Osteopathic Manipulative Treatment During Post-operative Recovery: A Scoping Review.

Surgery is a common and often necessary treatment option for a wide range of medical conditions, with an estimated 40 to 50 million surgeries performed in the US alone each year. While the various types of surgeries performed may be effective in treating or managing different conditions, the post-operative period can be challenging for patients. Osteopathic manipulative treatment (OMT) is a hands-on approach to medical care that seeks to restore balance and harmony to the body from the lens of an interconnected mind, body, and spirit. Given the potential for adverse events in patients following surgical treatments, OMT may be a viable adjunct post-operatively to enhance patient care and recovery. The purpose of this scoping review is to evaluate the state of current research examining the effectiveness of OMT in improving outcomes in post-operative patients. Three hundred articles were collected; 53 duplicates were removed. Eleven independent reviewers evaluated all 247 articles. Thirty articles were identified, including nine in general surgery, six in cardiothoracic surgery, five in orthopedic surgery, four in spinal surgery, three in neurosurgery, and three others (otolaryngology, oral/maxillofacial, and gynecologic surgery). Post-operative patients were treated with various OMT techniques with myofascial release and muscle energy being some of the most common treatments utilized in all surgical fields. Many studies demonstrated the benefits of OMT usage including significant pain relief, improved and earlier bowel function, and decreased lengths of hospital stay. This study demonstrates how OMT can be effective in reducing post-operative pain, reducing the incidence of post-operative ileus, and shortening the length of stay. Further research into the utilization of OMT in post-operative patients should be considered a potential adjunct to surgical intervention, especially in vulnerable patient populations.

The Contralateral Repeated Bout Effect of Elbow Flexors Is Not Observed in Young Women Following Mild Muscle Damage from Eccentric Exercises.

Investigation of the contralateral repeated bout effect (CL-RBE) in women is scarce. Therefore, this study aimed at examining whether CL-RBE exists in women. Twelve healthy women (age: 20.9 ± 2.5 years) performed two bouts of maximal elbow flexor eccentric exercise (3 sets × 15 repetitions per bout) separated by 14 days, using the opposite arms. Surface Electromyography (EMG) was recorded during both exercise bouts. The isokinetic muscle strength (60°/s), muscle soreness, range of motion (ROM), limb girth, and blood creatine kinase activity were measured pre-exercise, and at 24 and 48 h post-exercise with the muscle strength being measured immediately post-exercise as well. Significant main effects of time were observed for muscle strength, muscle soreness and ROM (p < 0.05). There were no significant differences between bouts for all the measured variables including the EMG median frequency (p > 0.05). These results suggest that the CL-RBE of elbow flexors was not evident in young healthy women. This was because the mild muscle damage induced by the initial bout of exercise was either not enough to initiate the CL-RBE or the CL-RBE in women lasted shorter than two weeks. This study provides important information for future studies on CL-RBE in women.

Valve-Sparing Aortic Root Replacement Technique: Valsalva Graft versus Two Straight Tubular Grafts.

Background: There are many variations in valve-sparing aortic root replacement techniques. Our aim is to determine the impact of the graft on mid-term outcomes: Valsalva graft vs. two straight tubular grafts. Methods: From 2004 to 2020, 332 patients underwent valve-sparing aortic root replacement with either a Valsalva graft (Valsalva group: n = 270) or two straight tubular grafts (two-graft group: n = 62). Data were obtained through chart review and the National Death Index. Primary outcomes were mid-term survival and freedom from reoperation. Results: The preoperative characteristics of the groups were similar, but the two-graft group had more type A dissections (32% vs. 19%) and emergent operations (26% vs. 15%) and was younger (45 vs. 50 years). Intraoperatively, the groups were similar, but the two-graft group had longer cross-clamp (245 vs. 215 minutes) and cardiopulmonary bypass times (284 vs. 255 minutes). Postoperative complications including reoperation for bleeding, stroke, pacemaker implantation, and renal failure were slightly more frequent in the Valsalva group, but the differences were not significant. Operative mortality was similar between the Valsalva and two-graft groups (0.7% vs. 0%). Five-year survival in the two-graft group was 100% compared to 96% in the Valsalva group (p=0.56). Five-year freedom from reoperation in the two-graft group was 100% compared to 93% in the Valsalva group (p=0.29). Conclusions: The Valsalva and two-graft techniques both have excellent short- and mid-term outcomes. The two-graft technique might have slightly better survival and freedom from reoperation, but a larger sample size and longer follow-up are needed to determine if these advantages are significant.

The Impact of Nonpharmacological Interventions on Patient Experience, Opioid Use, and Health Care Utilization in Adult Cardiac Surgery Patients: Protocol for a Mixed Methods Study.

