6-week Visit Research Articles

Long-Awaited AAP Hyperbilirubinemia Guidelines Have Arrived.

Long-Awaited AAP Hyperbilirubinemia Guidelines Have Arrived.

8942 Development of a Novel Physical Exam for Patients Undergoing Laparoscopic Excision of Endometriosis

Study Objective To create and validate a standardized physical exam for patients undergoing laparoscopic excision of endometriosis surgery. Design Prospective observational feasibility study. Setting Large academic hospital. Patients or Participants Patients (n = 17) undergoing operative laparoscopy for management of endometriosis were consented and enrolled before surgery and followed up to 6 weeks postoperatively. This is an ongoing study with plan to enroll 30 participants. Interventions N/A. Measurements and Main Results We developed a physical exam that included numerical pain ratings from regions typically affected by endometriosis. The complete exam was conducted at the preoperative visit and a modified version was performed at 2-week and 6-week postoperative visits for patient comfort. Composite pain scores were calculated from the modified physical exam to quantify physical symptom severity. These scores were compared to a validated patient-reported outcome measure for pain, Brief Pain Inventory (BPI). The composite physical exam pain scores improved progressively following surgery, decreasing from a median of 22.5 (IQR 14-34.29) preoperatively to 11.5 (IQR 5.26-16) at 6-weeks postoperative (p=0.072 using Wilcoxon signed-rank test). This was consistent with a decrease in average pain reported using BPI (p= 0.063). Spearman correlation coefficients showed a moderate correlation between preoperative physical exam scores and BPI (rho = 0.5419). Conclusion Currently, there is no consensus physical exam to describe symptom severity for patients with chronic pelvic pain. We report a novel standard physical exam to describe endometriosis symptom severity. Even though our results were not statistically significant, we observed a reduction in physical exam pain scores reported before and after surgery, which correlated with pain scores collected using a validated pain questionnaire. This proposed exam could be used to objectively follow up success of endometriosis excision. Our study is currently underpowered and anticipate achieving statistical significance after completing recruitment. To create and validate a standardized physical exam for patients undergoing laparoscopic excision of endometriosis surgery. Prospective observational feasibility study. Large academic hospital. Patients (n = 17) undergoing operative laparoscopy for management of endometriosis were consented and enrolled before surgery and followed up to 6 weeks postoperatively. This is an ongoing study with plan to enroll 30 participants. N/A. We developed a physical exam that included numerical pain ratings from regions typically affected by endometriosis. The complete exam was conducted at the preoperative visit and a modified version was performed at 2-week and 6-week postoperative visits for patient comfort. Composite pain scores were calculated from the modified physical exam to quantify physical symptom severity. These scores were compared to a validated patient-reported outcome measure for pain, Brief Pain Inventory (BPI). The composite physical exam pain scores improved progressively following surgery, decreasing from a median of 22.5 (IQR 14-34.29) preoperatively to 11.5 (IQR 5.26-16) at 6-weeks postoperative (p=0.072 using Wilcoxon signed-rank test). This was consistent with a decrease in average pain reported using BPI (p= 0.063). Spearman correlation coefficients showed a moderate correlation between preoperative physical exam scores and BPI (rho = 0.5419). Currently, there is no consensus physical exam to describe symptom severity for patients with chronic pelvic pain. We report a novel standard physical exam to describe endometriosis symptom severity. Even though our results were not statistically significant, we observed a reduction in physical exam pain scores reported before and after surgery, which correlated with pain scores collected using a validated pain questionnaire. This proposed exam could be used to objectively follow up success of endometriosis excision. Our study is currently underpowered and anticipate achieving statistical significance after completing recruitment.

Recovery from open osteocapsular débridement for primary elbow osteoarthritis is rapid and does not depend on preoperative motion.

