Efficacy and safety of apixaban compared to warfarin for nonvalvular atrial fibrillation in end-stage renal disease on hemodialysis.

BACKGROUND: This study compared the efficacy and safety of apixaban and warfarin in patients with nonvalvular atrial fibrillation (NVAF) and end-stage renal disease (ESRD) on hemodialysis (HD). Apixaban decreased incidence of stroke and bleeding compared with warfarin in major clinical trials that excluded patients with severe renal dysfunction. Apixaban is no longer contraindicated in patients with ESRD on HD with NVAF based on pharmacokinetic studies. Limited clinical data exist for patients with ESRD on HD on apixaban. METHODS: A retrospective chart review was performed on patients with a diagnosis of NVAF and ESRD on HD who were prescribed apixaban or warfarin for stroke prevention in the years 2018 through 2019. Patients' charts were reviewed for up to a 2-year period. Patients on renal replacement therapy other than HD, those using anticoagulation for reasons other than NVAF, patients with Child-Pugh Class C cirrhosis, and those with severe mitral valve stenosis were excluded. The primary outcome was emergency department visits or hospital admissions for ischemic stroke or transient ischemic attack. Secondary outcomes included major or minor bleeding and adverse effects. RESULTS: A total of 181 patients were screened; 110 patients met eligibility criteria and were included in the analysis. Four patients (7.5%) in the apixaban group and 6 patients (10.5%) in the warfarin group met the primary outcome of hospitalization or emergency department visit for stroke (P = 0.742). Symptomatic bleeding occurred in 39.6% of patients in the apixaban group and 36.8% in the warfarin group (P = 0.918). A trend in major bleeding occurred more often in the warfarin group, 52.4% versus 49.2% (P = 0.758). CONCLUSIONS: There were no statistically significant differences in efficacy and safety outcomes between apixaban and warfarin in patients with NVAF and ESRD on HD in the intention-to-treat analysis of our study. Larger trials are needed to further analyze this patient population.

Insurance-mandated weight management program completion before bariatric surgery provides no long-term clinical benefit.

BACKGROUND: There is no evidence that insurance-mandated weight loss before bariatric surgery affects outcomes. OBJECTIVE: This retrospective study evaluated the relationship between insurance-mandated weight management program (WMP) completion before primary bariatric surgery and postoperative outcomes. SETTING: Suburban academic medical center. METHODS: Patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB, n = 572) or sleeve gastrectomy (SG, n = 484) from 2014 to 2019 were dichotomized to presence (LRYGB n = 431, SG n = 348) or absence (LRYGB n = 141, SG n = 136) of insurance-mandated WMP completion. Primary endpoints included follow-up rate, percent total weight loss (%TWL), and percent excess weight loss (%EWL) through 60 months after surgery. The Mann-Whitney U test compared between-group means with significance at P < .05. RESULTS: Follow-up rate, %TWL, and %EWL were not different (P = NS) up to 60 months postoperation between groups for either surgery. Both LRYGB and SG patients without WMP completion maintained greater %TWL (LRYGB: 34.4 ± 11.1% versus 29.8 ± 11.0%, P = .159; SG: 21.4 ± 10.0% versus 18.2 ± 10.5%, P = .456) and %EWL (LRYGB: 71.3 ± 26.3% versus 67.6 ± 26.5%, P = .618; SG: 49.2 ± 18.8% versus 47.5 ± 28.8%, P = .753) at 36 months after surgery. Secondarily, duration of time to get to surgery was significantly greater among yes-WMP patients (LRYGB: 178 days versus 121 days, P < .001; SG: 169 days versus 95 days, P < .001). CONCLUSION: Insurance-mandated WMP completion before bariatric surgery delays patient access to surgery without improving postoperative weight loss potential and must be abandoned.

KIT Mutations Correlate with Higher Galectin Levels and Brain Metastasis in Breast and Non-Small Cell Lung Cancer.

