Postsurgical Management Research Articles

Optimisation de la prise en charge de la plaie post-chirurgicale par une équipe pluridisciplinaire : étude pilote de faisabilité

The management of post-surgical wounds is complex and suffers from a lack of coordination between the hospital and the community. The pharmacist could improve the efficiency of the care pathway by optimizing the compliance of discharge orders (DO) with current standards and reducing the associated expenditures. The objective of this study was to evaluate the impact of a multidisciplinary intervention on the quality and cost of acute post-surgical wound management. This is a pilot study, monocentric, prospective, before/after. Non-conformities (NC) of DO for post-surgical wounds were analyzed before and after a multidisciplinary intervention (development of protocols, provision of prescription aid supports, training) in 3surgical departments. The cost of each OS filled in the community was collected and the satisfaction of community pharmacists was evaluated. Out of 120OS collected, 576NC were detected. The intervention halved the number of DO with at least 1NC and divided the median number of NC per order by 7. Community pharmacists were 4times more satisfied with the quality of DO after the intervention. The cost of the multidisciplinary intervention was estimated at 787euro. This intervention did not change the average cost per prescription. The multidisciplinary intervention improved the quality of post-surgical wound management by making the hospital-city pathway more fluid. The intervention requires a low investment in human resources and could be economically interesting if the costs avoided by the prevention of complications were valued.

Controlled release of soy isoflavones from multifunctional 3D printed bone tissue engineering scaffolds

Recent challenges in post-surgical bone tumor management have elucidated the need for a multifunctional scaffold, which can be used for residual tumor-cell suppression, defect repair, and simultaneous bone regeneration. In this perspective, 3D printing allows to create a wide variety of patient-specific implant with complex porous architecture and compatible mechanical strength to that of cancellous bone. Here, a multifunctional bone graft substitute is designed by incorporating the three primary soy isoflavones: genistein, daidzein, and glycitein onto a 3D printed (3DP) tricalcium phosphate (TCP) scaffolds with designed pores, endowing them with in vitro chemopreventive, bone-cell proliferating and immune-modulatory potential. The interconnected porosity and biodegradability of 3DP TCP ceramics have allowed controlled release kinetics of genistein, daidzein and glycitein in acidic and physiological buffer medium for 16 days, which is fitted with Korsmeyer-Peppas model. Presence of genistein, a well-known natural biomolecule shows a 90% reduction in vitro osteosarcoma (MG-63) cell viability and proliferation after 11 days. Meanwhile, daidzein, the other primary isoflavone, promotes in vitro cellular attachment and enhances viability and proliferation of human fetal osteoblast cell (hFOB). Furthermore, controlled release of genistein, daidzein, and glycitein from 3DP TCP scaffold demonstrates improved hFOB cell proliferation, viability, and differentiation in a dynamic flow-perfusion bioreactor, which is utilized to better simulate the clinical microenvironment. Finally, in vivo H&E staining confirms controlled co-delivery of genistein-daidzein-glycitein from 3DP scaffold carefully modulated neutrophil recruitment to the surgery site after 24 h of implantation in a rat distal femur model. These results advance our understanding towards multipronged therapeutic approaches utilizing synthetic bone graft substitutes as a drug delivery vehicle, and more importantly, demonstrate the feasibility of localized tumor cell suppression and bone cell proliferation for post-surgical defect repair application. Statement of SignificanceDesigned multimodal porosity of 3D printed TCP scaffold allows a controlled and sustained release of soy isoflavones, genistein, daidzein and glycitein in both physiological and acidic pH. Presence of genistein shows 90% reduction in vitro bone cancer cell viability and proliferation. Meanwhile, controlled release of genistein, daidzein, and glycitein from 3DP TCP scaffolds demonstrate improved osteoblast cell proliferation, viability, and differentiation in static and dynamic flow-perfusion bioreactor. Furthermore, H&E staining at 24 h post-surgical specimens from rat distal femur model shows neutrophil recruitment at the surgery site is significantly decreased, suggesting the anti-inflammatory property of soy isoflavones. This work provides deeper understanding on the design of a multifunctional 3D printed patient-specific scaffold with enhanced in vitro chemopreventive, osteogenic and in vivo anti-inflammatory ability.

