Ryan Howard

Reduction in Opioid Prescribing Through Evidence-Based Prescribing Guidelines

rarily stopped in preparation for surgery and were therefore excluded from the study. The remaining 93 patients continued their normal AT regimen through surgery. There were 69 patients taking aspirin, 7 taking warfarin, 9 taking clopidogrel, 1 taking dabigatran, 3 taking warfarin plus aspirin, and 4 taking dual antiplatelet therapy. Patients treated with AT agents were older than the control group (mean, 66.1 years vs 56.9 years; P < .001). They were also more likely to be male (96.8% vs 84.4%; P = .002), diabetic (55.9% vs 22.9%; P < .001), and nonsmokers (82.8% vs 71.7%; P = .04). Average preoperative median nerve motor latencies at the wrist did not differ significantly between the AT user and non-AT user groups (6.9 milliseconds vs 6.7 milliseconds; P = .44), nor did the rate of intraoperative tourniquet use (32% vs 56% for AT user and nonuser groups, respectively; P = .22). Estimated blood loss was higher in the no-tourniquet group for both AT users (4.33 mL vs 3.22 mL; P = .02) and non-AT users (4.21 mL vs 3.13 mL; P = .006). Mean operating time was shorter in the no-tourniquet group for both those treated with AT agents (20.1 minutes vs 25.7 minutes; P = .001) and those not treated with AT agents (22.40 minutes vs 24.52 minutes; P = .13). There was no statistical difference in EBL (3.94 mL vs 3.89 mL; P = .87) or operative time (22.0 minutes vs 23.0 minutes; P = .38) in AT and non-AT patient groups overall. Rates of postoperative complications were similar between the AT group and the non-AT group (5.4% vs 4.9%; P > .99). No hematomas or neurological complications were reported, and no patients required reoperation during the study period. Overall, 91.8% of patients reported improvement of symptoms postoperatively, with a mean follow-up time of 3.3 months (Table).

Length polymorphism in the Period 3 gene is associated with sleepiness and maladaptive circadian phase in night-shift workers

The objective of the current study was to determine if night‐shift workers carrying the five‐repeat variant of the Period 3 gene show elevated levels of nocturnal sleepiness and earlier circadian phase compared with homozygotes for the four‐repeat allele. Twenty‐four permanent night‐shift workers were randomly selected from a larger study. Participants took part in an observational laboratory protocol including an overnight multiple sleep latency test and half‐hourly saliva collection for calculation of dim‐light melatonin onset. Period 3–/5 shift workers had significantly lower multiple sleep latency test during overnight work hours compared with Period 34/4 workers (3.52 ± 23.44 min versus 10.39 ± 6.41 min, P = 0.003). We observed no significant difference in sleepiness during early morning hours following acute sleep deprivation. Long‐allele carriers indicated significantly higher sleepiness on the Epworth Sleepiness Scale administered at 17:00 hours (12.08 ± 2.55 versus 8.00 ± 1.94, P < 0.001). We observed a significantly earlier melatonin onset in Period 3–/5 individuals compared with Period 34/4 shift workers (20:44 ± 6:37 versus 02:46 ± 4:58, P = 0.021). Regression analysis suggests that Period 3 genotype independently predicts sleepiness even after controlling for variations in circadian phase, but we were unable to link Period 3 to circadian phase when controlling for sleepiness. Period 3–/5 shift workers showed both subjective and objective sleepiness in the pathological range, while their Period 34/4 counterparts showed sleepiness within normal limits. Period 3–/5 night workers also show a mean circadian phase 6 h earlier (i.e. less adapted) than Period 34/4 workers. Because Period 3–/5 workers have maladaptive circadian phase as well as pathological levels of sleepiness, they may be at greater risk for occupational and automotive accidents. We interpret these findings as a call for future research on the role of Period 3 in sleepiness and circadian phase, especially as they relate to night work.

Contemporary Management of Secondary Aortoduodenal Fistula

BACKGROUND Secondary aortoduodenal fistula (SADF) is a rare, life-threatening complication of abdominal aortic reconstruction. Clinical presentation varies and treatment requires complex surgical repair associated with considerable morbidity and mortality. This retrospective study examines the contemporary management of SADF at a tertiary vascular surgical practice. METHODS Thirteen patients were managed for SADF between 2004 and 2014. Vascular and duodenal reconstructions were considered. Primary end points included bile leak, major complications, and mortality. RESULTS Of the 13 patients presenting with SADF, 6 presented with luminal blood loss. During mean follow-up (632 days), the rate of major complication was 77%. Overall, 38% developed duodenal leak. All leaks occurred after graft explantation with extra-anatomic bypass, and the majority of these patients (80%) had no preceding history of acute gastrointestinal (GI) bleed. There were no leaks identified after duodenal exclusion with gastrojejunostomy. Patients that developed duodenal leak had longer mean intensive care unit length of stay (LOS; 7.0 vs. 2.3 days, P = 0.004), longer mean overall hospital LOS (36.6 vs. 18.5 days, P = 0.012), and greater late mortality (40% vs. 13%). There were 2 SADF-related deaths. Overall mortality trended higher in females (67% vs. 20%, P = 0.125) and those that presented without acute GI bleed (43% vs. 17%, P = 0.308). CONCLUSIONS Surgical reconstruction for SADF results in major morbidity. Those presenting with acute GI bleed trended toward better outcomes than those without. Duodenal leak remains a serious complication. Duodenal exclusion may represent a more appropriate and conservative approach for management of the duodenal defect in select patients.

