Search

Surgery is a common gateway to opioid-related morbidity. Ambulatory anorectal cases are common, with opioids widely prescribed, but there is limited data on their role in this crisis. We sought to determine prescribing trends, new persistent opioid use rates, and factors associated with new persistent opioid use after ambulatory anorectal procedures.The Optum Clinformatics claims database was analyzed for opioid-naïve adults undergoing outpatient hemorrhoid, fissure, or fistula procedures from January 1, 2010, to June 30, 2017. The main outcome measure was the rate of new persistent opioid use after anorectal cases. Secondary outcomes were annual rates of perioperative opioid fills and the prescription size over time (oral morphine equivalents).A total of 23,426 cases were evaluated: 69.09% (n = 16,185) hemorrhoids, 24.29% (n = 5,690) fissures, and 6.45% (n = 1,512) fistulas. The annual rate of perioperative opioid fills decreased on average 1.2%/year, from 72% in 2010 to 66% in 2017 (P.001). Prescribing rates were consistently highest for fistulas, followed by hemorrhoids, then fissures (P.001). There was a significant reduction in prescription size (oral morphine equivalents) over the study period, with median oral morphine equivalents (interquartile range) of 280 (250-400) in 2010 and 225 (150-375) in 2017 (P.0001). Overall, 2.1% (n = 499) developed new persistent opioid use. Logistic regression found new persistent opioid use was associated with additional perioperative opioid fills (odds ratio 3.92; 95% confidence interval: 2.92-5.27; P.0001), increased comorbidity (odds ratio 1.15; confidence interval: 1.09-1.20; P.00001), tobacco use (odds ratio 1.79; confidence interval: 1.37-2.36; P.0001), and pain disorders (odds ratio, 1.49; confidence interval, 1.23-1.82); there was no significant association with procedure performed.Over 2% of ambulatory anorectal procedures develop new persistent opioid use. Despite small annual reductions in opioid prescriptions, there has been little change in the amount prescribed. This demonstrates a need to develop and disseminate best practices for anorectal surgery, focusing on eliminating unnecessary opioid prescribing.

To examine whether a service guideline reducing postoperative opioid prescription quantities and caregiver-reported education to use nonopioid analgesics first are associated with caregiver-reported pain control after pediatric tonsillectomy.Prospective cohort study (July 2018-April 2019).Pediatric otolaryngology service at a tertiary academic children's hospital.Caregivers of patients aged 1 to 11 years undergoing tonsillectomy (N = 764) were surveyed 7 to 21 days after surgery regarding pain control, education to use nonopioid analgesics first, and opioid use. Respondents who were not prescribed opioids or had missing data were excluded. Logistic regression modeled caregiver-reported pain control as a function of service guideline implementation (December 2018) recommending 20 rather than 30 doses for postoperative opioid prescriptions and caregiver-reported analgesic education, adjusting for patient demographics.Among 430 respondents (56% response), 387 patients were included. The sample was 43% female with a mean age of 5.0 years (SD, 2.5). Pain control was reported as good (226 respondents, 58%) or adequate/poor (161 respondents, 42%). Mean opioid prescription quantity was 27 doses (SD, 7.9) before and 21 doses (SD, 6.1) after guideline implementation (Caregiver education to use nonopioid analgesics first may be a modifiable health care practice to improve pain control as postoperative opioid prescription quantities are reduced.

Objective The importance of feedback is well recognized in surgical training. Although there is increased focus on leadership as an essential competency in surgical training, it is unclear whether surgical residents receive effective feedback on leadership performance. We performed an exploratory qualitative study with surgical residents to understand current leadership-specific feedback practices in one surgical training program. Design We conducted semistructured interviews with surgical residents. Using line-by-line coding in an iterative process, we focused on feedback on leadership performance to capture both semantic and conceptual data. Setting The general surgery residency program at the University of Michigan, a tertiary care, academic institution. Participants Residents were purposively selected to include key informants and comprise a balanced sample with respect to postgraduate year, gender, and race. Results Four major themes were identified during the thematic analysis: (1) the importance of feedback for leadership development in residency; (2) inadequacy of current feedback mechanisms; (3) barriers to giving and receiving leadership-specific feedback; and (4) resident-driven recommendations for better leadership feedback. Conclusions Many surgical residents do not receive effective leadership feedback, although they express strong desire for formal evaluation of leadership skills. Establishing avenues for feedback on leadership performance will help bridge this gap. Additionally, training to give and receive leadership-specific feedback may improve the quality and incorporation of delivered feedback for developing surgeon-leaders.

