Effects of Modification of Pain Protocol on Incidence of Post Operative Nausea and Vomiting.

BackgroundA Perioperative Surgical Home (PSH) care model applies a standardized multidisciplinary approach to patient care using evidence-based medicine to modify and improve protocols. Analysis of patient outcome measures, such as postoperative nausea and vomiting (PONV), allows for refinement of existing protocols to improve patient care. We aim to compare the incidence of PONV in patients who underwent primary total joint arthroplasty before and after modification of our PSH pain protocol.MethodsAll total joint replacement PSH (TJR-PSH) patients who underwent primary THA (n=149) or TKA (n=212) in the study period were included. The modified protocol added a single dose of intravenous (IV) ketorolac given in the operating room and oxycodone immediate release orally instead of IV Hydromorphone in the Post Anesthesia Care Unit (PACU). The outcomes were (1) incidence of PONV and (2) average pain score in the PACU. We also examined the effect of primary anesthetic (spinal vs. GA) on these outcomes. The groups were compared using chi-square tests of proportions.ResultsThe incidence of post-operative nausea in the PACU decreased significantly with the modified protocol (27.4% vs. 38.1%, p=0.0442). There was no difference in PONV based on choice of anesthetic or procedure. Average PACU pain scores did not differ significantly between the two protocols.ConclusionSimple modifications to TJR-PSH multimodal pain management protocol, with decrease in IV narcotic use, resulted in a lower incidence of postoperative nausea, without compromising average PACU pain scores. This report demonstrates the need for continuous monitoring of PSH pathways and implementation of revisions as needed

Single cell dissection of plasma cell heterogeneity in symptomatic and asymptomatic myeloma

Multiple myeloma, a plasma cell malignancy, is the second most common blood cancer. Despite extensive research, disease heterogeneity is poorly characterized, hampering efforts for early diagnosis and improved treatments. Here, we apply single cell RNA sequencing to study the heterogeneity of 40 individuals along the multiple myeloma progression spectrum, including 11 healthy controls, demonstrating high interindividual variability that can be explained by expression of known multiple myeloma drivers and additional putative factors. We identify extensive subclonal structures for 10 of 29 individuals with multiple myeloma. In asymptomatic individuals with early disease and in those with minimal residual disease post-treatment, we detect rare tumor plasma cells with molecular characteristics similar to those of active myeloma, with possible implications for personalized therapies. Single cell analysis of rare circulating tumor cells allows for accurate liquid biopsy and detection of malignant plasma cells, which reflect bone marrow disease. Our work establishes single cell RNA sequencing for dissecting blood malignancies and devising detailed molecular characterization of tumor cells in symptomatic and asymptomatic patients

Factors Influencing Discharge Destination After Total Hip Arthroplasty: A California State Database Analysis.

INTRODUCTION:With this growing demand, the length of stay for total hip arthroplasty (THA) procedures has decreased, and as a trade-off, we have seen a higher utilization of extended care facilities (ECFs). Both trends have significant economic implications on the health care system, and predicting the discharge destinations of THA patients would help policy makers plan for future health expenditures. We performed a retrospective data analysis of a large patient database to determine which variables are significant in predicting discharge destinations of THA patients. METHODS:We used the California Hospital Discharge data set of the year 2010, collected and provided by the Office of Statewide Health Planning and Development. The data set includes information about patient demographics, insurance type, diagnoses and procedures, and patient disposition. The study cohort included 14 326 patients. Discharge to home was the reference category. Discharge to ECF and discharge to home with home care were the 2 additional alternatives. RESULTS:In all, 46.9% of patients were discharged home with home health care, followed by 29.6% to ECF, and 23.5% to home without care. Discharge to ECF was more likely for patients with more comorbidities and a higher age. The strongest predictors were Medicaid and black or Asian race. Medicare relative to private payer was a strong predictor of ECF discharge. Male gender was the only factor that lowered the risk of discharge to ECF. The strongest predictor for discharge to home with home care was black race relative to whites. Medicaid lowered the risk of home care, and gender did not matter. CONCLUSION:This study serves to provide insight on which patient characteristics influence discharge destination after THA. Race, insurance, and morbidity were highly significant factors on patient discharge destination to a subacute nursing facility

Factors Influencing Discharge Destination After Total Hip Arthroplasty: A California State Database Analysis.