Opioid free anesthesia: feasible?

The present review aims to address the feasibility of opioid free anesthesia (OFA). The use of opioids to provide adequate perioperative pain management has been a central practice of anesthesia, and only recently has been challenged. Understanding the goals and challenges of OFA is essential as the approach to intraoperative analgesia and postsurgical management of pain has shifted in response to the opioid epidemic in the United States. OFA is an opioid sparing technique, which focuses on multimodal or balanced analgesia, relying on nonopioid adjuncts and regional anesthesia. Enhanced recovery after surgery protocols, often under the auspices of a perioperative pain service, can help guide and promote opioid reduced and OFA, without negatively impacting perioperative pain management or recovery. The feasibility of OFA is evident. However, there are limitations of this approach that warrant discussion including the potential for adverse drug interactions with multimodal analgesics, the need for providers trained in regional anesthesia, and the management of pain expectations. Additionally, minimizing opioid use perioperatively also requires a change in current prescribing practices. Monitors that can reliably quantify nociception would be helpful in the titration of these analgesics and enable anesthesiologists to achieve the goal in providing personalized perioperative medicine.

Combined ionized calcium and PTH evaluation in the management of post-thyroidectomy hypocalcemia.

The aim of our study was to investigate the postoperative course of calcium and parathyroid hormone (PTH) levels after total thyroidectomy to define a proper and low cost protocol. We studied 144 patients who underwent total thyroidectomy between 2007 and 2010. Ionized calcium was determined preoperatively and on day 1 (POD1), day 2 (POD2) and day 7 (POD7) postoperatively; PTH preoperatively and on POD7. Patients with ionized calcium ≤1.11 mmol/L were considered hypocalcemic and treated only if symptoms, ≤1 mmol/L were treated in all cases. Ionized calcium and PTH declined postoperative in all patients compared to preoperative levels (P=0.000). Ionized calcium increased on POD7 compared to POD1 and POD2 (P=0.000). All hypocalcemic untreated 30 patients returned normocalcemic on POD7. Thirty-eight hypocalcemic patients were treated but 23 (61%) safely suspended therapy on POD7. We tested PTH and ionized calcium as independent factors of prolonged hypocalcemia (that required therapy beyond 7 days) with the following results (sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy): PTH ≤11 pg/mL (80%, 100%, 100%, 96% and 97%, respectively), ionized calcium ≤1.11 mmol/L (80%, 88%, 59%, 95%, and 87%, respectively) and ionized calcium ≤1 mmol/L (28%, 100%, 100%, 87% and 88%, respectively). Our data show that our protocol, including serum ionized calcium on 1st, 2nd, 7th days and PTH on 7th day after surgery, is safe and low cost and therefore may be useful in the post-surgical management of total thyroidectomy.

The PEGASUS trial: Post-surgical liquid biopsy-guided treatment of stage III and high-risk stage II colon cancer patients.

