Outcomes of a Standardized Pain Pathway for Transgender Patients Undergoing Vaginoplasty and Vulvoplasty.

OBJECTIVE: To establish and evaluate a multimodal, opioid-minimizing pathway for gender-affirming vaginoplasty (GAVa) and vulvoplasty (GAVu) in treating postoperative pain. METHODS: A standardized pain pathway including opioids, non-opioid analgesics, and patient counseling was implemented at a single academic institution with a center for transgender care. Postoperative pain levels, analgesia methods, and opioid use for 84 GAVa and 64 GAVu patients were prospectively gathered during inpatient postoperative days 2-4 and outpatient follow-up at 2 weeks. Pertinent patient, operative, and medication administration data were extracted from patient charts and outpatient pain was measured with the Brief Pain Inventory short form (BPI-sf). RESULTS: On average, GAVa patients used 89.3 MME and GAVu patients used 41.8 MME during inpatient stay. MME decreased daily for both groups. There was no difference in MME between open and robotic GAVa. Forty-nine percent of GAVa patients and 54% of GAVu patients used ketorolac with decreasing daily inpatient use. Postoperative pain levels were similar between GAVa and GAVu patients. Fifty percent of respondents denied postoperative pain in the 24 hours preceding the survey. Forty-four percent of GAVa and of GAVu patients did not use any opioid medications in the outpatient setting, while 81% of GAVa and 83% of GAVu patients used fewer than 20 of 30 prescribed opioid tablets. Ibuprofen and acetaminophen were rated the most effective outpatient analgesics among GAVa and GAVu patients, respectively. CONCLUSION: The multimodal pathway demonstrated effective postoperative pain control for GAVa and GAVu patients while minimizing opioid use and has changed institutional prescribing practice.

Risks associated with chronic cannabis use on opioid use, length of stay, and revision rate for patients undergoing posterior lumbar interbody fusion.

BACKGROUND CONTEXT: Opioids are commonly prescribed to treat spinal pain, especially those undergoing surgery. Cannabis has been suggested as an agent that can modulate opioid needs in these patients. PURPOSE: To investigate the effect of cannabis use on perioperative opioid requirement and revision surgery rate in patients undergoing lumbar fusion. STUDY DESIGN: Retrospective cross-sectional study. PATIENT SAMPLE: A total of 48,499 patients from PearlDiver national database who underwent posterior lumbar interbody fusion. OUTCOME MEASURES: Opioid-use rates, MME, length of stay, and revision rates. METHODS: Using PearlDiver, we identified patients for posterior lumbar interbody fusion (PLIF), cannabis use disorder, revision lumbar fusion, demographics, and comorbidities. Cannabis users and non-users were propensity matched for age, sex, and tobacco use. Pre and postoperative cumulative morphine milli equivalence (MME) were calculated. Opioid-use rates, MME, length of stay (LOS), and revision rates were compared using univariate analysis. Revision rates were compared using Kaplan-Meyer log-rank analysis, and logistic and cox regression. RESULTS: Of 48,499 patients undergoing PLIF, 3.4% were identified as chronic cannabis users. They were younger, and more likely to be male and use tobacco. They had a higher rate and amount of opioid use within 90-days preoperatively, and 90- and 365-days postoperatively, after controlling for age, sex, and tobacco use. Cannabis users had longer LOS (4.4 vs 4.0 days), and a higher rate of revision surgery (6.9% vs 3.2%). Log-rank analysis, as well as logistic and cox regression confirmed an increased revision rate. Concurrent tobacco and cannabis use also had an additive effect on revision rate to 8.1%, compared with those who used only cannabis (5.4%) or tobacco (4.5%). CONCLUSIONS: Chronic cannabis use is associated with an increased preoperative and long-term postoperative opioid use, a longer length of stay, and an increased revision rate.

Robust intrinsic differences in mitochondrial respiration and H2O2 emission between L6 and C2C12 cells.

Rat L6 and mouse C2C12 cell lines are commonly used to investigate myocellular metabolism. Mitochondrial characteristics of these cell lines remain poorly understood despite mitochondria being implicated in the development of various metabolic diseases. To address this need, we performed high-resolution respirometry to determine rates of oxygen consumption and H2O2 emission in suspended myoblasts during multiple substrate-uncoupler-inhibitor titration protocols. The capacity for oxidative phosphorylation supported by glutamate and malate, with and without succinate, or supported by palmitoyl-l-carnitine was lower in L6 compared with C2C12 myoblasts (all P < 0.01 for L6 vs. C2C12). Conversely, H2O2 emission during oxidative phosphorylation was greater in L6 than C2C12 myoblasts (P < 0.01 for L6 vs. C2C12). Induction of noncoupled respiration revealed a significantly greater electron transfer capacity in C2C12 compared with L6 myoblasts, regardless of the substrate(s) provided. Mitochondrial metabolism was also investigated in differentiated L6 and C2C12 myotubes. Basal rates of oxygen consumption were not different between intact, adherent L6, and C2C12 myotubes; however, noncoupled respiration was significantly lower in L6 compared with C2C12 myotubes (P = 0.01). In summary, L6 myoblasts had lower respiration rates than C2C12 myoblasts, including lesser capacity for fatty acid oxidation and greater electron leak toward H2O2. L6 cells also retain a lower capacity for electron transfer compared with C2C12 following differentiation to form fused myotubes. Intrinsic differences in mitochondrial metabolism between these cell lines should be considered when modeling and investigating myocellular metabolism.