INTRODUCTION:With this growing demand, the length of stay for total hip arthroplasty (THA) procedures has decreased, and as a trade-off, we have seen a higher utilization of extended care facilities (ECFs). Both trends have significant economic implications on the health care system, and predicting the discharge destinations of THA patients would help policy makers plan for future health expenditures. We performed a retrospective data analysis of a large patient database to determine which variables are significant in predicting discharge destinations of THA patients. METHODS:We used the California Hospital Discharge data set of the year 2010, collected and provided by the Office of Statewide Health Planning and Development. The data set includes information about patient demographics, insurance type, diagnoses and procedures, and patient disposition. The study cohort included 14 326 patients. Discharge to home was the reference category. Discharge to ECF and discharge to home with home care were the 2 additional alternatives. RESULTS:In all, 46.9% of patients were discharged home with home health care, followed by 29.6% to ECF, and 23.5% to home without care. Discharge to ECF was more likely for patients with more comorbidities and a higher age. The strongest predictors were Medicaid and black or Asian race. Medicare relative to private payer was a strong predictor of ECF discharge. Male gender was the only factor that lowered the risk of discharge to ECF. The strongest predictor for discharge to home with home care was black race relative to whites. Medicaid lowered the risk of home care, and gender did not matter. CONCLUSION:This study serves to provide insight on which patient characteristics influence discharge destination after THA. Race, insurance, and morbidity were highly significant factors on patient discharge destination to a subacute nursing facility

Factors Influencing Discharge Destination After Total Knee Arthroplasty: A Database Analysis.

IntroductionThe demand for total knee arthroplasty (TKA) continues to challenge hospital financial resources. Hospitals have countered this economic demand by reducing patient length of stay (LoS), thus requiring a higher utilization of extended care facilities (ECF) and home with home health care (HHC). With an increase in the number of insured low-income families following the Affordable Care Act (ACA), TKA patients' demographics are anticipated to change. Both trends have significant economic implications, and predicting the discharge destinations of TKA patients would help plan for future health expenditures. The purpose of this study was to determine which variables are significant in predicting discharge destinations of patients treated with TKA.MethodsWe utilized the California Hospital Discharge data set of the year 2010. For each hospitalization, the data set includes information about patient demographics (age, gender, race, and ethnicity), insurance type, diagnoses and procedures, and patient disposition. Discharge to home was the reference category. Discharges to a skilled nursing home and discharge to home with home care were the 2 additional alternatives. Independent variables included the Charlson comorbidity index, payer category (private, Medicare, Medical, and other), race, ethnicity, age, and gender.ResultsOver 28 611 TKAs were reviewed with 45.9% discharged to HHC, 29.9% going to ECF, and 24.2% going home without home health care. Race, age, insurance, and morbidity proved to be highly significant factors influencing patient discharge destination (P < .001). Medicare coverage relative to private payers was a strong predictor for discharge destination (relative risk ratio (RRR) 1.69, P < .001). The strongest predictors were black and Asian races relative to whites (RRR 1.54, P < .01). Male gender was the only factor that lowered the risk of discharge to a nursing home (RRR 0.43, P < .001).ConclusionsThis study provides insight on which patient characteristics influence discharge destination after TKA. Race, age, insurance, and morbidity were highly significant (P < .001) factors on patient discharge destination

Factors Influencing Discharge Destination After Total Knee Arthroplasty: A Database Analysis.