TPS4124 Background: Moving stage III Colon Cancer (CC) into the precision medicine space is a priority in view of the lack of molecular markers driving adjuvant treatment. Retrospective studies have demonstrated the tremendous prognostic impact of circulating tumor DNA (ctDNA) analysis after curative intent surgery, and suggested that lack of conversion of ctDNA from detectable to undetectable after adjuvant chemotherapy reflects treatment failure. With these premises, we have designed the PEGASUS trial (NCT04259944). Methods: PEGASUS is a prospective multicentric study designed to prove the feasibility of using liquid biopsy (LB) to guide the post-surgical and post-adjuvant clinical management in 140 microsatellite stable Stage-III and T4N0 Stage-II CC patients. The LUNAR1 test (Guardant Health, Redwood City, CA, USA) will be used for ctDNA determination. For the efficacy analysis, the PEGASUS cohort will be compared with a 3:1 matched cohort of 420 patients from the TOSCA trial (NCT00646607). A LB executed 2-4 weeks post-surgery will guide a “Molecular Adjuvant” treatment: i) ctDNA+ patients will receive CAPOX for 3 months and ii) ctDNA- patients will receive capecitabine (CAPE) for 6 months but will be retested after 1 cycle, and if found ctDNA+ will be switched to CAPOX treatment. At the end of the “Molecular Adjuvant” treatment a further LB will be performed and instruct subsequent treatment. Positive patients (ctDNA+/+ and ctDNA-/+) will receive an up-scaled “Molecular Metastatic” systemic treatment for 6 months or until radiological progression or toxicity: i) ctDNA+/+ patients will be treated with FOLFIRI; ii) ctDNA-/+ patients with CAPOX. These patients will be subjected to a LB after 3 months and at the end of treatment: in case of positivity will be switched to FOLFIRI. ctDNA+/- patientswill receive a de-escalated treatment with CAPE for 3 months. 3 LB will be performed within 3 months and in case of positivity the patient will be switched to FOLFIRI. Patients with ctDNA-/- will be subjected to an interventional follow-up comprising 2 further LB and in case of positivity they will be switched to CAPOX treatment. PEGASUS is piggybacked to AlfaOmega (NCT04120935), a Master Observational Protocol that will follow patients from diagnosis to 5 years or recurrence/death (whichever comes first), collecting clinical data, radio-images and biological samples. AlfaOmega provides a clinical and logistic ecosystem for the seamless integration of PEGASUS clinical results with the biological underpinning of colon cancer. Clinical trial information: NCT04259944 .

Multifunctional Nanoparticle Loaded Injectable Thermoresponsive Hydrogel as NIR Controlled Release Platform for Local Photothermal Immunotherapy to Prevent Breast Cancer Postoperative Recurrence and Metastases

AbstractFor breast cancer patients who have undergone breast‐conserving surgery, effective treatments to prevent local recurrences and metastases is very essential. Here, a local injectable therapeutic platform based on a thermosensitive PLEL hydrogel with near‐infrared (NIR)‐stimulated drug release is developed to achieve synergistic photothermal immunotherapy for prevention of breast cancer postoperative relapse. Self‐assembled multifunctional nanoparticles (RIC NPs) are composed of three therapeutic components including indocyanine green, a photothermal agent; resiquimod (R848), a TLR‐7/8 agonist; and CPG ODNs, a TLR‐9 agonist. RIC NPs are physically incorporated into the thermosensitive PLEL hydrogel. The RIC NPs encapsulated PLEL hydrogel (RIC NPs@PLEL) is then locally injected into the tumor resection cavity for local photothermal therapy to ablate residue tumor tissues and produce tumor‐associated antigens. At the same time, NIR also triggers the release of immune components CPG ODNs and R848 from thermoresponsive hydrogels PLEL. The released immune components, together with tumor‐associated antigens, work as an in situ cancer vaccine for postsurgical immunotherapy by inducing effective and sustained antitumor immune effect. Overall, this work suggests that photothermal immunotherapy based on local hydrogel delivery system has great potential as a promising tool for the postsurgical management of breast cancer to prevent recurrences and metastases.

Surgical management of gangrenous mastitis in a 3-year-old red Sokoto doe: A case report

Gangrenous mastitis was managed in a 3-year-old lactating doe by partial mastectomy following unsuccessful medical management. The patient had progressive swelling, hardened and dark discolouration of its left half udder. There was left supra-mammary lymphadenopathy and an open wound at the proximal portion of the affected gland. The right half of the udder appeared normal and was warm to touch. Culture and sensitivity test of a swab sample from the open wound at the base of the affected mammary gland revealed Staphylococcus and Streptococcus species which were sensitive to amoxicillin, cloxicillin, gentamicin and chlortetracycline, but resistant to penicillin and streptomycin. Mastectomy was indicated because of the chronic nature of the disease and the presence of gangrene. The procedure was carried out using a standard sterile technique, and a fenestrated drainage tube was placed. The patient recovered uneventfully and was discharged 14 days post-surgery. The management protocol used in this case demonstrated that unilateral mastectomy with good post-surgical management could be used for effective management of gangrenous mastitis without complications while still preserving the unaffected gland for future lactation.

