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Naik BI, Durieux ME, Dillingham R, Waldman AL, Holstege M, Arbab Z, Tsang S, Cui Q, Li XJ, Singla A, Yen CP, Dunn LK. Mobile health supported multi-domain recovery trajectories after major arthroplasty or spine surgery: a pilot feasibility and usability study. BMC Musculoskelet Disord 2023; 24:794. [PMID: 37803365 PMCID: PMC10557197 DOI: 10.1186/s12891-023-06928-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 09/28/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Recovery after surgery intersects physical, psychological, and social domains. In this study we aim to assess the feasibility and usability of a mobile health application called PositiveTrends to track recovery in these domains amongst participants undergoing hip, knee arthroplasty or spine surgery. Our secondary aim was to generate procedure-specific, recovery trajectories within the pain and medication, psycho-social and patient-reported outcomes domain. METHODS Prospective, observational study in participants greater than eighteen years of age. Data was collected prior to and up to one hundred and eighty days after completion of surgery within the three domains using PositiveTrends. Feasibility was assessed using participant response rates from the PositiveTrends app. Usability was assessed quantitatively using the System Usability Scale. Heat maps and effect plots were used to visualize multi-domain recovery trajectories. Generalized linear mixed effects models were used to estimate the change in the outcomes over time. RESULTS Forty-two participants were enrolled over a four-month recruitment period. Proportion of app responses was highest for participants who underwent spine surgery (median = 78, range = 36-100), followed by those who underwent knee arthroplasty (median = 72, range = 12-100), and hip arthroplasty (median = 62, range = 12-98). System Usability Scale mean score was 82 ± 16 at 180 days postoperatively. Function improved by 8 and 6.4 points per month after hip and knee arthroplasty, respectively. In spine participants, the Oswestry Disability Index decreased by 1.4 points per month. Mood improved in all three cohorts, however stress levels remained elevated in spine participants. Pain decreased by 0.16 (95% Confidence Interval: 0.13-0.20, p < 0.001), 0.25 (95% CI: 0.21-0.28, p < 0.001) and 0.14 (95% CI: 0.12-0.15, p < 0.001) points per month in hip, knee, and spine cohorts respectively. There was a 10.9-to-40.3-fold increase in the probability of using no medication for each month postoperatively. CONCLUSIONS In this study, we demonstrate the feasibility and usability of PositiveTrends, which can map and track multi-domain recovery trajectories after major arthroplasty or spine surgery.
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Affiliation(s)
- Bhiken I Naik
- Department of Anesthesiology and Neurological Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Marcel E Durieux
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Rebecca Dillingham
- Division of Infectious Diseases, Martha Jefferson Hospital, Charlottesville, VA, USA
| | - Ava Lena Waldman
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA, USA
| | - Margaret Holstege
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Zunaira Arbab
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Siny Tsang
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Quanjun Cui
- Department of Orthopedics, University of Virginia, Charlottesville, VA, USA
| | - Xudong Joshua Li
- Department of Orthopedics, University of Virginia, Charlottesville, VA, USA
| | - Anuj Singla
- Department of Orthopedics, University of Virginia, Charlottesville, VA, USA
| | - Chun-Po Yen
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Lauren K Dunn
- Department of Anesthesiology and Neurological Surgery, University of Virginia, Charlottesville, VA, USA
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Esfahani K, Tennant W, Tsang S, Naik BI, Dunn LK. Comparison of oral versus intravenous methadone on postoperative pain and opioid use after adult spinal deformity surgery: A retrospective, non-inferiority analysis. PLoS One 2023; 18:e0288988. [PMID: 37478144 PMCID: PMC10361497 DOI: 10.1371/journal.pone.0288988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 07/09/2023] [Indexed: 07/23/2023] Open
Abstract
OBJECTIVE To compare efficacy of oral versus intravenous (IV) methadone on postoperative pain and opioid requirements after spine surgery. METHODS This was a retrospective, single-academic center cohort study evaluating 1010 patients who underwent >3 level spine surgery from January 2017 to May 2020 and received a one-time dose of oral or intravenous methadone prior to surgery. The primary outcome measured was postoperative opioid use in oral morphine equivalents (ME) and verbal response scale (VRS) pain scores up to postoperative day (POD) three. Secondary outcomes were time to first bowel movement and adverse effects (reintubation, myocardial infarction, and QTc prolongation) up to POD 3. RESULTS A total of 687 patients received oral and 317 received IV methadone, six patients were excluded. The IV group received a significantly greater methadone morphine equivalent (ME) dose preoperatively (112.4 ± 83.0 mg ME versus 59.3 ± 60.9 mg ME, p < 0.001) and greater total (methadone and non-methadone) opioid dose (119.1 ± 81.4 mg ME versus 63.9 ± 62.5 mg ME, p < 0.001), intraoperatively. Although pain scores for the oral group were non-inferior to the IV group for all postoperative days (POD), non-inferiority for postoperative opioid requirements was demonstrated only on POD 3. Based on the joint hypothesis for the co-primary outcomes, oral methadone was non-inferior to IV methadone on POD 3 only. No differences in secondary outcomes, including QTc prolongation and arrhythmias, were noted between the groups. CONCLUSIONS Oral methadone is a feasible alternative to IV methadone for patients undergoing spine surgery regarding both pain scores and postoperative opioid consumption.
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Affiliation(s)
- Kamilla Esfahani
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
| | - William Tennant
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
| | - Siny Tsang
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
| | - Bhiken I. Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Lauren K. Dunn
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States of America
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Abstract
Enhanced recovery after surgery (ERAS) protocols are standardized and designed to provide superior analgesia, reduce opioid consumption, improve patient recovery, and reduce hospital length of stay. Yet, moderate-to-severe postsurgical pain continues to afflict over 40% of patients and remains a major priority for anesthesia research. Methadone administration in the perioperative setting may reduce postoperative pain scores and have opioid-sparing effects, which may be beneficial for enhanced recovery. Methadone possesses a multimodal profile consisting of µ-opioid agonism, N-methyl-d-aspartate (NMDA) receptor antagonism, and reuptake inhibition of serotonin and norepinephrine. Furthermore, it may attenuate the development of chronic postsurgical pain. However, caution is advised with perioperative use of methadone in specific high-risk patient populations and surgical settings. Methadone's wide pharmacokinetic variability, opioid-related adverse effects, and potential negative impact on cost-effectiveness may also limit its use in the perioperative setting. In this PRO-CON commentary article, the authors debate whether methadone should be incorporated in ERAS protocols to provide superior analgesia with no increased risks.
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Affiliation(s)
- Ryan S D'Souza
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, Minnesota
| | | | - Lauren K Dunn
- Departments of Anesthesiology
- Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Naik BI, Dunn LK, Wanchek TN. Incremental Cost-effectiveness Analysis on Length of Stay of an Enhanced Recovery After Spine Surgery Program: A Single-center, Retrospective Cohort Study. J Neurosurg Anesthesiol 2023; 35:187-193. [PMID: 34907145 DOI: 10.1097/ana.0000000000000827] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Enhanced recovery after spine surgery (ERAS) is increasingly utilized to improve postoperative outcomes and reduce cost. There are limited data on the monetary benefits of ERAS when incorporating the costs of developing, operationalizing, and maintaining ERAS programs. The objective of this study was to calculate the incremental cost-effectiveness of a spine surgery ERAS program, modeling hospital and operational cost and length of stay (LOS). METHODS The study included adult patients undergoing spine surgery before and after implementation of an ERAS program. Variables included individual patient-level and ERAS personnel costs, with LOS as the outcome utility of interest. Propensity score matching was used to create a quasi-experimental design to equate the standard care and ERAS groups. RESULTS Four hundred and nine patients were included in the unmatched group, with 54 patients each in the standard care and ERAS groups after matching. In the matched cohort, the only imbalance in predictors (standard mean difference [SMD] >0.2) were race (SMD, 0.21), American Society of Anesthesiologist (ASA) physical status (SMD, 0.32), fluid balance in the operating room (SMD, 0.21), median (interquartile range) LOS (standard care, 2.0 [1.0, 3.75] days vs. ERAS, 4.0 [3.0, 5.0]; SMD, 0.81) and mean (±SD) total cost (standard care, $19,291.57±13,572.24 vs. ERAS, $24,363.45±26,352.45; SMD, 0.24). In the incremental cost effectiveness analysis, standard care was the dominant strategy in both 1-way and 2-way sensitivity analysis. CONCLUSIONS We report a real-world, cost-effectiveness analysis following implementation of an ERAS program for spine surgery at a quaternary medical center. Our study demonstrated that considering LOS as the sole determinant, standard care is the dominant cost-effective strategy compared with the ERAS protocol.
