Hepatic insufficiency within a week of orthotopic liver transplantation (OLT), termed early allograft dysfunction (EAD), occurs in 20–25

IMPORTANCE:Physical therapy (PT) interventions for patients supported with extracorporeal membrane oxygenation (ECMO) is thought to help preserve independence, but the impact of PT frequency on ECMO recovery is not well understood. OBJECTIVES:To explore the relationship between PT frequency and functional outcomes in patients supported with ECMO. DESIGN, SETTING, AND PARTICIPANTS:Retrospective, single-center study of patients supported with ECMO at a large volume ECMO referral center. Patients were grouped by PT frequency (high < 3 d, moderate 3-7 d, and low > 7 d between sessions). MAIN OUTCOMES AND MEASURES:The primary outcome was the final Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" Basic Mobility Score. For the subgroup of patients discharged alive, a multivariable logistic model was used to understand what affected a patient's odds of a final AM-PAC score greater than or equal to 18, indicating functional independence. RESULTS:One hundred forty-two subjects were included with a median age of 48 years (interquartile range, 35-58 yr). Patients received venovenous (55%, n = 78/142) or venoarterial (45%, n = 64/142) ECMO. Of the cohort, 61% (n = 86/142) were discharged alive. A final AM-PAC score of greater than or equal to 18 was seen in 30% of patients (n = 43/142) before discharge. High- and moderate-frequency groups were more likely to survive to hospital discharge (76%, n = 22/29 and 75%, n = 38/51 vs. 44%, n = 27/62; p = 0.001). Controlling for age, sex, PT frequency, and the number of PT sessions after ECMO, logistic regression showed the number of PT sessions on ECMO (odds ratio, 1.13; 95% CI, 1.02-1.28) significantly impacted the odds of a final AM-PAC score greater than or equal to 18. CONCLUSIONS AND RELEVANCE:In patients supported with ECMO, high- and moderate-frequency of PT and PT on ECMO were associated with improved functional outcomes at hospital discharge.

Refractory hypoxemia during veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) may require an additional cannula (VV-V ECMO) to improve oxygenation. This intervention includes risk of recirculation and other various adverse events (AEs) such as injury to the lung, cannula malpositioning, bleeding, circuit or cannula thrombosis requiring intervention (i.e., clot), or cerebral injury. During the study period, 23 of 142 V-V ECMO patients were converted to VV-V utilizing two separate cannulas for bi-caval drainage with an additional upper extremity cannula placed for return. Of those, 21 had COVID-19. In the first 24 h after conversion, ECMO flow rates were higher (5.96 vs 5.24 L/min, p = .002) with no significant change in pump speed (3764 vs 3630 revolutions per minute [RPMs], p = .42). Arterial oxygenation (PaO2) increased (87 vs 64 mmHg, p < .0001) with comparable pre-oxygenator venous saturation (61 vs 53.3, p = .12). By day 5, flows were similar to pre-conversion values at lower pump speed but with improved PaO2. Unadjusted survival was similar in those converted to VV-V ECMO compared to V-V ECMO alone (70% [16/23] vs 66.4% [79/119], p = .77). In a mixed effect regression model, any incidence of AEs, demonstrated a negative impact on PaO2 in the first 48 h but not at day 5. VV-V ECMO improved oxygenation with increasing flows without a significant difference in AEs or pump speed. AEs transiently impacted oxygenation. VV-V ECMO is effective and feasible strategy for refractory hypoxemia on VV-ECMO allowing for higher flow rate and unchanged pump speed.