Impact of Hysteroscopic Metroplasty on Reproductive Outcomes of Women with a Dysmorphic Uterus and Recurrent Miscarriages: A Systematic Review and Meta-Analysis

The aim of this systematic literature review and meta-analysis is to assess the impact of hysteroscopic metroplasty for dysmorphic uteri on reproductive outcomes in women with recurrent miscarriages.Available studies were identified through a PubMed, Scopus, and Cochrane search until June 2019. Live-birth rate, clinical pregnancy and miscarriage rate after hysteroscopic metroplasty was evaluated. DerSimonian and Laird’s random-effect model was used for relative risks, Freeman-Tukey Double Arcsine for pooled estimates and exact method to stabilize variances and CIs. Heterogeneity was quantified using I2-statistics. Six out of 164 published studies met the inclusion criteria. All (n = 221) women underwent metroplasty, using 5Fr-hysteroscope with bipolar electrodes or 26Fr/28Fr-resectoscope in outpatient or inpatient settings. After 6 to 60-month follow-up, reported live-birth rate was 50% (0.37-0.63 95% CI) from a clinical pregnancy rate of 73% (0.51-0.91 95% CI) and miscarriage rate was 23% (0.15-0.30 95% CI).Hysteroscopic metroplasty for dysmorphic uteri led half of the women who experienced recurrent miscarriages at least one live birth and is correlated to few surgical and obstetric complications. However, randomized clinical trials and case-control studies are unavailable due to ethical constrains; inhomogenity of follow-up durations and standardized protocols regarding preoperative diagnosis and post-surgical management resrict our conclusions.

Impact of Standardized Prescribing Guidelines on Postoperative Opioid Prescriptions after Ophthalmic Surgery

To determine the effect of implementing standardized opioid prescribing guidelines on prescription patterns for acute pain after ophthalmic surgery in opioid-naïve patients. Quality improvement study. Ophthalmic surgeons in an academic department of ophthalmology. Postoperative opioid prescribing patterns were compared before and after the implementation of standardized opioid prescribing guidelines for ophthalmic surgery at an academic institution. Only prescriptions provided to opioid-naïve patients 18 years of age or older were included. Surgeons reached a consensus for standardized prescribing guidelines appropriate for the type of surgery within their subspecialty. Guidelines were disseminated in conjunction with postsurgical pain management education to all ophthalmologists in the department, including trainees. The frequency of opioid prescriptions, the quantity of opioid prescribed (converted to oral morphine equivalent [OME]), and opioid prescription refill rates were compared before and after intervention. Prescriptions with more than 80 OME, frequency of opioid prescriptions, mean OME, and refill rates. Of 5349 ophthalmic surgeries performed during the 2 assessment periods, 196 (3.7%) were associated with opioid prescriptions for acute postoperative pain. The frequency of opioid prescriptions decreased to 3.0% (81/2736) after intervention compared with 4.4% (115/2613) before intervention (P= 0.005). When opioids were prescribed, the mean OME decreased from 93 (range, 27-500) before intervention to 42 (range, 14-100) after intervention (P= 0.003). The number of prescriptions for more than 80 OME decreased from 56 (2.1%) before intervention to 4 (0.1%) after intervention (P < 0.001). Based on the standardized guidelines, 103 of the 115 (89.6%) preintervention opioid prescriptions would not have adhered to the guidelines, whereas 39 of the 81 (48.1%) postintervention prescriptions did not adhere to the guidelines (P < 0.001). The proportion of refill prescriptions did not differ before and after intervention (P= 0.44). The process of discussing postsurgical pain management and developing standardized opioid prescribing guidelines reduces overprescribing of opioids after ophthalmic surgery without increasing refill rates. Continued education is required to improve adherence to the prescribing guidelines further.

The future of postsurgical pain management as envisaged from the perspective of preventing the development of chronic postsurgical pains

The future of postsurgical pain management as envisaged from the perspective of preventing the development of chronic postsurgical pains

Postsurgical Management of Dilated Biliary Tract in Children: Ultrasound-Guided Percutaneous Transhepatic Cholangial Drainage and Subsequent Percutaneous Ultrasound Cholangiography.