Purpose Surgical training is shifting toward competency-based models that promote earlier supervised autonomy. We assessed caregiver knowledge, willingness to consent, and opinions regarding trainee autonomy in their child's operation. Methods At two academic children's hospitals, 100 caregivers of children aged 0–17 years completed an electronic survey in the pediatric surgery clinic (1/2018–4/2018). Knowledge, willingness to consent, and opinions of trainee involvement in their child's operation in standard and competency-based training models were assessed. McNemar's test compared willingness to consent with standard and competency-based training (p Results Caregivers were 75% female, 41% age 30–39 years old, and 78% white. All provider roles were correctly identified by 14% of caregivers. For routine procedures, caregivers would consent to a fellow assisting (95%) or independently operating with the attending present (78%). They would less likely consent if the attending was not in the operating room (39%) or the hospital (25%). Competency-based training improved willingness to consent, but was significant only for independence with the attending present. Most caregivers wanted to know about (81%) and be asked permission for (82%) trainee involvement in their child's operation. Conclusions This study suggests that surgeons in academic settings must balance transparency with trainee autonomy when obtaining caregiver consent. Level of evidence Level III.

Acute pain after surgery is one of the most frequent indications for opioid prescribing in children. Opioids are often not stored or disposed of safely after their use, placing children and others in the home at risk for accidental ingestion or intentional misuse. We currently lack evidence-based guidelines for post-operative pain management after common ambulatory pediatric urologic procedures. Thus, each surgeon must decide if and how much opioid to prescribe based on his/her own assumptions of perceived post-operative pain.As part of an effort to establish opioid prescribing guidelines across two academic centers, the objectives of this study were to evaluate current variability in pediatric urologists' opioid prescribing factors and identify patients at greatest risk of being prescribed high doses of opioids after common ambulatory pediatric urologic procedures.We retrospectively evaluated post-operative opioid prescribing patterns after common ambulatory pediatric urology procedures (circumcision, orchiopexy, and hernia/hydrocele) at two major children's hospitals. Specifically, we evaluated if and how much opioid was prescribed for all children (18 years or younger) between 2016 and 2017. Bivariate analysis was performed using Kruskal-Wallis Test and Wilcoxon Rank Sum. Multivariable logistic regression was performed to determine patient, surgeon, and procedural factors that predicted the prescription of a high dose of opioids (greater than the median number of doses prescribed for that procedure).Over the two-year period, 811 circumcisions and 883 inguinal surgeries (inguinal orchiopexy and hernia/hydrocele) were performed. 94% of patients undergoing circumcision and 97% of those undergoing inguinal surgery were prescribed opioid analgesia. The median number of doses prescribed for circumcision was 20; for inguinal surgeries, 23.75% of patients received 15 opioid doses or more. Patients ages 0-2 years, who represented the largest age group (41% of all patients), received significantly more opioid doses than all other age groups, followed by those10 years (p 0.01). There was significant variation in opioid prescribing patterns by provider (p 0.01) (Figure 1) On multivariable logistic regression, younger age, pill form, and earlier year were all associated with a greater number of opioid doses prescribed for all surgeries.Across two institutions without a formal post-operative opioid prescribing policy for ambulatory pediatric urologic procedures, we observed considerable variability in provider prescribing patterns, with nearly all patients receiving an opioid, and those 0-2 years receiving the highest number of doses. This highlights the need for evidence-based guidelines for post-operative pain management after ambulatory pediatric urologic surgeries.

Background Surgical care represents an important source of opioid prescribing and chronic use, but rates of prolonged opioid use following pediatric procedures remain unclear. The authors describe the rates and risk factors for new persistent opioid use in patients after common cleft operations. Methods The authors examined claims from the Truven Marketscan databases from January 1, 2010 to December 31, 2014. The authors included opioid-naive patients ages 8 to 25, who underwent 1 of 10 cleft-related procedures. Patients were considered opioid-naive if they had no opioid prescription fills in the 11 months prior to the perioperative period. The authors obtained a random sample of age-matched, nonsurgical patients from the same dataset to be used as a control group. Included cleft patients had no procedural codes in the 6 months following surgery. All included patients filled an opioid prescription during the perioperative period, defined as 30 days before and 14 days after surgery. The primary outcome was new persistent opioid use, which is defined as continued opioid prescription fills between 90 and 180 days after the procedure. Results This cohort included 2039 cleft patients and 2100 control patients. The incidence of new persistent opioid use following surgery was 4.4% and 0.1% in the control group. Higher odds of opioid use 3 months beyond surgery were associated with distractor placement (OR 5.34, CI 2.00-14.24, P = 0.001). Increasing age (OR 1.11, CI 1.04-1.17, P = 0.001) and presence of a gastrointestinal comorbidity (OR 7.37, CI 1.49-36.54, P = 0.014) were also associated with new persistent use. Conclusions New persistent opioid use occurs after cleft-related procedures and could lead to chronic use in children, adolescents, and young adults.

