Significant reduction of postoperative pain and opioid analgesics requirement with an Enhanced Recovery After Thoracic Surgery protocol

ObjectiveTo evaluate differences in postoperative pain control and opioids requirement in thoracic surgical patients following implementation of an Enhanced Recovery after Thoracic Surgery protocol with a comprehensive postoperative pain management strategy.Material and MethodsA retrospective analysis of a prospectively maintained database of patients undergoing pulmonary resections by robotic thoracoscopy or thoracotomy from January 1, 2017, to January 31, 2019, was conducted. Multimodal pain management strategy (opioid-sparing analgesics, infiltration of liposomal bupivacaine to intercostal spaces and surgical sites, and elimination of thoracic epidural analgesia use in thoracotomy patients) was implemented as part of Enhanced Recovery after Thoracic Surgery on February 1, 2018. Outcome metrics including patient-reported pain levels, in-hospital and postdischarge opioids use, postoperative complications, and length of stay were compared before and after protocol implementation.ResultsIn total, 310 robotic thoracoscopy and 62 thoracotomy patients met the inclusion criteria. This pain management strategy was associated with significant reduction of postoperative pain in both groups with an overall reduction of postoperative opioids requirement. Median in-hospital opioids use (morphine milligram equivalent per day) was reduced from 30 to 18.36 (P = .009) for the robotic thoracoscopy group and slightly increased from 15.48 to 21.0 (P = .27) in the thoracotomy group. More importantly, median postdischarge opioids prescribed (total morphine milligram equivalent) was significantly reduced from 480.0 to 150.0 (P < .001) and 887.5 to 150.0 (P < .001) for the thoracoscopy and thoracotomy groups, respectively. Similar short-term perioperative outcomes were observed in both groups before and following protocol implementation.ConclusionsImplementation of Enhanced Recovery after Thoracic Surgery allows safe elimination of epidural use, better pain control, and less postoperative opioids use, especially a drastic reduction of postdischarge opioid need, without adversely affecting outcomes.     

Manejo de la enfermedad de Parkinson y otros trastornos del movimiento en mujeres en edad fértil: Parte 1

IntroductionThe main challenge of Parkinson's disease in women of childbearing age is managing symptoms and drugs during pregnancy and breastfeeding. The increase in the age at which women are having children makes it likely that these pregnancies will become more common in future.ObjectivesThis study aims to define the clinical characteristics of women of childbearing age with Parkinson's disease and the factors affecting their lives, and to establish a series of guidelines for managing pregnancy in these patients.ResultsThis consensus document was developed through an exhaustive literature search and a discussion of the available evidence by a group of movement disorder experts from the Spanish Society of Neurology.ConclusionsParkinson's disease affects all aspects of sexual and reproductive health in women of childbearing age. Pregnancy should be well planned to minimise teratogenic risk. A multidisciplinary approach should be adopted in the management of these patients in order to take all relevant considerations into account.     

Association of Multiple Plasma Biomarker Concentrations with Progression of Prevalent Diabetic Kidney Disease: Findings from the Chronic Renal Insufficiency Cohort (CRIC) Study

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Non-weightbearing imaging and standard knee radiographs are inferior to formal alignment radiographs for calculating coronal alignment of the knee