IntroductionThe demand for total knee arthroplasty (TKA) continues to challenge hospital financial resources. Hospitals have countered this economic demand by reducing patient length of stay (LoS), thus requiring a higher utilization of extended care facilities (ECF) and home with home health care (HHC). With an increase in the number of insured low-income families following the Affordable Care Act (ACA), TKA patients' demographics are anticipated to change. Both trends have significant economic implications, and predicting the discharge destinations of TKA patients would help plan for future health expenditures. The purpose of this study was to determine which variables are significant in predicting discharge destinations of patients treated with TKA.MethodsWe utilized the California Hospital Discharge data set of the year 2010. For each hospitalization, the data set includes information about patient demographics (age, gender, race, and ethnicity), insurance type, diagnoses and procedures, and patient disposition. Discharge to home was the reference category. Discharges to a skilled nursing home and discharge to home with home care were the 2 additional alternatives. Independent variables included the Charlson comorbidity index, payer category (private, Medicare, Medical, and other), race, ethnicity, age, and gender.ResultsOver 28 611 TKAs were reviewed with 45.9% discharged to HHC, 29.9% going to ECF, and 24.2% going home without home health care. Race, age, insurance, and morbidity proved to be highly significant factors influencing patient discharge destination (P < .001). Medicare coverage relative to private payers was a strong predictor for discharge destination (relative risk ratio (RRR) 1.69, P < .001). The strongest predictors were black and Asian races relative to whites (RRR 1.54, P < .01). Male gender was the only factor that lowered the risk of discharge to a nursing home (RRR 0.43, P < .001).ConclusionsThis study provides insight on which patient characteristics influence discharge destination after TKA. Race, age, insurance, and morbidity were highly significant (P < .001) factors on patient discharge destination

Long Head of the Biceps Tenodesis With Cortical Button Technique

There are several options for long head of the biceps (LHB) tenodesis and yet no standard of care. This technical note describes a cortical button technique for LHB tenodesis. We have taken the BicepsButton (Arthrex, Naples, FL) for distal biceps acute primary repair and applied it to the LHB. The biceps tenotomy is completed arthroscopically, and a standard subpectoral approach is used. The biceps is pulled out and whipstitched starting at the myotendinous junction and moving proximally. The humerus is drilled in a unicortical manner slightly larger than the tendon, and the button is passed through a small hole to the posterior cortex. A suture through the tendon provides additional fixation strength to the construct. This is an elegant and effective method of tenodesis that uses a smaller-diameter drill hole in the humerus. The goals of LHB tenodesis are to restore function, reduce pain, and improve cosmesis. This technique offers comparable function and cosmesis with the potential advantage of improving postoperative pain outcomes and lowering the rate of complications

Long term results of total hip arthroplasty with cemented and cementless tapered femoral component

Background: Excellent midterm results for total hip arthroplasties (THA) with cementless, tapered porous Taperloc® femoral stems have been reported. Reports regarding such cemented stems, however, are lacking. Objectives: To evaluate the long-term outcomes of both cemented and cementless THAs with the Taperloc femoral component. Methods: The medical records of 71 patients (76 hips), operated on between January 1991 and December 2003, who had a minimum follow-up of 10 years were available for analysis. Functional analysis was performed with the Harris hip score (HHS) questionnaire and the numerical analogue scale (NAS). Radiographic analysis was performed for subsidence, radiolucent lines and osteolysis. Results: The cohort was comprised of 47 female and 24 male patients, with a mean age of 59.7 ± 12.4 years. The mean follow-up was 17.8 ± 4.4 years. 52.6% of THAs analyzed were cementless and 47.4% were cemented. Post-operative radiographs were available for 57 surgeries. Subsidence, hypertrophic ossification, radiolucent lines and osteolysis were noted in 4 (7%), 2 (2.6%), 14 (18.4%) and 11 (14.5%) hips respectively. The average HHS score at a mean follow-up of 20.1 ± 3.9 years was 62.1 (±27.7) and the NAS score was 4.6 (±3.6). During the study period, five revision surgeries were performed due to stem-related problems, one of which was for aseptic loosening. Conclusions: Our long-term experience with the Taperloc stem, both cemented and cementless, demonstrates good outcomes, with low rates of failure. This makes this prosthesis an attractive option for THAs. Level of Evidence: I