Establishing Geriatric Opiate Use Patterns in Trauma.

Introduction: There is evidence that providers often overprescribe opiates in the postoperative period. Despite an ever-growing geriatric population, there is little research detailing current opiate usage in older patients after trauma. This population presents a unique set of challenges for pain management and prescription drug dependence due to sensitivity, a narrow therapeutic window, and high rates of pre-existing polypharmacy.Objective: Assess the use of narcotics in geriatric trauma patients with various injury patterns to establish a reference point for future intervention for reduction in narcotic dependence.Methods: We created a database of trauma patients' age ≥65 years admitted to a single level 1 trauma center in the Southeastern United States during the 2019 calendar year. Information gathered included patient factors, injury patterns, operative intervention, pain medications prescribed during hospitalization and at discharge, total and average daily morphine milligram equivalents (MME) inpatient and outpatient, and requests/prescriptions for narcotics at follow-up.Results: In 2019, there were 475 patients aged ≥65 admitted to our level 1 trauma center for acute traumatic injuries. 219 of those patients required operative intervention. Average total inpatient MME for this cohort was 169.0 with average daily MME of 22.89. The average total prescribed MME upon discharge was 79.27. There were 29 patients documented to request narcotic prescription refill at time of clinic follow-up, 27 of whom were prescribed a narcotic medication at follow-up.Conclusion: This dataset establishes a reference point for opiate use in geriatric trauma patients to facilitate further research for mitigation of risk in this population.

Geriatric Bariatric Surgery: Outcomes at a Single Institution.

Obesity, especially in those over the age of 65, is associated with multiple comorbidities and decreased quality of life. Bariatric surgery is an effective method of weight loss and management of comorbidities and is increasingly utilized in younger and middle-aged populations. A retrospective review was performed of patients ≥65 years old who underwent bariatric surgery between 2018 and 2021 at a single institution to evaluate the safety and efficacy of bariatric surgery in older populations. A total of 11 patients were identified with a mean age of 67.5, ranging from 65 to 78. All patients had obesity-related comorbidities including hypertension (90.9%), obstructive sleep apnea (72.7%), diabetes mellitus (54.5%), hyperlipidemia (45.5%), and others. The mean %EWL at 12 months was 26.1% with improvement in comorbidities and no post-operative complications. Our results demonstrate that bariatric surgery can be safe for the geriatric population with improvement in weight loss and comorbidities.

A rare case of emphysematous cystitis due to Candida glabrata.

Emphysematous cystitis (EC) is a rare condition characterized by gas within the bladder wall or lumen. EC is most commonly seen in elderly women with poorly controlled diabetes mellitus (DM). Escherichia coli and Klebsiella pneumoniae are most commonly implicated. We present a 68-year-old woman with poorly controlled DM who presented with altered mental state with growth of Candida glabrata in urine and blood cultures. CT abdomen and pelvis revealed air in the bladder lumen and the extraperitoneal space. Bladder rupture was suspected and bladder decompression was managed conservatively with a foley catheter.

Robotic Adrenalectomy in a Patient With Neurofibromatosis Type 1 and Pheochromocytoma.

A 27-year-old female with a past medical history of neurofibromatosis type 1 (NF1) presented with obstructive hydrocephalus due to a thalamic tumor. The neurosurgery team attempted an operative intervention twice, but both times, the patient experienced a hypertensive emergency and unstable supraventricular tachycardia upon induction of anesthesia. After the second failed surgery, a pheochromocytoma was suspected and the workup demonstrated a left pheochromocytoma. Pheochromocytomas in patients with NF1 are known to be more dangerous and labile, requiring in-depth discussion and preparation by personnel in endocrinology, anesthesia, neurosurgery, and minimally invasive surgery. Once the patient was stable and deemed fit for surgery, a robotic adrenalectomy followed by ventriculoperitoneal shunt placement began. After induction of anesthesia, the patient went into hypertensive emergency again. However, the anesthesia team was prepared and quickly resolved this with medical therapy. Minimally invasive surgeons had the patient's live vitals displayed on their robotic monitors to increase their awareness of patient hemodynamics. This provided live feedback on the surgeons' effect as they removed the pheochromocytoma. Surgeons also performed vein clamping to preemptively see the effects of adrenalectomy. When vein clamping demonstrated safety to proceed, adrenalectomy was completed without complication. This case not only highlights the rare pathology of a woman with NF1 with pheochromocytoma, but it also demonstrates the importance of preparedness and communication among a multidisciplinary team in complex cases to ensure a successful outcome. Novel techniques were also used in performing a robotic-assisted adrenalectomy that can aid other adrenal surgeons.

Papillary Muscle Approximation Reduces Systolic Tethering Forces and Improves Mitral Valve Closure in the Repair of Functional Mitral Regurgitation.

Background: Undersizing mitral annuloplasty (UMA) to repair functional mitral regurgitation lacks durability, as it forces leaflet coaptation without relieving the sub-leaflet tethering forces. In this biomechanical study, we demonstrate that papillary muscle approximation (PMA) prior to UMA can drastically relieve tethering forces and improve valve function, without the need for significant annular downsizing. Methods: An ex vivo model of functional mitral regurgitation (FMR) was used, in which pig mitral valves were geometrically perturbed to induce FMR, and the repairs were performed. Nine pig mitral valves were studied as follows: normal(baseline), functional mitral regurgitation (FMR), true-sized annuloplasty to 30mm (TSR), and undersized annuloplasty to 26mm (DSR); and concomitant papillary muscle approximation (PMA) at both ring sizes. Mitral regurgitation, valve kinematics, and chordal forces were measured and compared between groups. Results: FMR geometry induced a 16.31±7.33% regurgitant fraction, compared to none at baseline. 30mm/TSR reduced regurgitation to 6.05±5.63% and a 26mm/DSR to 5.06±6.76%. Addition of papillary muscle approximation prior to either rings, reduced regurgitation to 3.87±6.79% with the true sized ring (TSR+PMA), and 3.71±6.25% with the downsized ring (DSR+PMA). Peak anterior and posterior marginal chordal forces were elevated to 0.09±0.1N and 0.12±0.1N respectively with FMR, which were not reduced by annuloplasty of either sizes. Addition of PMA, reduced the forces significantly to 0.23±0.02N and 0.51±0.04N. Conclusion: This biomechanical study, demonstrates that papillary muscle approximation relieves tethering forces and when added to annuloplasty, and mobilizes the leaflets to achieve a good valve closure. Such a result could be achieved without the need for extensive annular downsizing.