BACKGROUND: New persistent opioid use is a common postoperative complication, with 6% of previously opioid-naïve patients continuing to fill opioid prescriptions 3–6 months after surgery. Despite these risks, it is unknown which specialties prescribe opioids to these vulnerable patients. OBJECTIVE: To identify specialties prescribing opioids to surgical patients who develop new persistent opioid use. DESIGN, SETTING, AND PARTICIPANTS: Using a national dataset of insurance claims, we identified opioid-naïve patients aged 18–64 years undergoing surgical procedures (2008–2014) who continued filling opioid prescriptions 3 to 6 months after surgery. We then examined opioid prescriptions claims during the 12 months after surgery, and identified prescribing physician specialty using National Provider Identifier codes. MAIN MEASURES: Percentage of opioid prescriptions provided by each specialty evaluated at 90-day intervals during the 12 months after surgery. KEY RESULTS: We identified 5276 opioid-naïve patients who developed new persistent opioid use. During the first 3 months after surgery, surgeons accounted for 69% of opioid prescriptions, primary care physicians accounted for 13%, Emergency Medicine accounted for 2%, Physical Medicine & Rehabilitation (PM&R)/Pain Medicine accounted for 1%, and all other specialties accounted for 15%. In contrast, 9 to 12 months after surgery, surgeons accounted for only 11% of opioid prescriptions, primary care physicians accounted for 53%, Emergency Medicine accounted for 5%, PM&R/Pain Medicine accounted for 6%, and all other specialties provided 25%. CONCLUSIONS: Among surgical patients who developed new persistent opioid use, surgeons provide the majority of opioid prescriptions during the first 3 months after surgery. By 9 to 12 months after surgery, however, the majority of opioid prescriptions were provided by primary care physicians. Enhanced care coordination between surgeons and primary care physicians could allow earlier identification of patients at risk for new persistent opioid use to prevent misuse and dependence. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-018-4463-1) contains supplementary material, which is available to authorized users.

Background The "Cushion Effect," the phenomenon in which obesity protects against abdominal injury in adults in motor vehicle accidents, has not been evaluated among pediatric patients. This work evaluates the association between subcutaneous fat cross-sectional area, quantified using analytic morphomic techniques and abdominal injury. Methods This retrospective study includes 119 patients aged 1 to 18years involved in frontal impact motor vehicle accidents (2003–2015) with computed tomography scans. Subcutaneous fat cross-sectional area was measured and converted to age- and gender-adjusted percentiles from population-based normative data. Multivariable analysis determined the risk of the primary outcome, Maximum Abbreviated Injury Scale (MAIS) 2+ abdominal injury, after adjusting for age, weight, seatbelt status, and impact rating. Results MAIS 2+ abdominal injuries occurred in 20 (16.8%) of the patients. Subcutaneous fat area percentile was not significantly associated with MAIS 2+ abdominal injury on multivariable logistic regression (adjusted Odds Ratio, 0.86; 95% CI, 0.72–1.03; p=0.10). Discussion The "cushion effect" was not apparent among pediatric frontal motor vehicle crash victims in this study. Future work is needed to investigate other analytic morphomic measures. By understanding how body composition relates to injury patterns, there is a unique opportunity to improve vehicle safety design. Level of Evidence Prognosis Study, Level III.

Background/purpose Analytic morphomics is being used to identify 3-D biologic measures with superior clinical utility and risk stratification over traditional factors such as age, height, and weight. The purpose of this study is to define age and gender specific Pediatric Reference Analytic Morphomics Population (PRAMP™) growth charts. Methods This retrospective study population contains 2591 individual CT scans of a normative reference population of males and females (1–20years old). Growth curves were constructed at the 5th, 25th, 50th, 75th, and 95th quantiles for morphomic variables, including psoas muscle area, trabecular bone density, and visceral fat area by age and gender. Results Total psoas muscle area increases over time until late adolescence. Trabecular bone density remains stable until adolescence, decreases during adolescence, and increases in young adulthood. Visceral fat area increases over time with greater variation between the 5th and 95th percentile with increasing age. Conclusions The PRAMP™ data have been used to construct age- and sex-specific reference growth curves. This may be used to better define "abnormal" in efforts to create unique risk-categorization algorithms specific to particular clinical and global health investigations. Level of evidence Level II.

Objective To characterize current youth perspectives of prescription pain medication. Study design In total, 1047 youths aged 14-24 years were recruited by targeted social media advertisements to match national demographic benchmarks. Youths were queried by open-ended text message prompts about exposure and access to prescription pain medication, perceived safety of prescribed and nonprescribed medication, and associations with the word “opioid.” Responses were analyzed inductively for emerging themes and frequencies. Results Among 745 respondents (71.2% response rate), 439 identified as female (59.3%), 561 as white (75.8%), and mean age was 18.3 ± 3.2 years. Previous exposure to prescription pain medication was reported by 377 respondents (52.0%), most commonly related to dentistry (32.8%), surgery (19.2%), and injury (12.0%). Nonmedical sources of access to prescription pain medication were identified by 256 respondents (36.9%) and medical sources other than their doctor by an additional 111 respondents (16.0%). Three additional themes emerged from youth responses: (1) prescribed medication was thought to be safer than nonprescribed medication, based on trust in doctors; (2) risks of addiction and overdose were thought to be greater for nonprescribed medication; (3) respondents had a widely ranging understanding of the word “opioid,” from historical to current events, medical to illicit substances, and personal to public associations. Conclusions Although youths are aware of the opioid crisis, they perceive less risk of prescription pain medication prescribed by a doctor, than from other sources. Policies should target education to youth in clinical and nonclinical settings, highlighting the risks of addiction and overdose with all opioids.