Osteocapsular débridement is a surgical treatment for functionally limiting primary elbow osteoarthritis (PEOA). We hypothesized that postoperative improvement in range of motion (ROM) following elbow osteocapsular débridement could be grouped into predictable patterns. We also hypothesized that significant improvements in ROM frequently take place for up to 6 months after surgery. A retrospective chart review of patients who underwent open elbow débridement for PEOA was performed. Demographic information and surgical approach were recorded. ROM data were also collected at preoperative, intraoperative, and postoperative intervals of 2 weeks, 6 weeks, 3 months, and 6 months. Growth mixture modeling and latent class growth analysis were performed to identify groups of motion recovery trajectories, while Student's t-tests were performed to compare ROM data between intervals. Our study included 76 patients who underwent open elbow débridement (9 with a lateral approach, 55 medial, and 12 both) for PEOA. The mean preoperative arc of motion was 95°±22°. This improved to a mean final motion arc of 127°±11 at final follow-up, which was 92% of the mean intraoperative arc. The mean time to achieve final motion was 3 months, with 79% of patients achieving their final ROM arc by this point. Patients achieved an average of 85% of their final arc of motion by the 2-week postoperative visit (92% of final flexion and 61% of final extension). Growth mixture modeling and latent class growth analysis did not identify any statistically significant groupings for postoperative ROM progression trajectories. Arc of motion preoperatively, intraoperatively, and at 2 weeks postoperatively did not correlate with the final arc of motion. There were no characteristics or thresholds of motion which conferred a higher likelihood of achieving a better result postoperatively. ROM recovery after osteocapsular débridement for PEOA is not dependent on preoperative, intraoperative, or 2-week postoperative arcs of motion. Most of the ROM recovery occurs in the early postoperative period, with flexion restored preferentially faster than extension. The final arc of motion can be expected by 3 months postoperatively. This knowledge has potential benefit in affecting patients' personal time commitment to rehabilitation and the overall cost for therapy and splinting beyond the 3-month time point.

Ureterolysis for Deep Infiltrating Endometriosis Using Indocyanine Green on the Robotic Platform

<h3>Study Objective</h3> To demonstrate safe identification of ureters in patients with deep infiltrating endometriosis or severe adhesive disease using indocyanine green under near-infrared fluorescence on the robotic platform. <h3>Design</h3> Stepwise demonstration using narrated video footage. <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> A 43-year-old G0 with stage IV endometriosis presented with chronic pelvic pain. Her surgical history is notable for two aborted hysterectomies due to severe adhesive disease, despite extensive lysis of adhesions. She desired surgical intervention. <h3>Interventions</h3> In cases of stage IV endometriosis, localizing the ureters can be challenging due to severe adhesive disease, surrounding fibrotic tissue, and distorted anatomy. Intravenous indocyanine green has previously been described to assist with resection of endometriosis.^1-3 Alternatively, we describe a technique that allows for easier identification of ureters using indocyanine green (ICG) injection retrogradely in ureteral stents while visualized under near-infrared fluorescence (NIRF).^4-5 1. Perform cystoscopy and place bilateral open-ended 5-French ureteral catheters. Inject indocyanine green retrogradely in each ureteral catheter, and place caps to seal the catheters to maximize ICG retention. 2. Once robotic-assisted laparoscopic surgery is started, use NIRF to identify the ureter. The ureter will emit green fluorescence, whereas the surrounding tissue will not. 3. Once the ureter is identified, NIRF is intermittently used to safely follow the course of the ureter and perform ureterolysis, while excising endometriosis. <h3>Measurements and Main Results</h3> The patient underwent robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral ureterolysis, low anterior bowel resection with primary anastomosis, and resection of endometriosis without intraoperative complications or ureteral injury. Her postoperative course was unremarkable. At her 3-week postoperative visit, pelvic pain had completely resolved. <h3>Conclusion</h3> This case demonstrates the use of intra-ureteral ICG and NIRF to identify the ureters and perform ureterolysis in cases of deep infiltrative endometriosis.

Effectiveness and tolerability of adjunctive perampanel in the treatment of pediatric patients with uncontrolled epilepsy: A retrospective, single-center, real-world study

ObjectiveThe main aim of this study was to assess the efficacy, safety, and tolerability of adjunctive perampanel (PER) in the treatment of children and adolescents with epilepsy. MethodsPediatric patients who visited the pediatric epilepsy clinic of Henan Provincial People’s Hospital between May 2020 and December 2021 were recruited. All participants were treated with PER as adjunctive therapy and were seen routinely (minimum: a baseline and 12-week visit). The efficacy and tolerability of adjunctive PER for the treatment of epilepsy were investigated. ResultsOne hundred and fourteen patients were enrolled, among whom 7 (6.1%) were lost to follow-up. At 12 weeks, the responder rate and the seizure-free rate were 56.1% (60/107) and 32.7% (35/107), respectively. The responder rate increased with the duration of PER administration and was significantly higher when PER was used as an early add-on (after ≤2 prior antiseizure medications (ASMs)) than a late add-on (after >2 prior ASMs). However, there was no significant difference in the treatment efficacy of adjunctive PER in patients with different epilepsy etiologies or types. Adverse events, including irritability, dizziness, somnolence, ataxic gait, weight gain, and tinnitus, were reported in thirty-two patients (29.9%). ConclusionsIn a routine clinical setting of pediatric patients with epilepsy, good effectiveness and tolerability of adjunctive PER were demonstrated. Notably, patients initiating PER as an early add-on showed a better seizure outcome than those initiating PER as a late add-on.

