Background Currently, perioperative stakeholders are guided to provide general anesthesia (GA) patients with either two or four antiemetic prophylaxis (AEPPx) medications based on the 1990s legacy risk factors (RFs). There are no Veteran-centric regional anesthesia (RA) or GA postoperative nausea and vomiting (PONV) RF studies, and only a few studies have explored these factors based on race/ethnicity. Thus, the currently accepted AEPPx in Veterans may be escalating symptoms, costs, and lengths of stay.Methods We first conducted institutional review board (IRB)-approved secondary analyses from a prospective Veteran-specific randomized trial to assess for RA-specific PONV RFs. Subsequently, we conducted IRB-approved retrospective analyses of observational quality improvement data from Veterans receiving GA with or without intrathecal morphine (ITM) preoperatively (with ITM cases accompanied by a five-drug AEPPx). The goal was to assess both Veteran-specific and anesthesia (RA and GA)-specific PONV RFs. For RA-specific PONV RF analyses in 115 Veterans, we queried electronic medical records (EMR) along with database-archived study data from case report forms. For GA-specific PONV RF analyses in 468 Veterans, we analyzed EMR data to compare PONV-free patients with PONV-positive patients, both for postoperative days 0-1 (POD#0-1 after surgery) and POD#2.Results Postoperative opioids were associated with increased PONV in both analyses. For RA, African-American Veterans were found to have more PONV despite lower overall opioid consumption than that in the race-referent group, while diabetic Veterans overall showed less PONV. For GA-specific analyses (informed by the risks and signals identified in RA analyses), African-American Veterans again had more PONV. Consensus-guided RFs added to the models were often non-predictive, particularly (i) smoking status and past PONV (RA-specific) and (ii) gender and past PONV (GA-specific). This may suggest underpowering in both limited sample sizes or, instead, indicate race as a profoundly overriding RF. RFs associated with POD#2 PONV after GA (after no PONV on POD#0-1) notably differed from factors driving POD#0-1 PONV.Conclusion Consensus-guided AEPPx may require reevaluation, particularly in Veterans undergoing RA or GA, if not population-wide. All Veterans could benefit from our 2023-described off-patent five-drug AEPPx before any anesthetic drug is administered, as described herein and elsewhere. Emerging RFs may have pharmacoequity and race-based implications.

Supplementary Figure from Relations of Current and Past Cancer with Severe Outcomes among 104,590 Hospitalized COVID-19 Patients: The COVID EHR Cohort at the University of Wisconsin

BackgroundFor major abdominal surgery, we explored “usual” opioid-avoiding effects of spinal magnesium 25 mg added to intrathecal morphine (250+ µg in women, 300+ µg in men; ITM + Mg+). We evaluated associated benefits of several integrated care “bundles”: 5-drug antiemetic prophylaxis, multiple-day postoperative antiemetic boosters (perphenazine and aprepitant), boosters for non-opioid transitional analgesia, and strategically-avoided usual opioids intraoperatively (fentanyl, hydromorphone, etc.). We also explored antiemetic outcomes, and pruritus, on postoperative days 0–2. We hypothesized these bundles would independently and interactively influence associated outcomes.MethodsWe used a mixed-method framework to demonstrate whether these bundles, integrated with ITM + Mg+, were all associated with one or more milestones en route to improving described outcomes [prevented postoperative nausea/vomiting (PONV), avoided postoperative opioids, etc.]. We did so via retrospective, case-matched quality improvement methodology for a single-hospital population of ITM-receiving Veterans, applying multiple regression to determine (i) PONV prevention success on days 0–1 separately from day 2, (ii) success of avoiding usual opioids (by withholding discretionary fentanyl/hydromorphone intraoperatively en route to avoiding the need for patient-requested hydromorphone/oxycodone postoperatively), and (iii) predictors/signals of itching, including related to the ITM-upgrade to ITM + Mg+.ResultsITM + Mg+, at the described doses, supported by 5-antiemetic prophylaxis and three-drug non-opioid transitional analgesics, was associated with significant opioid-avoiding improvements. Postoperative avoidance of usual opioids was associated with both ITM + Mg+ use and intraoperative and immediate postoperative avoidance of “usual opioids” (fentanyl, hydromorphone, etc.). PONV on days 0–1 (vs. day 2) appears to have differing predictor patterns, warranting both 5-MMAEPPx preoperatively, and future antiemetic upgrade from 2-drug booster prophylaxis (perphenazine/aprepitant) to also include palonosetron every 40 h. ITM historical control major abdominal surgery cases before ITM + Mg+ had a 14% “usual opioid avoidance rate” (35/246), which showed significant associated improvements with ITM + Mg+ use, usual opioid avoidance, and integration with the other described care bundles (34/60, 57%, P < 0.001).ConclusionMultiple “bundles” appear to address both sustained antiemetic success and “usual opioid avoidance.” ITM-related pruritus requires further study regarding prophylaxis and treatment, in order to allow ITM + Mg+ to achieve its full enhanced recovery potential, when trying to avoid postoperative exposure to usual opioids.

