A sustainable method to reduce postoperative oxycodone discharge prescribing in a metropolitan tertiary referral hospital.

The primary objective of this quality improvement project was to measure and reduce the number of oxycodone immediate-release tablets dispensed to overnight stay surgical patients at discharge. The secondary objective was to reduce the proportion of inappropriate oxycodone immediate-release prescriptions at discharge. Interrupted time series analysis was performed in four surgical wards of St Vincent's Public Hospital, Sydney. The baseline period was from January 2005 to August 2013. Interventions and follow-up occurred until July 2017. Baseline audit of oxycodone immediate-release tablet numbers showed prescribing increased significantly with a monthly linear trend of 1.8 (95%CI = 1.4-2.3; p = 0.001) tablets/100 surgical admissions from January 2005 to August 2013. Four sequential interventions produced no significant change in the primary objective. At the end of the first month of a fifth intervention, comprising audit-feedback plus individual academic detailing, the average number of oxycodone tablets decreased by 77 (95%CI 39-115) tablets/100 surgical cases, and the postintervention linear trend was a monthly reduction of 3.2 (coefficient -3.2 (95%CI -4.5 to -1.8); p = 0.001) tablets/100 surgical admissions. Baseline audit showed 27% of oxycodone prescriptions to be inappropriate. Following our intervention, this dropped to 17% (p = 0.048), and then to 10% (p = 0.002) after 3 years.

Outpatient anterior cervical discectomy and fusion for cervical disk disease: a prospective consecutive series of 96 patients.

OBJECTIVES: To evaluate surgical complications and clinical outcome in a consecutive series of 96 patients undergoing anterior cervical discectomy and fusion (ACDF) for cervical disk degeneration (CDD) in an outpatient setting. METHODS: Pre-, per-, and postoperative data on patients undergoing single- or two-level outpatient ACDF at the private Oslofjord Clinic were prospectively collected. RESULTS: This study includes 96 consecutive patients with a mean age of 49.1 years. 36/96 had a two-level ACDF. Mean postoperative observation time before discharge was 350 min, and 95/96 were successfully discharged either to their home or to a hotel on the day of surgery. The surgical mortality was 0%, while the surgical morbidity rate was 5.2%. Two (2.1%) patients developed postoperative hematoma, 2 (2.1%) patients experienced postoperative dysphagia, and 1 (1%) experienced deterioration of neurological function. Radicular pain, neck pain, and headache decreased significantly after surgery. 91% of patients were satisfied with the surgery, according to the NASSQ. CONCLUSION: ACDF in carefully selected patients with CDD appears to be safe in the outpatient setting, provided a sufficient postoperative observation period. The clinical outcome and patient satisfaction of outpatients are comparable to that of inpatients.

Surgical mortality and complications leading to reoperation in 318 consecutive posterior decompressions for cervical spondylotic myelopathy.

OBJECTIVE: To determine surgical mortality, incidence of surgery-related neurological deterioration and incidence of postoperative infection or hematoma requiring reoperation in a consecutive series of 318 patients surgically treated with laminectomy or laminoplasty for cervical spondylotic myelopathy (CSM). MATERIALS AND METHODS: This is a retrospective study of 318 consecutive patients treated with laminectomy or laminoplasty for CSM at Oslo University Hospital in the time period 2003-2008. The defined neurosurgical catchment area for OUS is the southeast region of Norway with 2.7 mill inhabitants. The patient charts were systematically reviewed, focusing primarily on operative notes, postoperative (po) complications, such as po deterioration of neurological function, po hematoma and po infection and neurological function at most recent follow-up. RESULTS: The mean age was 64 years (range 29-90 years). Laminectomy was performed in 310/318 (97.5%) and laminoplasty in 8/318 (2.5%) of the patients. The incidence of laminectomy/laminoplasty for CSM was 2.0/100,000 inhabitants per year. The surgical mortality was 0%, and 37 (11.6%) patients had a deterioration of neurological function in the immediate postoperative period. Four (1.3%) patients were reoperated because of po hematoma. We found a statistically significant association between po hematoma and previous posterior neck surgery and American Association of Anaesthetists (ASA) score. Five (1.6%) patients were reoperated because of postoperative infection. Univariate logistic regression analysis showed a statistically significant association between po infection and the number of levels decompressed. CONCLUSIONS: The incidence of laminectomy/laminoplasty for CSM is 2.0/100,000 inhabitants per year. Surgical mortality, postoperative hematoma and postoperative infection are rare complications of laminectomy/laminoplasty for CSM. Neurological deterioration is not an uncommon complication after posterior decompression for CSM.