BACKGROUND/IMPORTANCE Dietary interventions, vitamins, and nutritional supplementation are playing an increasingly important role in the management of neuropathic pain. Current pharmacological treatments are poorly tolerated and ineffective in many cases. OBJECTIVE This systematic review aims to study the efficacy of dietary interventions, vitamins, and nutritional supplementation in the management of chronic neuropathic pain in adults. EVIDENCE REVIEW The review followed PRISMA guidelines and was registered with PROSPERO (#CRD42022300312). Ten databases and gray literature, including Embase.com, MEDLINE and Web of Science, were systematically searched using a combination of keywords and controlled vocabulary related to chronic neuropathic pain and oral non-pharmacological supplements. Studies on adult humans published between 2000 and 2021 were considered for inclusion. The Cochrane Handbook was used to assess risk of bias, and Grading of Recommendations Assessment, Development, and Evaluation was used to determine overall quality of evidence. FINDINGS Forty studies were included in the final review, and results were categorized according to pain type including pain related to chemotherapy-induced peripheral neuropathy (CIPN, 22 studies, including 3 prospective cohorts), diabetic peripheral neuropathy (DPN, 13 studies, including 2 prospective), complex regional pain syndrome (CRPS-I, 3 studies, including 1 prospective), and other (2 studies, both RCT). The CIPN studies used various interventions including goshajinkigan (4 studies), vitamin E (5), vitamin B12 (3), glutamine (3), N-acetyl-cysteine (2), acetyl-l-carnitine (2), guilongtonluofang (1), ninjin'yoeito (1), alpha-lipoic acid (1), l-carnosine (1), magnesium and calcium (1), crocin (1), and antioxidants (1), with some studies involving multiple interventions. All CIPN studies involved varying cancers and/or chemotherapies, advising caution for generalizability of results. Interventions for DPN included alpha-lipoic acid (5 studies), vitamin B12 (3), acetyl-l-carnitine (3), vitamin E (1), vitamin D (2), and a low-fat plant-based diet (1). Vitamin C was studied to treat CRPS-I (3 studies, including 1 prospective). Magnesium (1) and St. John's wort (1) were studied for other or mixed neuropathologies. CONCLUSIONS Based on the review, we cannot recommend any supplement use for the management of CIPN, although further research into N-acetyl-cysteine, l-carnosine, crocin, and magnesium is warranted. Acetyl-l-carnitine was found to be likely ineffective or harmful. Alpha-lipoic acid was not found effective. Studies with goshajinkigan, vitamin B12, vitamin E, and glutamine had conflicting results regarding efficacy, with one goshajinkigan study finding it harmful. Guilongtonluofang, ninjin'yoeito, and antioxidants showed various degrees of potential effectiveness. Regarding DPN, our review supports the use of alpha-lipoic acid, acetyl-l-carnitine, and vitamin D. The early use of vitamin C prophylaxis for the development of CRPS-I also seems promising. Further research is warranted to confirm these findings.

BACKGROUND: Bleeding is a serious complication of cardiopulmonary bypass (CPB) in neonates. Blood product transfusions are often needed to adequately restore hemostasis, but are associated with significant risks. Thus, neonates would benefit from other effective, and safe, hemostatic therapies. The use of fibrinogen concentrate (FC; RiaSTAP, CSL Behring, Marburg, Germany) is growing in popularity, but has not been adequately studied in neonates. Here, we characterize structural and degradation effects on the neonatal fibrin network when FC is added ex vivo to plasma obtained after CPB. METHODS: After approval by the institutional review board and parental consent, blood samples were collected from neonates undergoing cardiac surgery and centrifuged to yield platelet poor plasma. Clots were formed ex vivo from plasma obtained at several time points: (1) baseline, (2) immediately post-CPB, and (3) post-transfusion of cryoprecipitate. In addition, we utilized post-CPB plasma to construct the following conditions: (4) post-CPB +0.5 mg/mL FC, and (5) post-CPB +0.9 mg/mL FC. The resultant fibrin networks were imaged using confocal microscopy to analyze overall structure, fiber density, and alignment. Clots were also analyzed using a microfluidic degradation assay. Fibrinogen content was quantified for all plasma samples. RESULTS: The addition of 0.5 or 0.9 mg/mL FC to post-CPB samples significantly enhanced the median fiber density when compared to untreated post-CPB samples (post-CPB = 0.44 [interquartile range {IQR}: 0.36–0.52], post-CPB +0.5 mg/mL FC = 0.69 [0.56–0.77], post-CPB +0.9 mg/mL FC = 0.87 [0.59–0.96]; P = .01 and P = .006, respectively). The addition of 0.9 mg/mL FC to post-CPB samples resulted in a greater fiber density than that observed after the in vivo transfusion of cryoprecipitate (post-transfusion = 0.54 [0.45–0.77], post-CPB +0.9 mg/mL FC = 0.87 [0.59–0.96]; P = .002). Median fiber alignment did not differ significantly between post-CPB samples and samples treated with FC. Degradation rates were not statistically significant from baseline values with either 0.5 or 0.9 mg/mL FC. In addition, we found a significant correlation between the difference in the baseline and post-CPB fibrinogen concentration with patient age (P = .033) after controlling for weight. CONCLUSIONS: Our results show that clots formed ex vivo with clinically relevant doses of FC (0.9 mg/mL) display similar structural and degradation characteristics compared to the in vivo transfusion of cryoprecipitate. These findings suggest that FC is effective in restoring structural fibrin clot properties after CPB. Future studies after the administration of FC in vivo are needed to validate this hypothesis.