Background Older adults are at higher risk of severe outcomes from COVID-19 with comorbidities increasing such risk. Much less is known about the outcomes of young adults with COVID-19 despite their having had high infection rates. Objectives Our objective was to determine outcomes of hospitalized young adults with COVID-19 infection including rates of oxygen use, mortality, ICU admission, intubation, duration of hospitalization, and factors associated with adverse outcomes. Study design This retrospective cohort study included EHR data from 21 health systems in the United States on 18–29-year-olds hospitalized with COVID-19 from March 1, 2020 – January 31, 2022. Oxygen need was used to identify symptomatic COVID-19. Rates for mortality, ICU admission, and intubation were calculated for the symptomatic and asymptomatic groups. Effects of demographic and health characteristics on outcomes were assessed as were changes in hospital outcomes over time. Results Our sample included 9871 young adults hospitalized with COVID-19; 35% required oxygen. Of those who required oxygen, 53.5% were female, 23.7% had an anxiety disorder, 2.6% died (n = 89), 27.7% were admitted to the ICU (n = 955), and 15.8% were intubated (n = 547). A past-year history of any cancer was associated with a 2.1 times increased odds of death. Vaccination was associated with a >40% reduction in the odds of ICU admission. Mortality rates did not change significantly across the study period. Conclusions COVID-19 caused significant morbidity and mortality in hospitalized young adults who required oxygen. A cancer history was associated with increased risk of death. Vaccination appeared to have had a protective effect on illness severity.

Adolescence is a unique period of physical and psychosocial changes as youth transition, over many years, to adulthood. The psychosocial changes that accompany adolescence include emotional separation from parents, greater influence of peer groups, an interest in self-identification and autonomy, and increased risk-taking behaviors. Substance use is a common form of risk-taking behavior in the adolescent developmental stage. Alcohol, nicotine, and cannabis are the most common types of substances used in the United States. In the adolescent transplant population, rates of substance use appear to be at, or slightly below, their peer counterparts. Substance use can lead to deleterious health outcomes for adolescent transplant patients as a result of impaired decision-making, reduction in medication and clinic visit compliance, increases in mental health disorders, and risk for developing dependence and a substance use disorder. Given the close relationship that many pediatric transplant providers have with their patients and families, transplant care teams are in an excellent position to help their patients by addressing adolescent substance use. This narrative review describes how providers can use proactive standardized approaches to identify and intervene with substance use behavior.

BACKGROUND:The COVID-19 pandemic was managed in part by the rapid development of vaccines, diagnostics, and therapeutics including antiviral agents and advances in emergency airway and ventilatory management. The impact of these therapeutic advances on clinically pertinent metrics of emergency care have not been well-studied. METHODS:We abstracted data from emergency department (ED) visits made to 21 US health systems during the first two years of the pandemic, from February 1, 2020 to January 31, 2022. These health systems were participants in the NIH-supported COVID EHR Cohort, in which the University of Wisconsin served as the coordinating site. Limited patient-level data files were submitted monthly. Data elements included demographic and clinical variables, as well as standard measures of ED outcomes including 72-h returns, 72-h returns leading to readmission, and in-hospital mortality. Multivariable models were fitted to identify correlates of each of the dependent variables. A test for trend was used to detect changes in outcomes over time. RESULTS:During the two-year period, 150,357 individuals aged 18 years or older visited the ED. The median age was 45.4 years (IQR 27), 58.1 % were female, 49 % were White, 18.3 % Hispanic/Latino, and 45 % were publicly insured or uninsured. The prevalence of 72-h ED returns, readmissions, and in-hospital mortality significantly declined across the two-year period. SARS-CoV-2 vaccination was associated with reduced ED returns and mortality. Therapeutic agents were associated with increased mortality risk but were likely confounded by unmeasured covariates. CONCLUSIONS:Operational and clinical outcomes of ED-based treatment of individuals with COVID-19 improved in the first two years of the pandemic. This improvement is likely multifactorial and includes the development and deployment of SARS-CoV-2-specific vaccines, therapeutic agents, and improved healthcare delivery in the ED and elsewhere addressing management of airway and ventilatory status, as well as increased innate immunity in the general population.