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Affiliation(s)
| | | | - Tanya N Wanchek
- Public Health Sciences, University of Virginia, Charlottesville, VA
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Dunn LK, Pham E, Kabil E, Kleiman AM, Hilton EJ, Lyons GR, Ma JZ, Nemergut EC, Forkin KT. The Impact of Physician Race and Sex on Patient Ranking of Physician Competence and Perception of Leadership Ability. Cureus 2023; 15:e34778. [PMID: 36909083 PMCID: PMC10005834 DOI: 10.7759/cureus.34778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/10/2023] Open
Abstract
Background Biases affect patient perceptions of their physician and influence the physician-patient relationship. While racial disparities in care and inequities in the healthcare workforce are well-documented, the impact of physician race on patient perceptions remains unclear. We aimed to investigate the association of physician race and sex on patient perceptions during simulated preoperative encounters. Methods Three hundred patients recruited consecutively in the Preanesthesia Evaluation and Testing Center viewed pictures of 4 anesthesiologists (black male, white male, black female, white female) in random order while listening to a set of paired audio recordings describing general anesthesia. Participants ranked each anesthesiologist on confidence, intelligence, and likelihood of choosing the anesthesiologist to care for their family member, and chose the one anesthesiologist most like a leader. Results Compared to white anesthesiologists, black anesthesiologists had greater odds of being ranked more confident (OR, 1.45; 95% CI, 1.10 to 1.89; P=0.008) and being considered a leader (OR, 2.06; 95% CI, 1.50 to 2.84; P<0.0001). Among white participants, black anesthesiologists had greater odds of being ranked more intelligent (OR, 2.08; 95% CI, 1.54 to 2.81; P<0.0001) and were more likely to be chosen to care for a family member (OR, 2.26; 95% CI, 1.66 to 3.08; P<0.0001). Female anesthesiologists had greater odds of being ranked more intelligent (OR, 1.36; 95% CI, 1.08 to 1.71; P=0.009) and were more likely to be chosen to care for a family member (OR, 1.58; 95% CI, 1.27 to 1.97; P<0.001) compared with male anesthesiologists. Conclusions Contrary to our hypothesis, patients ranked black physicians more highly on multiple competence and leadership quality metrics. Our data likely highlight the role social desirability bias may play in studies of racial disparities within medicine.
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Affiliation(s)
- Lauren K Dunn
- Anesthesiology, University of Virginia School of Medicine, Charlottesville, USA
| | - Elizabeth Pham
- Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Emmad Kabil
- Anesthesiology, University of Virginia School of Medicine, Charlottesville, USA
| | - Amanda M Kleiman
- Anesthesiology, University of Virginia School of Medicine, Charlottesville, USA
| | - Ebony J Hilton
- Anesthesiology, University of Virginia School of Medicine, Charlottesville, USA
| | - Genevieve R Lyons
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, USA
| | - Jennie Z Ma
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, USA
| | - Edward C Nemergut
- Anesthesiology, West Virginia University School of Medicine, Morgantown, USA
| | - Katherine T Forkin
- Anesthesiology, University of Virginia School of Medicine, Charlottesville, USA
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Vlisides PE, Mentz G, Leis AM, Colquhoun D, McBride J, Naik BI, Dunn LK, Aziz MF, Vagnerova K, Christensen C, Pace NL, Horn J, Cummings K, Cywinski J, Akkermans A, Kheterpal S, Moore LE, Mashour GA. Carbon Dioxide, Blood Pressure, and Perioperative Stroke: A Retrospective Case-Control Study. Anesthesiology 2022; 137:434-445. [PMID: 35960872 PMCID: PMC10324342 DOI: 10.1097/aln.0000000000004354] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The relationship between intraoperative physiology and postoperative stroke is incompletely understood. Preliminary data suggest that either hypo- or hypercapnia coupled with reduced cerebrovascular inflow (e.g., due to hypotension) can lead to ischemia. This study tested the hypothesis that the combination of intraoperative hypotension and either hypo- or hypercarbia is associated with postoperative ischemic stroke. METHODS We conducted a retrospective, case-control study via the Multicenter Perioperative Outcomes Group. Noncardiac, nonintracranial, and nonmajor vascular surgical cases (18 yr or older) were extracted from five major academic centers between January 2004 and December 2015. Ischemic stroke cases were identified via manual chart review and matched to controls (1:4). Time and reduction below key mean arterial blood pressure thresholds (less than 55 mmHg, less than 60 mmHg, less than 65 mmHg) and outside of specific end-tidal carbon dioxide thresholds (30 mmHg or less, 35 mmHg or less, 45 mmHg or greater) were calculated based on total area under the curve. The association between stroke and total area under the curve values was then tested while adjusting for relevant confounders. RESULTS In total, 1,244,881 cases were analyzed. Among the cases that screened positive for stroke (n = 1,702), 126 were confirmed and successfully matched with 500 corresponding controls. Total area under the curve was significantly associated with stroke for all thresholds tested, with the strongest combination observed with mean arterial pressure less than 55 mmHg (adjusted odds ratio per 10 mmHg-min, 1.17 [95% CI, 1.10 to 1.23], P < 0.0001) and end-tidal carbon dioxide 45 mmHg or greater (adjusted odds ratio per 10 mmHg-min, 1.11 [95% CI, 1.10 to 1.11], P < 0.0001). There was no interaction effect observed between blood pressure and carbon dioxide. CONCLUSIONS Intraoperative hypotension and carbon dioxide dysregulation may each independently increase postoperative stroke risk. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Phillip E. Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
- Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Aleda M. Leis
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI USA 48109
| | - Douglas Colquhoun
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Jonathon McBride
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Bhiken I. Naik
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA USA 22908
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, VA USA 22908
| | - Lauren K. Dunn
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA USA 22908
| | - Michael F. Aziz
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR USA 97239
| | - Kamila Vagnerova
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR USA 97239
| | - Clint Christensen
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT USA 84132
| | - Nathan L. Pace
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT USA 84132
| | - Jeffrey Horn
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT USA 84132
| | | | - Jacek Cywinski
- Anesthesiology Institute, Cleveland Clinic, OH USA 44195
| | - Annemarie Akkermans
- Department of Anesthesiology, University Medical Center Utrecht, Netherlands
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Laurel E. Moore
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - George A. Mashour
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
- Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI USA 48109
- Neuroscience Graduate Program, University of Michigan Medical School, Ann Arbor, MI USA
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Redinger J, Kabil E, Forkin KT, Kleiman AM, Dunn LK. Resting and Recharging: A Narrative Review of Strategies to Improve Sleep During Residency Training. J Grad Med Educ 2022; 14:420-430. [PMID: 35991104 PMCID: PMC9380640 DOI: 10.4300/jgme-d-21-01035.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/21/2022] [Accepted: 05/31/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Residency involves demanding training with long hours that may cause fatigue and sleep deprivation and adversely impact residents and patients under their care. OBJECTIVE To identify, using a narrative review, evidence-based interventions to reduce the physiologic effects of fatigue and sleep deprivation from overnight and night shift work. METHODS A PubMed literature search was conducted through August 30, 2021, using the terms "resident" and "sleep" in the title or abstract and further narrowed using a third search term. Observational studies, randomized controlled trials, systematic reviews, and meta-analyses of human subjects written and published in English were included. Studies that were not specific to residents or medical interns or did not investigate an intervention were excluded. Additional studies were identified by bibliography review. Due to the heterogeneity of study design and intervention, a narrative review approach was chosen with results categorized into non-pharmacological and pharmacological interventions. RESULTS Initially, 271 articles were identified, which were narrowed to 28 articles with the use of a third search term related to sleep. Bibliography review yielded 4 additional articles. Data on interventions are limited by the heterogeneity of medical specialty, sample size, length of follow-up, and reliance on self-report. Non-pharmacological interventions including strategic scheduling and sleep hygiene may improve sleep and well-being. The available evidence, including randomized controlled trials, to support pharmacological interventions is limited. CONCLUSIONS Non-pharmacological approaches to mitigating fatigue and sleep deprivation have varying effectiveness to improve sleep for residents; however, data for pharmacological interventions is limited.