Short-term effect of orthokeratology lens wear on choroidal blood flow in children with low and moderate myopia

We investigated changes in choroidal vascularity and choriocapillaris blood perfusion during orthokeratology (Ortho-K) lens wear. Sixty-two children with low to moderate myopia were enrolled. The Ortho-K group (n = 42) continuously wore Ortho-K lenses for 3 months, and the controls (n = 20) wore single-vision distance spectacles. All of the patients were instructed to return for follow-up visits after 1 day, 1 week and 1 month and 3 months of treatment. The subfoveal choroidal thickness (SFChT), choroidal vascularity [including the total choroidal area, luminal area, stromal area, and choroidal vascularity index (CVI)] and percentage of choriocapillaris flow voids (FV%) were determined with a Cirrus HD-OCT instrument. Additionally, ocular parameters were measured. In the Ortho-K group, the SFChT significantly increased by 12.61 ± 5.90 μm, the CVI was significantly increased by 2.99 ± 2.07% and 3.01 ± 2.32% on the horizontal and vertical scans respectively, and the FV% was significantly decreased by 0.89 ± 0.34% from baseline at the 1-week visit (all p < 0.001). The choroidal parameters remained unchanged at the 1-month and 3-month follow-ups with respect to the 1-week follow-up. In the control group, the choroidal parameters did not change significantly at 1 month (all p > 0.05). At the 3-month visit, the changes in the axial length (AL) and vitreous chamber depth (VCD) were significantly greater in the control group than in the Ortho-K group (0.14 ± 0.23 and 0.03 ± 0.05 mm in AL, 0.15 ± 0.23 and 0.06 ± 0.03 mm in VCD respectively). Our longitudinal study showed several choroidal parameter changes in the early stage in Ortho-K lens wearers with low to moderate myopia, and these changes persisted over 3 months. We speculate that Ortho-K lenses regulate choroidal thickness and blood perfusion, affecting myopia development.

Examining Age and Postoperative Opioid Use in the Urogynecology Population: A Prospective Study.

Surgeons must individualize postoperative pain management while also reducing the amount of unused prescribed opioids. This study compared postoperative opioid use in younger versus older women following urogynecologic surgery. We also assessed the likelihood of women returning unused opioids for safe disposal. This was a prospective study of women undergoing pelvic reconstructive surgery divided into 2 cohorts: younger (<65 years) and older (≥65 years). Our primary outcome was total opioid use, measured in morphine milligram equivalents (MME). We also assessed the average pain score during the first week after surgery measured by a numerical pain scale (range, 0-10). Our secondary outcome was the rate of return of unused prescribed opioids at the 6-week postoperative visit utilizing a disposable drug deactivation system. From April 2019 to September 2021, 152 participants were enrolled: 92 (61%) in the younger cohort (mean age, 51 ± 8 years) and 60 (39%) in the older cohort (mean age, 72 ± 6 years). For our primary outcome, younger women used significantly more opioids during the first postoperative week compared with older women (49 ± 71 vs 28 ± 40 MME, respectively, P = 0.04), despite no difference in average pain scores (4 ± 2 younger vs 3 ± 2 older, P = 0.05). For our secondary outcome, 23% of participants returned their opioids for disposal with the drug deactivation system. Younger women had higher postoperative opioid use despite similar pain scores after urogynecologic surgery. Among those prescribed opioids, a quarter of participants returned their opioids for disposal at their postoperative visit.

Risk factors for ocular hypotony after XEN Gel Stent implantation

PurposeTo investigate the incidence of postoperative hypotony, and risk factors for the development of hypotony in eyes who had undergone XEN Gel Stent implantation.MethodsIn this retrospective, single-centre case series, medical records of 170 consecutive eyes who had undergone XEN Gel Stent implantation with or without simultaneous phacoemulsification for primary or secondary open angle glaucoma were analysed. Primary outcome parameters were the incidence of postoperative hypotony and potential risk factors for its development, and secondary parameters were pre- and postoperative visual acuity, intraocular pressure (IOP), and number of IOP-lowering eye drops.ResultsPostoperative hypotony ≤ 6 mmHg occurred in 57% of eyes. Hypotony was without complications in 70.1%, 13.4% had transient complications with spontaneous resolution, and 16.5% had complications requiring treatment. Mean visual acuity logMAR before surgery accounted for 0.47 ± 0.46 in all eyes and 0.47 ± 0.48 at the 4-week visit. There was no significant difference of BCVA in the group of eyes with and without postoperative hypotony before and after surgery. The mean IOP before surgery was 24.6 ± 8.4 mmHg and decreased significantly to 18.4 ± 10.2 after 4 weeks.Eyes with an axial length over 24.3 mm had a threefold increased risk for postoperative hypotony (OR 3.226, 95% confidence interval 1.121–9.279). This risk was decreased in eyes with simultaneous cataract surgery (OR 0.483, 95% confidence interval 0.258–0.903).ConclusionIn our sample, postoperative hypotony was a common complication after XEN Gel Stent implantation, but serious, persistent complications were rare. A longer axial length predisposes the eye for the development of hypotony.