To investigate a potential role for galectins as biomarkers that enable diagnosis or prognostication of breast or non-small cell lung cancer, the serum levels of galectins -1, -3, -7, -8, and -9 of cancer patients determined by ELISA assays were compared to the mutation status of 50 known cancer-critical genes, which were determined using multiplex PCR in tumors of the same patients. Mutations in the KIT proto-oncogene, which codes for the c-Kit protein, a receptor tyrosine kinase, correlated with higher levels of galectins -1, -3, -8, and -9 in breast cancer patients and galectin-1 in non-small cell lung cancer patients. Mutations in the KIT gene were more likely found in brain metastases from both of these primary cancers. The most common KIT mutation in our panel was p.M541L, a missense mutation in the transmembrane domain of the c-Kit protein. These results demonstrate an association between KIT oncogenic signaling and elevated serum galectins in patients with metastatic disease. Changes in protein trafficking and the glycocalyx composition of cancer cells may explain the observed alterations in galectin expression. This study can be useful for the targeted selection of receptor tyrosine kinase and galectin inhibitor anti-cancer treatments.

Insights into Nuclear Cardiology in the United States from the first 3 years of the ImageGuide Registry.

BACKGROUND: Data registries facilitate knowledge acquisition and quality improvement. ImageGuide is a registry developed by the American Society of Nuclear Cardiology collecting data since 2015, providing insight into current nuclear cardiology practice. METHODS AND RESULTS: HIPAA de-identified data on > 100 practice- and patient-related variables from 19 US practices were obtained from ImageGuide. Continuous variables are reported as the mean ± standard deviation; discrete variables are reported as N (%). Practices were from 12 states; 9520 studies were submitted. The average patient was a 66-year-old man. Chest pain was the most common indication; 96% of studies were appropriate. Rest/stress 1-day studies were most common; stress/rest 1- and 2-day studies comprised < 5%. Tc-99 m was the most common radiopharmaceutical. Tl-201 was used in 14% of rest studies. Most studies were not corrected for attenuation. 89% were of good or better quality. 62% of studies were normal. CONCLUSIONS: Practice diversity is limited, but patient demographics are reflective of reported current practice. Most studies are appropriate and may obviate the need for invasive testing. Radiation dosimetry could be decreased with wider adoption of stress/rest studies and avoidance of Tl-201. ImageGuide will be an important tool to guide non-invasive cardiac imaging in the future.

Morbidity and Mortality in the Obese Trauma Intensive Care Unit Patient.

INTRODUCTION: Obesity is an epidemic in the United States, known to be associated with comorbidities. However, some data show that obesity may be a protective factor in some instances. The purpose of this study is to determine if there are differences in morbidity and mortality when comparing the obese and non-obese critically ill trauma patient populations. MATERIALS AND METHODS: This was a retrospective study conducted at Prisma Health Upstate in Greenville, South Carolina, an Adult Level 1 Trauma Center. Patients over the age of 18 years admitted due to trauma from February 6, 2016 to February 28, 2019 were included in this study. Burn patients were excluded. An online trauma database was used to obtain age, sex, body mass index, Glasgow coma score (GCS), injury severity score (ISS), revised trauma score (RTS), days on mechanical ventilation, hospital length of stay (LOS), and intensive care unit (ICU) LOS. RESULTS: There were 2365 critically ill trauma patients who met inclusion criteria for this study. 1570 patients were men (66.38%) and mean age was 53.2 ± 20.9. Of the patients, 2166 patients had blunt trauma (91.59%). Median GCS was 15 (interquartilerange [IQR]: 12, 15), median RTS was 12 (IQR: 11, 12), and median ISS was 17 (IQR: 9, 22). Obese critically ill trauma patients had significantly lower odds of mortality than nonobese (OR .686, CI 0.473-.977). Penetrating traumas (OR: 4.206, CI: 2.478, 6.990), increased ISS (OR: 1.095, CI: .473, 1.112), and increased age (OR: 1.036, CI: 1.038, 1.045) were associated with significantly increased odds of mortality. DISCUSSION: The obesity paradox is observed in the obese critically ill trauma patient population.

