Perioperative Management of a Patient Taking Suboxone® at the Time of Ambulatory Surgery.

In 2016, more than 11 million people reported misuse of opioids in the previous year. In an effort to combat opioid use disorder (OUD), the use of agonist/antagonist is becoming increasingly common, with more than 2.2 million patients reporting use of a buprenorphine containing medication such as Suboxone®. Buprenorphine is a unique opioid which acts as a partial µ agonist and ĸ antagonist. These properties make it an effective tool in treating OUD and abuse. However, despite its advantages in treating OUD and abuse, buprenorphine can make it difficult to control acute perioperative pain. We present a case in which the Mayo Clinic Arizona protocol for patients undergoing minimally invasive ambulatory surgery while taking Suboxone® is successfully executed, resulting in adequate postoperative pain control and timely discharge from the postanesthesia recovery unit.

Upper extremity regional anesthesia techniques: A comprehensive review for clinical anesthesiologists.

Surgeries and chronic pain states of the upper extremity are quite common and pose unique challenges for the clinical anesthesiology and pain specialists. Most innervation of the upper extremity involves the brachial plexus. The four most common brachial plexus blocks performed in clinical setting include the interscalene, supraclavicular, infraclavicular, and axillary brachial plexus blocks. These blocks are most commonly performed with the use of ultrasound-guided techniques, whereby analgesia is achieved by anesthetizing the brachial plexus at different levels such as the roots, divisions, cords, and branches. Additional regional anesthetic techniques for upper extremity surgery include wrist, intercostobrachial, and digital nerve blocks, which are most frequently performed using landmark anatomical techniques. This review provides a comprehensive summary of each of these blocks including anatomy, best practice techniques, and potential complications.

Beta-Alanine Does Not Enhance the Effects of Resistance Training in Older Adults.

To investigate the potential of beta-alanine to increase muscular endurance of elder individuals in specific resistance-training protocols, we randomly assigned 27 participants (60-82 years of age) to a 12-week double-blind intervention using 3.2 g/day beta-alanine or placebo with or without resistance training to determine the effects on anthropometrics, muscular performance, and activities of daily living (ADL). The endurance-based resistance-training program (ERT) was given three times per week and included two sets of 15-25 repetitions on 11 computerized pneumatic machines (alternating upper and lower body) at an intensity of 50% of maximum lifting weight (1RM). Mixed design analysis of variance (ANOVA) revealed no significant group × time interactions (p > .05) for any anthropometric or strength measures except 1RM leg press (p = .010). A post hoc analysis revealed significant improvements in 1RM leg press for both the resistance-training groups (p < .001) but no significant between-group difference attributable to beta-alanine. For the 20-repetition chest and leg press tests, no main effects of beta-alanine or group × time interactions for the exercise versus control groups were observed. Pairwise comparisons, however, did reveal significant improvements in peak and average power for both tests and fatigue index for the chest press in resistance-training groups. Although beta-alanine had no effect on any measures, the ERT program did positively affect three performance variables: 1RM, mechanical power, and fatigue patterns during muscular endurance testing. Future research should examine beta-alanine with different dosages and training programs to expand upon our findings using endurance-based resistance training.

Ruptured Abdominal Aortic Aneurysm: Prediction of Mortality From Clinical Presentation and Glasgow Aneurysm Score.

OBJECTIVE: To examine association of presenting clinical acuity and Glasgow Aneurysm Score (GAS) with perioperative and 1-year mortality. DESIGN: Retrospective chart review. SETTING: Major tertiary care facility. PARTICIPANTS: Patients with ruptured abdominal aortic aneurysm (rAAA) from 2003 through 2013. INTERVENTIONS: Emergency repair of rAAA. MEASUREMENTS AND MAIN RESULTS: The authors reviewed outcomes after stable versus unstable presentation and by GAS. Unstable presentation included hypotension, cardiac arrest, loss of consciousness, and preoperative tracheal intubation. In total, 125 patients (40 stable) underwent repair. Perioperative mortality rates were 41% and 12% in unstable and stable patients, respectively (p<0.001). Unstable status had 88% sensitivity and 41% specificity for predicting perioperative mortality. Using logistic regression, higher GAS was associated with perioperative mortality (p<0.001). Using receiver operating characteristic analysis, the area under the curve was 0.72 (95% CI, 0.62-0.82) and cutoff GAS≥96 had 63% and 72% sensitivity and specificity, respectively. Perioperative mortality for GAS≥96 was 51% (25/49), whereas it was 20% (15/76) for GAS≤95. The estimated 1-year survival (95% CI) was 75% (62%-91%) for stable patients and 48% (38%-60%) for unstable patients. Estimated 1-year survival (95% CI) was 23% (13%-40%) for GAS≥96 and 77% (67%-87%) for GAS≤95. CONCLUSIONS: Clinical presentation and GAS identified patients with rAAA who were likely to have a poor surgical outcome. GAS≥96 was associated with poor long-term survival, but>20% of these patients survived 1 year. Thus, neither clinical presentation nor GAS provided reliable guidance for decisions regarding futility of surgery.