Comparing Dermabond PRINEO versus Dermabond or staples for wound closure: a randomized control trial following total shoulder arthroplasty.

The method of surgical incision closure after total shoulder arthroplasty is an important factor to consider, as it affects operating room time, procedure cost, cosmetic outcomes, and patient satisfaction. The optimal method of wound management is unknown, but should be cost-effective, reproducible, and provide a reliable clinical result. This study aimed to compare the following wound closure methods after total shoulder arthroplasty: staples, Dermabond, and Dermabond PRINEO. We hypothesized that wound closure time for Dermabond PRINEO would be faster than Dermabond and comparable to that of staples, and Dermabond PRINEO would be more cost-effective than Dermabond and staples, and provide equal or superior closure outcomes to Dermabond and staples. A randomized, prospective clinical trial comparing wound closure time and cost for 2 surgeons' traditional technique with that of Dermabond PRINEO was conducted. This study included at least 18 subjects in each group. Surgeon 1's patients were randomized to traditional Dermabond or Dermabond PRINEO, whereas surgeon 2's patients were randomized to staples or Dermabond PRINEO. Cosmetic outcomes and satisfaction scores were collected at 6 weeks and 3 months, postoperatively. Incisions were photographed, at both the 6-week and 3-month visits, and subsequently evaluated by a plastic surgeon blinded to the treatment method. The wound closure time for surgeon 1 was significantly faster for Dermabond PRINEO vs. Dermabond, and surgeon 2 closed significantly faster with staples vs. Dermabond PRINEO. The mean cost of closure was significantly less with Dermabond PRINEO compared with Dermabond, whereas the mean cost of staples was significantly less than Dermabond PRINEO. For both surgeons 1and 2, there were no significant differences in patient satisfaction at 6 weeks or 3 months. In addition, the wound closure methods did not produce differing cosmetic outcomes. Although significant, the closing time for each method did not differ by a clinically relevant amount. Staples were the most cost-effective closing method, followed by Dermabond PRINEO. As neither method was superior over the other in terms of patient satisfaction, adverse events, and cosmetic outcomes, cost-effectiveness may be the greatest differentiator between the 3 methods.

Ciliochoroidal effusion and its association with the outcomes of micropulse transscleral laser therapy in glaucoma patients: a pilot study

We investigate the development of ciliochoroidal effusion following micropulse transscleral laser therapy (MPTLT) and evaluate the relationship between the early postoperative ciliochoroidal effusion (ECE) and short-term treatment outcomes. Glaucoma patients who underwent MPTLT were assessed for ciliochoroidal effusion by anterior segment optical coherence tomography (AS-OCT) at postoperative 1, 4, 12 weeks. The subjects were classified based on AS-OCT findings at postoperative 1 week into eyes with and without ECE. The absolute intraocular pressure (IOP), IOP reduction and number of antiglaucoma medications were compared between eyes with and without ECE. A total of 50 eyes were included, of which 23 (46%) developed ciliochoroidal effusion at postoperative 1 week. Almost all effusion resolved at 4 weeks. At 12 weeks, the mean IOP (SD) significantly decreased from 28.5 (12.8) mmHg to 17.8 (10.5) mmHg (p < 0.001), and the mean number of medications (SD) decreased from 4.1 (0.9) to 3.3 (1.1) (p < 0.001). Eyes with ECE had significantly greater IOP reduction (p = 0.009) and lower absolute IOP (p = 0.008) at the 4-week visit. There was no significant difference in number of medications between the groups. In conclusion, ciliochoroidal effusion was commonly observed following MPTLT. Eyes with ECE had overall greater IOP reduction during early post-operation.

Factors Associated With Visual Acuity in Non-arteritic Ischemic Optic Neuropathy Patients: A Five-Year Cross-Sectional Study.