Helicopter Transport of Trauma Patients Improves Survival Irrespective of Transport Time.

OBJECTIVES: Helicopter transport of trauma patients remains controversial. We examined the survival rates of patients undergoing helicopter versus ground transport to a Level 1 trauma center. METHODS: Retrospective analysis was performed on trauma patients treated between 2014 and 2017. Student's t-test was used to compare air versus ground transport times. A logistic regression was then used to examine the association of transportation type on survival controlling for demographics, mechanism of injury, transport time, field intubation, and injury severity. RESULTS: Of 3967 patients identified, 69.6% (2762) were male, and the average age was 40 years. Most patients suffered blunt injuries (86.8%, 3445), while the remaining had penetrating injuries (11.6%, 459) or burns (1.6%, 63). The majority of patients were transferred by ground (3449) with only 13% (518) transferred by air. Patients transported by air had increased Injury Severity Score (ISS) with a median of 17 (IQR 9-24) versus 9 (IQR 5-14), increased length of stay (LOS) at 6 days versus 3 (P < .001), and increased mortality at 12.6% vs 6.5% (P < .001). Patients transported by air arrived 16.6 ± 6.7 minutes faster compared with ground for the zip codes examined. When adjusting for the mechanism of injury, ISS, age, gender, intubation status, and transport time, air transport was associated with an increased likelihood of survival (odds ratio [OR] = 1.57, 95% CI = 1.06-2.40). CONCLUSION: In our analysis of 3967 patients, those transported by air had a significant improvement in the likelihood of survival compared with those transported by ground even when adjusting for both ISS and time.

Efficacy of beveled tip aspiration catheter in mechanical thrombectomy for acute ischemic stroke.

BACKGROUND: Direct aspiration thrombectomy techniques use large bore aspiration catheters for mechanical thrombectomy. Several aspiration catheters are now available. We report a bench top exploration of a novel beveled tip catheter and our experience in treating large vessel occlusions (LVOs) using next-generation aspiration catheters. METHODS: A retrospective analysis from a prospectively maintained database comparing the bevel shaped tip aspiration catheter versus non-beveled tip catheters was performed. Patient demographics, periprocedural metrics, and discharge and 90-day modified Rankin Scale (mRS) scores were collected. Patients were divided into two groups based on which aspiration catheter was used. RESULTS: Our data showed no significant difference in age, gender, IV tissue plasminogen activator administration, admission NIH Stroke Scale score, baseline mRS, or LVO location between the beveled tip and flat tip groups. With the beveled tip, Thrombolysis in Cerebral Infarction (TICI) 2C or better recanalization was more frequent overall (93.2% vs 74.2%, p=0.017), stent retriever usage was lower (9.1% vs 29%, p=0.024), and patients had lower mRS on discharge (median 3 vs 4, p<0.001) and at 90 days (median 2 vs 4, p=0.008). CONCLUSION: Patients who underwent mechanical thrombectomy with the beveled tip catheter had a higher proportion of TICI 2C or better and had a significantly lower mRS score on discharge and at 90 days.

Opioid Use After Inguinal and Ventral Hernia Repair.

BACKGROUND: Recent data on opioid consumption indicate that patients typically require far less than is prescribed. Prisma Health Upstate Hernia Center adopted standardized postoperative prescribing after hernia repair and began tracking patient-reported opioid utilization. The aim of this study is to evaluate patient opioid use after hernia repair in order to guide future prescribing. METHODS: All patients who underwent primary ventral (umbilical and epigastric), incisional, and inguinal hernia repair between February and May 2019 were reviewed. Patients reported the number of opioid pills taken at their first postoperative visit and documented either in the progress note or in the Americas Hernia Society Quality Collaborative (AHSQC) patient-reported outcomes (PRO) questionnaire. All demographic, operative, and outcomes data were captured prospectively in the AHSQC. Opioid use reported as milligram morphine equivalents (MME). RESULTS: A total of 162 surgeries were performed during the study period, and 107 had patient-reported opioid use for analysis. Inguinal hernia repair was performed in 36 patients, 10 primary ventral hernia repairs, and 61 incisional hernia repairs. No opioid use was reported in 63.9% of inguinal hernias, 60% of primary ventral hernias, and 20% of incisional hernias. Inguinal hernia patients consumed a mean of 10.5 MME, primary ventral patients 11 MME, and incisional hernia patients 78.5 MME. CONCLUSION: Patients require little to no opioid after primary ventral or inguinal hernia repair and opioid-free surgery is feasible. Incisional hernia is more heterogenous, but the majority of patients still required less opioid than previously thought.

