Other than the viewing technique, there were no significant variables associated with MH closure in the two groups. CONCLUSION: Surgeries conducted by trainee surgeons using 3D HUD had higher MH closure rates than those using SOM.

Good Gone Bad: Complications of Chemotherapy, Immunotherapy, and Radiotherapy on the CNS.

With recent advancements in cancer therapy, especially immunotherapy, overall survival of many cancers has increased and patient toxicity has been reduced. However, many complications of traditional cancer therapy are still prevalent and complications of novel therapies are just beginning to appear. The neuroradiologist may be the first to visualize signs of these complications on imaging. This article describes the notable imaging findings of several unique and characteristic complications of CNS cancer therapy, including toxicities of chemotherapies, immunotherapies, and radiotherapy. Complications of chemotherapeutic agents covered include methotrexate-induced and disseminated necrotizing leukoencephalopathy, and chemotherapy-induced myelopathy. Immunotherapy complications included are Tacrolimus-related Optic Neuropathy, Rituximab and Immune reconstitution inflammatory syndrome-associated Progressive Multifocal Leukoencephalopathy, Bevacizumab-associated late radiation-induced neurotoxicity, and Ipilimumab-induced hypophysitis. Lastly, radiation-induced neurotoxicities are covered, including myelopathy, radiation necrosis, cerebral atrophy, leukoencephalopathy, optic neuropathy, mineralizing microangiopathy, stroke-like migraine attacks, osteonecrosis, and vasculopathies. Neuroradiologists will increasingly encounter patients who have undergone treatment with more than 1 therapeutic modality, resulting in overlapping findings as well. Recognition of the common complications of these therapies on imaging is critical to minimizing the effects of these potential short- and long-term complications.

Communication of Incidental Imaging Findings on Inpatient Discharge Summaries After Implementation of Electronic Health Record Notification System.

OBJECTIVES: Inadequate follow-up of incidental imaging findings (IIFs) can result in poor patient outcomes, patient dissatisfaction, and provider malpractice. At our institution, radiologists flag IIFs during report dictation to trigger electronic health record (EHR) notifications to providers and patients. Nurse coordinators directly contact patients or their primary care physicians (PCPs) regarding IIFs if follow-up is not completed within the recommended time frame. Despite these interventions, many patients and their PCPs remain unaware of IIFs. In an effort to improve awareness of IIFs, we aim to investigate communication of IIFs on inpatient discharge summaries after implementation of our EHR notification system. METHODS: Inpatient records with IIFs from 2018 to 2021 were retrospectively reviewed to determine type of IIFs, follow-up recommendations, and mention of IIFs on discharge summaries. Nurse coordinators spoke to patients and providers to determine their awareness of IIFs. RESULTS: Incidental imaging findings were reported in 51% of discharge summaries (711/1383). When nurse coordinators called patients and PCPs regarding IIFs at the time follow-up was due, the patients and PCPs were aware of 79% of IIFs (1096/1383). CONCLUSIONS: With implementation of EHR notifications to providers regarding IIFs, IIFs were included in 51% of discharge summaries. Lack of inclusion of IIFs on discharge summaries could be related to transitions of care within hospitalization, provider alert fatigue, and many diagnostic testing results to distill. These findings demonstrate the need to improve communication of IIFs, possibly via automating mention of IIFs on discharge summaries, and the need for care coordinators to follow up on IIFs.