Background and objectiveNon-arteritic ischemic optic neuropathy (NAION) is a common cause of optic neuropathy in elderly patients. Currently, there is no definitive treatment for this condition, and the factors influencing visual outcomes have not yet been conclusively identified. In this study, we aimed to evaluate factors that affect visual outcomes and those that are predictors of the development of NAION in a Thai population.MethodsAll patients diagnosed with NAION at the Rajavithi Hospital between January 1, 2016, and December 31, 2020, were retrospectively reviewed to evaluate the improvement in their best-corrected visual acuity (BCVA) and determine the factors that are predictive of visual outcomes.ResultsThe 80 patients reviewed were predominantly male (55%) with a mean age of 55.8 ±9.89 years. Their most common comorbidities were dyslipidemia (DLP) (67.5%), diabetes mellitus (DM) (61.3%), and hypertension (HT) (48.8%). At the 12-week follow-up visit, there was a significant improvement of at least 0.2 logarithm of the minimum angle of resolution (logMAR) in BCVA (p=0.001). A significantly greater percentage of patients with higher age, DM, and HT was observed in the unfavorable visual recovery (UVR) group (p=0.002, p=0.001, and p=0.005 respectively). In contrast, neither baseline visual acuity nor cup-to-disc ratio (CDR) affected the result of visual recovery (p=0.275 and p=0.076, respectively). In multivariate logistic analysis, older age increased the odds of worse visual recovery [odds ratio (OR): 4.014; 95% CI: 1.038-15.515; p=0.044], as did having DM (OR: 3.809; 95% CI: 1.168-12.421; p=0.027), and HT (OR: 4.577; 95% CI: 1.491-14.049; p=0.008).ConclusionsNone of the baseline visual status parameters (visual acuity, CDR, or visual field defect) was able to determine the outcome of visual recovery at 12 weeks in our NAION patients. Regarding systemic vascular diseases, diabetes and HT are significant risk factors and also predictors of poor visual improvement in Thai populations. NAION patients who are elderly or have vascular diseases such as DM or HT should be closely followed up and advised about the likelihood of having inferior visual recovery.

Soft tissue phenotype modification impacts on peri-implant stability: a comparative cohort study.

Soft tissue phenotype modification (STPM) could be performed to maintain peri-implant health. Therefore, the aim of the study was to analyze tissue alteration around implants following soft tissue phenotype modification during implant uncovering surgery. Patients who had STPM (either pouch roll or modified roll technique) during implant second-stage surgery with at least 12-month follow-up were included. Clinical and radiographic parameters including mucosal tissue thickness (MTT), recession (REC), keratinized mucosa width (KMW), probing pocket depth (PPD), marginal bone loss (MBL), emergence profile, and emergence angle were extracted from 2-week, 2-month, and 12-month visits after second-stage surgery. Twenty-eight patients with 33 implants that fulfilled the inclusion criteria were included. After soft tissue phenotype modification, at 2weeks, REC was negatively correlated to mean MTT at mid-buccal site (r = - 0.41, p = 0.018) and borderline correlated at mid-lingual site (r = - 0.343, p = 0.051). Stable KMW was maintained from 2weeks to 12months with minimal shrinkage rate (3 ~ 14%). MBL change was limited (0.24 ~ 0.47mm) after STPM. All implants had shallow PPD (≤ 3mm) with the absence of bleeding on probing. Emergence angle at the mesial side, however, was significantly correlated to surgical techniques, which indicated pouch roll technique would have 6.96 degrees more than modified roll technique (p = 0.024). Soft tissue phenotype modification, either pouch roll or modified roll technique, during uncovering surgery resulted in favorable clinical outcomes. Thin mucosal tissue thickness and pouch roll technique are the factors related to more recession at 2weeks. Pouch roll technique could influence the restorative design by having a wide emergence angle at the mesial side. Modified and pouch roll techniques during uncovering surgery were viable methods to yield favorable peri-implant health, while the preciseness of pouch roll technique was required to avoid mucosal recession and inadequate restorative design.

Comparison of Early Post-Operative Hypoesthesia After a Low and Short or Traditional Sagittal Split Osteotomy

<h3>Purpose</h3> The purpose of this study was to determine if there is a difference in postoperative neurosensory testing (NST) score at 6-weeks between subjects that received a mandibular sagittal split osteotomy (SSO) using a low and short osteotomy (LSO) or traditional osteotomy (TRO). The null hypothesis was that no significant difference exists in post-operative NST score between subjects that received SSO with a TRO or LSO. <h3>Methods</h3> A retrospective chart review was conducted of subjects that received orthognathic surgery by the oral and maxillofacial surgery department at the University of Texas Southwestern Medical Center (UTSW) from 2017 to 2019. All subjects that received SSO by either TRO as defined by Hunsuck and Epker(1,2) or LSO defined by Posnick(3) were included. Subjects with syndromic conditions, prior injury to the inferior alveolar nerve, history of peripheral neuropathy or pain conditions, and those undergoing simultaneous genioplasty, repeat surgery or concomitant temporomandibular joint surgery were excluded. Neurosensory outcomes of the inferior alveolar nerve (IAN) were measured using clinical NST at the pre-operative and 6-week post-operative visit over a 1-centimeter area of the labiomental fold. Chi-squared analysis and t-tests were performed between the cohorts and their respective outcomes. Values of p < 0.05 were considered statistically significant. The primary predictor variable was osteotomy type, and the primary outcome variable was NST score at the 6 weeks post-operative visit. Secondary outcome variable was IAN location within the proximal or distal segment. <h3>Results</h3> A total of 26 subjects met the defined inclusion criteria for a total of 52 osteotomies. There were 32 osteotomies in the LSO group, and 20 in the TRO group. The average age of the LSO group was 23.1 years (SD=10), and the average age of the TRO group was 22.4 years (SD=6). There was no significant difference in age between the two groups (p=0.84). All subjects were NST level A pass bilaterally at the pre-operative visit. No nerve injury was witnessed at the time of surgery among either group. All IANs contained within the proximal segments were left in place. There was no statistically significant difference in NST score between the two groups at the 6-week post-operative visit (p = 0.40). Of the total 52 osteotomies, there was no significant difference between NST score at the 6 weeks post-operative visit in subjects with IAN located in the proximal segment or the distal segment regardless of technique used (p = 0.52). <h3>Conclusion</h3> There is no difference in post-operative NST score at 6-weeks between subjects that received a traditional osteotomy or low and short sagittal split osteotomy. Regardless of technique, there is no difference in post-operative NST score at 6 weeks if the IAN is in the proximal or distal segment after completion of sagittal split.