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Affiliation(s)
- Joyce Redinger
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Joyce Redinger, MD, is PGY-3 Resident
| | - Emmad Kabil
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Emmad Kabil, MD, is PGY-4 Resident
| | - Katherine T. Forkin
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Katherine T. Forkin, MD, is Associate Professor of Anesthesiology
| | - Amanda M. Kleiman
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Amanda M. Kleiman, MD, is Associate Professor of Anesthesiology
| | - Lauren K. Dunn
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Lauren K. Dunn, MD, PhD, is Associate Professor of Anesthesiology and Neurological Surgery
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Affiliation(s)
- Lauren K Dunn
- From the Department of Anesthesiology and Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cynthia A Wong
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Abstract
PURPOSE OF REVIEW Pituitary adenoma resections comprise a large proportion of intracranial tumor surgeries. This patient population is medically and physiologically complex and requires careful perioperative planning and management on the part of the anesthesiologist. This review will summarize anesthetic considerations for pre, intra, and postoperative management of patients undergoing transsphenoidal pituitary surgery. RECENT FINDINGS An endoscopic approach is favored for patients undergoing transsphenoidal pituitary surgery. Hemodynamic monitoring is important to maintain cerebral perfusion and avoid risk of bleeding; however, 'controlled' hypotension may have adverse effects. Multimodal analgesia is effective for the management of postoperative pain and may reduce the risk of postoperative complications, including respiratory depression and postoperative nausea and vomiting. SUMMARY Transsphenoidal pituitary surgery is a preferred approach for the surgical management of nonfunctioning pituitary macroadenomas with symptoms of mass effect and functioning adenomas that cannot be otherwise managed medically. Understanding tumor pathologies and systemic effects are essential for preoperative planning and providing safe anesthetic care during the perioperative period.
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Affiliation(s)
- Kamilla Esfahani
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
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Forkin KT, Dunn LK, Kotha NC, Bechtel AJ, Kleiman AM, Huffmyer JL, Collins SR, Lyons GR, Ma JZ, Nemergut EC. Anesthesiologist Age and Sex Influence Patient Perceptions of Physician Competence. Anesthesiology 2021; 134:103-110. [PMID: 33108442 PMCID: PMC7725924 DOI: 10.1097/aln.0000000000003595] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Uncovering patients' biases toward characteristics of anesthesiologists may inform ways to improve the patient-anesthesiologist relationship. The authors previously demonstrated that patients prefer anesthesiologists displaying confident body language, but did not detect a sex bias. The effect of anesthesiologists' age on patient perceptions has not been studied. In this follow-up study, it was hypothesized that patients would prefer older-appearing anesthesiologists over younger-appearing anesthesiologists and male over female anesthesiologists. METHODS Three hundred adult, English-speaking patients were recruited in the Preanesthesia Evaluation and Testing Center. Patients were randomized (150 per group) to view a set of four videos in random order. Each 90-s video featured an older female, older male, younger female, or younger male anesthesiologist reciting the same script describing general anesthesia. Patients ranked each anesthesiologist on confidence, intelligence, and likelihood of choosing the anesthesiologist to care for their family member. Patients also chose the one anesthesiologist who seemed most like a leader. RESULTS Three hundred patients watched the videos and completed the questionnaire. Among patients younger than age 65 yr, the older anesthesiologists had greater odds of being ranked more confident (odds ratio, 1.92; 95% CI, 1.41 to 2.64; P < 0.001) and more intelligent (odds ratio, 2.24; 95% CI, 1.62 to 3.11; P < 0.001), and had greater odds of being considered a leader (odds ratio, 2.62; 95% CI, 1.72 to 4.00; P < 0.001) when compared with younger anesthesiologists. The preference for older anesthesiologists was not observed in patients age 65 and older. Female anesthesiologists had greater odds of being ranked more confident (odds ratio, 1.46; 95% CI, 1.13 to 1.87; P = 0.003) and more likely to be chosen to care for one's family member (odds ratio, 1.80; 95% CI, 1.40 to 2.31; P < 0.001) compared with male anesthesiologists. The ranking preference for female anesthesiologists on these two measures was observed among white patients and not among nonwhite patients. CONCLUSIONS Patients preferred older anesthesiologists on the measures of confidence, intelligence, and leadership. Patients also preferred female anesthesiologists on the measures of confidence and likelihood of choosing the anesthesiologist to care for one's family member. EDITOR’S PERSPECTIVE
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Affiliation(s)
| | - Lauren K. Dunn
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Naveen C. Kotha
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Allison J. Bechtel
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Amanda M. Kleiman
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Julie L. Huffmyer
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Stephen R. Collins
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Genevieve R. Lyons
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA
| | - Jennie Z. Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA
| | - Edward C. Nemergut
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
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Dunn LK, Chen CJ, Taylor DG, Esfahani K, Brenner B, Luo C, Buell TJ, Spangler SN, Buchholz AL, Smith JS, Shaffrey CI, Nemergut EC, Durieux ME, Naik BI. Postoperative Low-Dose Tranexamic Acid After Major Spine Surgery: A Matched Cohort Analysis. Neurospine 2020; 17:888-895. [PMID: 33401867 PMCID: PMC7788407 DOI: 10.14245/ns.2040114.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/08/2020] [Indexed: 01/04/2023] Open
Abstract
Objective This was a retrospective, cohort study investigating the efficacy and safety of continuous low-dose postoperative tranexamic acid (PTXA) on drain output and transfusion requirements following adult spinal deformity surgery.
Methods One hundred forty-seven patients undergoing posterior instrumented thoracolumbar fusion of ≥ 3 vertebral levels at a single institution who received low-dose PTXA infusion (0.5–1 mg/kg/hr) for 24 hours were compared to 292 control patients who did not receive PTXA. The cohorts were propensity matched based on age, sex, American Society of Anesthesiologist physical status classification, body mass index, number of surgical levels, revision surgery, operative duration, and total intraoperative TXA dose (n = 106 in each group). Primary outcome was 72-hour postoperative drain output. Secondary outcomes were number of allogeneic blood transfusions.
Results There was no significant difference in postoperative drain output in the PTXA group compared to control (660 ±420 mL vs. 710 ±490 mL, p = 0.46). The PTXA group received significantly more crystalloid (6,100 ±3,100 mL vs. 4,600 ±2,400 mL, p < 0.001) and red blood cell transfusions postoperatively (median [interquartile range]: 1 [0–2] units vs. 0 [0–1] units; incidence rate ratio [95% confidence interval], 1.6 [1.2–2.2]; p = 0.001). Rates of adverse events were comparable between groups.
Conclusion Continuous low-dose PTXA infusion was not associated with reduced drain output after spinal deformity surgery. No difference in thromboembolic incidence was observed. A prospective dose escalation study is warranted to investigate the efficacy of higher dose PTXA.
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Affiliation(s)
- Lauren K Dunn
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Davis G Taylor
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Kamilla Esfahani
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Brian Brenner
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Charles Luo
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Sarah N Spangler
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Avery L Buchholz
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Christopher I Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Edward C Nemergut
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA.,Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Marcel E Durieux
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA.,Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA.,Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
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Esfahani K, Lacomis C, Dunn LK, Chen CJ, Zuo Z, Naik BI. A retrospective observational pilot study on the effects of dexmedetomidine on neurological outcomes after aneurysmal subarachnoid hemorrhage. J Clin Anesth 2020; 68:110106. [PMID: 33075634 DOI: 10.1016/j.jclinane.2020.110106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/01/2020] [Accepted: 10/10/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Kamilla Esfahani
- Department of Anesthesiology, University of Virginia Health Center, Charlottesville, VA, USA.
