Assessment of Persistent and Prolonged Postoperative Opioid Use Among Patients Undergoing Plastic and Reconstructive Surgery.
JAMA facial plastic surgery
Importance: Although the development of persistent opioid use after surgical procedures has garnered much attention in recent years, large-scale studies characterizing patterns of persistent opioid use among patients undergoing plastic and reconstructive surgery procedures are lacking.Objective: To assess the prevalence of immediate and long-term postoperative opioid use after plastic and reconstructive surgery procedures.Design, Setting, and Participants: In this population-based cohort study, patients who underwent 5 classes of plastic and reconstructive procedures (nasal, eye, breast, abdomen, and soft tissue reconstruction) between January 1, 2007, and December 31, 2015, were identified using IBM MarketScan Commercial and Medicare Supplemental research databases. Patients were excluded if they were younger than 18 years, lacked continuous insurance coverage for 1 year preoperatively and postoperatively, had a second anesthesia event within 1 year postoperatively, and filled an opioid prescription within the year prior to surgery.Main Outcomes and Measures: Analgesic prescription patterns in the immediate postoperative period. The primary outcome was rates of persistent opioid use (opioid prescriptions filled 90-180 days postoperatively). The secondary outcome was rates of prolonged opioid use (opioid prescriptions filled 90-180 days postoperatively and again 181-365 days postoperatively). Explanatory variables included patient demographics, procedure type, and relevant comorbidities.Results: Of the 466?677 patients who met inclusion criteria, 96?397 (45.3%) were men, and the mean (SD) age was 46.8 (17.7) years. Furthermore, 212?387 (54.6%) of the patients filled prescriptions for postoperative analgesics, with 212?387 (91.5%) of analgesic prescriptions filled being for opioids. Persistent opioid use occurred in 30?865 (6.6%) patients (5.1%-13.5% across procedure classes), while prolonged opioid use occurred in 10?487 (2.3%) patients (1.7%-5.6% across procedure classes). Patients who filled prescriptions for opioids in the perioperative period were significantly more likely to exhibit persistent (odds ratio [OR], 2.87; 95% CI, 2.80-2.94) and prolonged (OR, 2.90; 95% CI, 2.77-3.02) opioid use than those who did not fill perioperative opioid prescriptions, with the greatest odds for persistent use found in patients who underwent breast (OR, 4.36; 95% CI, 4.10-4.63) and nasal (OR, 3.51; 95% CI, 3.30-3.73) procedures. On multivariable logistic regression analysis, independent risk factors for persistent and prolonged opioid use included perioperative opioid use, procedure type, and prior-year mental health (depression and anxiety) and substance abuse diagnoses.Conclusions and Relevance: Given the significant risk of persistent opioid use after plastic and reconstructive procedures, it is imperative to develop best practices guidelines for postoperative opioid prescription practices in this population.Level of Evidence: NA.
View details for DOI 10.1001/jamafacial.2018.2035
View details for PubMedID 30844024
Health Outcome Studies in Skin Cancer Surgery.
Facial plastic surgery clinics of North America
2019; 27 (1): 163?70
As cutaneous cancers are the most common malignancies affecting US citizens, they represent a significant public health problem and health care cost burden. There are a variety of treatment options available to manage cutaneous malignancies, but limited data are available regarding outcomes, including quality of life, recurrence, and mortality. Here, we examine outcomes of skin cancer surgery as they relate to sociodemographic data and treatment factors.
View details for PubMedID 30420070
Relationship of Sociodemographic Factors and Outcomes in Functional Rhinoplasty.
Facial plastic surgery : FPS
The objective of this article was to compare the effect of such sociodemographic factors as gender, age, marital status, employment status, race, and income on short- and long-term rhinoplasty outcomes using a validated disease-specific instrument-Nasal Obstruction Symptom Evaluation (NOSE) scale, as well as complication and revision rates. Patients who underwent a functional (+/- cosmetic) rhinoplasty with the senior author between January, 1 2012, and September 9, 2017, and had both a preoperative and at least one postoperative NOSE score, were included in the study. Sociodemographic variables of binary gender, age, marital status, employment status, race, and income based on zip code were collected. The primary outcomes were the differences between the preoperative and postoperative NOSE scores with short-term (less than 3 months) and longer-term (greater than 3 months) follow-up. Secondary outcomes were general complications and specifically revision surgery. Standard descriptive statistics, as well as univariable linear and logistic regressions, were conducted with each outcome measure. A total of 341 patients were included in this study. No individual patient-level variables were found to significantly affect the short- or longer-term average change in NOSE scores, although older age trended toward significance in longer-term average change in NOSE scores (p=0.07). No factors significantly affected the rate of complications or revision surgery in this cohort. The authors found improvement in NOSE scores after rhinoplasty was not related to factors of age, gender, race, employment status, income, and marital status. This cohort also did not demonstrate differential rates in complications or revision surgery based on sociodemographic variables.
View details for PubMedID 30654390
2019; 321 (13): 1320
View details for PubMedID 30938797
Bilirubin-Induced Audiologic Injury in Preterm Infants
CLINICS IN PERINATOLOGY
2016; 43 (2): 313-?
Although hyperbilirubinemia is extremely common among neonates and is usually mild and transient, it sometimes leads to bilirubin-induced neurologic damage (BIND). The auditory pathway is highly sensitive to the effects of elevated total serum/plasma bilirubin (TB) levels, with damage manifesting clinically as auditory neuropathy spectrum disorder. Compared to full-term neonates, preterm neonates are more susceptible to BIND and suffer adverse effects at lower TB levels with worse long-term outcomes. Furthermore, although standardized guidelines for management of hyperbilirubinemia exist for term and late preterm neonates, similar guidelines for neonates less than 35 weeks gestational age are limited.