BACKGROUND: Despite pharmacological treatments, patients undergoing cardiac surgery experience severe anxiety and pain, which adversely affect outcomes. Previous work examining pediatric and nonsurgical adult patients has documented the effectiveness of inexpensive, nonpharmacological techniques to reduce anxiety and pain as well as health care costs and length of hospitalization. However, the impact of nonpharmacological interventions administered by a dedicated comfort coach has not been evaluated in an adult surgical setting. OBJECTIVE: This trial aims to assess whether nonpharmacological interventions administered by a trained comfort coach affect patient experience, opioid use, and health care utilization compared with usual care in adult cardiac surgery patients. This study has 3 specific aims: assess the effect of a comfort coach on patient experience, measure differences in inpatient and outpatient opioid use and postoperative health care utilization, and qualitatively evaluate the comfort coach intervention. METHODS: To address these aims, we will perform a prospective, randomized controlled trial of 154 adult cardiac surgery patients at Michigan Medicine. Opioid-naive patients undergoing first-time, elective cardiac surgery via sternotomy will be randomized to undergo targeted interventions from a comfort coach (intervention) versus usual care (control). The individualized comfort coach interventions will be administered at 6 points: preoperative outpatient clinic, preoperative care unit on the day of surgery, extubation, chest tube removal, hospital discharge, and 30-day clinic follow-up. To address aim 1, we will examine the effect of a comfort coach on perioperative anxiety, self-reported pain, functional status, and patient satisfaction through validated surveys administered at preoperative outpatient clinic, discharge, 30-day follow-up, and 90-day follow-up. For aim 2, we will record inpatient opioid use and collect postdischarge opioid use and pain-related outcomes through an 11-item questionnaire administered at the 30-day follow-up. Hospital length of stay, readmission, number of days in an extended care facility, emergency room, urgent care, and an unplanned doctor's office visit will be recorded as the primary composite endpoint defined as total days spent at home within the first 30 days after surgery. For aim 3, we will perform semistructured interviews with patients in the intervention arm to understand the comfort coach intervention through a thematic analysis. RESULTS: This trial, funded by Blue Cross Blue Shield of Michigan Foundation in 2019, is presently enrolling patients with anticipated manuscript submissions from our primary aims targeted for the end of 2020. CONCLUSIONS: Data generated from this mixed methods study will highlight effective nonpharmacological techniques and support a multidisciplinary approach to perioperative care during the adult cardiac surgery patient experience. This study's findings may serve as the foundation for a subsequent multicenter trial and broader dissemination of these techniques to other types of surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT04051021; https://clinicaltrials.gov/ct2/show/NCT04051021. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/21350.

Stentless valves for bicuspid and tricuspid aortic valve disease.

Objective: To determine long-term survival and reoperation rate in patients with a bicuspid aortic valve (BAV) and patients with a tricuspid aortic valve (TAV) after stentless aortic valve replacement (AVR)/aortic root replacement (ARR). Methods: Between 1992 and 2014, 1293 patients underwent first AVR/ARR with a stentless aortic valve using the modified inclusion operating technique, including 741 patients with a TAV and 552 with a BAV. Using propensity scoring with 26 variables, 330 matched pairs were identified with AVR with or without ascending aorta/arch replacement. Data were obtained through chart review, surveys, and the National Death Index. Results: Patient demographics were similar in the propensity score-matched groups. Both groups had similar cardiopulmonary bypass, cross-clamp, and hypothermia circulatory arrest times, cerebral protection strategies, and rate of aortic arch replacement. The median size of implanted valves was similar (BAV: 27 mm [range, 25-29 mm] vs TAV: 27 mm [range, 25-27 mm]). Compared with the TAV group, the BAV group had a shorter hospital stay (6 days vs 7 days; P = .001) but similar 30-day mortality (1.8% vs 1.2%). The BAV group had better long-term (15-year) survival (46% vs 33%; P = .002) but a higher cumulative incidence of reoperation for structural valve deterioration (15-year: 15% vs 11%; P = .048). Cox proportional hazard analysis identified a BAV as a protective factor for long-term mortality (hazard ratio [HR], 0.71; 95% CI, 0.56-0.91; P = .006), but a risk factor for reoperation due to structural valve deterioration (HR, 1.4 [95% CI, 0.8-2.6; P = .27] in the matched cohort and 2.2 [95% CI, 1.3-3.7; P = .004] in the unmatched cohort). Conclusions: The BAV patients had better long-term survival but a higher reoperation rate compared with TAV patients after stentless AVR. Our findings suggest caution in the use of bioprostheses for BAV patients.

Root abscess in the setting of infectious endocarditis: Short- and long-term outcomes.

OBJECTIVES: To evaluate the influence of an aortic root abscess on perioperative outcomes and long-term survival in patients with active infectious endocarditis that was treated surgically. METHODS: From 1996 to 2017, 336 consecutive patients were treated with aortic valve or root replacement for infective endocarditis, including patients with (n = 179) or without (n = 157) a root abscess. Data were obtained from the Society of Thoracic Surgeons data warehouse, through chart review, patient surveys, and National Death Index data. RESULTS: Demographic characteristics were similar between groups except the root abscess group had a significantly lower prevalence of congestive heart failure and higher rates of prosthetic valve endocarditis. The abscess group had significantly more aortic root replacements as well as longer cardiopulmonary bypass and crossclamp times. Operative mortality was 8.4% and 3.8% (P = .11) for the abscess and no abscess groups, respectively. Nevertheless, the root-abscess group had prolonged ventilation and longer intensive care unit stays. Kaplan-Meier survival was similar between root abscess and no abscess groups (10-year survival 41% vs 43%; P = .35). Significant risk factors for all-time mortality included age greater than 70 (hazard ratio [HR], 2.85; 95% confidence interval [CI], 1.55, 5.24), the presence of a root abscess (HR, 1.42; 95% CI, 1.02, 1.96), intravenous drug use (HR, 1.81; 95% CI, 1.13, 2.89), congestive heart failure (HR, 1.72; 95% CI, 1.22, 2.42), renal failure requiring dialysis (HR, 3.26; 95% CI, 2.30, 4.64), liver disease (HR, 3.04; 95% CI, 1.65, 5.60), and postoperative sepsis (HR, 3.00; 95% CI, 1.30, 6.93). The 10-year rate of reoperation was also similar between groups (5.9% vs 7.9%). CONCLUSIONS: Thorough and extensive debridement is critical for successful treatment of active endocarditis with root abscess. Bioprosthetic stented and stentless valves are valid conduits to treat endocarditis with root abscess.