| | | | - Lauren K Dunn
- Department of Anesthesiology, University of Virginia Health Center, Charlottesville, VA, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health Center, Charlottesville, VA, USA
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia Health Center, Charlottesville, VA, USA; Department of Neurological Surgery, University of Virginia Health Center, Charlottesville, VA, USA
| | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia Health Center, Charlottesville, VA, USA; Department of Neurological Surgery, University of Virginia Health Center, Charlottesville, VA, USA
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Affiliation(s)
- Lauren K Dunn
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Eric C Sun
- Departments of Anesthesiology, Perioperative and Pain Medicine and Health Research and Policy, Stanford University, Stanford, California
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Buell TJ, Taylor DG, Chen CJ, Dunn LK, Mullin JP, Mazur MD, Yen CP, Shaffrey ME, Shaffrey CI, Smith JS, Naik BI. Rotational thromboelastometry-guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study. Neurosurg Focus 2020; 46:E17. [PMID: 30933918 DOI: 10.3171/2019.1.focus18572] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 01/24/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVESignificant blood loss and coagulopathy are often encountered during adult spinal deformity (ASD) surgery, and the optimal intraoperative transfusion algorithm is debatable. Rotational thromboelastometry (ROTEM), a functional viscoelastometric method for real-time hemostasis testing, may allow early identification of coagulopathy and improve transfusion practices. The objective of this study was to investigate the effect of ROTEM-guided blood product management on perioperative blood loss and transfusion requirements in ASD patients undergoing correction with pedicle subtraction osteotomy (PSO).METHODSThe authors retrospectively reviewed patients with ASD who underwent single-level lumbar PSO at the University of Virginia Health System. All patients who received ROTEM-guided blood product transfusion between 2015 and 2017 were matched in a 1:1 ratio to a historical cohort treated using conventional laboratory testing (control group). Co-primary outcomes were intraoperative estimated blood loss (EBL) and total blood product transfusion volume. Secondary outcomes were perioperative transfusion requirements and postoperative subfascial drain output.RESULTSThe matched groups (ROTEM and control) comprised 17 patients each. Comparison of matched group baseline characteristics demonstrated differences in female sex and total intraoperative dose of intravenous tranexamic acid (TXA). Although EBL was comparable between ROTEM versus control (3200.00 ± 2106.24 ml vs 3874.12 ± 2224.22 ml, p = 0.36), there was a small to medium effect size (Cohen's d = 0.31) on EBL reduction with ROTEM. The ROTEM group had less total blood product transfusion volume (1624.18 ± 1774.79 ml vs 2810.88 ± 1847.46 ml, p = 0.02), and the effect size was medium to large (Cohen's d = 0.66). This difference was no longer significant after adjusting for TXA (β = -0.18, 95% confidence interval [CI] -1995.78 to 671.64, p = 0.32). More cryoprecipitate and less fresh frozen plasma (FFP) were transfused in the ROTEM group patients (cryoprecipitate units: 1.24 ± 1.20 vs 0.53 ± 1.01, p = 0.03; FFP volume: 119.76 ± 230.82 ml vs 673.06 ± 627.08 ml, p < 0.01), and this remained significant after adjusting for TXA (cryoprecipitate units: β = 0.39, 95% CI 0.05 to 1.73, p = 0.04; FFP volume: β = -0.41, 95% CI -772.55 to -76.30, p = 0.02). Drain output was lower in the ROTEM group and remained significant after adjusting for TXA.CONCLUSIONSFor ASD patients treated using lumbar PSO, more cryoprecipitate and less FFP were transfused in the ROTEM group compared to the control group. These preliminary findings suggest ROTEM-guided therapy may allow early identification of hypofibrinogenemia, and aggressive management of this may reduce blood loss and total blood product transfusion volume. Additional prospective studies of larger cohorts are warranted to identify the appropriate subset of ASD patients who may benefit from intraoperative ROTEM analysis.
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Affiliation(s)
| | | | | | - Lauren K Dunn
- 2Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Jeffrey P Mullin
- 3Department of Neurosurgery, University of Buffalo, New York; and
| | - Marcus D Mazur
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | | | | | | | | | - Bhiken I Naik
- Departments of1Neurosurgery and.,2Anesthesiology, University of Virginia, Charlottesville, Virginia
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Dunn LK, Thiele RH, Lin MC, Nemergut EC, Durieux ME, Tsang S, Shaffrey ME, Smith JS, Shaffrey CI, Naik BI. The Impact of Alvimopan on Return of Bowel Function After Major Spine Surgery - A Prospective, Randomized, Double-Blind Study. Neurosurgery 2020; 85:E233-E239. [PMID: 30951602 DOI: 10.1093/neuros/nyz005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/22/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pain management following major spine surgery requires high doses of opioids and is associated with a risk of opioid-induced constipation. Peripheral mu-receptor antagonists decrease the gastrointestinal complications of perioperative systemic opioid administration without antagonizing the analgesic benefits of these drugs. OBJECTIVE To investigate the impact of alvimopan in opioid-naive patients undergoing major spine surgery. METHODS Patients undergoing >3 levels of thoracic and/or lumbar spine surgery were enrolled in this prospective, randomized, double-blind study to receive either alvimopan or placebo prior to and following surgery. Opioid consumption; pain scores; and time of first oral intake, flatus, and bowel movement were recorded. RESULTS A total of 24 patients were assigned to the active group and 25 were assigned to the placebo group. There was no significant difference in demographics between the groups. Postoperatively, the alvimopan group reported earlier time to first solid intake [median (range): alvimopan: 15 h (3-25) vs placebo: 17 h (3-46), P < .001], passing of flatus [median (range): alvimopan: 22 h (7-63) vs placebo: 28 h (10-58), P < .001], and first bowel movement [median (range): alvimopan: 50 h (22-80) vs placebo: 64 h (40-114), P < .001]. The alvimopan group had higher pain scores (maximum, minimum, and median); however, there was no significant difference between the groups with postoperative opioid use. CONCLUSION This study shows that the perioperative use of alvimopan significantly reduced the time to return of bowel function with no increase in postoperative opioid use despite a slight increase in pain scores.
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Affiliation(s)
- Lauren K Dunn
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Robert H Thiele
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia
| | - Michelle C Lin
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Edward C Nemergut
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Marcel E Durieux
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Siny Tsang
- Department of Nutrition and Exercise Physiology, Washington State University, Pullman, Washington
| | - Mark E Shaffrey
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Esfahani K, Dunn LK, Naik BI. Blood Conservation for Complex Spine and Intracranial Procedures. Curr Anesthesiol Rep 2020. [DOI: 10.1007/s40140-020-00383-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Dunn LK, Taylor DG, Chen CJ, Singla P, Fernández L, Wiedle CH, Hanak MF, Tsang S, Smith JS, Shaffrey CI, Nemergut EC, Durieux ME, Blank RS, Naik BI. Ventilator Mode Does Not Influence Blood Loss or Transfusion Requirements During Major Spine Surgery. Anesth Analg 2020; 130:100-110. [DOI: 10.1213/ane.0000000000004322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Dunn LK, Taylor DG, Smith SJ, Skojec AJ, Wang TR, Chung J, Hanak MF, Lacomis CD, Palmer JD, Ruminski C, Fang S, Tsang S, Spangler SN, Durieux ME, Naik BI. Persistent post-discharge opioid prescribing after traumatic brain injury requiring intensive care unit admission: A cross-sectional study with longitudinal outcome. PLoS One 2019; 14:e0225787. [PMID: 31774864 PMCID: PMC6880998 DOI: 10.1371/journal.pone.0225787] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/12/2019] [Indexed: 12/16/2022] Open
Abstract
Traumatic brain injury (TBI) is associated with increased risk for psychological and substance use disorders. The study aim is to determine incidence and risk factors for persistent opioid prescription after hospitalization for TBI. Electronic medical records of patients age ≥ 18 admitted to a neuroscience intensive care unit between January 2013 and February 2017 for an intracranial injury were retrospectively reviewed. Primary outcome was opioid use through 12 months post-hospital discharge. A total of 298 patients with complete data were included in the analysis. The prevalence of opioid use among preadmission opioid users was 48 (87%), 36 (69%) and 22 (56%) at 1, 6 and 12-months post-discharge, respectively. In the opioid naïve group, 69 (41%), 24 (23%) and 17 (19%) were prescribed opioids at 1, 6 and 12 months, respectively. Preadmission opioid use (OR 324.8, 95% CI 23.1-16907.5, p = 0.0004) and higher opioid requirements during hospitalization (OR 4.5, 95% CI 1.8-16.3, p = 0.006) were independently associated with an increased risk of being prescribed opioids 12 months post-discharge. These factors may be used to identify and target at-risk patients for intervention.