INTRODUCTION:Valid measures of pain are helpful to adjust treatment plans in real time after total joint replacement (TJR). We enhanced the existing Defense and Veterans Pain Rating Scale (DVPRS) with items related to pain at rest and movement, in specific reference to operative and nonoperative joints, creating the TJR-DVPRS. This manuscript is presented to validate the modified survey instrument. The aims of this psychometric study were to evaluate (1) the latent structure of the TJR-DVPRS, (2) the relationships among the pain dimensions represented on the TJR-DVPRS and the reference-standard Short-Form McGill Pain Questionnaire (version 2, SF-MPQ-2), and (3) the responsiveness of these two measures before and after TJR.MATERIALS AND METHODS:This report involves a secondary analysis of pain surveys from 135 veterans undergoing TJR at one center who participated in a randomized trial. The study was approved by the institutional review boards from participating institutions. The TJR-DVPRS and SF-MPQ-2 were completed preoperatively, during postoperative day 1, and 6 weeks post-surgery. Standard psychometric evaluations included correlations, principal component analysis, and internal consistency of survey items and subscales, using preoperative baseline data as a frame of reference. Responsiveness analysis included assessing both effect size and thresholds of clinically important change for survey subscales using data from all three time points.RESULTS:Two reliable subscales were identified for the TJR-DVPRS, one including items about pain intensity and interference related to the operative joint (Cronbach's α = .809) and the other including two pain items on the nonoperative joint. Combining the subscales indicated a two-factor solution: The first valid factor entailed the four subscales of the SF-MPQ-2 and the TJR-DVPRS operative joint subscales, indicating that these subscales validly represent the same pain dimension. The second valid factor entailed the TJR-DVPRS subscale addressing the nonoperative joint. Responsiveness analysis following accepted psychometric methods demonstrated significant decreases in pain from the preoperative period to 6 weeks postoperatively for all subscales. The TJR-DVPRS and SF-MPQ-2 subscales were similarly responsive, except for the SF-MPQ-2 neuropathic and TJR-DVPRS nonoperative joint subscales, which were minimally responsive during the preoperative to 6-week period.CONCLUSIONS:The TJR-DVPRS is valid for use among veterans undergoing TJR and poses significantly less respondent burden than does the SF-MPQ-2. The brevity and ease of use of the TJR-DVPRS make it a practical tool for use during surgical recovery to monitor pain intensity at rest and with movement in the operative joint, and to assess pain interference with activity, sleep, and mood. The TJR-DVPRS is at least as responsive as the SF-MPQ-2, but the SF-MPQ-2 neuropathic and TJR-DVPRS nonoperative joint subscales were minimally responsive. Limitations of this study include the small sample size, under-representation of women (which would be expected in the veteran population), and using only veterans. Future validations studies should include civilians and active military TJR patients.

Abstract Background: There is mixed evidence about the relations of current versus past cancer with severe COVID-19 outcomes and how they vary by patient and cancer characteristics. Methods: Electronic health record data of 104,590 adult hospitalized patients with COVID-19 were obtained from 21 United States health systems from February 2020 through September 2021. In-hospital mortality and ICU admission were predicted from current and past cancer diagnoses. Moderation by patient characteristics, vaccination status, cancer type, and year of the pandemic was examined. Results: 6.8% of the patients had current (n = 7,141) and 6.5% had past (n = 6,749) cancer diagnoses. Current cancer predicted both severe outcomes but past cancer did not; adjusted odds ratios (aOR) for mortality were 1.58 [95% confidence interval (CI), 1.46–1.70] and 1.04 (95% CI, 0.96–1.13), respectively. Mortality rates decreased over the pandemic but the incremental risk of current cancer persisted, with the increment being larger among younger vs. older patients. Prior COVID-19 vaccination reduced mortality generally and among those with current cancer (aOR, 0.69; 95% CI, 0.53–0.90). Conclusions: Current cancer, especially among younger patients, posed a substantially increased risk for death and ICU admission among patients with COVID-19; prior COVID-19 vaccination mitigated the risk associated with current cancer. Past history of cancer was not associated with higher risks for severe COVID-19 outcomes for most cancer types. Impact: This study clarifies the characteristics that modify the risk associated with cancer on severe COVID-19 outcomes across the first 20 months of the COVID-19 pandemic. See related commentary by Egan et al., p. 3

Identifying patients at risk for readmission after severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection could facilitate care planning and prevention. This retrospective cohort study of 60‐day readmission included 105 543 COVID‐19 patients at 21 US healthcare systems who were discharged alive between February 2020 and November 2021. Generalized linear mixed regression analyses tested predictors of 60‐day readmission and severity. The all‐cause readmission rate was 15% (95% confidence interval [CI] = 10%–21%), with 22% (95% CI = 18%–26%) of readmitted patients needing intensive care, and 6% (95% CI = 05%–07%) dying. Factors associated with readmission included male sex, government insurance, positive smoking history, co‐morbidity burden, longer index admissions, and diagnoses at index admission (e.g., cancer, chronic kidney disease, and liver disease). Death and intensive care rates at readmission declined postvaccine availability. Receiving at least two COVID‐19 vaccine doses, which were more common among older patients and those with comorbid conditions, was not independently associated with readmission but predicted a reduced risk of death at readmission. This retrospective cohort study identified factors associated with all‐cause readmission for patients re‐admitted to the same health system after hospitalization with SARS‐CoV‐2 infection. Patients who are male, who smoke, who have a higher comorbidity burden, and have government insurance may benefit from additional postacute care planning.

