Efficacy of Electronic Reminders in Increasing the Enhanced Recovery After Surgery Protocol Use During Major Breast Surgery: Prospective Cohort Study.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are patient-centered, evidence-based guidelines for peri-, intra-, and postoperative management of surgical candidates that aim to decrease operative complications and facilitate recovery after surgery. Anesthesia providers can use these protocols to guide decision-making and standardize aspects of their anesthetic plan in the operating room. OBJECTIVE: Research across multiple disciplines has demonstrated that clinical decision support systems have the potential to improve protocol adherence by reminding providers about departmental policies and protocols via notifications. There remains a gap in the literature about whether clinical decision support systems can improve patient outcomes by improving anesthesia providers' adherence to protocols. Our hypothesis is that the implementation of an electronic notification system to anesthesia providers the day prior to scheduled breast surgeries will increase the use of the already existing but underused ERAS protocols. METHODS: This was a single-center prospective cohort study conducted between October 2017 and August 2018 at an urban academic medical center. After obtaining approval from the institutional review board, anesthesia providers assigned to major breast surgery cases were identified. Patient data were collected pre- and postimplementation of an electronic notification system that sent the anesthesia providers an email reminder of the ERAS breast protocol the night before scheduled surgeries. Each patient's record was then reviewed to assess the frequency of adherence to the various ERAS protocol elements. RESULTS: Implementation of an electronic notification significantly improved overall protocol adherence and several preoperative markers of ERAS protocol adherence. Protocol adherence increased from 16% (n=14) to 44% (n=44; P<.001), preoperative administration of oral gabapentin (600 mg) increased from 13% (n=11) to 43% (n=43; P<.001), and oral celebrex (400 mg) use increased from 16% (n=14) to 35% (n=35; P=.006). There were no statistically significant differences in the use of scopolamine transdermal patch (P=.05), ketamine (P=.35), and oral acetaminophen (P=.31) between the groups. Secondary outcomes such as intraoperative and postoperative morphine equivalent administered, postanesthesia care unit length of stay, postoperative pain scores, and incidence of postoperative nausea and vomiting did not show statistical significance. CONCLUSIONS: This study examines whether sending automated notifications to anesthesia providers increases the use of ERAS protocols in a single academic medical center. Our analysis exhibited statistically significant increases in overall protocol adherence but failed to show significant differences in secondary outcome measures. Despite the lack of a statistically significant difference in secondary postoperative outcomes, our analysis contributes to the limited literature on the relationship between using push notifications and clinical decision support in guiding perioperative decision-making. A variety of techniques can be implemented, including technological solutions such as automated notifications to providers, to improve awareness and adherence to ERAS protocols.

Postoperative Rehabilitation of Posterior Cruciate Ligament Surgery: A Systematic Review.

Posterior cruciate ligament (PCL) injuries can be debilitating knee injuries, having involvement in up to 44% of traumatic knee injuries. However, isolated PCL injuries are relatively infrequent. Therefore, effective evidence-based rehabilitation protocols have proven to be elusive. This systematic review aims to summarize the latest evidence on postoperative rehabilitation protocols for patients undergoing PCL reconstruction. Studies included in this paper included those published from 1991 to 2019 with a grade 1 to 5 level of evidence discussing the postoperative PCL rehabilitation. A multidatabase search using largely PubMed and Ovid was conducted using relevant keywords such as "PCL," "postoperative," and "rehabilitation," initially leading to 955 papers, which were narrowed by relevance to 12 final published studies used in the analysis. Through careful review of the evidence, crucial principles of rehabilitation, such as an initial focus on protecting the graft during strengthening, as well as an optimized PCL reconstruction protocol are presented here. Rehabilitation following PCL reconstruction continues to be limited by a lack of high-quality evidence-based publications.

Postoperative Rehabilitation of Ulnar Collateral Ligament Reconstruction: A Systematic Review.

The incidence of ulnar collateral ligament injuries has increased over the past few decades with greater participation in overhead throwing sports; however, optimal postoperative management following surgery remains unclear. This systematic review summarizes the latest evidence, on postoperative rehabilitation protocols for patients undergoing ulnar collateral ligament reconstruction (UCLR). Studies published in the English language from the year 2000 to 2019 with a level 1 to 4 grade of evidence and examined rehabilitation protocols following UCLR were eligible for inclusion. A multidatabase search was conducted. Two blinded reviewers screened and graded articles for inclusion and a third independent reviewer resolved any conflicts. Ten of the original 139 studies identified were used for analysis. Surgical techniques as well as rehabilitation protocols varied across studies. Analysis gave strong evidence that a 4-phase postoperative rehabilitation protocol utilizing milestone-based goals is effective in returning athletes back to preinjury levels of activity and sport within 1 year following UCLR.

Utilization of B12 for the treatment of chronic migraine.

Chronic migraine is a particular classification of a headache that is typically unilateral and pulsatile and lasts for at least 3 months. Owing to its high prevalence and detrimental impact on personal, social, and economic aspects of patient lives, much desire has gone into fully understanding the pathogenesis of migraine, and to search for therapeutic agents. In addition to current therapeutics such as triptans, ergotamine, and monoclonal antibodies targeting calcitonin gene-related peptide receptors, vitamin B12 has been investigated for its possible use as a prophylactic agent for migraines. Specifically, the observed effects of vitamin B12 on nitric oxide and homocysteine prompt further investigation of its underlying mechanisms in migraine pathophysiology. In this comprehensive review, we provide a brief overview of migraines and current therapies while focusing on the promising role of vitamin B12 as a possible treatment option for chronic migraine management.

An evidence-based review of CGRP mechanisms in the propagation of chronic visceral pain.

Chronic pain is typically defined as pain that persists after acute tissue damage and inflammation or as pain that follows a chronic disease process and lasts more than three months. Because of its debilitating impact on the quality of life of patients, recent research aims to investigate the mechanisms behind nociception to discover novel therapeutic agents to alleviate pain. One such target is the neuropeptide calcitonin gene-related peptide (CGRP), which has shown to play an integral role in migraine pathophysiology. Effective treatments of migraines with CGRP antagonists have stimulated our efforts toward checking a possible involvement of CGRP in nonheadache pain conditions such as hypertension, congestive heart failure, Alzheimer's disease, and vascular ischemia. Here, we provide a brief overview of chronic pain, with a particular emphasis on the role of CGRP as a fundamental mediator of nociceptive pain as well as a target for novel therapeutic agents.

Influence of Sulfoxide Group Placement on Polypeptide Conformational Stability.

The synthesis of a homologous series containing five new nonionic sulfoxide containing polypeptides was described. Sulfoxide groups bestowed water solubility for all homologues, which allowed their use as a model for study of helix-coil transitions in water while avoiding contributions from charged groups or phase separation. Polypeptides were found to adopt chain conformations in water that were dependent on distance of sulfoxides from chain backbones, overall side-chain lengths, and solvent. These results allow preparation of polypeptide segments with different chain conformations without changing chemical functionality for potential use in structural studies and functional applications.