Shared decision-making for postoperative opioid prescribing and preoperative pain management education decreases excess opioid burden.

Managing postoperative pain requires an individualized approach in order to balance adequate pain control with risk of persistent opioid use and narcotic abuse associated with inappropriately outsized narcotic prescriptions. Shared decision-making has been proposed to address individual pain management needs. We report here the results of a quality improvement initiative instituting prescribing guidelines using shared decision-making and preoperative pain expectation and management education to decrease excess opioid pills after surgery and improve patient satisfaction. Pre-intervention prescribing habits were obtained by retrospective review perioperative pharmacy records for patients undergoing general surgeries in the 24months prior to initiation of intervention. Patients scheduled to undergo General Surgery procedures were given a survey at their preoperative visit. Preoperative education was performed by the surgical team as a part of the Informed Consent process using a standardized handout and patients were asked to choose the number of narcotic pills they wished to obtain within prescribing recommendations. Postoperative surveys were administered during or after their 2-week postoperative visit. 131 patients completed pre-intervention and post-intervention surveys. The average prescription size decreased from 12.29 oxycodone pills per surgery prior to institution of pathway to 6.80 pills per surgery after institution of pathway (p < 0.001). The percentage of unused pills after surgery decreased from an estimated 70.5% pre-intervention to 48.5% (p < 0.001) post-intervention. 61.1% of patients with excess pills returned or planned to return medication to the pharmacy with 16.8% of patients reporting alternative disposal of excess medication. Patient-reported satisfaction was higher with current surgery compared to prior surgeries (p < 0.001). Institution of procedure-specific prescribing recommendations and preoperative pain management education using shared decision-making between patient and provider decreases opioid excess burden, resulting in fewer unused narcotic pills entering the community. Furthermore, allowing patients to participate in decision-making with their provider results in increased patient satisfaction.

Developing a patient-centered opioid prescribing model: A prospective evaluation of opioid prescribing and utilization patterns among gynecologic oncology patients (581)

<b>Objectives:</b> The opioid epidemic is recognized as a public health crisis. Overprescribing opioids for postoperative pain management is commonly reported in surgical specialties, yet prescription guidelines are not well described after gynecologic oncology surgery. We sought to describe opioid prescribing and utilization patterns in gynecologic oncology patients to inform the development of a patient-centered opioid prescribing algorithm. <b>Methods:</b> This prospective cohort study recruited opioid naïve, gynecologic oncology patients undergoing hysterectomy. Demographic data, surgical data, inpatient opioid use, validated PROMIS pain inference questionnaires, and satisfaction surveys were collected. Medication diaries were collected at the 2- and 6-week postoperative visits. Outpatient postoperative opioid use was collected and converted to oral morphine milligram equivalents (MME). A retrospective chart view was completed to abstract details of the operation and the patient's inpatient opioid requirement. Descriptive statistics were used to quantify opioid prescribing and utilization patterns in MME. Wilcoxon rank-sum tests were used to compare opioid requirements by the surgical route. Nonparametric statistical methods were used to identify factors associated with outpatient narcotic use. An algorithm for future opioid prescribing was developed using the 95^th percentile of outpatient opioid use. <b>Results:</b> From January 2021 to July 2021, 65 women were recruited, with 57 completing follow-up data collection. The surgical approach was divided evenly with 49% open and 51% minimally invasive groups (MIS). The amounts of outpatient opioid prescription and use were lower in the MIS group compared to the open surgery group (p 0.011 and p 0.045, respectively). In the MIS group, the median prescribed opioids were 38 MME (IQR: 20-75 MME), equivalent to five pills of 5mg Oxycodone while median usage was 4 MME (IQR: 0-22), equivalent to one pill of 5mg Oxycodone. For the open group, 96 MME was prescribed (IQR: 38-150), equivalent to 20 pills, while usage was 31 MME (IQR: 0-82), equivalent to five pills. Twenty-four patients (42%) did not use any narcotics. Factors that correlated with postoperative opioid use included surgical procedure, estimated blood loss, the amount of narcotic taken during the last 24 hours as an inpatient, tobacco use, and patient's BMI. Patient reported high satisfaction with their preoperative teaching specific to pain control. Finally, 84% of patients had pain ratings on the PROMIS survey within normal limits at 6-week compared to a referent population. <b>Conclusions:</b> In this cohort, opioids were overprescribed for all patients, necessitating the need for more restrictive, personalized prescribing practices. As described in Figure 1, surgical route and last 24 hours inpatient MME can help delineate patient's opioid requirements and aid in the development of patient-centered guidelines for opioid prescribing in the postoperative period. Fig. 1