IntroductionRealignment knee osteotomy relies on accurate preoperative assessment of coronal alignment. Weightbearing (WB) ‘long-leg’ (LL) radiographs are the accepted gold-standard investigation, though in practice standard knee radiographs (short leg; SL) and non-weightbearing (NWB) cross-sectional imaging such as computed tomography (CT) scanograms have been used. We compare the accuracy of SL and NWB radiographs to formal LL alignment radiographs.MethodsA prospectively maintained osteotomy database was reviewed to identify the study population. All patients underwent standardised weightbearing long-leg alignment radiographs. The series was screened consecutively until 30 patients who also underwent WB SL radiographs (‘WB cohort’), and 30 with NWB SL (‘NWB cohort’) radiographs, were identified. Anatomic tibiofemoral angle was calculated by independent reviewers using a validated technique from both radiographs and contrasted.Results60 patients were identified as outlined in the study protocol. There were no differences in baseline demographics. Coronal alignment calculated from SL and LL radiographs differed significantly (median difference 2.1°, p < 0.001). Alignment values from weightbearing SL radiographs demonstrated markedly greater agreement with LL values than those from NWB radiographs (intraclass correlation coefficient 0.878 vs 0.657), with the NWB cohort also exhibiting greater outlier and extreme outlier incidence.ConclusionOur data adds to the growing evidence that SL radiographs are inadequate in the interpretation of knee alignment. In addition, we demonstrate that NWB radiographs (and by extension other NWB modalities such CT scanograms) demonstrate poorer agreement to gold-standard than WB methods. Coronal alignment of the knee cannot be reliably measured from non-weightbearing imaging modalities.Implications for practiceThough potentially useful as an adjunct, non-weightbearing cross-sectional imaging and standard knee radiographs should not be used as a proxy for formal weightbearing long-leg radiographs in osteotomy planning.     

Clot Burden Score and Collateral Status and Their Impact on Functional Outcome in Acute Ischemic Stroke

BACKGROUND AND PURPOSE:Collateral status and thrombus length have been independently associated with functional outcome in patients with acute ischemic stroke. It has been suggested that thrombus length would influence functional outcome via interaction with the collateral circulation. We investigated the individual and combined effects of thrombus length assessed by the clot burden score and collateral status assessed by a FLAIR vascular hyperintensity–ASPECTS rating system on functional outcome (mRS).MATERIALS AND METHODS:Patients with anterior circulation acute ischemic stroke due to large-vessel occlusion from the ASTER and THRACE trials treated with endovascular thrombectomy were pooled. The clot burden score and FLAIR vascular hyperintensity score were determined on MR imaging obtained before endovascular thrombectomy. Favorable outcome was defined as an mRS score of 0–2 at 90 days. Association of the clot burden score and the FLAIR vascular hyperintensity score with favorable outcome (individual effect and interaction) was examined using logistic regression models.RESULTS:Of the 326 patients treated by endovascular thrombectomy with both the clot burden score and FLAIR vascular hyperintensity assessment, favorable outcome was observed in 165 (51%). The rate of favorable outcome increased with clot burden score (smaller clots) and FLAIR vascular hyperintensity (better collaterals) values. The association between clot burden score and functional outcome was significantly modified by the FLAIR vascular hyperintensity score, and this association was stronger in patients with good collaterals, with an adjusted OR = 6.15 (95% CI, 1.03–36.81).CONCLUSIONS:The association between the clot burden score and functional outcome varied for different collateral scores. The FLAIR vascular hyperintensity score might be a valuable prognostic factor, especially when contrast-based vascular imaging is not available.

Therapeutic reperfusion with endovascular thrombectomy (EVT) is consistently associated with a better long-term functional outcome in anterior circulation acute ischemic stroke (AIS).¹ Early reperfusion is the mainstay of therapy because it strongly predicts functional outcome.² Many factors impact clinical outcomes, including the extent of clot and collateral supply.^3–7The clot burden score (CBS) assessed by the T2* MR imaging sequence (T2*-CBS), which was adapted from the CTA-CBS,⁸ has been used to assess the extent of the clot⁹ and has been independently associated with functional outcome in patients undergoing EVT.¹⁰Good collaterals have been related to better clinical outcome through 2 distinct mechanisms. First, collaterals are thought to contribute to prolonged penumbra sustenance.^11,12 Second, good retrograde collateral filling beyond the occlusion could promote successful reperfusion by providing more access to thrombolytics at the distal end of the clot and robust collaterals dissolving clot fragments in the distal vasculature.^13,14 The Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration analysis suggested a benefit with EVT across all strata of collateral circulation status;¹⁵ however, patients with poor collaterals are less likely to benefit from EVT than those with better collaterals.Most interesting, FLAIR vascular hyperintensity (FVH) on baseline MR imaging could indicate the formation of a leptomeningeal collateral circulation and serve as a prognostic marker for patients with AIS.^16-18 Both collaterals and the CBS were separately associated with functional outcome in patients undergoing EVT,^10,16 but their combined effect regarding clinical outcome is still poorly understood and has been assessed and quantified only with CTA or contrast-enhanced MRA in patients with AIS.^14,15 Furthermore, the lack of adjustment for possible confounders because of the small number of patients with very low collateral scores might also have influenced results in these studies.The purpose of this study was to determine whether there is an association between the CBS and FVH score and whether the association between the CBS and functional outcome is modified by the FVH score for patients who were treated by EVT for large-vessel occlusion within the framework of the Contact Aspiration versus Stent Retriever for Successful Revascularization (ASTER) and the THRombectomie des Artères CErebrales (THRACE) randomized trials.^19,20     