Introduction Available evidence is mixed concerning associations between smoking status and COVID-19 clinical outcomes. Effects of nicotine replacement therapy (NRT) and vaccination status on COVID-19 outcomes in smokers are unknown. Methods Electronic health record data from 104 590 COVID-19 patients hospitalized February 1, 2020 to September 30, 2021 in 21 U.S. health systems were analyzed to assess associations of smoking status, in-hospital NRT prescription, and vaccination status with in-hospital death and ICU admission. Results Current (n = 7764) and never smokers (n = 57 454) did not differ on outcomes after adjustment for age, sex, race, ethnicity, insurance, body mass index, and comorbidities. Former (vs never) smokers (n = 33 101) had higher adjusted odds of death (aOR, 1.11; 95% CI, 1.06-1.17) and ICU admission (aOR, 1.07; 95% CI, 1.04-1.11). Among current smokers, NRT prescription was associated with reduced mortality (aOR, 0.64; 95% CI, 0.50-0.82). Vaccination effects were significantly moderated by smoking status; vaccination was more strongly associated with reduced mortality among current (aOR, 0.29; 95% CI, 0.16-0.66) and former smokers (aOR, 0.47; 95% CI, 0.39-0.57) than for never smokers (aOR, 0.67; 95% CI, 0.57, 0.79). Vaccination was associated with reduced ICU admission more strongly among former (aOR, 0.74; 95% CI, 0.66-0.83) than never smokers (aOR, 0.87; 95% CI, 0.79-0.97). Conclusions Former but not current smokers hospitalized with COVID-19 are at higher risk for severe outcomes. SARS-CoV-2 vaccination is associated with better hospital outcomes in COVID-19 patients, especially current and former smokers. NRT during COVID-19 hospitalization may reduce mortality for current smokers. Implications Prior findings regarding associations between smoking and severe COVID-19 disease outcomes have been inconsistent. This large cohort study suggests potential beneficial effects of nicotine replacement therapy on COVID-19 outcomes in current smokers and outsized benefits of SARS-CoV-2 vaccination in current and former smokers. Such findings may influence clinical practice and prevention efforts and motivate additional research that explores mechanisms for these effects.

INTRODUCTION:E-cigarette use has been increasing for years with a limited understanding of how to help users quit. Quit lines are a potential resource for e-cigarette cessation. Our objective was to characterize e-cigarette users who call state quit lines and to examine trends in e-cigarette use by callers.METHODS:This retrospective study examined data from adult callers to the Wisconsin Tobacco Quit Line from July 2016 through November 2020, including demographics, tobacco product use, motivations for use, and intentions to quit. Descriptive analyses were performed by age group with pairwise comparisons.RESULTS:A total of 26,705 encounters were handled by the Wisconsin Tobacco Quit Line during the study period. E-cigarettes were used by 11% of callers. Young adults aged 18-24 had the highest rates of use at 30%, and their use rose significantly from 19.6% in 2016 to 39.6% in 2020. E-cigarette use among young adult callers peaked at 49.7% in 2019, coinciding with an outbreak of e-cigarette-related lung injury. Only 53.5% of young adult callers used e-cigarettes to "cut down on other tobacco," compared to 76.3% of adult callers aged 45-64 (P <0.05). Of all callers using e-cigarettes, 80% were interested in quitting.CONCLUSIONS:E-cigarette use among callers to the Wisconsin Tobacco Quit Line has increased, driven largely by young adults. Most e-cigarette users who call the quit line want to quit. Thus, quit lines can serve an important role in e-cigarette cessation. A better understanding of strategies to help e-cigarette users quit is needed, particularly in young adult callers.

