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W Michael Hooten,1 Jodie Dvorkin,2 Nafisseh S Warner,1 Amy CS Pearson,3 M Hassan Murad,4 David O Warner11Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA; 2Institute for Clinical Systems Improvement, Minneapolis, MN, USA; 3Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA, USA; 4Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USABackground: The primary objective of this systematic review was to identify the characteristics of physicians who prescribe opioids to adults with chronic pain. This review was limited to studies examining fully-trained physicians, as relevant characteristics of resident physicians and non-physician clinicians may differ.Methods: A comprehensive search of databases from January 1, 1980 to December 5, 2017 was conducted. Eligible study designs included (1) randomized trials; (2) nonrandomized prospective and retrospective studies; and (3) cross-sectional observational studies. The risk of bias in the included studies was assessed using an adapted version of the Newcastle-Ottawa Scale for cross-sectional studies. A total of 2508 records were screened and 22 studies met inclusion criteria. The majority of studies were cross-sectional (n=20) and the total number of participants was 8433.Results: The risk of bias was high overall. The majority of physicians were confident managing and prescribing opioids for chronic pain but had high levels of dissatisfaction. Physicians reported high awareness of the potential for opioid misuse and were concerned about inadequate prior training in pain management. The majority of physicians were less likely to prescribe for patients with a history of substance abuse and reported major concerns about regulatory scrutiny.Conclusion: This systematic review provides the foundation for the development of prospective studies aimed at further elucidating the constellation of mechanisms that influence physicians who manage pain and prescribe opioids.Keywords: systematic review, opioid, prescription, physician characteristics

Background: Acute lung injury (ALI) is a serious postoperative complication with limited treatment options. A preoperative risk-prediction model would assist clinicians and scientists interested in ALI. The objective of this investigation was to develop a surgical lung injury prediction (SLIP) model to predict risk of postoperative ALI based on readily available preoperative risk factors.Methods: Secondary analysis of a prospective cohort investigation including adult patients undergoing high-risk surgery. Preoperative risk factors for postoperative ALI were identified and evaluated for inclusion in the SLIP model. Multivariate logistic regression was used to develop the model. Model performance was assessed with the area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test.Results: Out of 4,366 patients, 113 (2.6%) developed early postoperative ALI. Predictors of postoperative ALI in multivariate analysis that were maintained in the final SLIP model included high-risk cardiac, vascular, or thoracic surgery, diabetes mellitus, chronic obstructive pulmonary disease, gastroesophageal reflux disease, and alcohol abuse. The SLIP score distinguished patients who developed early postoperative ALI from those who did not with an area under the receiver operating characteristic curve (95% CI) of 0.82 (0.78-0.86). The model was well calibrated (Hosmer-Lemeshow, P = 0.55). Internal validation using 10-fold cross-validation noted minimal loss of diagnostic accuracy with a mean ± SD area under the receiver operating characteristic curve of 0.79 ± 0.08.Conclusions: Using readily available preoperative risk factors, we developed the SLIP scoring system to predict risk of early postoperative ALI. [ABSTRACT FROM AUTHOR]

BACKGROUND: : Secondhand smoke exposure poses health risks to children, including increased risks for anesthesia. In adult smokers, surgery serves as a teachable moment to motivate quitting. For parents who smoke, having a child undergo surgery may also serve as a teachable moment for smoking behavioral change. This study determined if there is an association between children undergoing a surgical procedure and changes in their parents' smoking behavior. METHODS: : Secondary analyses were performed using logistic regression analysis of 2005 survey data from the National Health Interview Survey. Analyses included 9,289 parent respondents who provided information on both themselves and their children. RESULTS: : Of the sampled children, 1,112 (12.6%, 95% CI:11.7, 13.4) lived in a home with at least one person who smoked inside in a usual week. In multivariate analysis of the relationship between parent and child surgical history in the past 12 months and smoking behavior, surgery in either the parent (odds ratio 2.19, 95% CI: 1.55, 3.08) or child (odds ratio 2.61, 95% CI: 1.56, 4.35) was associated with an increased likelihood of a quit attempt by the parent. However, these attempts were more likely to be successful if the parents (odds ratio 2.35, 95% CI: 1.35, 4.07), not their child (odds ratio 0.51, 95% CI: 0.20, 1.28), had surgery within the past 12 months. CONCLUSIONS: : Parents who smoke were more likely to make a quit attempt within the past 12 months if their children had surgery within this time, but they were not more likely to succeed in maintaining abstinence and thus could benefit from assistance. [ABSTRACT FROM AUTHOR]