Procedure-specific prescribing guidelines and trainee education have reduced opioid overprescribing in adult surgical patients, but tailored interventions do not yet exist for children. It is unknown what effect these adult interventions have had on postoperative opioid prescribing in children at the same institution, where trainees rotate across both adult and pediatric services.This retrospective study of patients (18 y) undergoing pediatric surgery (PS), pediatric otolaryngology (ENT), or pediatric urology (URO) procedures at a single tertiary academic center assessed opioid doses per patient before (January 01, 2015 to September 30, 2016) and after (January 01, 2017 to March 31, 2018) opioid prescribing guidelines and trainee education were instituted for adult laparoscopic cholecystectomy. Patient demographics, postoperative opioid prescribing, opioid refills, and emergency department (ED) visits21 d after surgery were compared using chi-squared analyses and t-tests. Interrupted time-series analyses (ITSA) assessed changes in the rate of opioid prescribing pre- and postintervention for each subspecialty.There were 3371 patients preintervention and 2439 patients postintervention. After the intervention, fewer patients were prescribed opioids (ENT: 97% versus 93%, P 0.001; URO: 98% versus 94%, P 0.001; PS: 61% versus 25%, P 0.001) and fewer opioid doses were prescribed in each prescription (ENT: 63.8 ± 26.1 versus 50.8 ± 22.0 doses, P 0.001; URO: 33.5 ± 23.4 versus 22.1 ± 11.3, P 0.001; PS: 20.4 ± 12.8 versus 13.8 ± 11.4 doses, P 0.001). There were no changes in opioid refill or ED visit rates postintervention. A decreasing rate in ENT prescribing was seen preintervention, with no significant change postintervention (-2.3 ± 1.1 versus -3.3 ± 0.7; P = 0.24). Whereas, the rate of decrease in PS and URO prescribing significantly slowed postintervention (PS: -2.0 ± 0.1 versus -0.9 ± 0.1, P 0.001; URO: -4.2 ± 0.2 versus -2.3 ± 0.5, P = 0.005).Opioid prescribing rates are decreasing, but adult interventions did not achieve reductions in pediatric opioid prescribing at the same institution. There was no concomitant rise in postoperative ED visits or opioid refills as prescribing declined, indicating that the risks of reducing opioid prescriptions may be minimal. Development of evidence-based, procedure-specific prescribing guidelines that specifically address pediatric patients are needed to effectively minimize opioid overprescribing in this population.

Importance Prior studies have found a substantial risk of persistent opioid use among adolescents and young adults undergoing surgical and dental procedures. It is unknown whether family-level factors, such as long-term opioid use in family members, is associated with persistent opioid use. Objective To determine whether long-term opioid use in family members is associated with persistent opioid use among opioid-naive adolescents and young adults undergoing surgical and dental procedures. Design, Setting, and Participants This retrospective cohort study used data from a commercial insurance claims database for January 1, 2010, to June 30, 2016, to study 346 251 opioid-naive patients aged 13 to 21 years who underwent 1 of 11 surgical and dental procedures and who were dependents on a family insurance plan. Exposures Long-term opioid use in family members, defined as having 1 or more family members who (1) filled opioid prescriptions totaling a 120 days’ supply or more during the 12 months before the procedure date or (2) filled 3 or more opioid prescriptions in the 90 days before the procedure date. Main Outcomes and Measures The main outcome measure was persistent opioid use, defined as 1 or more postoperative prescription opioid fills between 91 and 180 days among patients with an initial opioid prescription fill. Generalized estimating equations with robust SEs clustered at the family level were used to model persistent opioid use as a function of long-term opioid use among family members, controlling for procedure, total morphine milligram equivalents of the initial fill, and patient and family characteristics. Results A total of 346 251 patients (mean [SD] age, 17.0 [2.3] years; 175 541 [50.7%] female) were studied. Among these patients, 257 085 (74.3%) had an initial opioid fill. Among patients with an initial opioid fill, 11 016 (4.3%) had long-term opioid use in a family member. Persistent opioid use occurred in 453 patients (4.1%) with long-term opioid use in a family member compared with 5940 patients (2.4%) without long-term opioid use in a family member (adjusted odds ratio, 1.54; 95% CI, 1.39-1.71). Conclusion and Relevance The findings suggest that long-term opioid use among family members is associated with persistent opioid use among opioid-naive adolescents and young adults undergoing surgical and dental procedures. Physicians should screen young patients for long-term opioid use in their families and implement heightened efforts to prevent opioid dependence among patients with this important risk factor.

Gastrojejunostomy tubes (GJTs) have been associated with intestinal perforation in children6 months or6 kg. This study evaluated the impact of an institutional practice change recommending a new soft tip GJT for children10 kg.We performed a single-center review of GJT placements among children10 kg before (1/1/2010-12/31/2013) and after (7/1/2014-12/31/2016) the practice change. Intestinal perforation, nasojejunal tube (NJT) for30 days, and GJT replacement were assessed.Sixty GJTs were placed in 35 children (54% male; 17.2±9.0 months old) after compared to 147 GJTs in 77 children (44% male, p=0.32; 14.1±11.8 months, p=0.08) before the practice change. Use of soft tip GJT was adhered to in 19 placements (32%). There were no intestinal perforations after the practice change (before: 6 (4.1%); p=0.11). NJT remained30 days in 15 patients (65%) after the practice change (before: 13 (35%); p=0.02). Replacement was required for 53% with soft tip GJT and 18% with standard GJT (p=0.006).A reduction in intestinal perforation with an institutional practice change may be explained by fewer GJT placements in high-risk children and longer length of NJT placement. Future protocols may consider age and size restrictions rather than alternative tube types.Treatment study.Level III.