Patient-centered surgical prehabilitation

The preoperative time period must focus on optimal patientcentered decision-making and optimization of patient wellness. Currently, focus is on preoperative testing and assessment of medical comorbidity. A more strategic approach to mitigate remediable risk has the potential to improve perioperative outcomes. This focus must include patient psychology and spirituality, at least indirectly through clinical perioperative optimization programs focusing on patient empowerment. The evidence for prehabilitation is minimal; but the potential to transform perioperative care is remarkable.1

Large Animal Model of Pumpless Arteriovenous Extracorporeal CO2 Removal Using Room Air Via Subclavian Vessels

End-stage lung disease (ESLD) causes progressive hypercapnia and dyspnea and impacts quality of life. Many extracorporeal support (ECS) configurations for CO2 removal resolve symptoms but limit ambulation. An ovine model of pumpless ECS using subclavian vessels was developed to allow for ambulatory support. Vascular grafts were anastomosed to the left subclavian vessels in four healthy sheep. A low-resistance membrane oxygenator was attached in an arteriovenous (AV) configuration. Device function was evaluated in each animal while awake and spontaneously breathing and while mechanically ventilated with hypercapnia induced. Sweep gas (FiO2 = 0.21) to the device was increased from 0 to 15 L/min, and arterial and postdevice blood gases, as well as postdevice air, were sampled. Hemodynamics remained stable with average AV shunt flows of 1.34 ± 0.14 L/min. In awake animals, CO2 removal was 3.4 ± 1.0 ml/kg/min at maximum sweep gas flow. Respiratory rate decreased from 60 ± 25 at baseline to 30 ± 11 breaths per minute. In animals with induced hypercapnia, PaCO2 increased to 73.9 ± 15.1. At maximum sweep gas flow, CO2 removal was 3.4 ± 0.4 ml/kg/min and PaCO2 decreased to 49.1 ± 6.7 mm Hg. Subclavian AV access is effective in lowering PaCO2 and respiratory rate and is potentially an effective ambulatory destination therapy for ESLD patients.

Frailty as a Predictor of Colonoscopic Procedural Risk: Robust Associations from Fragile Patients

Colonoscopy, the current “gold standard” for colorectal cancer and precancer detection and removal, is generally recommended for the screening of adults aged 50–75. Through recommendations and guidelines such as the 80% screening rate by 2018 set by the National Colorectal Cancer Roundtable [1], its use has nearly doubled over the past two decades [2]. Colonoscopy also carries the risk of major complications such as hemorrhage, perforation, and cardiopulmonary events [3], for which the incidence remains low, although its growing use will increase the number of patients experiencing adverse events. Moreover, it may be of limited benefit in a subset of older patients. A method for determining the patients in which the risk of colonoscopy outweighs its benefit has the potential to help clinicians improve the procedural risk/benefit. This issue of Digestive Diseases and Sciences features a study by Taleban and colleagues which addresses the problem of risk stratification by using frailty as a predictor of complications associated with colonoscopy [4]. Frailty is a state of decreased physiologic capacity and reserve in which patients are more vulnerable to acute stressors such as surgery. This is often associated with sarcopenia. As the authors point out, it can be used to predict outcomes following a variety of procedures. In patients undergoing elective surgery, for example, frailty is an independent predictor of postoperative complications, length of hospital stay, and discharge to a nursing facility [5]. While frailty has now been successfully used to risk-stratify patient risk across a wide range of surgeries, to our knowledge the current study is the first time it has been used as a screening instrument for colonoscopy risk. This prospective cohort study divided the patients into two groups—prefrail/frail and non-frail—using an easily administered upper-extremity frailty test. In this test, participants wear motion sensors and flex and extend their dominant elbow as many times as possible in 20s. The authors then recorded adverse events associated with colonoscopy, reporting that frailty and American Society of Anesthesiologists (ASA) status were significantly associated with colonoscopy-associated adverse events, with 70% of patients in the prefrail/frail group experiencing an adverse event compared to 41% of non-frail patients. We commend the authors on their novel application of frailty as a screening tool for colonoscopy risk. Not only are frail patients at increased risk of colonoscopy complications, they are also less likely to derive any real benefit given the association of frailty with shorter life expectancy [6]. Therefore, determining a patient’s frailty index could significantly inform the decision to pursue colonoscopy to screen for colorectal cancer. Another strength of this study is the practicality of its application. There are several methods by which to determine a patient’s frailty index. Although there is no “gold standard” for diagnosing frailty, several methods rely on determining factors such as weight loss, exhaustion with activity, level of physical activity, and physical weakness and slowness. This often involves a lengthy evaluation and interview process. Such a robust evaluation process may have strengthened the conclusions of this paper, but readers would be left wondering how best to implement this. By using a validated strength test that takes under a minute to administer, the authors greatly enhance the ease of test application and the scalability of their results. Frailty diagnosis may also be useful given the ongoing debate that often surrounds the use of screening * David Machado-Aranda dmachad@med.umich.edu