Effect of Prescription Size on Opioid Use and Patient Satisfaction After Minor Hand Surgery: A Randomized Clinical Trial.

OBJECTIVE: To determine the influence of initial prescription size on opioid consumption after minor hand surgeries. Secondary outcomes include efficacy of pain control, patient satisfaction, and refill requests. BACKGROUND: Retrospective studies have shown that opioid prescriptions for acute pain after surgical procedures are often excessive in size, which encourages misuse. This is the first prospective randomized trial on the influence of initial prescription size on opioid consumption in the setting of acute postsurgical pain. METHODS: In a prospective randomized trial at a single-academic institution, patients were provided an initial prescription of either 10 or 30 hydrocodone/acetaminophen (5/325 mg) pills after surgery. Two hundred opioid-naive patients, aged 19 to 69, undergoing elective outpatient minor hand surgeries were enrolled over 9 months, with a follow-up period of 10 to 14 days. RESULTS: One hundred seventy-four patients were included in this analysis. Patients initially prescribed 30 pills (n = 79), when compared with patients initially prescribed 10 pills (n = 95), used significantly more opioid (P = <0.001, mean 11.9 vs 6.4 pills), had significantly more leftover medication (P = <0.001, mean 20.0 vs 5.2 pills), and were over 3 times more likely to still be taking opioid at follow-up (15% vs 4%). There was no significant difference in refills requested, or in patient satisfaction with postoperative pain control. CONCLUSIONS: Providing large opioid prescriptions for the management of acute pain after minor upper extremity surgeries increases overall opioid use when compared with smaller initial prescriptions. The size of initial opioid prescription is a modifiable variable that should be considered both in patient care and research design.

Increased complication rate in obese patients undergoing laparoscopic adrenalectomy.

OBJECTIVES: Laparoscopic adrenalectomy has become the standard of care for resection of adrenal masses, with extremely low morbidity and mortality. This study investigates the difference in outcomes in patients who underwent laparoscopic adrenalectomy, comparing obese with healthy weight patients. METHODS: A retrospective chart review was performed on patients undergoing laparoscopic adrenalectomy between January 2000 and February 2010. Intraoperative and postoperative complications in the patients were compared. A patient with a body mass index >30kg/m(2) was considered obese. RESULTS: Eighty patients underwent laparoscopic adrenalectomy between January 2000 and February 2010. Forty-nine patients (61%) were considered obese based on the body mass index criteria. Operative time, estimated blood loss, and length of stay did not differ significantly between the 2 cohort groups. There was no 30-day mortality in the population. There were 9 complications in the obese population and no complications in the healthy weight population (P<.011). Four obese patients had intraoperative complications, and 5 obese patients had postoperative morbidity. CONCLUSIONS: A significant increase occurred in intraoperative and postoperative complications for obese individuals undergoing laparoscopic adrenalectomy compared with healthy weight individuals. However, high body mass index should not preclude elective laparoscopic adrenalectomy.

Preoperative weight loss before bariatric surgery.

HYPOTHESIS: Preoperative weight loss reduces the frequency of surgical complications in patients undergoing bariatric surgery. DESIGN: Review of records of patients undergoing open or laparoscopic gastric bypass. SETTING: A comprehensive, multidisciplinary obesity treatment center at a tertiary referral center that serves central Pennsylvania. PATIENTS: A total of 881 patients undergoing open or laparoscopic gastric bypass from May 31, 2002, through February 24, 2006. INTERVENTION: All preoperative patients completed a 6-month multidisciplinary program that encouraged a 10% preoperative weight loss. MAIN OUTCOME MEASURES: Loss of excess body weight (EBW) and total and major complication rates. RESULTS: Of the 881 patients, 592 (67.2%) lost 5% or more EBW and 423 (48.0%) lost more than 10% EBW. Patients referred for open gastric bypass (n = 466) were generally older (P < .001), had a higher body mass index (P < .001), and were more often men (P < .001) than those undergoing laparoscopic gastric bypass (n = 415). Total and major complication rates were higher in patients undergoing open gastric bypass (P < .001 and P = .03, respectively). Univariate analysis revealed that increasing preoperative weight loss is associated with reduced complication frequencies for the entire group for total complications (P =.004) and most likely for major complications (P = .06). Controlling for age, sex, baseline body mass index, and type of surgery in a multiple logistic regression model, increased preoperative weight loss was a predictor of reduced complications for any (P =.004) and major (P = .03) complications. CONCLUSION: Preoperative weight loss is associated with fewer complications after gastric bypass surgery.

Role of Radiation-induced TGF-beta Signaling in Cancer Therapy.

TGF-ß signaling regulates several different biological processes involving cell-growth, differentiation, apoptosis, motility, angiogenesis, epithelial mesenchymal transition and extracellular matrix production that affects embryonic development and pathogenesis of various diseases, including cancer, its effects depending on the cellular context and physiological environment. Growth suppression mediated by TGF-ß signaling often associated with inhibition of c-myc, cdks and induction of p15, p27, Bax and p21. Despite its growth inhibitory effect, in certain conditions TGF-ß may act as a promoter of cell proliferation and invasion. Loss of responsiveness to growth suppression by TGF-ß due to mutation or loss of TGF-beta type II receptor (TßRII) and Smad4 in several different cancer cells are reported. In addition, TGF-ß binding to its receptor activates many non-canonical signaling pathways. Radiation induced TGF-ß is primarily involved in normal tissue injury and fibrosis. Seminal studies from our group have used radio-adjuvant therapies, involving classical components of the pathway such as TßRII and SMAD4 to overcome the growth promoting effects of TGF-ß. The main impediment in the radiation-induced TGF-ß signaling is the induction of SMAD7 that blocks TGF-ß signaling in a negative feedback manner. It is well demonstrated from our studies that the use of neutralizing antibodies against TGF- ß can render a robust radio-resistant effect. Thus, understanding the functional interactions of TGF-ß signaling components of the pathway with other molecules may help tailor appropriate adjuvant radio-therapeutic strategies for treatment of solid tumors.

A noncommercial polymerase chain reaction-based method to approach one hundred percent recombinant clone selection efficiency.

Molecular cloning is an important procedure in molecular biology, but this is often a rate-limiting step and can be very time-consuming, possibly due to low ligation efficiency. Here, we describe a simple polymerase chain reaction (PCR)-based strategy to approach 100% selection efficiency. The post-ligation mixture containing the recombinant was subjected to insert-specific primer-mediated PCR amplification using a high-fidelity DNA Pfu polymerase generating a plasmid containing staggered nicks. The PCR mixture was then digested with endonuclease DpnI, which digests the methylated and hemimethylated parental DNA template. The nicked vector was transformed into XL1 blue supercompetent cells where the nicks were repaired, thus amplifying and selecting only the newly amplified recombinant clones.