BACKGROUND Chronic pain is a common reason adults seek care; patients often feel that their pain is inadequately managed. Spine-related pain is the most common chronic pain concern, and lumbar radiculopathy is often the cause. Racial and ethnic disparities in the pharmacologic management of pain are well described, but less is known about these disparities regarding interventional procedures. OBJECTIVE To study the utilization rates of physical therapy, epidural steroid injection, surgery, and spinal cord stimulation in hospitalized patients with lumbar radiculopathy across different races, ethnicities, and genders. STUDY DESIGN A retrospective cross-sectional study design. METHODS The National Inpatient Sample was used to identify 252,790 patients with lumbar radiculopathy, after sample weighting, from 2016-2019. Independent variables were race, ethnicity, age, gender, insurance, geography, year, and severity. Dependent variables were physical therapy, epidural steroid injection, spinal cord stimulator, or surgery (reference group). Conservative management was defined as nonoperative treatment ranging from physical therapy to epidural steroid injection. Data were analyzed with a logistic regression for complex surveys. Regressions were adjusted for age, insurance, geography, and other socioeconomic factors. RESULTS Most patients were white (78.3%) and received surgery (95.0%). Severe disease was most common among African Americans (9.3%), but was similar across other races, ethnicities, and genders. Medicaid was more common among African Americans and Hispanics. An adjusted analysis showed that African Americans and Hispanics received more epidural steroid injections (odds ratio [OR] = 1.52; 95%CI, 1.3 - 1.8) and (OR = 1.43; 95%CI, 1.1 - 1.8) respectively; and physical therapy (OR = 1.65; 95%CI, 1.1 - 2.5) and (OR = 1.83; 95%CI, 1.2 - 2.8) respectively, than whites compared to surgery. African Americans received a spinal cord stimulator less often than whites compared to surgery (OR = 0.63; 95%CI. 0.4 - 0.9). Women received an epidural steroid injection more frequently than men compared to surgery (OR = 1.29; 95%CI, 1.2 - 1.4). LIMITATIONS Generalizability is limited because conservative therapies are often outpatient treatments. CONCLUSION Disparities were observed in lumbar radiculopathy treatment after independent variable adjustment. African Americans received conservative therapy more often than whites despite increased disease severity. Hispanics and women had similar disease severity compared to whites and men, respectively, but received more conservative therapies. Further investigation in outpatient settings is needed to definitively describe these disparities. KEY WORDS Chronic pain, pain management, back pain, lumbar radiculopathy, epidural steroid injection, spinal cord stimulation, low back surgery, physical therapy, racial disparities, gender disparities.

