Cirrhosis and Portal Hypertension Worsen Bowel Preparation for Screening Colonoscopy.

BACKGROUND: Colonoscopy is a diagnostic and therapeutic procedure that reduces colorectal cancer incidence and mortality but requires adequate bowel cleansing for high-quality examination. Past studies have suggested cirrhosis as a risk factor for worse bowel preparation. METHODS: We carried out a match-controlled retrospective study evaluating patients with and without cirrhosis who underwent outpatient screening colonoscopies to assess the effect of cirrhosis and portal hypertension complications on preparation quality and endoscopic measures. We also did a subgroup analysis excluding patients with obesity. RESULTS: We examined 1464 patients with cirrhosis and matched controls. Cirrhotic patients had lower mean Boston Bowel Preparation Scale (BBPS) scores and slower cecal intubation times. We found a single point increase in the Model for End-stage Liver Disease (MELD) score, as well as ascites, hepatic encephalopathy, and variceal hemorrhage were all associated with a longer cecal intubation time. Subgroup analysis excluding patients with obesity again found a significantly lower BBPS score and longer cecal intubation time while also finding a 24% drop in polyp detection. CONCLUSIONS: Patients with cirrhosis have worse BBPS scores and longer cecal intubation times. Nonobese cirrhotic patients additionally have a lower polyp detection rate. Portal hypertension complications were associated with worsened preparation quality and longer cecal intubation times. Each incremental increase in MELD score lengthened cecal intubation time. These findings support a more aggressive bowel preparation strategy for patients with cirrhosis, especially patients with severe disease or portal hypertension complications.

Risk Factors for Postoperative Ileus in Patients Undergoing Spine Surgery.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: Postoperative ileus (POI) is a common complication following elective spinal surgeries. The aim of this study was to determine the incidence of POI and identify demographic and surgical risk factors for developing POI after elective instrumented fusion of the thoracolumbar spine. METHODS: The University of Utah Institutional Review Board (IRB) approved this retrospective study. The study does not require informed consent given the data reviewed was deidentified and collected in accordance with the institution's standard of care. A designated IRB committee determined that study is exempt under exemption category 7. IRB approval number 00069703. Patients undergoing instrumented thoracolumbar fusion for one or more levels were retrospectively identified from an internal spine surgery database. Cases performed for trauma, infection, or tumors were excluded. Demographics, medical comorbidities, surgical variables, and opioid medication administration (morphine milligram equivalents, MME) were abstracted from the electronic medical record. Univariate analysis was used to identify variables associated with POI. These variables were then tested for independent association with POI using multivariate logistic regression. RESULTS: 418 patients were included in the current study. The incidence of POI was 9.3% in this cohort. There was no significant relationship between development of POI and patient age, gender, BMI, diabetes mellitus, thyroid dysfunction, lung disease, CKD, GERD, smoking status, alcohol abuse, anemia, or prior abdominal surgery. Univariate analysis demonstrated significant association between POI and fusion ≥7 levels compared to fusions of fewer levels (P = .001), as well as intraoperative sufentanil compared to other opioids (35.9% vs 20.1%, P = .02). POI was not significantly associated with total intraoperative MME, approach, use of interbody cage, or osteotomy. Multivariate logistic regression confirmed total 24-hour postoperative MME as an independent risk factor for POI (OR 1.004, P = .04), however, intraoperative sufentanil administration was not an independent risk factor for POI when controlling for other variables. CONCLUSIONS: This retrospective cohort study demonstrates that greater postoperative MME is an independent risk factor for POI after thoracolumbar spine fusion when accounting for demographic, medical, and surgical variables with multiple logistic regression. Prospective studies are warranted to evaluate clinical measures to decrease the risk of POI among patients undergoing instrumented thoracolumbar spinal fusions.

In Vitro Simulation of Shoulder Motion Driven by Three-Dimensional Scapular and Humeral Kinematics.