OBJECTIVE. The purpose of this study was to evaluate the feasibility of ultrasound (US)-guided percutaneous transhepatic cholangial drainage (PTCD) and consequent percutaneous US cholangiography in managing the dilated biliary tracts of children who have undergone hepatobiliary surgery. SUBJECTS AND METHODS. Sixteen children (11 boys, five girls; age range, 3-144 months) who underwent hepatobiliary surgery from December 2016 to October 2018 and had US evidence of biliary dilatation were included. All patients had undergone US-guided PTCD because of elevated postoperative serum bilirubin levels or bile duct infection. Immediately after the PTCD procedure, diluted sulphur hexafluoride microbubbles dispersion was injected through the PTCD tube to evaluate the anastomosis and the intrahepatic bile duct tree. Laboratory results, including those of serum bilirubin measurement, liver function tests, and routine blood tests, were evaluated before and after PTCD. Nine of 16 patients also underwent percutaneous transhepatic cholangiography (PTC). The percutaneous US cholangiography findings were evaluated and compared with the PTC findings. RESULTS. Liver enzyme levels decreased after PTCD with a statistically significant difference from the values before PTCD. Percutaneous US cholangiography showed that the anastomosis in 6 of the 16 patients (37.5%) was patent and depicted the morphologic featuresof intrahepatic bile duct tree in five of these patients. In the other 10 patients, the anastomosis was completely obstructed, and percutaneous US cholangiography depicted the morphologic features of intrahepatic bile duct tree in eight patients. In the nine patients who underwent PTC, the percutaneous US cholangiographic findings were the same as the PTC findings. CONCLUSION. US-guided PTCD is helpful in relieving jaundice and inflammation in children who have undergone hepatobiliary surgery and have biliary dilatation. Findings at consequent percutaneous US cholangiography are comparable to those of PTC in depicting the anastomosis in these patients.

Neurosurgery in a Case of Suspected Prion Disease: Challenges Faced

AbstractThis report refers to a rare case of a patient with suspected prion disease and the steps taken for the infection control measures in postsurgical management of a large sphenoid wing meningioma. Stringent measures are needed to prevent the transmission of Creutzfeldt–Jakob disease (CJD) to other patients or healthcare workers. The main concern, especially in a neurosurgical case, is the handling of highly infective tissue and hence the higher risk of disease transmission. This report provides guidance based on the experience in this case, as an aid to similar surgeries.

Erratum. Predictors of recurrence and high growth rate of residual meningiomas after subtotal resection.

OBJECTIVE The extent of resection has been shown to improve outcomes in patients with meningiomas. However, resection can be complicated by constraining local anatomy, leading to subtotal resections. An understanding of the natural history of residual tumors is necessary to better guide postsurgical management and minimize recurrence. This study seeks to identify predictors of recurrence and high growth rate following subtotal resection of intracranial meningiomas. METHODS Adult patients who underwent primary surgical resection of a WHO grade I meningioma at a tertiary care institution from 2007-2017 were retrospectively reviewed. Volumetric tumor measurements were made on patients with subtotal resections. Stepwise multivariate proportional hazards regression analyses were performed to identify factors associated with time to recurrence, as well as stepwise multivariate regression analyses to assess for factors associated with high postoperative growth rate. RESULTS Of the 141 patients (18%) who underwent radiographic subtotal resection of an intracranial meningioma during the reviewed period, 74 (52%) suffered a recurrence, in which the median (interquartile range, IQR) time to recurrence was 14 (IQR 6-34) months. Among those tumors subtotally resected, the median pre- and postoperative tumor volumes were 17.19 cm3 (IQR 7.47-38.43 cm3) and 2.31 cm3 (IQR 0.98-5.16 cm3), which corresponded to a percentage resection of 82% (IQR 68%-93%). Postoperatively, the median growth rate was 0.09 cm3/year (IQR 0-1.39 cm3/year). Factors associated with recurrence in multivariate analysis included preoperative tumor volume (hazard ratio [HR] 1.008,95% confidence interval [CI] 1.002-1.013, p = 0.008), falcine location (HR 2.215, 95% CI 1.179-4.161, p = 0.021), tentorial location (HR 2.410, 95% CI 1.203-4.829, p = 0.024), and African American race (HR 1.811, 95% CI 1.042-3.146, p = 0.044). Residual volume (RV) was associated with high absolute annual growth rate (odds ratio [OR] 1.175, 95% CI 1.078-1.280, p < 0.0001), with the maximum RV benefit at < 5 cm3 (OR 4.056, 95% CI 1.675-9.822, p = 0.002). CONCLUSIONS By identifying predictors of recurrence and growth rate, this study helps identify potential patients with a high chance of recurrence following subtotal resection, which are those with large preoperative tumor volume, falcine location, tentorial location, and African American race. Higher RVs were associated with tumors with higher postoperative growth rates. Recurrences typically occurred 14 months after surgery.