BACKGROUND: Telephone quitlines that provide counseling support are efficacious in helping cigarette smokers quit and have been widely disseminated; currently, they are underused. Surgery represents a teachable moment for smoking cessation, which can benefit surgical outcomes; however, few surgical patients receive smoking cessation interventions. This study developed and tested a clinician-delivered intervention to facilitate quitline use by adult patients scheduled for elective surgery. METHODS: After formative work involving patients and clinicians, a brief intervention was designed to facilitate telephone quitline use. It was then evaluated in a randomized trial of 300 adults scheduled for elective surgery. A control standard brief stop-smoking intervention served as a comparator, with both interventions delivered by clinicians. The primary outcome was the use rate of a quitline accessed through a dedicated toll-free telephone number, with use defined as completing at least one full counseling session. Secondary outcomes included self-reported abstinence from cigarettes at 30 and 90 days postoperatively. RESULTS: Subject characteristics were similar between the two groups. Records from the designated quitline documented that 29 of 149 subjects (19.5%) in the quitline intervention group and 0 of 151 subjects in the control group completed the first full counseling session (P < 0.0001). There were no significant differences in the self-reported point-prevalent and continuous abstinence rates between groups at either 30 or 90 days postoperatively, although rates tended to be higher in the quitline intervention group. CONCLUSIONS: Clinicians can effectively facilitate quitline use by surgical patients. Further work is necessary to evaluate the efficacy of this approach in terms of long-term abstinence from cigarette smoking. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To investigate the Incidence of postoperative venous thromboembolism (VTE) in patients who had flown long distances before major surgery. PATIENTS AND METHODS: Using the Mayo Clinic computerized patient database, we Identified patients who had flown more than 5000 km before major surgery (travelers) and had experienced an episode of clinically significant VTE within 28 days after surgery. Individual medical records were reviewed for the diagnosis of VTE, pertinent risk factors, and outcome. We compared the Incidence of VTE in travelers to the incidence of VTE in patients from North America (nontravelers) undergoing similar surgical procedures. RESULTS: Eleven patients met our criteria for long-haul air travel and clinically significant VTE within 28 days after surgery. Compared with nontravelers undergoing similar surgical procedures, long-haul travelers had a higher Incidence of VTE (4.9% vs 0.15%; P < .001). Compared with nontravelers who developed VTE, travelers were younger (P = .006), developed VTE earlier in the postoperative course (P = .01), had higher American Society of Anesthesiologists physical status classification (P = .02), and had higher prevalence of smoking (P = .007). Of the 11 travelers with VTE, 10 were of Middle Eastern origin. CONCLUSION: Prolonged air travel before major surgery significantly increases the risk of perioperative VTE. Such patients should receive more Intensive VTE prophylactic measures during the flight and throughout the perioperative period. [ABSTRACT FROM AUTHOR]