Editor—We reviewed the recent statement by the International Society for Perioperative Care of the Patient with Obesity (ISPCPO) and the American Society for Metabolic and Bariatric Surgery (ASMBS) 1 Schumann R. Ziemann-Gimmel P. Sultana A. et al. Postoperative nausea and vomiting in bariatric surgery: a position statement endorsed by the ASMBS and the ISPCOP. Surg Obes Relat Dis. 2021; 17: 1829-1833 Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar regarding the Fourth Postoperative Nausea/Vomiting (PONV) Consensus Guidelines from 2020. 2 Gan T.J. Belani K.G. Bergese S. et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2020; 131: 411-448 Crossref PubMed Scopus (398) Google Scholar ISPCPO/ASMBS recommended administering at least two or three antiemetics from different pharmacologic categories 'even in the absence of … risk factors.' However, one of ISPCPO/ASMBS-recommended drugs, transdermal scopolamine, is not supported by a recent Cochrane Review, 3 Weibel S. Rücker G. Eberhart L.H. et al. Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis. Cochrane Database Syst Rev. 2020; 10: CD012859 PubMed Google Scholar as combination of scopolamine and antidopaminergic antiemetics, or combination of scopolamine and aprepitant, could reduce efficacy of both agents. Meanwhile, recent loss of patent protection for aprepitant and palonosetron has led our centre to 'Aim for Zero', and apply routine five-drug prophylaxis regardless of consensus 2 Gan T.J. Belani K.G. Bergese S. et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2020; 131: 411-448 Crossref PubMed Scopus (398) Google Scholar -guided risk factors. In 2021, we began using intrathecal morphine for bariatric and other general surgery procedures otherwise performed under general anaesthesia. These patients received palonosetron 75 μg i. v. as part of a five-drug plan that also included 4–8 mg perphenazine p. o., aprepitant 40 mg p. o., diphenhydramine 12.5 mg i. v., and dexamethasone 4 mg i. v. Use of this regimen for patients undergoing general anaesthesia began after notification of peer-reviewed manuscript acceptance 4 Williams B.A. Ibinson J.W. Cellurale M. Nalepka T. Becker D.B. Same-day and next-day pain and nausea parameters after intrathecal morphine for abdominal panniculectomy and mastectomy post-bariatric surgery. Pain Med. 2021; 22: 3114-3116 Crossref PubMed Scopus (3) Google Scholar of a case report and case series related to successful five-drug prophylaxis associated with intrathecal morphine (with local anaesthetic bupivacaine or tetracaine) use for total joint replacement (TJR) under spinal anaesthesia. The impetus for improvement was also motivated by a recent report indicating an unacceptably high 44% incidence of PONV on postoperative Day 0 (POD0) and 1 (POD1) after colorectal surgery in an enhanced recovery pathway including intrathecal morphine including three antiemetics (ondansetron, dexamethasone, and either the patent-protected aprepitant or off-patent perphenazine). 5 Holder-Murray J. Esper S.A. Boisen M.L. et al. Postoperative nausea and vomiting in patients undergoing colorectal surgery within an institutional enhanced recovery after surgery protocol: comparison of two prophylactic antiemetic regimens. Korean J Anesthesiol. 2019; 72: 344-350 Crossref PubMed Scopus (9) Google Scholar We opted for a novel strategy of pan-prophylaxis against all available emetogenic mechanisms regardless of risk factors before any emetogenic stimuli were experienced, including preoperative intrathecal morphine given in a separate location outside the operating room. 6 Williams B.A. Kentor M.L. Williams J.P. et al. Process analysis in outpatient knee surgery: effects of regional and general anesthesia on anesthesia-controlled time. Anesthesiology. 2000; 93: 529-538 Crossref PubMed Scopus (143) Google Scholar Postoperative nausea and vomiting: is the big little problem becoming a smaller little problem?British Journal of AnaesthesiaVol. 131Issue 1PreviewPostoperative nausea and vomiting (PONV) has been identified as a big (very frequently encountered) little (not linked to life-threatening outcomes) problem. Traditional drugs (dexamethasone, droperidol or similar drugs, serotonin receptor antagonists) each have significant but limited effect, leading to an increasing use of combination therapies. High-risk patients, often identified through use of risk scoring systems, remain with a significant residual risk despite combining up to three traditional drugs. Full-Text PDF

Main objective There is limited information on how patient outcomes have changed during the COVID-19 pandemic. This study characterizes changes in mortality, intubation, and ICU admission rates during the first 20 months of the pandemic. Study design and methods University of Wisconsin researchers collected and harmonized electronic health record data from 1.1 million COVID-19 patients across 21 United States health systems from February 2020 through September 2021. The analysis comprised data from 104,590 adult hospitalized COVID-19 patients. Inclusion criteria for the analysis were: (1) age 18 years or older; (2) COVID-19 ICD-10 diagnosis during hospitalization and/or a positive COVID-19 PCR test in a 14-day window (+/- 7 days of hospital admission); and (3) health system contact prior to COVID-19 hospitalization. Outcomes assessed were: (1) mortality (primary), (2) endotracheal intubation, and (3) ICU admission. Results and significance The 104,590 hospitalized participants had a mean age of 61.7 years and were 50.4% female, 24% Black, and 56.8% White. Overall risk-standardized mortality (adjusted for age, sex, race, ethnicity, body mass index, insurance status and medical comorbidities) declined from 16% of hospitalized COVID-19 patients (95% CI: 16% to 17%) early in the pandemic (February-April 2020) to 9% (CI: 9% to 10%) later (July-September 2021). Among subpopulations, males (vs. females), those on Medicare (vs. those on commercial insurance), the severely obese (vs. normal weight), and those aged 60 and older (vs. younger individuals) had especially high mortality rates both early and late in the pandemic. ICU admission and intubation rates also declined across these 20 months. Conclusions Mortality, intubation, and ICU admission rates improved markedly over the first 20 months of the pandemic among adult hospitalized COVID-19 patients although gains varied by subpopulation. These data provide important information on the course of COVID-19 and identify hospitalized patient groups at heightened risk for negative outcomes. Trial registration ClinicalTrials.gov Identifier: NCT04506528 ( https://clinicaltrials.gov/ct2/show/NCT04506528 ).