Demographics, Diagnoses, Care Patterns, and Outcomes of Patients Admitted to a Cardiac Intensive Care Unit in a High-Volume Referral Tertiary Center in Latin America

Background Single and multi-center studies have described substantial changes in the landscape of health care in cardiac intensive care units (CICU). Few reports have quantitatively characterized current diagnoses in a contemporary CICU in Latin America. This study aims to describe demographics, diagnoses, care patterns, and outcomes in patients admitted to a CICU in a high-volume center in South America. Methods A total of 1629 consecutive patients admitted to CICU from December 2017 to April 2020 were included in a prospective registry. The variables analyzed included demographic data, admission and final diagnoses, management, and outcomes. Results Among 1629 participants, 32.4% were women, and the median age was 62 years (53-71). Admissions were due to primary cardiac causes in 1335 (81.9%), postsurgical care in 13.3%, and a combination of general and cardiac diagnoses in 4.8% of patients. The most frequent diagnosis on admission was acute coronary syndrome (ACS) (35.7%). Primary reasons for CICU admission were postprocedural observation (PPO) (31.8%), diagnosed or suspected ACS (31.7%), heart failure (10.1%), postsurgical management after cardiovascular surgery (8.9%), arrhythmia (5.8%), shock (4.5%) and cardiac arrest (CA) (1.2%). Advanced CICU therapy requirements were ventilatory assistance (19.3%) and vasoactive or inotropic drug use (19.6%). The overall mortality rate was 6.4%. Admission diagnoses associated with the highest mortality rates were CA (52.6%), noncardiogenic shock (39.5%), and cardiogenic shock (32.3%). Notably, patients admitted solely for PPO had a mortality rate of 0.8%. Conclusions In a contemporary CICU from a high-volume reference center in South America, the most frequent diagnosis was an ACS, although it represented only one-third of the admissions. One-fifth of admissions required advanced CICU therapies. CA and shock on admission carried a poor prognosis. We identified PPO as a substantially low-risk population.

Total Thyroidectomy with Central Node Dissection is a Valuable Option in Papillary Thyroid Cancer Treatment.

SUMMARYIntroductionPapillary thyroid cancer is one of the cancers with favorable prognosis, although the long-term recurrence rate in the paratracheal region is reported to be as high as 30%. The use of 131I is considered to be a reliable treatment option for lymph node metastases in the paratracheal region. According to the majority of internationally accepted guidelines, it is not recommended to perform central node dissection (CND) routinely. Total thyroidectomy (TT) remains an adequate treatment for these patients. According to many studies, CND is associated with higher rates of hypoparathyroidism. However, CND improves staging.MethodsWe performed a retrospective study. We included 248 patients treated for papillary thyroid cancer during a 20-year period. Data were collected on patient (age, sex) and tumor (size, focality) characteristics, presence of metastases in the central neck compartment, incidence of postoperative hypoparathyroidism, and locoregional failure. We divided patients into two groups based on pathological analysis: those without positive lymph nodes (N0) and those with positive paratracheal lymph nodes (N1). We compared patient and tumor characteristics and risk of recurrence between the two groups. Results: There were 39.5% patients with central neck metastases in our series. In the central neck dissection specimen, 5.5 nodes were found on average. Hypoparathyroidism was found in 23.4% of patients and remained permanent in 3.2% of patients. Female and older patients had a lower chance of central compartment metastases, as did patients with smaller and unifocal tumors. Recurrence risk was doubled for the N1 group. All tested differences between the groups reached statistical significance.Discussion and conclusionIn our hands, CND was a safe and effective surgical procedure. It improved staging and postsurgical management. Efforts should be made to improve the preoperative work-up in order to more accurately identify high-risk patients.