Implementation of an Evidence-Based Protocol Significantly Reduces Opioid Prescribing After Ventral Hernia Repair.

BACKGROUND: Increased recognition of the dangers of opioid analgesia has led to significant focus on strategies for reducing use through multimodal analgesia, enhanced recovery protocols, and standardized guidelines for prescribing. Our institution implemented a standard protocol for prescribing analgesics at discharge after ventral hernia repair (VHR). We hypothesize that this strategy significantly reduces opioid use. METHODS: A standardized protocol for discharge prescribing was implemented in March 2018. Patients were prescribed ibuprofen, acetaminophen, and opioids based on milligram morphine equivalent (MME) use the 24 hours prior to discharge. We retrospectively reviewed prescriptions of opioids for two 6-month periods-July-December 2017 (PRE) and July-December 2018 (POST)-for comparison using EPIC report and the South Carolina Prescription Monitoring Program. Analysis performed included Mann-Kendall linear trend test and Student's t-test for continuous variables. RESULTS: VHR was performed in 105 patients in the PRE and 75 patients in the POST group. Total MME prescribed decreased significantly from mean 322.7 + 261.3/median 225 (IQR 150-400) MME to 141.6 + 150.4/median 100 (50-184) MME (P < .001). This represents a 57% reduction in mean opioid MME prescriptions. Acetaminophen prescribing increased from 10% to 65%, and ibuprofen from 7.6% to 61.3%. Refills were prescribed in 21 patients (20%) during the PRE period, which decreased to 10.7% during the POST group (P = .141). Implementation of an evidence-based protocol significantly reduces opioid prescribing after VHR. DISCUSSION: A multimodal approach to postoperative pain management decreases the need for opioids. The additional implementation of an evidence-based prescribing protocol results in significant reduction of opioid use following VHR.

Association Between a Physical Activity Vital Sign and Cardiometabolic Disease in High-Risk Patients.

OBJECTIVE: To determine the association between the physical activity vital sign (PAVS) and markers of cardiometabolic disease. DESIGN: Patients were assessed through the PAVS, a validated tool self-reporting the frequency and duration of physical activity. Patients were categorized into 3 groups: inactive (0 minutes per week), underactive (1-149 minutes per week), and active (>150 minutes per week). Associations were tested between the PAVS and the cardiometabolic disease biomarkers of body mass index, hemoglobin A1c (A1c), blood pressure, and low-density lipoprotein (LDL) using one-way analyses of variance. SETTING: High-risk family medicine residency clinic. PARTICIPANTS: Two thousand three hundred twenty-one adult patients (age ≥ 18 years). RESULTS: Participants reported a mean of 97.87 (SD = 149.35) minutes per week of exercise. Overall, 50.1% reported physical inactivity, 25.7% were underactive, and 24.3% were active. Younger individuals (P < 0.001) and men (P < 0.05) reported more physical activity than older individuals and women. Patients who reported being active were significantly less likely to be overweight (P < 0.05), obese (P < 0.05), or hypertensive (P < 0.05), but there was no association with A1c or LDL levels. CONCLUSIONS: This is the first investigation to examine the PAVS in a high-risk population. In these patients, reported levels of physical inactivity are 150% higher than other clinical settings, and the PAVS is only associated with improvements in 2 of 4 major cardiometabolic risk factors. For this group, self-reported levels of physical activity may need to be higher for cardiovascular benefits to be realized in all 4 cardiometabolic domains. The PAVS offers health professionals an opportunity to encourage lifestyle-based interventions to reduce cardiovascular risk, but refinements may be necessary to address this population.