Editor—Across disciplines, mentorship has been found to increase positive attitudes at work, personal satisfaction, success, and increase retention in organisations.1Eby L.T. Allen T.D. Evans S.C. Ng T. Dubois D. Does mentoring matter? A multidisciplinary meta-analysis comparing mentored and non-mentored individuals.J Vocat Behav. 2008; 72: 254-267Crossref PubMed Scopus (574) Google Scholar Mentoring is vital to success in academic medicine,2Sambunjak D. Straus S.E. Marusic A. Mentoring in academic medicine: a systematic review.JAMA. 2006; 296: 1103-1115Crossref PubMed Scopus (1078) Google Scholar,3Palepu A. Friedman R.H. Barnett R.C. et al.Junior faculty members' mentoring relationships and their professional development in U.S. medical schools.Acad Med. 1998; 73: 318-323Crossref PubMed Scopus (322) Google Scholar and a lack of mentorship has been identified as the most important factor hindering career progress in this field.4Jackson V.A. Palepu A. Szalacha L. Caswell C. Carr P.L. Inui T. Having the right chemistry": a qualitative study of mentoring in academic medicine.Acad Med. 2003; 78: 328-334Crossref PubMed Scopus (352) Google Scholar The prevalence of formal mentoring programs for faculty in anaesthesiology departments in the USA is unknown. In addition, no studies have evaluated perspectives of anaesthesiology faculty on mentoring programs. The goal of this study was to explore the mentorship attitudes and practices of active academic anaesthesiologists in the USA. The primary objective was to determine the prevalence of formal mentoring programs in university-based anaesthesiology departments in the USA. The secondary objectives were to determine the proportion of academic anaesthesiologists who are actively mentored, the demographics of mentoring relationships, and barriers to mentorship within anaesthesiology. This study was granted Institutional Review Board exemption by Emory University, Atlanta, GA, USA (STUDY00000998) and University of California, Los Angeles, CA, USA (IRB#21–000626). Survey questions were created based on similar studies5Alisic S. Boet S. Sutherland S. Bould M.D. A qualitative study exploring mentorship in anesthesiology: perspectives from both sides of the relationship.Can J Anaesth. 2016; 63: 851-861Crossref PubMed Scopus (29) Google Scholar and expert consensus. To ensure face validity, content experts contributed during the developmental process. Questions were developed iteratively based on feedback from these experts and a small pilot group. A subset of subjects (n=12) was used for the pilot group to assess construct validity using factor analysis for specific components of the questionnaire. The electronic survey was then sent to the American Society of Anesthesiologists (ASA) for approval and dissemination to active physician anaesthesiologists in the USA who completed postgraduate training by March 31, 2021. Members were invited to complete the survey by clicking on a link in the email message. The link directed respondents to a consent page which outlined the purpose of the survey. By agreeing to continue, consent was implied. Participation was voluntary and all responses were anonymous. No personal identifying information was collected. Two reminders to complete the survey were e-mailed 7 days apart, and the survey remained open for 21 days. Analysis was conducted using descriptive statistics. Categorical variables were summarised using frequencies and percentages. Comparisons of groups were made using χ2 test, Fischer's exact test, and the two-proportion Z-test, where indicated. A P-value <0.05 was considered significant. Analyses were performed using Microsoft Excel version 16.54 (Microsoft Corp., Redmond, WA, USA) and SAS version 9.4 (SAS Institute Inc., Cary, NC, USA). The survey was distributed to 25 824 active ASA member US anaesthesiologists. Of those, 1223 (4.7%) completed the survey. Twenty-nine percent of survey respondents identified as female, 48% identified as male, 19% did not identify a sex. Forty-seven percent of respondents were in academic practice, which was defined as teaching learners and providing clinical care. Further analysis focused on this subset of respondents. Most academic anaesthesiologists (67%) were clinician–educators. Thirty-nine percent responded that their current institution has a formal faculty mentoring program. Eleven percent responded that they had a formal mentor within their department, 21% had an informal mentor, and 60% did not have a mentor. The majority (61%) of respondents had never sought a mentor outside of their institution. More clinician–researchers at all levels of academic rank had mentors (60%) compared with clinician educators (39%) (P=0.013). Of note, 53% of survey respondents were in private practice, 71% of whom did not have a mentor. Sixty-three percent of women respondents in academic practice had at least one mentor, compared with 52% of men (P=0.011). Most respondents indicated that lack of sufficient time was a significant barrier to mentoring, followed by lack of formal mentor training, and lack of compensation for the work. Most departments do not offer compensation or time for mentoring activities. The goal of this study was to investigate the prevalence of mentorship programs in academic anaesthesiology departments in the USA, which has not been studied previously. We found that only a minority of departments had formal faculty mentoring programs, and most academic anaesthesiologists had no mentor. Barriers to mentoring included lack of time, lack of formal training, and