Conserving resources in the diagnosis of intraoral fibroepithelial polyps

Fibroepithelial polyps (FEPs) are common, benign intraoral lesions that tend to develop slowly at predictable sites, often in response to local irritation or trauma. Historical precedent often results in referral to oral and maxillofacial surgery (OMFS) departments for biopsy, often irrespective of symptoms, and histological assessment. OMFS and pathology services are struggling to cope with an increasing workload that will potentially lead to widespread delays to diagnosis and treatment. Over the past 20 years, clinical pathways and guidance have been developed to ensure that healthcare interventions, such as the removal of third molars, tonsils, skin tags, and benign moles, are evidence-based, have a net patient benefit, and ensure the best use of finite NHS resources. However, no such guidance exists for intraoral lesions and we regard this as an oversight. We analysed the removal of 682 FEPs over a seven-year period and report sensitivities of 92.4% for a “confirmed clinical suspicion of an FEP” and 99.7% for a “confirmed clinical suspicion of a benign diagnosis”. The incidence of non-benign disease was 0.3%. Primary care dentists should be able to diagnose and monitor FEPs and refer only if symptoms are serious or in high-risk patients or sites. Adopting this practice across the UK could free up to 1825 four-hour OMFS clinics, 405 hours of consultant histopathologists’ time, and recurring savings to the NHS estimated to be in the region of £620 000/annum. We believe that the removal of FEPs should be reclassified as an “intervention not normally funded”, and the time and resources put to better use treating patients with lesions of questionable pathology.     

Patients’ narratives of orthognathic treatment for facial asymmetry: a qualitative study

To explore patients’ experiences of orthognathic treatment for facial asymmetry and their adaptation to facial changes after surgery, we did a qualitative, cross-sectional study of patients after treatment for non-cleft asymmetry at two UK sites. A total of 15 patients aged 19-40 years were approached after being identified using patient databases and clinical notes. Individual and photo-elicitation interviews were conducted covering experiences prior to treatment, during treatment, and after surgery. Interviews were transcribed and thematic narrative analysis undertaken. Participants were largely positive about their orthognathic treatment. The following themes were identified: preoperative (becoming aware, negative impacts of asymmetry, committing to treatment, establishing expectations), pre-surgery orthodontics and inpatient experiences (challenges and coping strategies, preparedness, support, and shared experiences); and postoperative (surgery as ‘worth it’, positive impacts of treatment, adapting to facial change). Undergoing orthognathic surgery was portrayed as a journey involving recognisable narratives (treatment unfinished, threat of liminality, treatment as resolution, and treatment as transformation). Patients’ experiences of facial asymmetry are associated with feeling ‘abnormal’, and negative impacts, and orthognathic treatment for facial asymmetry is worthwhile. Having the feeling that something is ‘wrong’ legitimised by clinicians allows patients access to a recognisable treatment narrative (resolution). Orthognathic treatment is also described as transformation from ‘normal abnormality’ to being ‘normal’. Nevertheless, the associated challenges can be frustrating, particularly if resolution is hard to envisage. Further psychological input could help patients cope with these challenges and the complex process of adapting to facial change.