Factors affecting salvage rate of infected prosthetic mesh.

BACKGROUND: Prosthetic mesh infection (PMI) is a challenging complication of ventral hernia repair (VHR). The sparsity of data leaves only experience and judgment to guide surgical decision-making. METHODS: Retrospective review of patients diagnosed with PMI. Subsequent abdominal operation (SAO) constitutes any intraabdominal operation occurring after the index hernia repair prior to PMI presentation. Any mesh removal was considered salvage failure. Analysis was performed using Chi-square test, Fishers Exact, or Mann-Whitney U test. Analyses completed using R Version 3.0.2. RESULTS: We identified 213 instances of PMI. Most cases (58.7%) involved intraperitoneal mesh. Thirty-seven percent of patients had an SAO, only 25.3% of which were clean cases. Enteroprosthetic fistula occurred in 38 patients (17.8%). Mean time to presentation was 19.9 mos after index hernia repair or SAO for infection alone, and 48.1 mos when a fistula was present (p < 0.001). Percutaneous drainage was used to treat 29 cases, successfully in 10 (34.5%), 8 of which were macroporous polypropylene and 2 biologic mesh. Negative pressure wound therapy (NPWT) was used in 46 patients, but successful in only 16 (34.8%), all of which were macroporous polypropylene. Local wound care alone successfully salvaged only 16 of 85 meshes (18.8%), 13 of which were macroporous polypropylene. Macroporous polypropylene mesh was salvaged in 65% of cases overall, and 72.2% when in an extraperitoneal position. Mesh salvage was not possible in any case involving composite or PTFE mesh, and rarely for microporous polypropylene (7.7%) multifilament polyester (4.2%), or intraperitoneal mesh (2.4%). Closure of the defect after mesh removal significantly lowers recurrence rate (p < 0.001). CONCLUSION: PMI involving composite, PTFE, multifilament polyester, or microporous polypropylene mesh requires explantation in nearly all cases. Infected macroporous polypropylene mesh in an extraperitoneal position is salvageable in most cases. Furthermore, the risk of secondary mesh infection after SAO, particularly with intraperitoneal mesh, should be considered during index VHR.

Safety and Efficacy of Synthetic Mesh for Ventral Hernia Repair in a Contaminated Field.

BACKGROUND: Controversy remains about appropriate mesh selection during ventral hernia repair (VHR) in a contaminated field. Fear of mesh infection has led to increased use of biologic and absorbable synthetic meshes rather than permanent synthetic mesh in these cases. We report the safety and efficacy of permanent synthetic mesh during contaminated VHR. STUDY DESIGN: Retrospective review of our database identified all cases of contaminated VHR from July 2007 to May 2019. Student's t-test and Wilcoxon rank sum were used to analyze continuous variables, and discrete variables with Fisher's or Kruskal-Wallis test. RESULTS: There were 541 contaminated cases: 245 clean-contaminated, 214 contaminated, and 82 dirty cases. Suture repair was performed in 46 patients, biologic mesh was used in 38, absorbable synthetic mesh in 55, and permanent synthetic mesh in 402. Mesh was extraperitoneal in 97% of cases. Incidence of surgical site infection in each group was 17.4%, 36.8%, 32.7%, and 14.2%, respectively (p < 0.001). Multivariate analysis showed no effect of mesh selection on risk of surgical site infection. Mesh was removed in 7 patients; 5 were permanent synthetic (1.2%), 1 was absorbable synthetic (1.8%), and 1 was biologic (2.6%). In 4 patients there was mesh-specific complication and the remaining meshes were removed during exploration for indications unrelated to the mesh. At a median follow-up of 30.2 months, recurrence occurred in 15.2% of patients and was significantly lower with permanent synthetic mesh. CONCLUSIONS: Permanent synthetic mesh placed in an extraperitoneal position is not only safe for VHR in a contaminated field, but it confers a significantly lower rate of surgical site infection and recurrence compared with biologic or bioabsorbable meshes.