lack of compensation (Fig 1). Most academic anaesthesiologists select a clinician–educator or clinician–researcher track, both of which require continuous professional development and academic productivity to advance in academic rank. Despite this, mentoring approaches have been better described for clinician–researcher mentees building research careers than for clinician–educators. There is a positive association between mentorship and grant applications, grant funding, and publications.2Sambunjak D. Straus S.E. Marusic A. Mentoring in academic medicine: a systematic review.JAMA. 2006; 296: 1103-1115Crossref PubMed Scopus (1078) Google Scholar,3Palepu A. Friedman R.H. Barnett R.C. et al.Junior faculty members' mentoring relationships and their professional development in U.S. medical schools.Acad Med. 1998; 73: 318-323Crossref PubMed Scopus (322) Google Scholar The majority of our respondents were clinician–educators. Even for clinician–educators, metrics for academic promotion depend less on patient care and more on academic productivity such as peer-reviewed publications and grant funding. Our results indicate that many academic anaesthesiology departments do not have formal faculty mentorship programs, with the majority of faculty without mentors. We found that few respondents pursued mentoring relationships outside their departments and institutions possibly because of physical distance and limited opportunities to approach potential mentors. We did not investigate barriers to inter-institutional mentoring. However, a lack of local mentors does not need to limit access; mentoring is often done virtually.6Gotian R. How do you find a decent mentor when you're stuck at home?.Harv Bus Rev. 2020; https://hbr.org/2020/08/how-do-you-find-a-decent-mentor-when-youre-stuck-at-homeGoogle Scholar Most faculty respondents with mentors chose their mentors rather than had one appointed. Previous studies have shown that successful mentoring relationships require personal connection and shared values,7Straus S.E. Johnson M.O. Marquez C. Feldman M.D. Characteristics of successful and failed mentoring relationships: a qualitative study across two academic health centers.Acad Med. 2013; 88: 82-89Crossref PubMed Scopus (324) Google Scholar and these are likely present when mentees pick their mentors. We found that the most common challenge facing mentors is lack of time. Most respondents indicated that their departments failed to provide protected time or compensation for mentoring or mentor training. Mentoring continues to be undervalued by leaders and organisations. Johnson and colleagues8Johnson W.B. Smith D.G. Haythornthwaite J. Why your mentorship program isn't working.Harv Bus Rev. 2020; https://hbr.org/2020/07/why-your-mentorship-program-isnt-working#:∼:text=Marginal%20or%20mediocre%20mentoring%20may,%2C%20evaluate%2C%20or%20reward%20mentoringGoogle Scholar wrote of Fortune 500 companies in the Harvard Business Review that 'leaders fail to give resources to evaluate or reward mentoring. With no meaningful incentives attached, it is justifiably seen as an onerous add-on duty, a thankless distraction from real work leading to pay and advancement'. Academic anaesthesiology departments must address these barriers, reward strong mentors, and value mentoring relationships to yield the benefits of increased professional productivity, career satisfaction, and improved self-efficacy. Consideration for mentor training programs focused on improving active listening, collegiality, and situational awareness may further enhance mentoring programs. The authors declare that they have no conflict of interest. Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA seed grant.

Advanced age, American Society of Anesthesiologists physical status (ASA) classification and the presence of cognitive impairment are associated with an elevated risk of postoperative morbidity and mortality. The visual paired comparison (VPC) task, which relies on recognition of novel images, examines declarative memory. VPC scores have demonstrated the ability to detect mild cognitive impairment and track progression of neurodegenerative disease. Quantitative pupillometry may have similar value. We evaluate for associations between these variables of interest and the feasibility of performing these tests in the preoperative clinic. Prospective data from 199 patients seen in the preoperative clinic at a tertiary academic center were analyzed. A 5 min VPC task (Neurotrack Technologies, Inc, Redwood City, CA) was administered during their scheduled preoperative clinic visit. Pupillary light reflexes were measured at the same visit (PLR-3000™, Neuroptics Corp, Irvine, California).Thirty-four percent of patients were categorized as ASA 2 and 58% as ASA 3. Median age was 57 (IQR: 44–69). Associations were demonstrated between age and ASA physical status (Mann–Whitney U Test, p < 0.0001), maximum pupil size (Spearman Rank Correlation, r = − 0.40, p < 0.0001), and maximum constriction velocity (Spearman Rank Correlation, r = − 0.39, p < 0.0001). Our data also revealed an association between VPC score and age (Spearman Rank Correlation, p = 0.0016, r = − 0.21) but not ASA score (Kruskal–Wallis Test, p = 0.14). When compared to a nonsurgical cohort with no history of memory impairment, our population scored worse on the VPC task (Mann–Whitney U Test, p = 0.0002). A preoperative 5 min VPC task and pupillometry are feasible tests in the preoperative setting and may provide a valuable window into an individual’s cognition prior to elective surgery.