Millions of cigarette smokers require surgery each year. Those who quit smoking may reduce their risk of respiratory, cardiovascular, and wound-related complications. Scheduling of surgery may present a unique opportunity to help smokers quit permanently. Primary care providers can play an important role in helping their patients scheduled for surgery quit smoking before their operation and maintain their abstinence after surgery. To do so effectively, physicians need to understand (1) the consequences of smoking in the perioperative period and how quitting can mitigate these problems, (2) how surgery can serve as a 'teachable moment' to aid in smoking cessation, and (3) specific techniques that can be used to help their patients quit smoking, including brief counseling and pharmacotherapy. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To test the hypothesis that obesity is an independent risk factor for unplanned hospital admission or readmission among patients scheduled for ambulatory surgery in a tertiary medical center. PATIENTS AND METHODS: Existing databases were used to identify 235 obese patients (body mass index [BMI] >40) scheduled for ambulatory surgery from January 2, 2002, through December 31, 2003, at Mayo Clinic's site in Rochester, MN. Each patient was matched to a normal-weight control (BMI <25) by age, sex, surgical procedure, type of anesthesia, and date of surgery, and the medical records of all patients were reviewed. Conditional logistic regression analysis was performed to assess whether obesity is an independent risk factor for unplanned postoperative hospital admission. In all cases, 2-sided tests were performed. P<.05 was considered statistically significant. RESULTS: Obese patients (mean +/- SD BMI, 44+/-4) were matched with control patients (mean +/- SD BMI, 23+/-2). Comorbidity was more frequent in the obese cohort. The frequency of unplanned hospital admission did not differ between groups: 61 obese patients (26.0%) and 52 control patients (22.1%) were admitted (odds ratio, 1.3; 95% confidence interval, 0.8-2.0; P=.30). CONCLUSION: Obesity is not a significant independent risk factor for unplanned admission after ambulatory surgery, suggesting that obesity per se should not prevent ambulatory surgery from being scheduled. [ABSTRACT FROM AUTHOR]

While studies have evaluated the utility of telehealth in replacing in-person clinical encounters, there is a dearth of literature examining the quality of patient-physician communication with telehealth encounters. Accordingly, this study assessed the feasibility of using virtual cardiology clinical encounters to examine patient-physician interaction, communication, and perceptions of the clinical encounter. Telemedicine cardiology clinical encounters were audio- and video-recorded following the encounter, patients, and cardiologists completed an electronic survey to assess perceptions of the encounter. Qualitative analysis of the communication and statistical analysis of the survey data was conducted, providing descriptive data. The study included 11 patient-physician dyads; all patients were non-Hispanic White. Cardiologists were more racially and ethnically diverse (63% Asian). Most patients agreed telemedicine was comparable to in-person encounters (85.7%), with all cardiologists reporting that patients appeared satisfied with the encounter. We utilized an assessment tool to examine patient-physician communication in the recorded virtual encounters. This study suggests examining patient-physician communication using virtual clinical encounters is feasible, although there are barriers that need addressing for larger studies., Competing Interests: The author(s) declared no potential conflicts of interest regarding the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Competing Interests: The authors declare no conflicts of interest.

Competing Interests: The authors declare no conflicts of interest.

Objectives: Racial disparities are pervasive in access to pediatric surgery. The goal of this study was to test the hypotheses that, compared with White children, non-White and Hispanic children: (1) were less likely to attend evaluations by otolaryngologists after a diagnosis of otitis media (OM) eligible for surgical referral, and (2) these children were less likely to receive tympanostomy tube (TT) after surgical consultation., Methods: The OptumLabs Data Warehouse is a de-identified claims database of privately insured enrollees. Guidelines on the management of OMs suggest that children should be evaluated for surgery if they have recurrent acute OM or chronic OM with effusion. A cohort of children who were diagnosed with OM were constructed. For Hypothesis 1, the primary outcome was otolaryngology office visit within 6 months of a diagnosis of recurrent or chronic OM. For Hypothesis 2, the outcome was TT placement within 6 months following the otolaryngology office visit. Cox regression models were used to determine the relationship between race/ethnicity and the primary outcomes., Results: Among 187,776 children with OMs, 72,774 (38.8%) had otolaryngology visits. In a multivariate Cox model, the hazard ratios of attending otolaryngology visit for Black, Hispanic, and Asian children were 0.93 (95% CI,0.90, 0.96), 0.86 (0.83, 0.88), and 0.74 (0.71, 0.77), compared with White children. Among the children evaluated by otolaryngologists, 46,554 (63.97%) received TT. Black, Hispanic, and Asian children with recurrent acute OM had lower likelihood of receiving TT., Conclusions: Racial disparities in attending otolaryngology office visit contributed to the disparities in receiving TT., Quality of Evidence: Level 3 Laryngoscope, 134:3846-3852, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