Preoperative Portal Vein Embolization Is Not Associated with Increased Postoperative Complications After Major Hepatectomy: a Study of the National Surgical Quality Improvement Database.

BACKGROUND: Preoperative portal vein embolization (PVE) is selectively performed to induce hypertrophy of the future liver remnant prior to major liver resection. The primary aim of this study was to determine the association of PVE with liver-specific and overall postoperative morbidity. METHODS: A retrospective cohort study of patients who underwent major hepatectomy from 2014 to 2016 within the ACS-NSQIP hepatectomy-specific module was performed. RESULTS: Of the 3912 patients identified, 9.9% (N = 388) underwent PVE. Patients who underwent PVE were older (59.1 vs. 57.7 years). Most patients in the PVE cohort underwent right hepatectomy (51.8%, N = 201) or trisectionectomy (46.1%, N = 179), compared with right (49.3%, N = 1738) and left hepatectomy (29.6%, N = 1042) in the non-PVE cohort (p < 0.001). Median operative time was longer in the PVE group (310 vs. 276 min, p < 0.001). Post-hepatectomy liver failure was more common among patients undergoing PVE (18.6% (N = 72) vs. 9.9% (N = 350), p < 0.001), as was bile leak (17.3% (N = 67) vs. 12.2% (N = 428), p = 0.005). Overall complication rates were higher among patients who underwent PVE (45.9% (N = 178) vs. 34.0% (N = 1199), p < 0.001). However, on multivariable analysis controlling for patient and technical factors, PVE remained associated with an increased risk of liver-specific complications (OR 1.33, 95% CI 1.01-1.74) but not with overall complications (OR 1.17, 95% CI 0.92-1.50). CONCLUSION: Within a national cohort, patients treated with PVE are older and undergo a more extensive liver resection. When controlling for patient and technical factors, PVE is neither associated with an increase in overall morbidity nor mortality, suggesting that PVE can be safely used in appropriate patients undergoing major hepatectomy.

Delayed gastric emptying after pancreaticoduodenectomy: A study of the national surgical quality improvement program.

BACKGROUND: Delayed gastric emptying (DGE) remains common after pancreaticoduodenectomy (PD). Risk factors for DGE have been difficult to identify due to a lack of a standard definition. The purpose of this study was to identify factors associated with DGE using a standard definition across a national cohort of patients. METHODS: A retrospective cohort study of patients who underwent PD from 2014 to 2016 within the ACS-NSQIP pancreatectomy-specific module was performed. Multivariable (MV) regression was used to determine perioperative risk factors for DGE. RESULTS: Of 10,249 patients undergoing PD, 16.6% developed DGE and were older (65.3 vs. 64.3 years), more often male (62.5% vs. 51.9%), overweight/obese (66.7% vs. 61.3%), and American Society of Anesthesiologist (ASA) class 3 (80.0% vs. 76.0%). Rates of pylorus preservation (41.4% vs. 38.7%) were higher, and median operative time (373 vs. 354 min) longer. On MV analysis, age≥65 years [OR 1.26 (95%CI 1.13-1.41)], male sex [OR 1.54 (95%CI 1.38-1.72), body mass index (BMI) > 30 [OR 1.22 (95%CI 1.06-1.40)], ASA class≥3 [OR 1.24 (95%CI 1.08-1.42)], pylorus preservation [OR 1.08 (95%CI 1.02-1.14)], and longer operative time [OR 1.26 (95%CI 1.13-1.40)] remained associated with DGE. Preoperative chemotherapy was associated with decreased risk of DGE [OR 0.77 (95%CI 0.64-0.93)]. CONCLUSION: In this national, multicenter cohort of patients undergoing PD, 16.6% of patients developed DGE based on a standardized definition. Perioperative factors including age, BMI, ASA class, pylorus preservation, and operative time were associated with increased risk of DGE. Further research is warranted to identify opportunities for prevention via preoperative rehabilitation strategies and treatment.

Prevalence of Clinic First Curricula: A Survey of AFMRD Members.