This study aimed to evaluate postoperative outcomes after minimally invasive repair of pectus excavatum (Nuss procedure) using video-assisted intercostal nerve cryoablation (INC) compared to thoracic epidural (TE).We performed a single center retrospective review of pediatric patients who underwent Nuss procedure with INC (n = 19) or TE (n = 13) from April 2015 to August 2017. Preoperative, intraoperative, and postoperative characteristics were collected. The primary outcome was length of stay (LOS) and secondary outcomes were intravenous and oral opioid use, pain scores, and complications. Opioids were converted to oral morphine milligram equivalents per kilogram (oral morphine equivalent [OME]/kg). Mann-Whitney U test was used for continuous and chi-squared analysis for categorical variables.There were no significant differences in patient characteristics, except Haller Index (INC: median [interquartile range] 4.3 [3.6-4.9]; TE: 3.2 [2.8-4.0]; P = 0.03). LOS was shorter with INC (INC: 3 [3-4] days; TE: 6 [5-7] days; P 0.001). Opioid use was higher intraoperatively (INC: 1.08 [0.87-1.37] OME/kg; TE: 0.46 [0.37-0.67] OME/kg; P = 0.002) and unchanged postoperatively (INC: 1.78 [1.26-3.77] OME/kg; TE: 1.82 [1.05-3.37] OME/kg; P = 0.80), and prescription doses were lower at discharge in INC (INC: 30 [30-40] doses; TE: 42 [40-60] doses; P = 0.005). There was no significant difference in postoperative complications (INC: 42.1%; TE: 53.9%; P = 0.51).INC during Nuss procedure reduced LOS, shifting postoperative opioid use earlier during admission. This may reflect the need for improved early pain control until INC takes effect. Prospective evaluation after INC is needed to characterize long-term pain medication requirements.

BACKGROUND Motor vehicle crashes are the leading cause of injury-related mortality in children, with a higher rate of multiorgan injuries than in adults. This may be related to increased solid organ volume relative to abdominal cavity and decreased protection of an underdeveloped cartilaginous rib cage in young children. To date, these anatomic relationships have not been fully described. Our study used analytic morphomics to obtain precise measures of the pediatric liver, spleen, kidneys, and ribs. METHODS This pilot study included 215 trauma patients (aged 0-18 years) with anonymized computed tomography (CT) scans. Liver, spleen, and kidney volumes were modeled using semiautomatic algorithms (MATLAB 2013a, MathWorks Inc., Natick, MA). Thirty-one scans were adequate to model the rib cage. Pearson's r was used to correlate absolute organ volume, fractional organ volume, and organ exposure with age and weight. RESULTS Spleen, right and left kidney, and liver volumes increased with age and weight (p < 0.01). Right/left kidney and liver fractional volumes decreased with age (p < 0.01), whereas spleen fractional volume remained relatively constant. Exposed surface area of the liver only significantly decreased with age in the anterior (p < 0.01), right (p < 0.01), and posterior views (p = 0.02). DISCUSSION With this study, we have demonstrated the ability to model solid organ and rib cage anatomy of children using cross-sectional imaging. In younger children, there may be a decrease in fractional organ volume and increase in liver surface exposure, although analysis of a larger sample size is warranted. In the future, this information may be used to improve the design of safety restraints in motor vehicles.

This study investigates patient-reported opioid consumption after pediatric operations.

In the setting of cardiovascular (CV) risk evaluation before major elective surgery, current risk assessment tools are relatively poor for discriminating among patients. For example, patients with clinical CV risk factors can be clearly identified; but among those without appreciated clinical CV risk, there may be a subset with stigmata of CV disease noted during the preoperative radiographic evaluation. Our study evaluated the relationship between abdominal aortic (AA) calcification measured on preoperative computed tomography (CT) imaging and surgical complications in patients undergoing general elective and vascular surgery. We hypothesized that patients with no known CV risk factors but significant aortic calcification on preoperative imaging will have inferior surgical outcomes.The study group included 1180 patients from the Michigan Surgical Quality Collaborative (MSQC) database who underwent major general or vascular elective surgery between 2006 and 2009 and who had a CT scan of the abdomen specifically for preoperative planning. AA calcification was measured using novel analytic morphomic techniques and reported as a percentage of the total wall area containing calcification. Patients were divided into cohorts by clinical CV risk and extent of AA calcification. Univariate analysis was used to compare postoperative morbidity between patient cohorts. Multivariate logistic regression analysis was used to compare continuous AA calcification with overall morbidity in patients with no clinical CV risk factors.AA calcification was strongly skewed to the right (53.5% had no AA calcification) and was significantly correlated with age (ρ = 0.43, P0.001). Unadjusted univariate analysis of morbidity showed no significant differences in complication rates between patients in the clinical CV risk and significant AA calcification (no known CV risk factor) categories. The clinical CV risk (P0.001) and significant AA calcification without CV risk factors (P = 0.009) populations both had significantly more infectious and overall complications than patients with no AA calcification and no clinical CV risk. Multivariate logistic regression confirmed that AA calcification was a significant predictor of morbidity in patients with no clinical CV risk factors (odds ratio = 1.35, P = 0.017).This study suggests that AA calcification may be related to progression of CV disease and surgical outcomes. A better understanding of the complex interaction of patient physiology with overall ability to recover from major surgery, using novel approaches such as analytic morphomics, has great potential to improve risk stratification and patient selection.