In response to the COVID-19 pandemic, the American Board of Anesthesiology transitioned from in-person to virtual administration of its APPLIED Examination, assessing more than 3000 candidates for certification purposes remotely in 2021. Four hundred examiners were involved in delivering and scoring Standardized Oral Examinations (SOEs) and Objective Structured Clinical Examinations (OSCEs). More than 80% of candidates started their exams on time and stayed connected throughout the exam without any problems. Only 74 (2.5%) SOE and 45 (1.5%) OSCE candidates required rescheduling due to technical difficulties. Of those who experienced "significant issues", concerns with OSCE technical stations (interpretation of monitors and interpretation of echocardiograms) were reported most frequently (6% of candidates). In contrast, 23% of examiners "sometimes" lost connectivity during their multiple exam sessions, on a continuum from minor inconvenience to inability to continue. 84% of SOE candidates and 89% of OSCE candidates described "smooth" interactions with examiners and standardized patients/standardized clinicians, respectively. However, only 71% of SOE candidates and 75% of OSCE candidates considered themselves to be able to demonstrate their knowledge and skills without obstacles. When compared with their in-person experiences, approximately 40% of SOE examiners considered virtual evaluation to be more difficult than in-person evaluation and believed the remote format negatively affected their development as an examiner. The virtual format was considered to be less secure by 56% and 40% of SOE and OSCE examiners, respectively. The retirement of exam materials used virtually due to concern for compromise had implications for subsequent exam development. The return to in-person exams in 2022 was prompted by multiple factors, especially concerns regarding standardization and security. The technology is not yet perfect, especially for testing in-person communication skills and displaying dynamic exam materials. Nevertheless, the American Board of Anesthesiology's experience demonstrated the feasibility of conducting large-scale, high-stakes oral and performance exams in a virtual format and highlighted the adaptability and dedication of candidates, examiners, and administering board staff., (© 2024. The Author(s).)

Background: Postoperative nausea and vomiting (PONV) are frequent after volatile anesthesia. We hypothesized that coadministration of propofol with volatile anesthetic compared to pure volatile anesthetics would decrease the need for postoperative antiemetic treatments and shorten recovery time in the postanesthesia care unit (PACU)., Methods: We retrospectively identified adult patients who underwent procedures using general anesthesia with volatile agents, with or without propofol infusion, from May 2018 through December 2020, and who were admitted to the PACU. Inverse probability of treatment weighting (IPTW) analysis was performed using generalized estimating equations with robust variance estimates to assess whether propofol was associated with decreased need for rescue antiemetics., Results: Among 47,847 patients, overall IPTW rescue antiemetic use was 4.7% for 17,573 patients who received propofol and 8.2% for 30,274 who did not (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.49-0.61; P <.001). This effect associated with propofol was present regardless of the intensity of antiemetic prophylaxis (OR, 0.59, 0.51, and 0.58 for 0-1, 2, and ≥3 antiemetics used, respectively), procedural duration (OR, 0.54, 0.62, and 0.47 for ≤2.50, 2.51-4.00, ≥4.01 hours), and type of volatile agent (OR, 0.51, 0.52, and 0.57 for desflurane, isoflurane, and sevoflurane) (all P <.001). This effect was dose dependent, with little additional benefit for the reduction in the use of PACU antiemetics when propofol rate exceeded 100 μg/kg/min. Patients who received rescue antiemetics required longer PACU recovery time than those who did not receive antiemetics (ratio of the geometric mean, 1.31; 95% CI, 1.28-1.33; P <.001), but use of propofol did not affect PACU recovery time (ratio of the geometric mean, 1.00; 95% CI, 0.98-1.01; P =.56)., Conclusions: The addition of propofol infusions to volatile-based anesthesia is associated with a dose-dependent reduction in the need for rescue antiemetics in the PACU regardless of the number of prophylactic antiemetics, duration of procedure, and type of volatile agent used, without affecting PACU recovery time., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2024 International Anesthesia Research Society.)