BACKGROUND:Perioperative opioids are problematic following craniotomy as they can impede neurological examination because of excessive sedation and mask surgical complications. Multimodal anesthetic techniques including nerve blocks have been used successfully to deliver opioid-free anesthesia in other surgical populations; however, no clinical data evaluating opioid-free anesthesia for craniotomy exists within the current body of literature.MATERIALS AND METHODS:Six prospectively identified patients underwent supratentorial craniotomy at Emory University Hospital using a multimodal opioid-free anesthetic (OFA) technique consisting of preoperative scalp block, dexmedetomidine and intravenous acetaminophen. These opioid-free patients were matched by age, sex, incision length, and incision location to 18 retrospectively identified control patients who underwent craniotomy using conventional, opioid-based anesthetic techniques. Postoperative opioid consumption and pain scores were compared and analyzed for noninferiority.RESULTS:Noninferiority of the OFA technique was demonstrated for opioid consumption at all measured intervals from postanesthesia care unit arrival to 24 hours postoperatively. Noninferiority was also demonstrated with respect to average postoperative pain scores from 0 to 12 hours, 0 to 24 hours, as well as length of postanesthesia care unit stay. Noninferiority was not shown for time to first rescue opioid postoperatively, pain scores for the 12 to 24 hours postoperative period, or time to emergence from anesthesia.CONCLUSIONS:This pilot study demonstrates the feasibility of an OFA technique for patients undergoing supratentorial craniotomy and suggests that larger prospective randomized controlled trials are indicated to examine the role of multimodal anesthetic techniques for craniotomy.

Purpose:Low-dose naltrexone (LDN) has increased in popularity as a non-opioid medication that may decrease chronic pain symptoms. LDN is most commonly used to treat fibromyalgia, complex regional pain syndrome (CRPS), and painful diabetic neuropathy. Other studies suggest that LDN provides general symptom reduction in inflammatory conditions such as Crohn's disease and multiple sclerosis. We reviewed our experience with patients to whom we have prescribed LDN to see what types of painful conditions were most responsive to LDN in our patient population.Patients and Methods:Charts from patients who came to the Pain Center between 2014 and 2021 were reviewed.Results:Of the n = 137 patients who were prescribed LDN, 44% had no evidence of ever filling the prescription, and 4.4% of the responses were not charted. Of the remaining who took LDN (n = 70), 64% had some relief and were designated as 'Responders'. The most common pain diagnosis was neuropathic pain which, when added to the diagnosis of complex regional pain syndrome, accounted for 51% of responders to LDN. Patients who experienced greater than 50% pain relief from LDN were more likely to have the diagnosis of neuropathic pain or complex regional pain syndrome (p = 0.038, Fisher's Exact Test). There was a significant difference in the diagnosis of patients who responded to LDN. Patients with spondylosis were much less likely to respond to LDN when compared with other diagnoses (p = 0.00435, Chi-Square Test).Conclusion:Patients with all types of neuropathic pain, including CRPS, were significantly more likely to have pain relief from LDN than patients with spondylosis (p=0.018). The diagnosis of spondylosis was more often associated with a lack of response to LDN than any other diagnosis. Patients may need to have a trial of several weeks before analgesic effects are seen with LDN.