View details for DOI 10.1016/j.clp.2016.01.006
View details for Web of Science ID 000378367300010
View details for PubMedID 27235210
View details for PubMedCentralID PMC4884602
Cortical Activation Patterns Correlate with Speech Understanding After Cochlear Implantation
EAR AND HEARING
2016; 37 (3): E160-E172
Cochlear implants are a standard therapy for deafness, yet the ability of implanted patients to understand speech varies widely. To better understand this variability in outcomes, the authors used functional near-infrared spectroscopy to image activity within regions of the auditory cortex and compare the results to behavioral measures of speech perception.The authors studied 32 deaf adults hearing through cochlear implants and 35 normal-hearing controls. The authors used functional near-infrared spectroscopy to measure responses within the lateral temporal lobe and the superior temporal gyrus to speech stimuli of varying intelligibility. The speech stimuli included normal speech, channelized speech (vocoded into 20 frequency bands), and scrambled speech (the 20 frequency bands were shuffled in random order). The authors also used environmental sounds as a control stimulus. Behavioral measures consisted of the speech reception threshold, consonant-nucleus-consonant words, and AzBio sentence tests measured in quiet.Both control and implanted participants with good speech perception exhibited greater cortical activations to natural speech than to unintelligible speech. In contrast, implanted participants with poor speech perception had large, indistinguishable cortical activations to all stimuli. The ratio of cortical activation to normal speech to that of scrambled speech directly correlated with the consonant-nucleus-consonant words and AzBio sentences scores. This pattern of cortical activation was not correlated with auditory threshold, age, side of implantation, or time after implantation. Turning off the implant reduced the cortical activations in all implanted participants.Together, these data indicate that the responses the authors measured within the lateral temporal lobe and the superior temporal gyrus correlate with behavioral measures of speech perception, demonstrating a neural basis for the variability in speech understanding outcomes after cochlear implantation.
View details for DOI 10.1097/AUD.0000000000000258
View details for Web of Science ID 000375151900003
View details for PubMedID 26709749
View details for PubMedCentralID PMC4844823
Quantification of maxillary sinus accessibility via a middle meatal antrostomy
AMERICAN JOURNAL OF RHINOLOGY & ALLERGY
2015; 29 (5): 394-396
To quantify maxillary sinus volume and mucosal surface area (SA) that is accessible endoscopically via a middle meatal antrostomy and to explore the financial implications of using multiple disposable instruments for this procedure.Eight cadaver maxillary sinuses configured with image guidance software were evaluated. In each sinus, a standard middle meatal antrostomy was created, through which curved microdebriders of 15, 40, 70, and 120° were placed. The SA and volume of the region accessible by each microdebrider tip was calculated.Mean maxillary sinus volume was 16.5 ± 2.5 cm(3) and mean SA was 31.0 ± 2.3 cm(2). The 15, 40, 70 and 120° microdebriders accessed an average of 10, 25, 41, and 66%, respectively, of the SA, and of 2, 9, 17, and 36%, respectively, of the volume. There was a trend toward improved accessibility of the superior half versus the inferior half of the maxillary sinus. When instruments of different degrees were combined to maximize accessibility, 81% of the SA of the sinus could be accessed.Microdebriders with increasing curvatures allowed for greater access of the maxillary sinus mucosa through an middle meatal antrostomy. No single microdebrider curvature or combination of curvatures reached the entirety of the maxillary sinus wall. Knowledge about the area of reach for these blades can lead to lower per procedure costs.
View details for DOI 10.2500/ajra.2015.29.4203
View details for Web of Science ID 000364337200023
View details for PubMedID 26358354
Audiologic impairment associated with bilirubin-induced neurologic damage.
Seminars in fetal & neonatal medicine
2015; 20 (1): 42-46
Hyperbilirubinemia occurs commonly in neonates and is usually mild and transient, with no long-lasting sequelae. However, bilirubin-induced neurologic damage may occur in some infants. The auditory pathway is the most sensitive part of the central nervous system to bilirubin-induced toxicity, and permanent sequelae may result from only moderately elevated total serum/plasma bilirubin levels. The damage to the auditory system occurs primarily within the brainstem and cranial nerve VIII, and manifests clinically as auditory neuropathy spectrum disorder.
View details for DOI 10.1016/j.siny.2014.12.006
View details for PubMedID 25575899
View details for PubMedCentralID PMC4314954
Auditory cortex activation to natural speech and simulated cochlear implant speech measured with functional near-infrared spectroscopy.
2014; 309: 84-93
The primary goal of most cochlear implant procedures is to improve a patient's ability to discriminate speech. To accomplish this, cochlear implants are programmed so as to maximize speech understanding. However, programming a cochlear implant can be an iterative, labor-intensive process that takes place over months. In this study, we sought to determine whether functional near-infrared spectroscopy (fNIRS), a non-invasive neuroimaging method which is safe to use repeatedly and for extended periods of time, can provide an objective measure of whether a subject is hearing normal speech or distorted speech. We used a 140 channel fNIRS system to measure activation within the auditory cortex in 19 normal hearing subjects while they listed to speech with different levels of intelligibility. Custom software was developed to analyze the data and compute topographic maps from the measured changes in oxyhemoglobin and deoxyhemoglobin concentration. Normal speech reliably evoked the strongest responses within the auditory cortex. Distorted speech produced less region-specific cortical activation. Environmental sounds were used as a control, and they produced the least cortical activation. These data collected using fNIRS are consistent with the fMRI literature and thus demonstrate the feasibility of using this technique to objectively detect differences in cortical responses to speech of different intelligibility.
View details for DOI 10.1016/j.heares.2013.11.007
View details for PubMedID 24342740
View details for PubMedCentralID PMC3939048