Background: Although people who smoke cigarettes are overrepresented among hospital inpatients, few are connected with smoking cessation treatment during their hospitalization. Training, accountability for medication use, and monitoring of all patients position pharmacists well to deliver cessation interventions to all hospitalized patients who smoke. Methods: A large Midwestern University hospital implemented a pharmacist-led smoking cessation intervention. A delegation protocol for hospital pharmacy inpatients who smoked cigarettes gave hospital pharmacists the authority to order nicotine replacement therapy (NRT) during hospitalization and upon discharge, and for referral to the Wisconsin Tobacco Quit Line (WTQL) at discharge. Eligible patients received the smoking cessation intervention unless they actively refused (ie, “opt-out”). The program was pilot tested in phases, with pharmacist feedback between phases, and then implemented hospital-wide. Interviews, surveys, and informal mechanisms identified ways to improve implementation and workflows. Results: Feedback from pharmacists led to changes that improved workflow, training and patient education materials, and enhanced adoption and reach. Refining implementation strategies across pilot phases increased the percentage of eligible smokers offered pharmacist-delivered cessation support from 37% to 76%, prescribed NRT from 2% to 44%, and referred to the WTQL from 3% to 32%. Conclusion: Hospitalizations provide an ideal opportunity for patients to make a tobacco quit attempt, and pharmacists can capitalize on this opportunity by integrating smoking cessation treatment into existing inpatient medication reconciliation workflows. Pharmacist-led implementation strategies developed in this study may be applicable in other inpatient settings.