BACKGROUND AND OBJECTIVES: Clinic First residency curricular approaches hold promise as models to successfully prepare primary care residents for future practice. The objective of our study was to estimate the prevalence of the Clinic First model in current family medicine residency training environments, and assess beliefs surrounding curricular structure and postgraduate practice. METHODS: An eight-question survey was conducted among Association of Family Medicine Residency Directors (AFMRD) members in 2017. Data were grouped and analyzed for statistical significance and correlation using analysis of variance, Kendall's τ, χ2, and Fisher exact test. RESULTS: Two hundred-eleven AFMRD members responded to the survey; 27% described their current curriculum as Clinic First; 68% stated that their ideal curriculum is Clinic First. Residents in Clinic First programs spend more half-days in continuity clinic per week compared with traditional programs during PGY1 (1.79, 1.39, P=0.001) and PGY2 (3.18, 2.90, P=0.024). In group analyses, 63% of Clinic First respondents prioritized clinic in developing resident schedules, compared with 8% of traditional respondents (P<0.001). Seventy-four percent of Clinic First respondents described their philosophy as full spectrum, compared with 93% of traditional respondents (P<0.001). Seventy-five percent of respondents listed their graduates' most common practice type as outpatient practice, and there were no differences between groups (P=0.361). Sixty-one percent of traditional respondents stated that their ideal curriculum is Clinic First (P<0.001). CONCLUSIONS: There is a high level of interest in the Clinic First model as a tool to prepare residents for future practice, but barriers to implementation need to be explored and addressed.

Length of Stay and Opioid Dose Requirement with Transversus Abdominis Plane Block vs Epidural Analgesia for Ventral Hernia Repair.

BACKGROUND: Major abdominal operations often requires postoperative opioid analgesia. However, there is growing recognition of the potential for abuse. We previously reported a significant reduction in opioid consumption after implementation of an Enhanced Recovery after Surgery protocol after ventral hernia repair focusing on opioid reduction. Epidural use was routine for postoperative pain control in this protocol. Recently, we have transitioned to transversus abdominis plane (TAP) block instead of epidural analgesia. We hypothesize that this modification reduces length of stay and lowers opioid use in ventral hernia repair. METHODS: All patients undergoing open ventral hernia repair were recorded prospectively in the Americas Hernia Society Quality Collaborative database. All patients receiving either TAP or epidural between February 2015 and March 2018 were identified. Additional review was performed to quantify opioid use in morphine milligram equivalents (MMEs). Primary outcomes were length of stay and opioid use. RESULTS: Epidural was used in 172 patients and TAP block in 74. There were no significant comorbidity differences between groups. The TAP group had a slightly higher BMI (33.6 kg/m2 vs 28.3 kg/m2) and slightly smaller hernias (8.8 cm vs 10.8 cm). There was no difference in 30-day surgical site infections. Hospital length of stay was significantly shorter with TAP block (2.4 vs 4.5 days; p < 0.001). Total MME requirements for patients receiving TAP block were lower than those with epidural during postoperative days 1 and 2 (mean 40 vs 54.1 MMEs; p = 0.033 and 36.1 vs 52.5 MMEs; p = 0.018). CONCLUSIONS: Use of TAP block significantly reduces length of stay and decreases opioid dose requirements in the early postoperative period compared with epidural analgesia.

Medially-stabilized total knee arthroplasty does not alter knee laxity and balance in cadaveric knees.