Implementation of a Post-Surgical, Multimodal Analgesia Pain Management Order Set in Opioid-Naive Patients

Perioperative pain management guidelines recommend using multimodal analgesia to improve pain control while reducing opioids administered. The primary objective of this study was to assess whether implementing multimodal analgesia on general surgery postoperative pain management order sets would reduce opioid quantities postoperatively. Opioid-naive patients undergoing nonemergent general surgery procedures were evaluated before and after order set revision. The primary outcome was the total quantity of inpatient opioids administered. The secondary outcomes were inpatient naloxone administration, patient-reported pain scores, and opioid quantities prescribed at discharge. The average daily opioid consumption was less each postoperative day (POD) after implementing the revised postsurgical multimodal analgesia pain management order set. On POD 1 and POD 2, average opioid consumption was 53.6 and 47.9 oral morphine equivalents (OME) before the multimodal analgesia order set, respectively, compared with 21.2 and 21.4 OME after, respectively (p < 0.01 and p < 0.01, respectively). Average daily opioid consumption through POD 3 was 60.6 OME before and 21.14 OME after the revision. Average daily pain scores were similar on POD 0, 1, and 2 before and after (3.2, 2.8, and 2.4 compared with 2.8, 3.1, and 2.7, respectively; p = 0.09, 0.33, and 0.12, respectively). On POD 3, pain scores were higher in the postorder set group (2.8 compared with 1.9; p < 0.01), but this was considered clinically insignificant. Average daily pain score through POD 3 was 2.6 before implementation compared with 2.8 after implementation. Neither group required naloxone administration. Using perioperative multimodal analgesia reduces opioid consumption without increasing pain scores.

Multivesicular Liposome (Depofoam) in Human Diseases.

Drug development is a key point in the research of new therapeutic treatments for increasing maximum drug loading and prolonged drug effect. Encapsulation of drugs into multivesicular liposomes (DepoFoam) is a nanotechnology that allow delivery of the active constituent at a sufficient concentration during the entire treatment period. This guarantees the reduction of drug administration frequency, a very important factor in a prolonged treatment. Currently, diverse DepoFoam drugs are approved for clinical use against neurological diseases and for post-surgical pain management while other are under development for reducing surgical bleeding and for post-surgical analgesia. Also, on pre-clinical trials on cancer DepoFoam can improve bioavailability and stability of the drug molecules minimizing side effects by site-specific targeted delivery. In the current work, available literature on structure, preparation and pharmacokinetics of DepoFoam are reviewed. Moreover, we investigated approved DepoFoam formulations and preclinical studies with this nanotechnology.

RADIOISOTOPE DIAGNOSTIC ALGORITHM FOR THE RELAPSE AND METASTASES DETECTION IN THE IODINE-NEGATIVE DIFFERENTIATED THYROID CANCER.