Background Obesity is a known risk factor for surgical site infection (SSI). Our hypothesis is that morphometric measures of midline subcutaneous fat will be associated with increased risk of SSI and will predict SSI better than conventional measures of obesity. Study Design We identified 655 patients who underwent midline laparotomy (2006 to 2009) using the Michigan Surgical Quality Collaborative database. Using novel, semiautomated analytic morphometric techniques, the thickness of subcutaneous fat along the linea alba was measured between T12 and L4. To adjust for variations in patient size, subcutaneous fat was normalized to the distance between the vertebrae and anterior skin. Logistic regression analyses were used to identify factors independently associated with the incidence of SSI. Results Overall, SSIs were observed in 12.5% (n = 82) of the population. Logistic regression revealed that patients with increased subcutaneous fat had significantly greater odds of developing a superficial incisional SSI (odds ratio [OR] = 1.76 per 10% increase, 95% CI 1.10 to 2.83, p=0.019). Smoking, steroid use, American Society of Anesthesiologists (ASA) classification, and incision-to-close operative time were also significant independent risk factors for superficial incisional SSI. When comparing subcutaneous fat and body mass index (BMI) as the only model variables, subcutaneous fat significantly improved model predictions of superficial incisional SSI (area under the receiver operating characteristic curve [AUC] 0.60, p=0.023); BMI did not (AUC 0.52, p=0.73). Conclusions Abdominal subcutaneous fat is an independent predictor of superficial incisional SSI after midline laparotomy. Novel morphometric measures may improve risk stratification and help elucidate the pathophysiology of surgical complications.

Objectives Determining operative risk in patients undergoing aortic surgery is a difficult process, as multiple variables converge to affect overall mortality. Patient frailty is certainly a contributing factor, but is difficult to measure, with surgeons often relying on subjective or intuitive influences. We sought to use core muscle size as an objective measure of frailty, and determine its utility as a predictor of survival after abdominal aortic aneurysm (AAA) repair. Methods Four hundred seventy-nine patients underwent elective open AAA repair between 2000 and 2008. Two hundred sixty-two patients (54.7%) had preoperative computed tomography (CT) scans available for analysis. Cross-sectional areas of the psoas muscles at the level of the L4 vertebra were measured. The covariate-adjusted effect of psoas area on postoperative mortality was assessed using Cox regression. Results Of the 262 patients, there were 55 deaths and the mean length of follow-up was 2.3 years. Cox regression revealed a significant association between psoas area and postoperative mortality (P = .003). The effect of psoas area was found to decrease significantly as follow-up time increased (P = .008). Among all covariates included in the Cox models (including predictors of mortality such as American Society of Anesthesiologists [ASA] score), the psoas area was the most significant. Conclusion Core muscle size, an objective measure of frailty, correlates strongly with mortality after elective AAA repair. A better understanding of the role of frailty and core muscle size may aid in risk stratification and impact timing of surgical repair, especially in more complex aortic operations.

Regional surgical quality improvement consortiums are becoming more common. Herein we have reported the effectiveness of a statewide consortium focusing on open vascular operative procedures.The statewide Michigan Surgical Quality Consortium was established in 2005 with 16 hospitals that report cases of vascular open operative intervention, in a sampling manner consistent with the private sector National Surgical Quality Improvement Program. Data are abstracted by onsite trained nurses using defined and validated pre-, peri-, and postoperative variables with 30-day follow-up. Outpatient and emergent cases were excluded. We compared outcomes over the course of the consortium (era I, April 2005-March 2007; era II, April 2007-March 2008) via univariate and multivariate techniques.Era I (n = 2,453) and era II (n = 3,409) cases were similar in age (mean, 68 years), gender (61% male), relative value units (mean, 21), and distribution of Current Procedural Terminology codes. Duration of stay and operative time decreased by 15% and 11%, respectively, when comparing era I with era II (P.001). Mortality at 30 days was not different between eras I and II (2.7% vs 2.5%; P = NS), but morbidity was decreased (15.8% vs 13.8%; P = .02). Specific decreases were noted in sepsis and pulmonary, but not cardiac or renal, complications. When evaluating both eras, modifiable variables (able to be altered by the surgeon) for morbidity included increased length of operation (odds ratio [OR], 1.004; 95% confidence interval [CI], 1.003-1.005; P.0001), hypertension (OR, 1.46; 95% CI, 1.03-2.1; P = .03), and blood transfusion (OR, 2.8; 95% CI, 2.04-3.88; P.0001). However, anemic patients (11%; hematocrit30) who were transfused were less likely to suffer morbidity (OR, 56; 95% CI, 0.47-0.67; P.0001) than those transfused who were not anemic. The absolute 2% reduction in complications led to a $172 cost savings for the payers per patient in era II compared with era I.A statewide quality-of-care consortium with timely feedback of data was associated with decreased morbidity over a relatively short follow-up period in vascular patients. Focusing on best processes in real-world practice, such as appropriate transfusion and length of operation, may further improve vascular surgical outcomes.