Background: Emergency abdominal surgery, including surgery for trauma, is associated with a high rate of postoperative complications and death. The prevalence of cardiac complications in trauma patients remains unclear. We hypothesized that older patients experience higher rates of mortality after emergent surgery for trauma because of cardiac complications.Methods and Materials: We performed a retrospective cohort study using our institutional trauma registry. Patients aged 45 years and older who underwent exploratory laparotomy for trauma within 3 days of traumatic injury, between 1/1/2014-12/31/2019 were included. The association between acute myocardial infraction (AMI) and in-hospital mortality after emergent exploratory laparotomy for trauma, mortality rates, ICU length of stay, and prolonged ventilator use was determined.Results: Four hundred fifty-five patients met inclusion criteria. The median age = 54y (IQR 4960) with the majority being men (n=323, 71%), a median injury severity scale (ISS) = 20 (IQR 10-29). Eighty (18%) had elevated troponin I levels and fifty-three (12%) suffered an AMI.Patients who had elevated troponin or an MI were more likely to die during their hospital stay: O.R. 7.19, (95% CI 2.60-20.0), and O.R. 5.59 (95% CI 2.75-11.36) respectively. Overall mortality rate = 18%. Older age was the strongest predictor of MI (O.R. 1.08, 95% CI 1.04-1.11).Conclusion: Patients older than 55 years undergoing exploratory laparotomy due to trauma are at higher risk of MI and death. Increased surveillance of older patients after emergent surgery and monitoring for myocardial ischemia may lead to earlier interventions and decreased mortality.

ObjectiveThe Enhanced Recovery after Surgery Cardiac Society recommends using multimodal analgesia (MMA) for postoperative pain however, evidence-based guidelines have yet to be established. This study examines the impact of a standardized postoperative MMA pathway in reducing opioid consumption and related complications after cardiothoracic surgery (CTS). MethodsWithin a multicenter healthcare system, a postoperative MMA pathway was developed and implemented at two CTS intensive care units (ICU) while the other CTS ICU opted to maintain the existing opioid-based pathway. A retrospective chart review was conducted on patients admitted to a CTS ICU within this healthcare system after conventional coronary artery bypass grafting and/or valve surgery from September 1, 2018, to June 30, 2019. Comparative analysis was conducted on patients prescribed MMA versus those managed with an opioid-based pathway. The primary outcome was total opioid consumption, converted to morphine milligram equivalents, 72-h post-surgery. Secondary outcomes included mobility within one-day post-surgery, ICU length of stay (LOS), time to first bowel movement (BM), and time to first zero Richmond Agitation-Sedation Scale (RASS). ResultsSeven hundred sixty-two adults were included for final analysis. The MMA group had a higher body mass index, higher percentage of females, were more likely classified as African American and had higher scores for risk-adjusted complications. General Linear Model analysis revealed higher opioid consumption in the MMA group (Est. 0.22, p < 0.0009); however, this was not statistically significant after adjusting for differences in fentanyl usage. The MMA group was more likely to have mobility within one-day post-surgery (OR 0.44, p < 0.0001), have longer time to first BM (OR 1.93, p = 0.0011), and longer time to first zero RASS (OR 1.62, p = 0.0071). The analgesia groups were not a predictor for ICU LOS. ConclusionsOpioid consumption was not reduced secondary to this postoperative MMA pathway. The MMA group was more likely to have mobility within one-day post-surgery. Patients in the MMA group were also more likely to have prolonged time to first BM and first zero RASS. Development and evaluation of a perioperative MMA pathway should be considered.

OBJECTIVE:The aim of the study is to investigate barriers to opioid use disorder (OUD) care among acute and chronic pain physicians and advanced practice providers, including hypothesized barriers of lack of interest in OUD care and stigma toward this patient population.METHODS:The study used an anonymous 16-item online survey through Google Forms. Respondents were 153 health practitioners across the United States and Canada, all of whom are registered in one of several pain or anesthesia professional societies. Data were analyzed with descriptive and categorical statistics.RESULTS:The most common barriers include "lack of appropriate clinical environment for prescribing by both acute and chronic pain practitioners" (48%) and "lack of administrative/departmental support" (46%). A total of 32% of respondents reported that OUD care was important but they were not interested in doing more, while 28% of practitioners believed that they treat patients with OUD differently than others in a negative way. More males reported "difficulty" in treating OUD as a barrier (45% vs 25%). Chronic pain practitioners reported poor payor mix as a barrier twice as often as their acute pain colleagues. In free response, lack of multidisciplinary OUD care was a notable barrier.CONCLUSIONS:The top barriers to OUD treatment were clinical environment, departmental support, difficulty in treating the condition, and payor mix, supporting the hypotheses. Given an OUD patient scenario, 55% of acute pain physicians and 73% of chronic pain physicians expressed a willingness to prescribe buprenorphine.

