A Prospective Evaluation of Opioid Utilization After Upper-Extremity Surgical Procedures: Identifying Consumption Patterns and Determining Prescribing Guidelines.

BACKGROUND: Although adequate management of postoperative pain with oral analgesics is an important aspect of surgical procedures, inadvertent overprescribing can lead to excess availability of opioids in the community for potential diversion. The purpose of our study was to prospectively evaluate opioid consumption following outpatient upper-extremity surgical procedures to determine opioid utilization patterns and to develop prescribing guidelines. METHODS: All patients undergoing outpatient upper-extremity surgical procedures over a consecutive 6-month period had the following prospective data collected: patient demographic characteristics, surgical details, anesthesia type, and opioid prescription and consumption patterns. Analysis of variance and post hoc comparisons were performed using t tests, with the p value for multiple pairwise tests adjusted by the Bonferroni correction. RESULTS: A total of 1,416 patients with a mean age of 56 years (range, 18 to 93 years) were included in the study. Surgeons prescribed a mean total of 24 pills, and patients reported consuming a mean total of 8.1 pills, resulting in a utilization rate of 34%. Patients undergoing soft-tissue procedures reported requiring fewer opioids (5.1 pills for 2.2 days) compared with fracture surgical procedures (13.0 pills for 4.5 days) or joint procedures (14.5 pills for 5.0 days) (p \u3c 0.001). Patients who underwent wrist surgical procedures required a mean number of 7.5 pills for 3.1 days and those who underwent hand surgical procedures required a mean number of 7.7 pills for 2.9 days, compared with patients who underwent forearm or elbow surgical procedures (11.1 pills) and those who underwent upper arm or shoulder surgical procedures (22.0 pills) (p \u3c 0.01). Procedure type, anatomic location, anesthesia type, age, and type of insurance were also all significantly associated with reported opioid consumption (p \u3c 0.001). CONCLUSIONS: In this large, prospective evaluation of postoperative opioid consumption, we found that patients are being prescribed approximately 3 times greater opioid medications than needed following upper-extremity surgical procedures. We have provided general prescribing guidelines, and we recommend that surgeons carefully examine their patients\u27 opioid utilization and consider customizing their opioid prescriptions on the basis of anatomic location and procedure type to prescribe the optimal amount of opioids while avoiding dissemination of excess opioids

Predicting Elective Orthopaedic Sports Medicine Surgical Cancellations Based on Patient Demographics.

Purpose:To evaluate whether patient demographics are associated with cancellation of elective orthopaedic sports medicine surgical procedures. Methods:We retrospectively reviewed the electronic medical records of 761 patients who were scheduled to undergo an elective sports medicine orthopaedic operation from January 1, 2015, to December 31, 2017. The patients were divided into 2 groups: those who underwent the scheduled procedure (group A) and those in whom the operation was canceled for any reason prior to the surgical date and not rescheduled (group B). Univariate analysis assessed patient factors consisting of age, sex, race, language, marital status, occupation status, type of insurance (Medicaid or Medicare vs private), smoking history, employment status, and history of surgery to determine which demographic factors led to an increased risk of elective case cancellation. Results:Patients who canceled were significantly older (46.5 years vs 41.5 years, t = 2.432, P = .015) than those who do not. In addition, current smokers (22.5% vs 10.9%, χ2 = 10.85, P = .001), patients with Medicare or Medicaid versus private insurance (16.7% vs 10.0%, χ2 = 5.35, P = .021), non-English-speaking patients (29.5% vs 11.6%, χ2 = 11.43, P = .001), and patients without a history of surgery requiring anesthesia (18.8% vs 9.6%, χ2 = 9.96, P = .002) were all more likely to cancel. When all studied variables were examined in a logistic regression analysis, of the above demographic variables, only insurance status was no longer significant, given its correlation with age and language. Conclusions:Increased age (≥46.5 years), non-English speaking, smoking, lack of a history of surgery requiring anesthesia, and Medicaid or Medicare insurance were found to contribute to an increased risk of elective orthopaedic surgery cancellation. Level of Evidence:Level III, case-control study

1, 2, 3, 4: Infusing Quantitative Literacy into Introductory Biology

Biology of the twenty-first century is an increasingly quantitative science. Undergraduate biology education therefore needs to provide opportunities for students to develop fluency in the tools and language of quantitative disciplines. Quantitative literacy (QL) is important for future scientists as well as for citizens, who need to interpret numeric information and data-based claims regarding nearly every aspect of daily life. To address the need for QL in biology education, we incorporated quantitative concepts throughout a semester-long introductory biology course at a large research university. Early in the course, we assessed the quantitative skills that students bring to the introductory biology classroom and found that students had difficulties in performing simple calculations, representing data graphically, and articulating data-driven arguments. In response to students' learning needs, we infused the course with quantitative concepts aligned with the existing course content and learning objectives. The effectiveness of this approach is demonstrated by significant improvement in the quality of students' graphical representations of biological data. Infusing QL in introductory biology presents challenges. Our study, however, supports the conclusion that it is feasible in the context of an existing course, consistent with the goals of college biology education, and promotes students' development of important quantitative skills

Outcomes of Distal Ulna Fractures Associated With Operatively Treated Distal Radius Fractures