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Affiliation(s)
- Lauren K. Dunn
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
- * E-mail:
| | - Davis G. Taylor
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Samantha J Smith
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Alexander J. Skojec
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Tony R. Wang
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Joyce Chung
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Mark F. Hanak
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Christopher D. Lacomis
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Justin D. Palmer
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Caroline Ruminski
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Shenghao Fang
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Siny Tsang
- Nutrition and Exercise Physiology, Washington State University, Spokane, Washington, United States of America
| | - Sarah N. Spangler
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Marcel E. Durieux
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Bhiken I. Naik
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
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Affiliation(s)
| | - Marcel E Durieux
- From the Departments of Anesthesiology.,Neurosurgery, University of Virginia, Charlottesville, Virginia
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Dunn LK, Yerra S, Fang S, Hanak MF, Leibowitz MK, Tsang S, Durieux ME, Nemergut EC, Naik BI. Incidence and Risk Factors for Chronic Postoperative Opioid Use After Major Spine Surgery: A Cross-Sectional Study With Longitudinal Outcome. Anesth Analg 2019; 127:247-254. [PMID: 29570151 DOI: 10.1213/ane.0000000000003338] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Chronic opioid use is a significant public health concern. Surgery is a risk factor for developing chronic opioid use. Patients undergoing major spine surgery frequently are prescribed opioids preoperatively and may be at risk for chronic opioid use postoperatively. The aim of this study was to investigate the incidence of and perioperative risk factors associated with chronic opioid use after major spine surgery. METHODS The records of patients who underwent elective major spine surgery at the University of Virginia between March 2011 and February 2016 were retrospectively reviewed. The primary outcome was chronic opioid use through 12 months postoperatively. Demographic data, medical comorbidities, preoperative pain scores, and medication use including daily morphine-equivalent (ME) dose, intraoperative use of lidocaine and ketamine, estimated blood loss, postoperative pain scores and medication use, and postoperative opioid use were collected. Logistic regression models were used to examine factors associated with chronic opioid use. RESULTS Of 1477 patient records reviewed, 412 patients (27.9%) were opioid naive and 1065 patients (72.3%) used opioids before surgery. Opioid data were available for 1325 patients, while 152 patients were lost to 12-month follow-up and were excluded. Of 958 preoperative opioid users, 498 (52.0%) remained chronic users through 12 months. There was a decrease in opioid dosage (mg ME) from preoperative to 12 months postoperatively with a mean difference of -14.7 mg ME (standard deviation, 1.57; 95% confidence interval [CI], -17.8 to -11.7). Among 367 previously opioid-naive patients, 67 (18.3%) became chronic opioid users. Factors associated with chronic opioid use were examined using logistic regression models. Preoperative opioid users were nearly 4 times more likely to be chronic opioid users through 12 months than were opioid-naive patients (odds ratio, 3.95; 95% CI, 2.51-6.33; P < .001). Mean postoperative pain score (0-10) was associated with increased odds of chronic opioid use (odds ratio for a 1 unit increase in pain score 1.25, 95% CI, 1.13-1.38; P < .001). Use of intravenous ketamine or lidocaine was not associated with chronic opioid use through 12 months. CONCLUSIONS Greater than 70% of patients presenting for major spine surgery used opioids preoperatively. Preoperative opioid use and higher postoperative pain scores were associated with chronic opioid use through 12 months. Use of ketamine and lidocaine did not decrease the risk for chronic opioid use. Surveillance of patients for these factors may identify those at highest risk for chronic opioid use and target them for intervention and reduction strategies.
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Affiliation(s)
- Lauren K Dunn
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Sandeep Yerra
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Shenghao Fang
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Mark F Hanak
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Maren K Leibowitz
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Siny Tsang
- Department of Epidemiology, Columbia University, New York, New York
| | - Marcel E Durieux
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Edward C Nemergut
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Bhiken I Naik
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.,Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Potter JF, Kleiman AM, Myers EG, Herberg TJ, Bechtel AJ, Forkin KT, Dunn LK, Collins SR, Huffmyer JL, Shilling AM, Nemergut EC. Generative Retrieval Does Not Improve Long-Term Retention of Regional Anesthesia Ultrasound Anatomy in Unengaged Learners. J Educ Perioper Med 2019; 21:E623. [PMID: 31988984 PMCID: PMC6972972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Ultrasound-guided regional anesthesia is increasingly used in the perioperative period but performance requires a mastery of regional ultrasound anatomy. We aimed to study whether the use of generative retrieval to learn ultrasound anatomy would improve long-term recall. METHODS Fourth-year medical students without prior training in ultrasound techniques were randomized into standard practice (SP) and generative retrieval (GR) groups. An initial pre-test consisted of 74 regional anesthesia ultrasound images testing common anatomic structures. During the study/learning session, GR participants were required to verbally identify an unlabeled anatomical structure within 10 seconds of the ultrasound image appearing on the screen. A labeled image of the structure was then shown to the GR participant for 5 seconds. SP participants viewed the same ultrasound images labeled with the correct anatomical structure for 15 seconds. Retention was tested at 1 week and 1 month following the study session. Participants completed a satisfaction survey after each session. RESULTS Forty-five medical students were enrolled with forty included in the analysis. There was no statistically significant difference in baseline scores (GR = 11.5 ± 4.9; SP = 11.2 ± 6.2; P = 0.84). There was no difference in scores at both the 1-week (SP = 54.5 ± 13.3; GR = 53.9 ± 10.5; P = 0.88) and 1-month (SP = 54.0 ± 14.5; GR = 50.7 ± 11.1; P = 0.42) time points. There was no statistically significant difference in learner satisfaction metrics between the groups. CONCLUSIONS The use of generative retrieval practice to learn regional anesthesia ultrasound anatomy did not yield significant differences in learning and retention compared with standard learning.
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Kleiman AM, Potter JF, Bechtel AJ, Forkin KT, Dunn LK, Collins SR, Lyons G, Nemergut EC, Huffmyer JL. Generative retrieval results in positive academic emotions and long-term retention of cardiovascular anatomy using transthoracic echocardiography. Adv Physiol Educ 2019; 43:47-54. [PMID: 30615478 DOI: 10.1152/advan.00047.2018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
With increasing medical knowledge, procedural, and diagnostic skills to learn, it is vital for educators to make the limited amount of teaching time available to students effective and efficient. Generative retrieval is an effective and efficient learning tool, improving long-term retention through the practice of retrieval from memory. Forty medical students were randomized to learn normal cardiovascular anatomy using transthoracic echocardiography video clips in a generative retrieval (GR) or standard practice (SP) group. GR participants were required to verbally identify each unlabeled cardiovascular structure after viewing the video. After answering, participants viewed the correctly labeled video. SP participants viewed the same video clips labeled with the correct cardiovascular structure for the same amount of total time without verbally generating an answer. All participants were tested for intermediate (1-wk), late (1-mo), and long-term (6- to 9-mo) retention of cardiovascular anatomy. Additionally, a three-question survey was incorporated to assess perceptions of the learning method. There was no difference in pretest scores. The GR group demonstrated a trend toward improvement in recall at 1 wk [GR = 74.3 (SD 12.3); SP = 65.4 (SD 16.7); P = 0.10] and 1 mo [GR = 69.9 (SD15.6); SP = 64.3 (SD 15.4); P = 0.33]. At the 6- to 9-mo time point, there was a statistically significant difference in scores [GR = 74.3 (SD 9.9); SP = 65.0 (SD 14.1); P = 0.042]. At nearly every time point, learners had a statistically significantly higher perception of effectiveness, enjoyment, and satisfaction with GR. In addition to improved recall, GR is associated with increased perceptions of effectiveness, enjoyment, and satisfaction, which may lead to increased engagement, time spent studying, and improved retention.