This pharmacoepidemiology study uses commercial claims database data to describe the rate of persistent opioid use among patients aged 13 to 30 years prescribed perioperative opioids for wisdom tooth extraction.

BACKGROUND Current measures of obesity do not accurately describe body composition. Using cross-sectional imaging, objective measures of musculature and adiposity are possible and may inform efforts to optimize liver transplantation outcomes. METHODS Abdominal visceral fat area and psoas muscle cross-sectional area were measured on CT scans for 348 liver transplant recipients. After controlling for donor and recipient characteristics, survival analysis was performed using Cox regression. RESULTS Visceral fat area was significantly associated with post-transplant mortality (p < 0.001; HR = 1.06 per 10 cm(2) , 95% CI: 1.04-1.09), as were positive hepatitis C status (p = 0.004; HR = 1.78, 95% CI: 1.21-2.61) and total psoas area (TPA) (p < 0.001; HR = 0.91 per cm(2) , 95% CI: 0.88-0.94). Among patients with smaller TPA, the patients with high visceral fat area had 71.8% one-yr survival compared to 81.8% for those with low visceral fat area (p = 0.15). At five yr, the smaller muscle patients with high visceral fat area had 36.9% survival compared to 58.2% for those with low visceral fat area (p = 0.023). CONCLUSIONS Abdominal adiposity is associated with survival after liver transplantation, especially in patients with small trunk muscle size. When coupled with trunk musculature, abdominal adiposity offers direct characterization of body composition that can aid preoperative risk evaluation and inform transplant decision-making.

Alvimopan was approved by the Food and Drug Administration in May 2008 and has been shown to accelerate gastrointestinal recovery after colectomy. Our independent study evaluated alvimopan as it is used in actual hospital practice in the state of Michigan. We hypothesized that alvimopan significantly decreases incidence of prolonged ileus and reduces length of stay (LOS) in patients who have undergone colectomy.We identified 4749 patients from the Michigan Surgical Quality Collaborative (N = 28 hospitals) database between August 2007 and December 2010 who underwent elective colectomy operations. A total of 528 patients received alvimopan both pre- and postoperatively. We first selected a control group of patients from hospitals that had never administered alvimopan (n = 1833) and used propensity matching to manage differences in patient demographics and clinical characteristics. To control for hospital and surgeon characteristics, we then performed a sensitivity analysis, using a separate group of historical control patients treated before May 2008 in hospitals that would later administer alvimopan (n = 270). The Fisher exact test was used to compare complication rates, and the Student t test was used to compare LOS.Patients who received alvimopan had significantly lower incidence of prolonged ileus (2.3% vs 7.9%; P0.001) and a significantly shorter LOS (4.84 ± 4.54 vs 6.40 ± 4.45 days; P0.001) than control patients in hospitals that had never administered alvimopan. No differences were noted in these outcomes using sensitivity analysis.This study suggests that the actual utilization of alvimopan leads to a reduction in prolonged ileus and LOS in patients who underwent colectomy. By accelerating postoperative recovery, alvimopan has the potential to benefit patients and health care systems by improving outcomes, ensuring patient comfort, and reducing cost.

Assess the relationship between lean core muscle size, measured on preoperative cross-sectional images, and surgical outcomes.Novel measures of preoperative risk are needed. Analytic morphomic analysis of cross-sectional diagnostic images may elucidate vast amounts of patient-specific data, which are never assessed by clinicians.The study population included all patients within the Michigan Surgical Quality Collaborative database with a computerized tomography(CT) scan before major, elective general or vascular surgery (N = 1453). The lean core muscle size was calculated using analytic morphomic techniques. The primary outcome measure was survival, whereas secondary outcomes included surgical complications and costs. Covariate adjusted outcomes were assessed using Kaplan-Meier analysis, multivariate cox regression, multivariate logistic regression, and generalized estimating equation methods.The mean follow-up was 2.3 years and 214 patients died during the observation period. The covariate-adjusted hazard ratio for lean core muscle area was 1.45 (P = 0.028), indicating that mortality increased by 45% per 1000 mm(2) decrease in lean core muscle area. When stratified into tertiles of core muscle size, the 1-year survival was 87% versus 95% for the smallest versus largest tertile, whereas the 3-year survival was 75% versus 91%, respectively (P0.003 for both comparisons). The estimated average risk of complications significantly differed and was 20.9%, 15.0%, and 12.3% in the lower, middle, and upper tertiles of lean core muscle area, respectively. Covariate-adjusted cost increased significantly by an estimated $10,110 per 1000 mm(2) decrease in core muscle size (P = 0.003).Core muscle size is an independent and potentially important preoperative risk factor. The techniques used to assess preoperative CT scans, namely analytic morphomics, may represent a novel approach to better understanding patient risk.