Background: The purpose of this study was to report outcomes in patients with nonstyloid distal ulna fractures treated in conjunction with open reduction internal fixation (ORIF) of distal radius fractures. Methods: A retrospective review of all patients who had undergone ORIF of a distal radius fracture over a 5-year period at a single institution was performed. Radiographic review was performed to identify patients with a concomitant fracture of the distal ulna. Radiographs were examined to determine whether and how the distal ulna fracture was stabilized and to assess healing of the distal ulna. Range of motion (ROM) was determined by review of the patients' charts. All skeletally mature patients with distal ulna fractures (not including isolated styloid fractures) undergoing surgical fixation of the distal radius fracture were included. Patients were excluded if follow-up was inadequate. There were 172 fractures of the distal ulna meeting the inclusion criteria. Seven patients were excluded. There were 91 patients treated without ulna fixation (ulna-no) and 74 patients treated with ulna fixation (ulna-yes). Results: Seventy-two (97%) of the ulna-yes patients healed. All patients in the ulna-no group healed. The only significant difference in ROM was in pronation, although the magnitude of this difference was relatively small. Conclusions: Fractures of the distal ulna have high rates of healing and result in equivalent motion regardless of whether the distal ulna is treated operatively. Routine surgical fixation of concomitant distal ulna fractures during distal radius ORIF does not appear to be necessary

Morphometric Assessment of the Residual Width of the Distal Hamate Articular Surface after Graft Harvest for Hemi-hamate Arthroplasty

Background: The hemi-hamate arthroplasty (HHA) can restore joint congruity and stability in chronic fracture-dislocations of the proximal interphalangeal joint (PIPJ). Purpose of this study was to compare the width of the distal hamate articular surface (DHAS) to the width of the base of the middle phalanges (P2) of the fingers. We hypothesized the dimensions of the width of the DHAS would be similar to those of P2, leaving a small amount of residual DHAS width after autograft harvest. Methods: Fifty-nine CT scans of the hand without any bony pathology were evaluated. Three observers measured the following parameters and compared: (a) Width of the DHAS in the axial and coronal planes; (b) Width of the P2 articular bases of all four fingers; (c) Maximum capitate length (MaxCap) in the coronal plane. Results: The residual DHAS on the coronal plane after graft harvest (bone remaining on the radial and ulnar aspects each, not accounting for saw blade or osteotomy width thickness) among all patients was 1.3, 0.9, 1.4, and 2.4 mm for the index, long, ring and small fingers respectively. There was a strong correlation between DHAS and MaxCap r=0.76. Conclusion: There is likely to be a very small amount of residual hamate articular surface width left after the graft is harvested if the entire base of P2 is reconstructed

The Effect of Intraoperative Corticosteroid Injections on the Risk of Surgical Site Infections for Hand Procedures

Purpose The aim of the study was to assess the risk of surgical site infection (SSI) in patients who received an intraoperative injection (IOI) with a corticosteroid at the same time as hand surgery for a different condition. Methods This was a retrospective chart review of all patients who underwent hand surgery and corticosteroid injections concurrently over an 8-year period. Comparison of the rates of SSI was made of patients who had received an IOI and a matched control cohort of patients with no intraoperative injection (nIOI). There were 391 patients in each group. Results There were 8 SSIs in the IOI group compared with 2 in the nIOI group. One patient in the IOI group had a deep infection whereas all other infections were superficial. In the IOI group, 206 patients had injections on the side ipsilateral to their surgical procedure. Six of these patients had SSIs, a significant difference compared with the control group. There were 185 patients who had contralateral injections. Two of these patients had SSIs. Compared with the control group, this difference was not significant. Conclusions Concomitant injection of steroid into the same side as the surgical site increases the risk of postoperative infection. We do not recommend administering a corticosteroid injection at the time of hand surgery

Recruiting International Master\u27s-Level Students: Research and Good Practices

The presentation highlights new research on how international master’s-level students from different countries decide which schools to apply with a focus on how institutions can leverage this information to improve their outreach and recruitment efforts. This is followed by a panel discussion on good practices led by international recruitment experts

Post-operative Opioid, Benzodiazepine and Sedative Usage in Medicare versus Commercial Insurance Hand Surgery Patients

Background: Opioid usage has increased in recent years. The purpose of this study is to assess post-operative opioid, sedative, and benzodiazepine usage in a Medicare population. Methods: Consecutive patients undergoing elbow, wrist, and hand surgery by hand surgeons at one academic outpatient surgical center were prospectively enrolled. Patients were excluded if they were minors or if they underwent more than one surgical procedure during the study period. There were 269 patients enrolled, and this group was divided by insurance type into younger commercial insurance (CI) and older Medicare (MC) groups. The Pennsylvania Physician Drug Monitoring Program website was used to document all prescriptions of controlled substances filled six months prior to and after the surgical procedure. Results: The mean age in the CI group was 45.8 years (range: 16-88) and 69.2 years (range: 43-91) in the MC group. Postoperatively, the CI patients filled significantly less opioid prescriptions than the MC group, 1.10 vs. 1.79. Patients in the CI group were given an average of 0.3 benzodiazepine prescriptions before surgery and 0.2 after surgery. Patients in the MC group were given 0.6 prescriptions before and 0.5 prescriptions of benzodiazepines after surgery. The CI group was given an average of 0.1 sedative/hypnotic prescriptions before surgery and 0.1 after surgery. The MC group was given 0.7 prescriptions before and 0.4 prescriptions of sedative/hypnotics after surgery. There were 0.17 prescriptions per patient in the CI group and 0.75 per patient in the MC group (P <.05). Twenty-two of 208 (10.6%) of CI and 16/61 (26.2%) of MC patients filled a prescription between 3-8 months post-operatively. Conclusion: Prolonged use of opioid, benzodiazepine and sedative medications is common after upper extremity surgical procedures. Older patients are also at risk, and may be even more likely than younger patients to use these medications post-operatively