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Affiliation(s)
- Amanda M Kleiman
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
| | - Jennifer F Potter
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
| | - Allison J Bechtel
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
| | - Katherine T Forkin
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
| | - Lauren K Dunn
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
| | - Stephen R Collins
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
| | - Genevieve Lyons
- Department of Public Health Sciences, University of Virginia , Charlottesville, Virginia
| | - Edward C Nemergut
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
- Department of Neurosurgery, University of Virginia , Charlottesville, Virginia
| | - Julie L Huffmyer
- Department of Anesthesiology, University of Virginia , Charlottesville, Virginia
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Affiliation(s)
- Honorio T Benzon
- From the Departments of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL; University of Virginia School of Medicine, Charlottesville, VA; and McGill University, Montreal, Quebec, Canada
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Esfahani K, Naik BI, Dunn LK. Chronic opioid use after spine surgery: what is the prescription for reducing opioid dependence? J Spine Surg 2018; 4:817-819. [PMID: 30714017 PMCID: PMC6330574 DOI: 10.21037/jss.2018.11.01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 11/06/2018] [Indexed: 06/09/2023]
Affiliation(s)
- Kamilla Esfahani
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Lauren K Dunn
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA
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Dunn LK, Yerra S, Fang S, Hanak MF, Leibowitz MK, Alpert SB, Tsang S, Durieux ME, Nemergut EC, Naik BI. Safety profile of intraoperative methadone for analgesia after major spine surgery: An observational study of 1,478 patients. J Opioid Manag 2018; 14:83-87. [PMID: 29733094 DOI: 10.5055/jom.2018.0435] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate the incidence of perioperative adverse events in patients receiving intravenous methadone for major spine surgery. DESIGN Retrospective review of perioperative records from March 2011 and February 2016. SETTING University of Virginia Healthsystem. PATIENTS Adult patients undergoing elective spinal fusion of two or more levels. MAIN OUTCOME MEASURES Incidence of respiratory depression, time to extubation, hypotension, hypoxemia, reintubation, cardiac complications, and death. RESULTS Reviewed 1,478 patient records. Mean intraoperative methadone dose was 0.14 ± 0.07 mg/kg. A total of 1,142 patients (77.4 percent) were extubated in the operating room, 543 (36.8 percent) experienced respiratory depression, 1,180 (79.8 percent) hypoxemia, and 22 (1.5 percent) required reintubation. Cardiac complications included arrhythmias (289 patients, 29.9 percent), QTc prolongation (568 patients, 58.8 percent), and myocardial infarction (16 patients, 1.1 percent). Two in hospital deaths occurred (0.14 percent). CONCLUSIONS Mild-moderate respiratory depression is observed following a one-time dose of intraoperative methadone, and monitoring in an appropriate postoperative setting is recommended.
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Affiliation(s)
- Lauren K Dunn
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Sandeep Yerra
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Shenghao Fang
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Mark F Hanak
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Maren K Leibowitz
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Salome B Alpert
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Siny Tsang
- Department of Epidemiology, Columbia University, New York, New York
| | - Marcel E Durieux
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia; Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Edward C Nemergut
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia; Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia; Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Affiliation(s)
- Lauren K Dunn
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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Dunn LK, Durieux ME, Fernández LG, Tsang S, Smith-Straesser EE, Jhaveri HF, Spanos SP, Thames MR, Spencer CD, Lloyd A, Stuart R, Ye F, Bray JP, Nemergut EC, Naik BI. Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery. J Neurosurg Spine 2017; 28:119-126. [PMID: 29125426 DOI: 10.3171/2017.5.spine1734] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Perception of perioperative pain is influenced by various psychological factors. The aim of this study was to determine the impact of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain scores, and quality of recovery in adults who underwent spine surgery. METHODS Patients undergoing spine surgery were enrolled in this study, and the preoperatively completed questionnaires included the verbal rating scale (VRS), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS), and Oswestry Disability Index (ODI). Quality of recovery was assessed using the 40-item Quality of Recovery questionnaire (QoR40). Opioid consumption and pain scores according to the VRS were recorded daily until discharge. RESULTS One hundred thirty-nine patients were recruited for the study, and 101 completed the QoR40 assessment postoperatively. Patients with higher catastrophizing scores were more likely to have higher maximum pain scores postoperatively (estimate: 0.03, SE: 0.01, p = 0.02), without increased opioid use (estimate: 0.44, SE: 0.27, p = 0.11). Preoperative anxiety (estimate: 1.18, SE: 0.65, p = 0.07) and depression scores (estimate: 1.06, SE: 0.71, p = 0.14) did not correlate with increased postoperative opioid use; however, patients with higher preoperative depression scores had lower quality of recovery after surgery (estimate: -1.9, SE: 0.56, p < 0.001). CONCLUSIONS Catastrophizing, anxiety, and depression play important roles in modulating postoperative pain. Preoperative evaluation of these factors, utilizing a validated tool, helps to identify patients at risk. This might allow for earlier psychological intervention that could reduce pain severity and improve the quality of recovery.
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Affiliation(s)
| | - Marcel E Durieux
- Departments of1Anesthesiology and.,2Neurosurgery, University of Virginia, Charlottesville, Virginia; and
| | | | - Siny Tsang
- 3Department of Epidemiology, Columbia University, New York, New York
| | | | | | | | | | | | | | | | - Fan Ye
- Departments of1Anesthesiology and
| | | | - Edward C Nemergut
- Departments of1Anesthesiology and.,2Neurosurgery, University of Virginia, Charlottesville, Virginia; and
| | - Bhiken I Naik
- Departments of1Anesthesiology and.,2Neurosurgery, University of Virginia, Charlottesville, Virginia; and
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Dunn LK, Durieux ME, Nemergut EC. Non-opioid analgesics: Novel approaches to perioperative analgesia for major spine surgery. Best Pract Res Clin Anaesthesiol 2016; 30:79-89. [DOI: 10.1016/j.bpa.2015.11.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 10/27/2015] [Accepted: 11/16/2015] [Indexed: 01/07/2023]
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Stalvey MS, Clines KL, Havasi V, McKibbin CR, Dunn LK, Chung WJ, Clines GA. Osteoblast CFTR inactivation reduces differentiation and osteoprotegerin expression in a mouse model of cystic fibrosis-related bone disease. PLoS One 2013; 8:e80098. [PMID: 24236172 PMCID: PMC3827431 DOI: 10.1371/journal.pone.0080098] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 09/30/2013] [Indexed: 11/18/2022] Open
Abstract
Low bone mass and increased fracture risk are recognized complications of cystic fibrosis (CF). CF-related bone disease (CFBD) is characterized by uncoupled bone turnover—impaired osteoblastic bone formation and enhanced osteoclastic bone resorption. Intestinal malabsorption, vitamin D deficiency and inflammatory cytokines contribute to CFBD. However, epidemiological investigations and animal models also support a direct causal link between inactivation of skeletal cystic fibrosis transmembrane regulator (CFTR), the gene that when mutated causes CF, and CFBD. The objective of this study was to examine the direct actions of CFTR on bone. Expression analyses revealed that CFTR mRNA and protein were expressed in murine osteoblasts, but not in osteoclasts. Functional studies were then performed to investigate the direct actions of CFTR on osteoblasts using a CFTR knockout (Cftr−/−) mouse model. In the murine calvarial organ culture assay, Cftr−/− calvariae displayed significantly less bone formation and osteoblast numbers than calvariae harvested from wildtype (Cftr+/+) littermates. CFTR inactivation also reduced alkaline phosphatase expression in cultured murine calvarial osteoblasts. Although CFTR was not expressed in murine osteoclasts, significantly more osteoclasts formed in Cftr−/− compared to Cftr+/+ bone marrow cultures. Indirect regulation of osteoclastogenesis by the osteoblast through RANK/RANKL/OPG signaling was next examined. Although no difference in receptor activator of NF-κB ligand (Rankl) mRNA was detected, significantly less osteoprotegerin (Opg) was expressed in Cftr−/− compared to Cftr+/+ osteoblasts. Together, the Rankl:Opg ratio was significantly higher in Cftr−/− murine calvarial osteoblasts contributing to a higher osteoclastogenesis potential. The combined findings of reduced osteoblast differentiation and lower Opg expression suggested a possible defect in canonical Wnt signaling. In fact, Wnt3a and PTH-stimulated canonical Wnt signaling was defective in Cftr−/− murine calvarial osteoblasts. These results support that genetic inactivation of CFTR in osteoblasts contributes to low bone mass and that targeting osteoblasts may represent an effective strategy to treat CFBD.