Improved meta-analytic methods show no effect of chromium supplements on fasting glucose.

The trace mineral chromium has been extensively researched over the years in its role in glucose metabolism. Dietary supplement companies have attempted to make claims that chromium may be able to treat or prevent diabetes. Previous meta-analyses/systematic reviews have indicated that chromium supplementation results in a significant lowering of fasting glucose in diabetics but not in nondiabetics. A meta-analysis was conducted using an alternative measure of effect size, d(ppc2) in order to account for changes in the control group as well as the chromium group. The literature search included MEDLINE, the Cochrane Controlled Trials Register, and previously published article reviews, systematic reviews, and meta-analyses. Included studies were randomized, placebo-controlled trials in the English language with subjects that were nonpregnant adults, both with and without diabetes. Sixteen studies with 809 participants (440 diabetics and 369 nondiabetics) were included in the analysis. Screening for publication bias indicated symmetry of the data. Tests of heterogeneity indicated the use of a fixed-effect model (I² = 0 %). The analysis indicated that there was no significant effect of chromium supplementation in diabetics or nondiabetics, with a weighted average effect size of 0.02 (SE = 0.07), p = 0.787, CI 95 % = -0.12 to 0.16. Chromium supplementation appears to provide no benefits to populations where chromium deficiency is unlikely.

Progression-free Survival Decreases with Each Subsequent Therapy in Patients Presenting for Phase I Clinical Trials.

BACKGROUND: There is often a finite progression-free interval of time between one systemic therapy and the next when treating patients with advanced cancer. While it appears that progression-free survival (PFS) between systemic therapies tends to get shorter for a number of factors, there has not been a formal evaluation of diverse tumor types in an advanced cancer population treated with commercially-available systemic therapies. METHODS: In an attempt to clarify the relationship between PFS between subsequent systemic therapies, we analyzed the records of 165 advanced cancer patients coming to our clinic for consideration for participation in six different phase I clinical trials requiring detailed and extensive past medical treatment history documentation. RESULTS: There were 77 men and 65 women meeting inclusion criteria with a median age at diagnosis of 55.3 years (range 9.4-81.6). The most common cancer types were colorectal (13.9%), other gastrointestinal (11.8%), prostate (11.8%). A median of 3 (range 1-11) systemic therapies were received prior to phase I evaluation. There was a significant decrease in PFS in systemic therapy for advanced disease from treatment 1 to treatment 2 to treatment 3 (p = 0.002), as well as, from treatment 1 through treatment 5 (p < 0.001). CONCLUSIONS: In an advanced cancer population of diverse tumor types, we observe a statistically significant decrease in PFS with each successive standard therapy. Identification of new therapies that reverse this trend of decreasing PFS may lead to improved clinical outcomes.

Basal cell adenocarcinoma of the supraglottic larynx: treatment of recurrent disease with tamoxifen.

At the age of 83, a woman presented with an extremely rare cancer, basal cell adenocarcinoma (BCAC) of the supraglottic larynx. Pathology revealed a stage IVA tumor, pathological stage T4N0M0. She was treated with surgery and did not receive any adjuvant chemotherapy or radiation therapy. At the age of 93, during a routine examination, the patient was found to have palpable adenopathy and underwent a fine needle aspiration in June 2010. Pathology revealed similar histologic characteristics of her 2001 BCAC diagnosis, and further IHC stains revealed positive estrogen receptor staining.