Developing of algorithm for the post-surgical management of patients with iodine-negative metastasesof differentiated thyroid cancer (DTC). The DTC patients with iodine-negative metastases (n = 115) were enrolled in the study.Of them the whole body scintigraphy (WBS) was performed with technetium-99m-hexakis-2-methoxyisobutylisonitrile(99mTc-MIBI) (n = 30), WBS with technetium-99m dimercaptosuccinic acid (99mTc-DMSA) (n = 30), 18FDG PET (n = 30), andcomputer tomography (CT-scan) (n = 25). Complex 99mTc-pertechnetate scans including the dynamic and static scintigraphy was performed supplementary to 99mTc-MIBI WBS in 10 patients to obtain the angiographic curves from DTCmetastatic foci. The non-radioiodine radiopharmaceutical technologies, namely the labeled 99mTc-MIBI, 99mTc-DMSA, 99mTc-pertechnetate, and 18FDG were applied to detect the iodine-negative DTC metastases. Radioisotopic examinationswere performed at the dual-head gamma camera (Mediso Medical Imaging Systems Ltd., Hungary) and single photonemission computed tomography (SPECT) scanner «E.CAM» (Siemens, Germany). PET/CT scans were performed on the«Biograph 64 TruePoint» imaging platform (Siemens, Germany) in accordance with the European Association of NuclearMedicine (EANM) recommendations for the Siemens imaging devices with 3D-mode data acquisition. The conducted research suggested that it is feasible to use the non-radioiodine (99mTc-MIBI and 99mTc-DMSA)radiopharmaceutical technologies to detect the iodine-negative DTC metastases. 18FDG PET is a highly informativetechnology for the detection of iodine-negative DTC metastases in case of lung involvement in the process. Compareof the non-radioiodine radiopharmaceuticals, CT scan and 18FDG-PET/CT indicated the highest sensitivity of 18FDGPET/CT (p < 0.05). WBS with 99mTc-MIBI and 99mTc-DMSA featured the highest specificity (100 %, p < 0.05). X-ray CTis marked by the significantly lower either sensitivity, specificity, and accuracy rate (p > 0.05). Developing andapplication of algorithm for the post-surgical management of patients with iodine-negative forms of DTC will allowfor the betimes detection of relapses and metastases with administration of adequate surgical, radiation, and targeted treatment. Obtained results offer the opportunity to optimize the post-surgical management of patients withiodine-negative DTC forms using the options of radionuclide diagnostics with non-radioiodine radiopharmaceuticals. The latter are readily available providing the cost-cutting of diagnostic support in these patients. Place ofmorphological methods of diagnosis is determined and stage of monitoring of patients with the iodine-negativemetastases is established. Possibility of the 18FDG-PET tests for the early diagnosis of iodine-negative metastases inDTC for the first time have been studied and substantiated in Ukraine. A comprehensive radiation algorithm for thelong-term monitoring of this category of patients will allow the timely detection of recurrences and metastases ofDTC and appropriate surgery, radiation and targeted therapy administration. Data obtained as a result of the studyallowed to improve the overall and recurrence-free survival rates in the able-bodied DTC patients and reduce thecosts of follow-up of patients with iodine-negative forms of DTC.

Histopathologic Influences of Tissue Eosinophilia Among Chronic Rhinosinusitis Patients.

Background A subset of chronic rhinosinusitis (CRS) patients demonstrates tissue eosinophilia on structured histopathology. Prior studies have suggested that these patients are at increased risk for recurrent disease. The goals of this study are to identify histopathologic features of CRS patients with tissue eosinophilia and compare the influence of tissue eosinophilia to the effects of age and revision surgery on histopathology. Methods A structured histopathology report was utilized to analyze sinus tissue removed during functional endoscopic sinus surgery. Binomial logistic regression analysis was conducted to evaluate the association of age at diagnosis, tissue eosinophil count, and history of revision surgery with histopathology variables. Results A total of 281 CRS patients were included, of which 106 had tissue eosinophilia. Regression analysis demonstrated that tissue eosinophilia was associated with degree of inflammation (odds ratio [OR] 5.744; P &lt; .001), neutrophilic infiltrate (OR 1.882; P = .020), basement membrane thickening (OR 3.561; P &lt; .001), squamous metaplasia (OR 3.315; P &lt; .001), fibrosis (OR 2.246; P = .002), presence of Charcot–Leyden crystals (OR 20.700; P = .004), and eosinophilic aggregates (OR 34.172; P &lt; .001). Age and history of revision surgery were not significant predictors of histopathology variables on multivariate analysis. Conclusion Tissue eosinophilia appears to be the predominant driving factor of histopathologic changes irrespective of previous sinus surgery or age at diagnosis. These findings may have important implications for postsurgical management and prognosis for patients with tissue eosinophilia presenting for revision surgery.

CLET – Cultivated Limbal Epithelium Transplantation

AbstractInjury and inflammatory factors disturb the homeostasis of corneal epithelium renewal. The idea for restoring the physiologic condition is therefore not only to provide the proper cell population within a zone of damage, but also to ensure stable conditions of the surrounding microenvironment. Transplantation methods based on either allogeneic grafts or autologous corneal epithelial stem cells are recognized as effective methods of treating the limbal stem cells insufficiency. Treating the disease, we try to create optimal conditions for development and maintenance of the function of stem cells. Autologous approach, in recent years, has become an minimally invasive and the most efficient technique of treatment. Long‐term observations of such patients allow to present conclusions regarding presurgical as well as postsurgical management.