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Affiliation(s)
- Michael S. Stalvey
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Katrina L. Clines
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Viktoria Havasi
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Christopher R. McKibbin
- Department of Medicine, University of Virginia, Charlottesville, Virginia, United States of America
| | - Lauren K. Dunn
- Department of Medicine, University of Virginia, Charlottesville, Virginia, United States of America
| | - W. Joon Chung
- Department of Neurobiology, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Gregory A. Clines
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- Veterans Administration Medical Center, Birmingham, Alabama, United States of America
- * E-mail:
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Colquhoun DA, Dunn LK, Thiele RH. The relationship between respiratory variation in the pulmonary arterial pressure tracing and intra-thoracic pressure changes: A pilot study. J Med Eng Technol 2013; 37:252-8. [DOI: 10.3109/03091902.2013.789564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Thiele RH, Knipper E, Dunn LK, Nemergut EC. Auditory stimuli as a contributor to consciousness while under general anesthesia. Med Hypotheses 2013; 80:568-72. [DOI: 10.1016/j.mehy.2013.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/16/2013] [Accepted: 01/23/2013] [Indexed: 11/30/2022]
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Colquhoun DA, Forkin KT, Dunn LK, Bogdonoff DL, Durieux ME, Thiele RH. Non-invasive, minute-to-minute estimates of systemic arterial pressure and pulse pressure variation using radial artery tonometry. J Med Eng Technol 2013; 37:197-202. [DOI: 10.3109/03091902.2013.774443] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Abstract
BACKGROUND The incidence of intraoperative awareness under general anesthesia approaches 1% in high-risk patients. Anesthesiologists commonly utilize processed electroencephalograms (EEG) in order to monitor "depth" of anesthesia, the most common of which is the Bispectral Index (BIS). The B-aware and B-Unaware trials, which were designed to test the efficacy of the BIS monitor, noted an auditory component in 16 of 17 confirmed cases of intraoperative awareness. Implicit auditory memory formation has been documented under general anesthesia. Small studies have documented a significant effect of noise on BIS scores during monitored anesthesia care. METHODS Twenty-two patients undergoing general anesthesia received earplugs after the induction of anesthesia. Every ten minutes the earplugs were reinserted or removed. Noise levels were recorded every 0.125 s and both average and maximal BIS scores were recorded every minute. Non-parametric analysis of both populations (with and without earplugs) was performed. A mixed effects model with one degree of freedom (with and without earplugs) was generated to take into account the effect of anesthetic agents on BIS scores. RESULTS 3009 min of data were recorded. The median and range (25-75%) BIS scores were 39 (29-46) and 39 (28-44) with and without earplugs in place, respectively. Earplugs were associated with lower BIS scores (p=0.0183). The mixed effects model confirmed this relationship (p<0.001). Subgroup analysis of BIS scores in which the potential for awareness existed (maximum BIS>60 in any one minute epoch) showed a 32% reduction in the incidence of maximal BIS scores exceeding 60 (p=0.0012). There was no relationship between ambient noise level and average maximal BIS score (R(2)=0.003). CONCLUSIONS Our study suggests that earplugs may reduce the incidence of BIS scores >60 in patients undergoing total intravenous anesthesia and that auditory stimuli may affect EEG interpretation. Because of the low cost and safety of noise reduction, as well as the catastrophic implications of intraoperative awareness, further studies to explore the effects of auditory stimuli on awareness and anesthesia are warranted.
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Affiliation(s)
- Robert H Thiele
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA 22908, USA.
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Abstract
Liver transplantation may be complicated by massive intraoperative bleeding, and red blood cell (RBC) transfusions may be required. The storage duration or age of transfused RBCs has been shown to affect the morbidity and mortality of critically ill, trauma, and cardiac surgery patients. Here we investigate the effect of RBC age on the outcomes of liver transplant patients. Five hundred thirty-one patients underwent orthotopic liver transplantation between January 1, 2000 and August 15, 2010. The patient demographics, the Model for End-Stage Liver Disease-sodium (MELD-Na) score, and the number and age of RBC units were evaluated with univariate and multivariate models of outcomes, which included mortality rates 2 years after transplantation, postoperative infections, and organ rejection. In a univariate analysis, the number of RBC units (but not the RBC age) was associated with increased 2-year mortality, an increased risk of infection, and a decreased risk of organ rejection. Only the number of RBC units was associated with increased 2-year mortality in a multivariate Cox regression model. The mortality risk was decreased by two-thirds for patients who received <10 U of RBCs versus those who received ≥10 U (hazard ratio = 0.33, 95% confidence interval = 0.16-0.69, P = 0.003). The number of transfused RBC units was not associated with the risk of infection or organ rejection in a multivariate logistic regression model. In conclusion, the RBC age is not associated with infection, organ rejection, or death in liver transplant patients. Patients who receive more blood have an increased risk of death. In a multivariate model, the MELD-Na score was not associated with increased mortality, and this is consistent with previous studies demonstrating that the MELD-Na score is a poor predictor of long-term survival after transplantation.
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Affiliation(s)
- Lauren K Dunn
- Departments of Anesthesiology, University of Virginia Health System, Charlottesville, VA 22908, USA
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Dunn LK, Gaar LR, Yentzer BA, O'Neill JL, Feldman SR. Acitretin in dermatology: a review. J Drugs Dermatol 2011; 10:772-782. [PMID: 21720660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Acitretin is a systemic retinoid drug used in the treatment of severe psoriasis. It has also been used for a spectrum of other difficult-to-treat dermatoses, including hyperkeratotic and inflammatory dermatoses and non-melanoma skin cancers. Here we review the available data regarding both FDA-approved and off-label uses of acitretin, clinically relevant adverse events, precautions and monitoring. METHODS A PubMed literature search was conducted utilizing the search term "acitretin," which yielded 714 hits. Results were further limited to English language clinical trials in human subjects. Of 78 articles evaluated for relevance, 60 were included for review. RESULTS Acitretin is effective as monotherapy and in multidrug therapeutic regimens for the treatment of psoriasis and other hyperkeratotic and inflammatory disorders, as well as for malignancy chemoprevention. Its use is limited by its teratogenic potential and other adverse effects, including mucocutaneous effects and hepatotoxicity. Potential adverse effects may be reduced or avoided by using lower doses of acitretin or in combination with other therapies. LIMITATIONS The reviewed studies include many small trials and case reports of the use of acitretin for psoriasis. Studies of acitretin therapy for the treatment of other cutaneous disorders are limited. CONCLUSION Acitretin is a beneficial treatment for psoriasis, and should be considered when not contraindicated. Particularly when used in combination with ultraviolet (UV) phototherapy, is a safe and cost effective therapeutic strategy.
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Affiliation(s)
- Lauren K Dunn
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1071, USA
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Dunn LK, O'Neill JL, Feldman SR. Acne in adolescents: quality of life, self-esteem, mood, and psychological disorders. Dermatol Online J 2011; 17:1. [PMID: 21272492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
INTRODUCTION Acne is a significant adolescent problem and may precipitate emotional and psychological effects. The impact of acne on psychological parameters and implications for acne treatment are not fully understood. METHODS We performed a MEDLINE search using the terms "acne" and "adolescent" along with "psychological," "depression," or "psychiatric," which yielded 16 reviewed studies. RESULTS Qualitative review of the selected articles revealed that the presence of acne has a significant impact on self-esteem and quality of life. Depression and other psychological disorders are more prevalent in acne patients and acne treatment may improve symptoms of these disorders. LIMITATIONS The reviewed studies were semi-quantitative analyses utilizing various standardized surveys or questionnaires. Therefore, quantitative analysis of selected studies was not possible. CONCLUSION The presence of co-morbid psychological disorders should be considered in the treatment of acne patients and future prospective trials are needed to assess the impact of treatment on psychological outcomes.