The etiology of patellofemoral pain is likely related to pathological femoral shape and soft-tissue restraints imbalance. These factors may result in various maltracking patterns in patients with patellofemoral pain. Thus, we hypothesized that femoral shape influences patellofemoral kinematics, but that this influence differs between kinematically-unique subgroups of patients with patellofemoral pain. 3D MRIs of 30 knees with patellofemoral pain and maltracking (“maltrackers”) and 33 knees of asymptomatic subjects were evaluated retrospectively. Dynamic MRI was acquired during a flexion-extension task. Maltrackers were divided into two subgroups (non-lateral and lateral maltrackers) based on previously defined kinematic criteria. Nine measures of femoral trochlear shape and two measures of patellar shape were quantified. These measures were correlated with patellofemoral kinematics. Differences were found in femoral shape between the maltracking and asymptomatic cohorts. Femoral shape was correlated with patellofemoral kinematics, but the kinematic parameters that demonstrated significant correlation varied across maltracking subgroups. Femoral shape parameters were associated with patellar kinematics in patients with patellofemoral pain and maltracking, but the correlations were unique across subgroups within this population. The ability to better categorize patients with patellofemoral pain will likely improve treatment by providing a more specific etiology of maltracking in individual patients.

Morphometric assessment has emerged as a strong predictor of postoperative morbidity and mortality. However, a gap exists in translating this knowledge to bedside decision making. We introduced a novel measure of patient-centered surgical risk assessment: morphometric age.To investigate the relationship between morphometric age and posttransplant survival.Medical records of recipients of deceased-donor liver transplants (study population) and kidney donors/trauma patients (morphometric age control population).A retrospective cohort study of 348 liver transplant patients and 3313 control patients. We assessed medical records for validated morphometric characteristics of aging (psoas area, psoas density, and abdominal aortic calcification). We created a model (stratified by sex) for a morphometric age equation, which we then calculated for the control population using multivariate linear regression modeling (covariates). These models were then applied to the study population to determine each patient's morphometric age.All analytic steps related to measuring morphometric characteristics were obtained via custom algorithms programmed into commercially available software. An independent observer confirmed all algorithm outputs. Trained assistants performed medical record review to obtain patient characteristics.Cox proportional hazards regression model showed that morphometric age was a significant independent predictor of overall mortality (hazard ratio, 1.03 per morphometric year [95% CI, 1.02-1.04; P .001]) after liver transplant. Chronologic age was not a significant covariate for survival (hazard ratio, 1.02 per year [95% CI, 0.99-1.04; P = .21]). Morphometric age stratified patients at high and low risk for mortality. For example, patients in the middle chronologic age tertile who jumped to the oldest morphometric tertile have worse outcomes than those who jumped to the youngest morphometric tertile (74.4% vs 93.2% survival at 1 year [P = .03]; 45.2% vs 75.0% at 5 years [P = .03]).Morphometric age correlated with mortality after liver transplant with better discrimination than chronologic age. Assigning a morphometric age to potential liver transplant recipients could improve prediction of postoperative mortality risk.

A cornerstone of a surgeon's clinical assessment of suitability for major surgery is best described as the "eyeball test." Preoperative imaging may provide objective measures of this subjective assessment by calculating a patient's morphometric age. Our hypothesis is that morphometric age is a surgical risk factor distinct from chronologic age and comorbidity and correlates with surgical mortality and length of stay.This is a retrospective cohort study within a large academic medical center. Using novel analytic morphomic techniques on preoperative CT scans, a morphometric age was assigned to a random sample of patients having inpatient general and vascular abdominal surgery from 2006 to 2011. The primary outcomes for this study were postoperative mortality (1-year) and length of stay (LOS).The study cohort (n = 1,370) was stratified into tertiles based on morphometric age. The postoperative risk of mortality was significantly higher in the morphometric old age group when compared with the morphometric middle age group (odds ratio 2.42, 95% CI 1.52 to 3.84, p0.001). Morphometric old age patients were predicted to have a LOS 4.6 days longer than the morphometric middle age tertile. Similar trends were appreciated when comparing morphometric middle and young age tertiles. Chronologic age correlated poorly with these outcomes. Furthermore, patients in the chronologic middle age tertile found to be of morphometric old age had significantly inferior outcomes (mortality 21.4% and mean LOS 13.8 days) compared with patients in the chronologic middle age tertile found to be of morphometric young age (mortality 4.5% and mean LOS 6.3 days, p0.001 for both).Preoperative imaging can be used to assign a morphometric age to patients, which accurately predicts mortality and length of stay.