To the Editor We congratulate and thank the Fourth Consensus Conference addressing Guidelines for the Management of Postoperative Nausea and Vomiting (PONV).1 We wholeheartedly agree with its "one major change in this iteration of the guideline…that in adults, the panel consensus is now to implement multimodal PONV prophylaxis in patients with 1 or 2 risk factors, in an attempt to reduce risk of inadequate prophylaxis." However, since patients with 0 risk factors still have a 10% PONV risk, and because at least 3 nonsedating off-patent inexpensive antiemetics are easily available with minimal side effect burden, we endorse 2 integrated approaches that differ from those presented by the current or previous Consensus Guidelines. First, and principally, we endorse that oral perphenazine 8 mg (OP8) is a low-cost and efficacious tool for prevention of PONV. Second, we will demonstrate the theoretical value of "the perphenazine-dexamethasone-ondansetron (P-D-O) technique" (OP8, dexamethasone 4 mg intravenous [IV], and ondansetron 4 mg IV), applied to every PONV risk category in such a way that the patient may receive a greater number of PONV-prophylactic agents than what the Consensus Guidelines recommend. Specifically, Consensus "wait and see" patients get 3 antiemetics (P-D-O); those for whom 2 agents are recommended receive 3 agents (P-D-O); and those for whom 3 or 4 agents are recommended all get 4 (P-D-O and an neurokinin-1 receptor-antagonist such as aprepitant [40 mg orally, per os]). Perphenazine, a phenothiazine with antihistamine properties, at 5 mg IV, was included in the Consensus manuscript's Table 4, but the IV preparation has not been commercially available in the United States since the early 2000s. We have had extensive experience with OP8 in adults as part of a multimodal antiemetic plan, with its cost at the undersigned authors' institutions ranging from 50 cents to 2 dollars per dose (US currency). For this low cost per patient, we have previously reported2 a 27.2% reduction in the need for IV ondansetron rescue in the postanesthesia care unit (PACU) in nearly 9500 patients from 2002 to 2006. The implications of a routinely applied P-D-O technique, including for "zero risk factor" patients, is illustrated in a scenario analysis given in the Table. In the classic factorial trial by Apfel et al,3 ondansetron 4 mg, dexamethasone 4 mg, and droperidol 1.25 mg each reduced the risk of PONV by approximately 25%. Based on our 2002–2006 aforementioned2 ~25% reduction in need-for-rescue when OP8 was used preoperatively, the Table illustrates that the 3-drug low-cost P-D-O reduces the theoretical risk from 20/200 (10%) to 8/200 (4%) in patients that the Consensus-recommended prophylaxis plan would entail rescue-only without prophylaxis. With the sequential 25% risk reduction per each prophylactic drug, OP8 reduces 20/200 to 15/200, dexamethasone reduces 15/200 to 11/200, and ondansetron reduces 11/200 to 8/200. For patients with 20%–40% risk, we assume 2-agent antiemetic prophylaxis in the Consensus-treated group with ondansetron-dexamethasone (4 mg each IV), and the P-D-O technique-treated group having a 25% further risk reduction than the Consensus-treated group. Finally, for the 60%–80% risk groups where the Consensus guideline is for 3 or 4 antiemetics, we assume half of the Consensus-treated group gets ondansetron-dexamethasone-droperidol 1.25 mg IV for "3 antiemetics," and the other half of the Consensus-treated group gets ondansetron-dexamethasone-droperidol-aprepitant 40 mg po for "4 antiemetics"; meanwhile, we recommend that P-D-O-aprepitant be given for the 60%–80% risk P-D-O–treated groups. Table. - Scenario Analysis of Side-by-Side Estimated Incidences of PONV When the Consensus Guidelines Are Followed Versus the Proposed P-D-O Technique Baseline PONV risk Consensus-recommended intervention1 Consensus-dosed, PONV cases per 2001 P-D-O technique, PONV cases per 2002,3 PONV prevented with P-D-O, cases per 2002 10% Wait and see 20 8 12 20% 2 antiemetics 22 16 6 40% 2 antiemetics 45 32 13 60% 3 or 4 antiemetics 25 + 19 = 44 38* 6 80% 3 or 4 antiemetics 34 + 25 = 59 51* 8 Difference in incidence (column total) 190 per 1000 145 per 1000 45 cases per 1000 prevented P-D-O technique: perphenazine (8 mg orally before surgery) plus dexamethasone (4 mg IV after induction) plus ondansetron (4 mg IV before emergence). When the Consensus-recommended intervention involves a range of options (eg, 3 or 4 antiemetics), the Consensus-dosed PONV cases per 200 represents a weighted average (half receiving 3, the other half receiving 4), *but for the P-D-O technique, a fourth agent (eg, aprepitant) is what we recommend (and assume) for all cases to have a 25% further risk reduction. Further prospective study is needed to confirm this clinical impression. In this illustration, oral perphenazine 8 mg2 is assumed to be a viable substitute to IV droperidol 1.25 mg3, with a ~25% risk reduction. Further prospective study is needed to confirm this clinical impression. No other multimodal techniques are assumed to have been given in either treatment arm (eg, regional or total IV anesthesia). Based on this estimate, 45 fewer patients per 1000 would encounter PONV with the P-D-O technique, representing a 24% risk reduction when compared with the Consensus guideline prophylaxis scheme using ondansetron-dexamethasone, with or without droperidol, and with or without aprepitant, based on the risk estimate category given above.Abbreviations: IV, intravenous; P-D-O, perphenazine-dexamethasone-ondansetron; PONV, postoperative nausea and vomiting We previously2 encouraged prospective, randomized research with OP8, especially in light of nonsedating benefits in the setting of ambulatory anesthesia fast-tracking and phase 1 PACU bypass, but (13 years after that recommendation) do not anticipate the costs of this research to be underwritten by industry sponsors due to its long-standing availability as a generic preparation, and the implications of a generic medication showing equal efficacy to branded medications. We have found OP8 useful as follows: (1) as a nonsedating antiemetic; (2) as a preventative measure similar to the antihistamine promethazine4 against ketamine-induced psychotomimetic effects; and (3) as a safe single-dose drug (only 1.3 extrapyramidal events per 10,000 patients receiving 4–8 mg oral dose, with all events easily treated).5 We have published a case series/review2 and a randomized trial6 of emetic outcomes after the use of OP8 and dexamethasone, with6 or not necessarily with2 ondansetron (ie, before ondansetron became available as a generic medication). Additionally, we evaluated the efficacy of single-dose OP8 to a single 40 mg dose of aprepitant given preoperatively in colorectal surgery patients at our academic center within an enhanced recovery protocol, which was designed to mitigate opioid utilization, reduce PONV, and optimize patient recovery.7 In this retrospective study, no differences were noted in antiemetic requirement on postoperative days 0 and 1 between patients receiving OP8 versus aprepitant. In addition, when patients were matched for preoperative, procedural, and anesthesia characteristics, no differences were noted in late PONV between patients receiving OP8 versus aprepitant. As enhanced recovery protocols become more widespread and continue to be applied to other surgical specialties, effective PONV prevention is imperative for improving patient outcomes. OP8 deserves to be properly evaluated (by clinical study, and/or in routine clinical practice) as a part of a cost-effective multimodal enhanced recovery strategy. As a reminder, metoclopramide should be considered contraindicated for perioperative use if perphenazine is used preoperatively, due to drug interaction risk. According to the Consensus Guideline, "Metoclopramide may be useful in institutions where other dopamine antagonists are not available, but otherwise may not be very efficacious."1 CONCLUSIONS The search for the best, cost-effective approach to PONV is far from complete. We recommend that anesthesiology/surgery departments and hospital clinicians on Pharmacy & Therapeutics committees consider in earnest the value of routine preoperative, single-dose OP8, as part of the described P-D-O technique, for patients who have (1) no history of extrapyramidal reactions to similar drugs, (2) no concomitant current long-term prescriptions for antidopaminergic psychiatric drugs, including aripiprazole, and (3) no coexisting Parkinson Disease or cerebral palsy. Our threshold age for dose reduction (0–4 mg instead of 8 mg) is 70 years, if there is no plan for concomitant ketamine use. Brian A. Williams, MD, MBADepartment of Anesthesiology and Perioperative MedicineUniversity of PittsburghPittsburgh, Pennsylvania[email protected] Jennifer M. Holder-Murray, MDDepartment of SurgeryUniversity of PittsburghPittsburgh, Pennsylvania Stephen A. Esper, MD, MBAKathirvel Subramaniam, MDDepartment of Anesthesiology and Perioperative MedicineUniversity of PittsburghPittsburgh, Pennsylvania Susan J. Skledar, BS Pharm, MPH, FASHPDepartment of Pharmacy and TherapeuticsUniversity of PittsburghPittsburgh, Pennsylvania Michael L. Kentor, MDSteven L. Orebaugh, MDMichael P. Mangione, MDJames W. Ibinson, MD, PhDJonathan H. Waters, MDJohn P. Williams, MDJacques E. Chelly, MD, PhD, MBADepartment of Anesthesiology and Perioperative MedicineUniversity of PittsburghPittsburgh, Pennsylvania