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Affiliation(s)
- Lauren K Dunn
- Department of Dermatology, Center for Dermatology Research, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Dunn LK, O'Neill JL, Feldman SR. Acne in Adolescents: Quality of Life, Self-Esteem, Mood and Psychological Disorders. Dermatol Online J 2011. [DOI: 10.5070/d34hp8n68p] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Mohammad KS, Javelaud D, Fournier PGJ, Niewolna M, McKenna CR, Peng XH, Duong V, Dunn LK, Mauviel A, Guise TA. TGF-beta-RI kinase inhibitor SD-208 reduces the development and progression of melanoma bone metastases. Cancer Res 2010; 71:175-84. [PMID: 21084275 DOI: 10.1158/0008-5472.can-10-2651] [Citation(s) in RCA: 172] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Melanoma often metastasizes to bone where it is exposed to high concentrations of TGF-β. Constitutive Smad signaling occurs in human melanoma. Because TGF-β promotes metastases to bone by several types of solid tumors including breast cancer, we hypothesized that pharmacologic blockade of the TGF-β signaling pathway may interfere with the capacity of melanoma cells to metastasize to bone. In this study, we tested the effect of a small molecule inhibitor of TGF-β receptor I kinase (TβRI), SD-208, on various parameters affecting the development and progression of melanoma, both in vitro and in a mouse model of human melanoma bone metastasis. In melanoma cell lines, SD-208 blocked TGF-β induction of Smad3 phosphorylation, Smad3/4-specific transcription, Matrigel invasion and expression of the TGF-β target genes PTHrP, IL-11, CTGF, and RUNX2. To assess effects of SD-208 on melanoma development and metastasis, nude mice were inoculated with 1205Lu melanoma cells into the left cardiac ventricle and drug was administered by oral gavage on prevention or treatment protocols. SD-208 (60 mg/kg/d), started 2 days before tumor inoculation prevented the development of osteolytic bone metastases compared with vehicle. In mice with established bone metastases, the size of osteolytic lesions was significantly reduced after 4 weeks treatment with SD-208 compared with vehicle-treated mice. Our results demonstrate that therapeutic targeting of TGF-β may prevent the development of melanoma bone metastases and decrease the progression of established osteolytic lesions.
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Affiliation(s)
- Khalid S Mohammad
- Division of Endocrinology, Department of Medicine, Indiana University PurdueUniversity at Indianapolis, Indianapolis, USA
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Dunn LK, Feldman SR. Alefacept treatment for chronic plaque psoriasis. Skin Therapy Lett 2010; 15:1-3. [PMID: 20361167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Biologic agents were introduced during the past decade as a new class of treatments for chronic psoriasis. These agents provide therapeutic alternatives to traditional topical and systemic therapies. Alefacept, the first such biologic agent, was approved by the US FDA in January 2003 for the treatment of chronic plaque psoriasis. This review will discuss data from clinical trials that have provided new insights into the efficacy, safety, and cost effectiveness of alefacept as a treatment for psoriasis.
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Affiliation(s)
- L K Dunn
- Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, US
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Donnenfeld AE, Librizzi RJ, Dunn LK, Craparo F, Godmilow L, Weiner S. Chorionic villus sampling followed by amniocentesis in the same pregnancy. Am J Med Genet 1993; 45:361-4. [PMID: 7679544 DOI: 10.1002/ajmg.1320450316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
In our consecutive series of 2,574 chorionic villus sampling (CVS) patients, 146 women (5.7%) underwent a subsequent amniocentesis in the same pregnancy for the indications of absent or insufficient villi (3.3%), elevated maternal serum alpha-fetoprotein (0.93%), CVS mosaicism (0.89%), culture failure (0.23%), specimen contamination (0.15%), and CVS aneuploidy (0.12%). Patients presenting for a CVS should be informed of the possible need for a subsequent amniocentesis in the same pregnancy. There is a need for individual prenatal diagnosis programs to analyze their own data and provide genetic counseling information which pertains specifically to their institution.
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Affiliation(s)
- A E Donnenfeld
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Philadelphia 19107
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Muenke M, Ruchelli ED, Rorke LB, McDonald-McGinn DM, Orlow MK, Isaacs A, Craparo FJ, Dunn LK, Zackai EH. On lumping and splitting: a fetus with clinical findings of the oral-facial-digital syndrome type VI, the hydrolethalus syndrome, and the Pallister-Hall syndrome. Am J Med Genet 1991; 41:548-56. [PMID: 1776653 DOI: 10.1002/ajmg.1320410436] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The three midline malformation complexes, the oral-facial-digital syndrome type VI (OFDS VI) or Váradi syndrome, the hydrolethalus syndrome (HS), and the Pallister-Hall syndrome (PHS) have been described as distinct genetic entities. Here, we report a fetus with a combination of clinical findings of all 3 syndromes similar to the twin fetuses described in the accompanying paper (Hingorani et al., 1991). The phenotypic overlap in these fetuses with the OFDS VI, HS, and PHS raises the question as to whether or not they indeed represent separate genetic entities as previously assumed.
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Affiliation(s)
- M Muenke
- Children's Hospital of Philadelphia, Division of Human Genetics and Molecular Biology, PA 19104
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Schauer GM, Dunn LK, Godmilow L, Eagle RC, Knisely AS. Prenatal diagnosis of Fraser syndrome at 18.5 weeks gestation, with autopsy findings at 19 weeks. Am J Med Genet 1990; 37:583-91. [PMID: 2175543 DOI: 10.1002/ajmg.1320370433] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Sonography permitted the diagnosis of Fraser syndrome (cryptophthalmos-syndactyly syndrome) at 18.5 weeks of gestation in a fetus whose parents had had a previous affected child. The karyotype of that child was 46,XX,inv(9)(p11q21); the karyotype of the phenotypically normal father and of the fetus was 46,XY,inv(9)(p11q21). Findings on sonography included oligohydramnios with nonvisualization of kidneys, hypertelorism and microphthalmia, and markedly enlarged lungs. On autopsy at 19 weeks, findings included renal agenesis, cryptophthalmos with multiple abnormalities of the eyes and ocular adnexa, laryngeal atresia, pulmonary hyperplasia with accelerated maturation, absence of the Eustachian tube with connective tissue occupying the tympanic cavity and bone occluding the external acoustic meatus, and soft-tissue webbing between the digits. This is the second reported instance of prenatal diagnosis of Fraser syndrome in the second trimester. The histopathologic findings in Fraser syndrome at this gestational age, in particular the eye and ear, have not been described previously.
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Affiliation(s)
- G M Schauer
- Department of Pathology, Pennsylvania Hospital, Philadelphia
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Dunn LK. Fetal heart rate monitoring during cesarean section. Am J Obstet Gynecol 1990; 163:253. [PMID: 2375359 DOI: 10.1016/s0002-9378(11)90731-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Affiliation(s)
- A Wyman
- University Department of Surgery, Northern General Hospital, Sheffield, UK
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Powell B, Cunnane MF, Dunn LK, Corson SL. Leiomyoma uteri in a rudimentary uterine horn in a woman with the Rokitansky-Kuster-Hauser syndrome. A case report. J Reprod Med 1988; 33:493-4. [PMID: 3385707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A 4-cm leiomyoma was found in a woman with the Rokitansky-Kuster-Hauser syndrome. It was discovered six years after she presented to a gynecologist. In the ensuing years she successfully developed vaginal dilation. This is the fourth reported case of leiomyoma associated with the Rokitansky-Kuster-Hauser syndrome.
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Affiliation(s)
- B Powell
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, University of Pennsylvania School of Medicine, Philadelphia
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Abstract
Multiple congenital anomalies were identified at 16 weeks gestation in one fetus of an unsuspected twin pregnancy while ultrasound examination was performed before routine genetic amniocentesis. Further sonographic studies documented the amniotic band sequence (ABS) and transient oligohydramnios in the affected fetus. The latter finding supports the theory of amnion rupture followed by amniotic fluid leakage through an ineffective chorion barrier as the pathogenesis of compression related anomalies in this syndrome. Extensive craniofacial involvement including hydrocephalus, encephalocele, and multiple facial clefts in the affected fetus, combined with an erroneous ultrasound diagnosis of ABS in the unaffected twin, created an extremely difficult management and counseling situation. A review of ABS, the embryology of placental membrane development, and a discussion of selective termination procedures are presented.
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Roberts NS, Dunn LK, Weiner S, Godmilow L, Miller R. Midtrimester amniocentesis. Indications, technique, risks and potential for prenatal diagnosis. J Reprod Med 1983; 28:167-88. [PMID: 6189994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Dunn LK, Redstone D, Roe HL, Steer PJ, Beard RW. The relationship between tissue and arterial pH in hypercarbic rabbits. Arch Gynecol 1978; 226:31-8. [PMID: 33619 DOI: 10.1007/bf02116724] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Continuous tissue pH and intermittent central arterial pH were measured in six rabbits during 10-min exposures to a mixture of 10% CO2 and 90% O2. In control and recovery situations tissue pH was more acidic than arterial pH by a mean value of 0.07 pH units. During periods of rapidly increasing pCO2, the steady state relationship was inverted with tissue pH being more alkaline than arterial pH. After a second exposure to CO2, mean tissue pH values did not recover to baseline. It is concluded that in the rabbit during acute hypercarbia, the relationship of tissue to central pH is variable. The possible implications of these results in human fetuses during labor are discussed.
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