Background: Radiofrequency ablation (RFA) is a denervation therapy commonly performed for pain of facet etiology. Degenerative spondylolisthesis, a malalignment of the spinal vertebrae, may be a co-existing condition contributing to pain; yet the effect of RFA on advancing listhesis is unknown. To the extent that denervating RFA may weaken para-spinal muscles that provide stability to the spine, the therapy can potentially contribute to progressive spinal instability. Methods: Single-center, prospective, observational pilot study in an interventional pain practice to test the hypothesis that RFA of painful facets in the setting of spondylolisthesis may contribute to advancement of further degenerative spondylolisthesis. Fifteen participants with pre-existing degenerative Grade I or Grade II spondylolisthesis and coexisting axial lumbar pain underwent lumbar RFA encompassing spondylolisthesis level and followed with post-RFA imaging at 12 months and beyond to measure percent change in spondylolisthesis. Results: The primary outcome was the percent advancement of spondylolisthesis per year measured on post-RFA lateral lumbar spine imaging compared with non-intervention inferred baseline advancement of 2% per very limited observational studies. Among the 15 participants enrolled, 14 completed the study (median age 66; 64.3% women; median BMI 33.5; mean follow-up time 23.9 months). The mean advancement of spondylolisthesis per year after RFA was 1.30% (95% CI -0.14 to 2.78%), with 9/14 below 1.25%. Conclusion: Among patients with lumbar pain originating from facets in the setting of degenerative spondylolisthesis who underwent lumbar RFA, the observed advancement of spondylolisthesis is clinically similar to the estimated maximum baseline of 2% per year change. The study findings did not find a destabilizing effect of lumbar RFA in advancing spondylolisthesis in this patient population.

Introduction: Celiac plexus neurolysis (CPN) has been verified for mitigating pancreatic cancer pain. However, information regarding CPN's use beyond this remains limited. Objectives: Identify which cancers benefit from CPN, which symptoms improve, and when symptoms improve. Methods: Retrospective analysis was conducted on 173 patients who received CPN for pain caused by various malignancies. Mean symptom changes on the MD Anderson Symptom Inventory (MDASI) from baseline to 2 weeks, 1 month, and 2 months after CPN were analyzed overall and then by cancer type: pancreatic (all stages and stages III–IV), hepatobiliary, and nonpancreatic, nonhepatobiliary gastrointestinal (NPNH-gastrointestinal). Results: Eighty-two pancreatic, 43 NPNH-gastrointestinal, 14 hepatobiliary, and 34 patients with other cancers met inclusion criteria. Statistically significant changes included decrease in the pain score at 1 month by 1.01 points for all cancers, 1.65 points for all pancreatic cancers, and 1.88 points for late-stage pancreatic cancers. At 2 months, pain decreased by 1.50 points for all cancers, 1.68 points for all pancreatic cancers, 2.37 points for late-stage pancreatic cancers, and 1.50 points in NPNH-gastrointestinal cancers. At 2 months, quality of life improved by 1.07 points for all cancers and 1.53 points for all pancreatic cancers. Sleep improved at 2 months for all cancers by 0.73 points and 1.60 points in late-stage pancreatic cancers. At 2 months, pancreatic cancer patients improved in general activity by 0.93 points, walking by 1.00 points, and working by 1.12 points. Conclusion: Celiac plexus neurolysis can decrease cancer symptom burden beyond pain including quality of life and sleep for pancreatic and nonpancreatic cancers, as well as general activity for pancreatic cancers.