Surgeon preferences are associated with utilization of telehealth in fracture care.

BackgroundThe SARS-CoV-2 (COVID-19) pandemic has the potential to evoke lasting changes in the delivery of care, and the utilization of telehealth. We sought associations between surgeon personal factors and greater use of telehealth to treat fractures relative to in-person care.MethodsSeventy-five fracture surgeons participated in a survey-based experiment. All surgeons were asked about their preferences regarding remote compared to in-person communication. Participants rated the following items on slider scales: their degree of introversion, the importance of a hands-on/physical exam and surgeon preferences regarding telehealth. We identified factors associated with the use of, and comfort with, telehealth.ResultsThe use of telehealth during the pandemic was associated with comfort evaluating wounds via telehealth. A greater proportion of remote visits was associated with comfort evaluating wounds and confidence teaching exercises via telehealth. There was consensus that telehealth did not alter utilization rates of radiographs or offer of discretionary surgery. The use of absorbable sutures to limit in-person visits was associated with a preference for working from home and greater comfort with evaluating wounds remotely. The use of 2- and 6-week post-operative telehealth visits and plans to use telehealth after the pandemic (52%) were associated with greater comfort in evaluating wounds through telehealth and greater confidence with video instruction of exercises.ConclusionsThe finding that personal factors are associated with utilization of telehealth helps target strategies for increased use of telehealth and other technologies as the pandemic wanes. Given that telehealth adds convenience for people with ambulatory difficulties or in remote areas, such efforts are warranted.Level of EvidenceNot applicable.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00068-022-02065-z.

Augmented Rehabilitation Program for Patients 60 Years and Younger Following Total Hip Arthroplasty-Feasibility Study.

The purpose of this study is to examine the feasibility, safety and outcomes of a study comparing a 6-week post-operative rehabilitation program to usual care in patients ≤60 years undergoing elective unilateral total hip arthroplasty (THA). Methods: A cohort of 24 THA patients were recruited during their 6-week postoperative visit to their surgeons. The community-based rehabilitation program, which was designed to improve function and increase activity, consisted of 12 structured exercise classes on land and water over 6 weeks. Physical activity was assessed using a Sense Wear Pro Armband (SWA). Participants completed the Hip Osteoarthritis Outcome Score (HOOS) and THA satisfaction questionnaire before and immediately after the intervention. Results: 14 participants received the augmented rehabilitation, and 10 participants were in the control group. All except one in the intervention group completed at least 80% of the sessions. The intervention group took significantly more steps/day (mean difference = 2440 steps/day, 95% CI = 1678, 4712) (p < 0.05), at the follow-up compared to baseline. The intervention group had a higher mean change of number of weekly PA bouts than the control group. Within the intervention group, all HOOS subscales were significantly higher at the follow-up compared to baseline. Conclusion: Findings provided pragmatic insight regarding the intervention and assessments of implementing an augmented rehabilitation program for elective THA.

Opioid-free shoulder arthroplasty is safe, effective, and predictable compared with a traditional perioperative opiate regimen: a randomized controlled trial of a new clinical care pathway.