OBJECTIVES Current screening questions for pediatric tobacco smoke exposure are suboptimal. Factors influencing screening accuracy, particularly in the pediatric inpatient setting, are unknown. Our objective was to identify facilitators of and barriers to parental disclosure of smoke exposure when screened during their child’s hospitalization and strategies to promote accurate disclosure. METHODS This qualitative study was conducted with a convenience sample of parents of children admitted to the medical and surgical unit of a Midwest tertiary care children’s hospital. Eligible parents included those with documented disclosure of smoke exposure in the child’s electronic health record. A researcher trained in qualitative methods conducted semistructured, in-depth interviews with parents regarding their experiences with smoke exposure screening in the inpatient pediatric setting. Two researchers independently identified concepts directed at barriers, facilitators, and strategies for effective screening, which were compared and reconciled by a third researcher. RESULTS Facilitators of disclosing their child’s smoke exposure included the following: (1) the caregiver’s internal characteristic(s) promoting disclosure, (2) perceived relevance of the screening question to the child’s health, and (3) the questioner being viewed positively. Barriers included the following: (1) fear of negative consequences, (2) a vague question, (3) lack of knowledge, (4) guilt, and (5) unconducive environment and timing. The strategies parents suggested to improve screening for smoke exposure included the following: (1) communicate preemptively, (2) provide specific exposure examples, (3) improve questioner-caregiver rapport, and (4) improve screening environment and timing. CONCLUSIONS Parents identified various mechanisms to improve tobacco smoke exposure screening. The facilitators, barriers, and strategies provide opportunities to improve the inpatient pediatric screening process.

OBJECTIVE To compare pain outcome reports of patients undergoing hip or knee replacement who received single-injection nerve/plexus blocks with plain bupivacaine (BPV) to patients who received injections of buprenorphine-clonidine-dexamethasone (BCD) admixed with BPV. DESIGN Prospective, parallel arms, randomized, double-blind trial. SETTING A single Veterans hospital. SUBJECTS 98 Veterans, scheduled for total hip or knee replacement surgery, with spinal as the primary anesthetic. METHODS Participants were randomized to BPV-BCD or plain BPV groups. They underwent nerve/plexus blocks in the L2-L4 and L4-S3 distributions in advance of joint replacement surgery. The primary outcome was change in pain from baseline during the post-operative day assessed by the total pain score in the short-form McGill Pain Questionnaire-v2 (SF-MPQ-2). Secondary outcomes were pain during movement, pain interference, range of motion, mobility, and quality of recovery. RESULTS On post-operative day one, the SF-MPQ-2 total score for the BPV-BCD group demonstrated greater pain reduction compared to the plain BPV group (mean difference 1.8 points, 95% CI 0.6 to 3.0, P = 0.003). The BPV-BCD group also had larger reductions in pain during movement in the surgical joint and less pain interference, along with increased range of hip and knee flexion, compared to the plain BPV group. Outcomes of mobility and quality of recovery were not different between groups. CONCLUSIONS Preoperative BPV-BCD blocks in the L2-L4 and L4-S3 nerve distributions for hip and knee replacements led to less pain on post-operative day one and increased knee and hip range of motion, compared to plain BPV blocks.