Instability after total knee arthroplasty (TKA) can lead to suboptimal outcomes and revision surgery. Medially-stabilized implants aim to more closely replicate normal knee motion than other implants following TKA, but no study has investigated knee laxity (motion under applied loads) and balance (i.e., difference in varus/valgus motion under load) following medially-stabilized TKA. The primary purposes of this study were to investigate how medially-stabilized implants change knee laxity in non-arthritic, cadaveric knees, and if it produces a balanced knee after TKA. Force-displacement data were collected on 18 non-arthritic cadaveric knees before and after arthroplasty using medially-stabilized implants. Varus-valgus and anterior-posterior laxity and varus-valgus balance were compared between native and medially-stabilized knees at 0°, 20°, 60°, and 90° under three different loading conditions. Varus-valgus and anterior-posterior laxities were not different between native and medially-stabilized knees under most testing conditions (p ≥ 0.068), but differences of approximately 2° less varus-valgus laxity at 20° of flexion and 4 mm more anterior-posterior laxity at 90° were present from native laxities (p < 0.017) Medially-stabilized implant balance had ≤1.5° varus bias at all flexion angles. Future studies should confirm if the consistent laxity afforded by the medially-stabilized implant is associated with better and more predictable postoperative outcomes. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:335-349, 2019.

Postoperative outcomes in bariatric surgical patients participating in an insurance-mandated preoperative weight management program.

BACKGROUND: Many insurance companies require patient participation in a medically supervised weight management program (WMP) before offering approval for bariatric surgery. Clinical data surrounding benefits of participation are limited. OBJECTIVE: To evaluate the relationship between preoperative insurance-mandated WMP participation and postoperative outcomes in bariatric surgery patients. SETTING: Regional referral center and teaching hospital. METHODS: A retrospective review of patients who underwent vertical sleeve gastrectomy or Roux-en-Y gastric bypass between January 2014 and January 2016 was performed. Patients (N = 354) were divided into 2 cohorts and analyzed according to presence (n = 266) or absence (n = 88) of an insurance-mandated WMP requirement. Primary endpoints included rate of follow-up and percent of excess weight loss (%EWL) at postoperative months 1, 3, 6, and 12. All patients, regardless of the insurance-mandated WMP requirement, followed a program-directed preoperative diet. RESULTS: The majority of patients with an insurance-mandated WMP requirement had private insurance (63.9%). Both patient groups experienced a similar proportion of readmissions and reoperations, rate of follow-up, and %EWL at 1, 3, 6, and 12 months (P = NS). Median operative duration and hospital length of stay were also similar between groups. Linear regression analysis revealed no significant improvement in %EWL at 12 months in the yes-WMP group. CONCLUSION: These data show that patients who participate in an insurance-mandated WMP in addition to completing a program-directed preoperative diet experience no significant benefit to rate of readmission, reoperation, follow-up, or %EWL up to 12 months postoperation. Our findings suggest that undergoing bariatric surgery without completing an insurance-mandated WMP is safe and effective.

Resident Preferences for Program Director Role in Wellness Management.

BACKGROUND: Burnout and depression are prevalent among resident physicians, though the supportive role of the program director (PD) is not well defined. OBJECTIVE: To understand the residents' view of the residency program director's role in assessing and promoting resident wellness. METHODS: A single institution survey of all house staff was conducted in 2017. Rates of burnout and depression were identified via the 2-item Maslach Burnout Inventory (MBI) and the Patient Health Questionaire-2 (PHQ-2), respectively. Residents then qualified their preferences for various assistance services and for the role of their program directors in assisting them. RESULTS: One-hundred sixty-one of 202 (79.7%) residents completed the survey. The rate of depression was 28%. Rates of emotional exhaustion and depersonalization (2-item MBI) were 44 and 62%, respectively. Only 4% of respondents had used the Employee Assistance Program (EAP) in the prior 12 months. Eighty-two percent of residents were in favor of PDs inquiring about wellness regardless of their job performance and only 1% of residents stated the PD should not inquire about wellness at all. Thirty-three percent of residents reported that they would be likely to contact EAP on their own if they felt unwell. Significantly more residents (62%) reported being more likely to contact EAP if recommended by their PD (33 vs 62%, p < 0.001%). Important perceived barriers to seeking assistance were lack of time (65%), lack of knowledge of how to contact EAP (41%), and concerns about appearing weak (35%). CONCLUSIONS: Despite a high prevalence of burnout and depression, residents are unlikely to seek help on their own. Program directors have an important role in assessing and promoting the wellness of their residents. The majority of residents wants their PD to inquire about wellness and may be more likely to seek and receive help if recommended and facilitated by their PD.