Opiate-based regimens have been used as a foundation of postoperative analgesia in orthopedic surgery for decades, and the vast majority of orthopedic patients in the United States receive postoperative opioid prescriptions. Both the safety and efficacy of opioid use in orthopedic patients have been questioned because of mounting evidence that postoperative opioid use can be detrimental to outcomes and patient satisfaction. The purpose of this study is to compare a new, opioid-free pain management pathway with a traditional opioid-containing, multimodal pathway in patients undergoing shoulder arthroplasty. This is a single-center randomized clinical trial in which 67 patients who underwent shoulder arthroplasty were allocated into 2 treatment arms: either a completely opioid-free, multimodal perioperative pain management pathway (OF), or a traditional opioid-containing perioperative pain management pathway (OC). Pain was measured on a numeric rating scale from 0 to 10 at 6-, 12-, 24-hour, 2-week, and 6-week time points. Deviations from the OF pathway, morphine milligram equivalents, readmissions, and opioid-related side effects were analyzed. Pain levels were significantly lower in the OF group at 12 hours, 24 hours, and 2 weeks. At 12 hours, the median pain rating was 0 compared with a median pain rating of 3 in the OC group (P=.003). At 24 hours, the OF group reported a median pain rating of 1 and the OC group reported a median pain rating of 4 (P<.001). The median pain rating at the 2-week time point in the OF group was 2 compared with 4 in the OC group (P=.006). Median pain ratings were similar between the OF group and the OC group at the 6-week time point. The median pain rating in the OF group at 6 weeks was 1, compared with 1.5 in the OC group. Of the 35 patients in the OF pathway, 1 required a rescue opioid medication for left cervical radiculopathy that ultimately necessitated cervical spine fusion after recovery from right shoulder arthroplasty, and 1 was noted to have taken an opioid medication, diverted from a prior prescription, at the 2-week visit. The morphine milliequivalents received in the OF group was 20 compared with 4936.25 in the OC group. There were no readmissions in the OF pathway, and no differences between the groups with regard to constipation, falls, or delirium. A multimodal, opioid-free perioperative pain management pathway is safe and effective in patients undergoing total shoulder arthroplasty and offers superior pain relief to that of a traditional opioid-containing pain management pathway at 12 hours, 24 hours, and 2 weeks postoperatively.

A nurse-led Asthma Care Team transitioning patients from hospital to home improves asthma control: A pilot study exploring an alternative model of care.

Recurrent asthma admissions are frequent in our patients at a tertiary Australian hospital and are commonly related to poor health literacy and medication adherence. A need exists to improve these asthma self-management skills within our current model of care, especially during the vulnerable postdischarge period. To examine if the addition of a nurse-led Asthma Care Transition Team (ACTT) compared with usual care alone (UC) (1) improves asthma control at 12 weeks posthospital discharge; the number of patients using a Written Action Plan (WAP), compliance with inhaler therapy at 12 weeks, and readmission rates at 6months. Adults admitted with asthma were randomised to either: UC: involving review of asthma medication and self-management skills by the ward team prior to discharge; a standard 6-week post discharge clinic visit and a 12-week study visit where an independent assessor assessed outcomes; or ACTT: In addition to UC, involved ACTT nurse-led review at 1week and 6 weeks. Key aspects included a pre defined, structured review reinforcing education and self-management skills, and telephone support during working hours. Sixty participants (UC and ACTT) had similar baseline characteristics: Mean age: 41 vs 38 years, asthma duration: 20 vs 18 years, baseline Asthma Control Questionnaire 3.1 vs 3.4. At 12 weeks Asthma Control Questionnaire (ACQ) improved significantly in both groups but more so with ACTT; ACTT group had a higher uptake of WAP and a trend to reduced readmissions. A nurse-led ACTT improves asthma control and self-management skills following discharge and may lead to fewer readmissions.

Evaluation of effectiveness, acceptability and safety of thermal ablation in the treatment of cervical neoplasia in Burundi.

This longitudinal study aimed at evaluating the effectiveness, acceptability and safety of the thermal ablation procedure (TA) in the treatment of cervical neoplasia. Women referred to the Gynaecology ward for symptoms or for opportunistic screening were assessed by visual inspection with acetic acid (VIA) and colposcopy. Those with lesions eligible to ablation were counselled and treated by TA. They were inquired about the level of pain during the procedure, and their level of satisfaction. Patients were followed up at 6 weeks for any complication and reassessed by VIA and colposcopy at 12 months for any persistent or recurrent lesion and for any adverse event. A total of 86 women with a positive VIA test were included in the study. The mean age was 46 years (28-61 years). Most of the women did not complain about any adverse event during treatment; one-third presented mild pain or cramp. At the 6-week visit, watery discharge was the main adverse event reported. All women were highly satisfied with TA and most of them would recommend it. At the 12-month visit, 82 women were examined (95% follow-up rate), and the overall cure rate was 96% (low-grade lesions: 98%; high-grade lesions: 94%). Three women presented low- and high-grade lesions that were treated by TA. No major adverse event or hospitalisation after the treatment was reported. In conclusion, TA was an effective procedure with a high cure rate at the 1-year follow-up visit. It was acceptable and safe, with only minor short-term side-effects reported and with a high satisfaction rate among the patients.