Study Objective: To evaluate the association between pretransfusion and posttransfusion hemoglobin concentrations and the outcomes of children undergoing noncardiac surgery., Design: Retrospective review of patient records. We focused on initial postoperative hemoglobin concentrations, which may provide a more useful representation of transfusion adequacy than pretransfusion hemoglobin triggers (the latter often cannot be obtained during acute surgical hemorrhage)., Setting: Single-center, observational cohort study., Patients: We evaluated all pediatric patients undergoing noncardiac surgery who received intraoperative red blood cell transfusions from January 1, 2008, through December 31, 2018., Interventions: None., Measurements: Associations between pre- and posttransfusion hemoglobin concentrations (g/dL), hospital-free days, intensive care unit admission, postoperative mechanical ventilation, and infectious complications were evaluated with multivariable regression modeling., Main Results: In total, 113,713 unique noncardiac surgical procedures in pediatric patients were evaluated, and 741 procedures met inclusion criteria (median [range] age, 7 [1-14] years). Four hundred ninety-eight patients (68%) with a known preoperative hemoglobin level had anemia; of these, 14% had a preexisting diagnosis of anemia in their health record. Median (IQR) pretransfusion hemoglobin concentration was 8.1 (7.4-9.2) g/dL and median (IQR) initial postoperative hemoglobin concentration was 10.4 (9.3-11.6) g/dL. Each decrease of 1 g/dL in the initial postoperative hemoglobin concentration was associated with increased odds of transfusion within the first 24 postoperative hours (odds ratio [95% CI], 1.62 [1.37-1.93]; P < .001). No significant relationships were observed between postoperative hemoglobin concentrations and hospital-free days (P = .56), intensive care unit admission (P = .71), postoperative mechanical ventilation (P = .63), or infectious complications (P = .74)., Conclusions: In transfused patients, there was no association between postoperative hemoglobin values and clinical outcomes, except the need for subsequent transfusion. Most transfused patients presented to the operating room with anemia, which suggests a potential opportunity for perioperative optimization of health before surgery., Competing Interests: Declaration of competing interest No conflicts of interest declared., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To evaluate the associations between prescription opioid exposures in community-dwelling older adults and gray and white matter structure by magnetic resonance imaging., Methods: Secondary analysis was conducted of a prospective, longitudinal population-based cohort study employing cross-sectional imaging of older adult (≥65 years) enrollees between November 1, 2004, and December 31, 2017. Gray matter outcomes included cortical thickness in 41 structures and subcortical volumes in 6 structures. White matter outcomes included fractional anisotropy in 40 tracts and global white matter hyperintensity volumes. The primary exposure was prescription opioid availability expressed as the per-year rate of opioid days preceding magnetic resonance imaging, with a secondary exposure of per-year total morphine milligram equivalents (MME). Multivariable models assessed associations between opioid exposures and brain structures., Results: The study included 2185 participants; median (interquartile range) age was 80 (75 to 85) years, 47% were women, and 1246 (57%) received opioids. No significant associations were found between opioids and gray matter. Increased opioid days and MME were associated with decreased white matter fractional anisotropy in 15 (38%) and 16 (40%) regions, respectively, including the corpus callosum, posterior thalamic radiation, and anterior limb of the internal capsule, among others. Opioid days and MME were also associated with greater white matter hyperintensity volume (1.02 [95% CI, 1.002 to 1.036; P=.029] and 1.01 [1.001 to 1.024; P=.032] increase in the geometric mean, respectively)., Conclusion: The duration and dose of prescription opioids were associated with decreased white matter integrity but not with gray matter structure. Future studies with longitudinal imaging and clinical correlation are warranted to further evaluate these relationships., (Copyright © 2024 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)