In vitro simulation of three-dimensional (3D) shoulder motion using in vivo kinematics obtained from human subjects allows investigation of clinical conditions in the context of physiologically relevant biomechanics. Herein, we present a framework for laboratory simulation of subject-specific kinematics that combines individual 3D scapular and humeral control in cadavers. The objectives were to: (1) robotically simulate seven healthy subject-specific 3D scapulothoracic and glenohumeral kinematic trajectories in six cadavers, (2) characterize system performance using kinematic orientation accuracy and repeatability, and muscle force repeatability metrics, and (3) analyze effects of input kinematics and cadaver specimen variability. Using an industrial robot to orient the scapula range of motion (ROM), errors with repeatability of ±0.1 mm and <0.5 deg were achieved. Using a custom robot and a trajectory prediction algorithm to orient the humerus relative to the scapula, orientation accuracy for glenohumeral elevation, plane of elevation, and axial rotation of <3 deg mean absolute error (MAE) was achieved. Kinematic accuracy was not affected by varying input kinematics or cadaver specimens. Muscle forces over five repeated setups showed variability typically <33% relative to the overall simulations. Varying cadaver specimens and subject-specific human motions showed effects on muscle forces, illustrating that the system was capable of differentiating changes in forces due to input conditions. The anterior and middle deltoid, specifically, showed notable variations in patterns across the ROM that were affected by subject-specific motion. This machine provides a platform for future laboratory studies to investigate shoulder biomechanics and consider the impacts of variable input kinematics from populations of interest, as they can significantly impact study outputs and resultant conclusions.

Comparing Risk Profiles in Critical Care Patients With Stage 2 and Deep Tissue Pressure Injuries: Exploratory Retrospective Cohort Study.

BACKGROUND: Understanding hospital-acquired pressure injury (HAPrI) etiology is essential for developing effective preventive interventions. Pressure injuries are classified based on the degree of visible tissue damage; the two most commonly identified HAPrI stages in critical care patients are stage 2 and deep tissue injury (DTI). Some experts speculate that stage 2 and DTI have different etiologies, with stage 2 injuries formed from the "outside in" as a result of tissue deformation, decreased perfusion, and subsequent ischemia caused by external pressure and/or shear forces, whereas DTI emerges from the "inside out" due to inadequate perfusion to the deeper tissues causing tissue ischemia. OBJECTIVE: The purpose of this study was to compare risk profiles of intensive care unit (ICU) patients who developed stage 2 injuries versus DTIs. METHODS: This was a retrospective cohort study to compare the risk profiles of patients in the ICU with stage 2 injuries and DTIs using electronic health record data. Eligible patients were admitted to the surgical or cardiovascular ICU at an academic medical center in the United States between 2014 and 2018. Anatomic locations were examined, and differences in anatomic patterns were compared using the χ2 test. Risk profile variables included demographic characteristics, Braden Scale scores, vasopressor infusions, hypotension, surgical factors, length of stay, BMI, laboratory values, diabetes, Charlson Comorbidity Index, and the levels of sedation or agitation. The distributions of potential risk variables between patients with stage 2 injuries and DTIs were summarized and compared. A logistic regression model with the least absolute shrinkage and selection operator method was developed to identify the critical risk factors for distinguishing stage 2 and DTI patients. RESULTS: A total of 244 patients developed a stage 2 injury or DTI during the study period. Of those, 38 patients with medical device-related pressure injury were excluded. The final study sample consisted of 206 patients (n=146 stage 2 and n=60 DTI). Compared with DTIs, stage 2 HAPrIs were more likely to be located on a bony prominence (n=206, χ21=8.43, P=.03). The multivariate model showed that patients who developed stage 2 HAPrIs had a longer length of stay in the ICU than those with DTIs (odds ratio [OR] 1.001, 95% CI 1-1.002, P=.03) but were less likely than patients with DTIs to experience a diastolic blood pressure <50 mmHg (OR 0.179, 95% CI 0.072-0.416, P<.001) or receive an epinephrine infusion (OR 0.316, 95% CI 0.079-0.525, P=.008). CONCLUSIONS: Stage 2 injuries and DTIs have different risk factors and different anatomic patterns. Patients who developed DTIs were more likely to experience low diastolic blood pressure and receive epinephrine, a potent vasopressor. Stage 2 injuries were more likely to occur on the bony prominences, whereas DTIs commonly occurred on the fleshy parts of the body such as the buttock.

Morphine Equivalent Dose-Days (MED-D): Predicting the Impact of Opioid Prescription on Total Workers' Compensation Claim Costs for Acute Low Back Pain.

OBJECTIVE: To assess the effect of morphine equivalent dose-days (MED-D) on the total cost for acute low back pain (LBP) workers' compensation claims. METHODS: Simple random samples of 123 opioid and 141 nonopioid acute LBP claims were obtained. Opioid claims were divided into low, medium, and high subgroups for MED-D, MED, and prescription duration. Subgroup mean total costs were compared to the nonopioid group using multivariate regression analyses. RESULTS: MED-D and prescription duration were each, respectively, associated with significantly increased total costs at both medium and high levels. Increasing MED had a negative association with total cost, though stratification by duration abrogated this perceived trend. Interaction testing indicated MED and duration together better explained cost than MED alone. CONCLUSION: MED-D is a better predictor of total cost in acute LBP claims than MED alone.