Childhood cardiac function after twin-to-twin transfusion syndrome--a 10-year follow up.

AIM: To perform a 10-year follow up of cardiac structure and function after twin-to-twin transfusion syndrome (TTTS)--a severe foetal circulatory complication associated with myocardial hypertrophy in the recipient twin. METHODS: Cardiac dimensions, systolic and diastolic function as assessed by echocardiography including flow and tissue Doppler velocimetry in 22 healthy survivors of TTTS with a mean age of 9.6 (7.2-11.8) years. RESULTS: The donor and recipient twin did not show any differences in end-diastolic ventricular size, interventricular septum thickness, diameter of right ventricular outflow tract, cardiac valves, coronary arteries or in systolic blood flow velocities. However, compared with the donors, the recipients had significantly lower E/A ratios because of lower E-waves in both mitral (-0.15 +/- 0.10, p < 0.01) and tricuspid (-0.09 +/- 0.07, p < 0.01) valves, indicating reduced early diastolic ventricular fillings compared with donors. CONCLUSION: At school age, twins surviving TTTS had a cardiac structure and function within normal range. There were no differences in heart structure or systolic ventricular function between twins but, compared with the donor twin, we found a reduced early diastolic function in the recipient.

Discordant twin growth in utero and differences in blood pressure and endothelial function at 8 years of age.

OBJECTIVE: Low birth weight is associated with increased prevalence of hypertension and cardiovascular disease in adults. The aim of this study was to evaluate genetic and intrauterine environmental contributions to blood pressure (BP) and vascular functions in twins with discordant growth in utero. SUBJECTS: We studied 31 twin pairs (21 monozygous and nine dizygous), mean age 8 years) with large within-pair differences in birth weight. Among the monozygous pairs, nine had suffered from twin-to-twin-transfusion syndrome (TTTS). METHODS: Apart from BP, we determined diameters and elasticity of the carotid artery and abdominal aorta with ultrasonography, and endothelial function in skin vessels with a laser Doppler technique, before and after transdermal delivery of acetylcholine and nitroglycerin. RESULTS: Eight of 62 twin subjects had a systolic BP above the 90th percentile in a North-American reference population. Among these, seven/eight were monozygous with a history of poor fetal growth and/or TTTS. In monozygous twin pairs without TTTS, systolic BP and pulse pressure were higher and vascular endothelial function was impaired in the lower birth weight twin. In the TTTS group, the lighter twin had a narrower carotid artery but there was no within-pair difference in arterial elasticity. Pre-eclampsia during the index pregnancy enhanced within-pair differences in BP but abolished within-pair differences in endothelial function. CONCLUSIONS: Severe fetal growth retardation contributes to higher BP, arterial narrowing and endothelial dysfunction in childhood. Pre-eclampsia may act both as an effect modifier and confounder of these associations.

Intracerebral abscess caused by Nocardia otitidiscaviarum in a renal transplant patient--cured by evacuation plus antibiotic therapy.

We present a 50-year-old female who experienced generalized convulsion 3 months after a successful cadaveric renal transplantation. The first cerebral CT scan indicated cerebral frontal infarction. Repeat CT some days later revealed progressive lesions, and a highly malignant tumor or abscess was suspected. Antifungal and broad-spectrum antibacterial therapy was initiated. Cerebral MRI could not differentiate between these conditions, but a neutrophil granulocyte scan strongly suggested an infectious process. A stereotactic puncture of the frontal lobe was followed by temporary improvement. A severe progressive left-sided hemiparalysis gave indication for a craniotomy with evacuation of the abscess 9 days later. Culture of aspirated pus yielded growth of a gram-positive, rod-shaped bacterium, later identified as Nocardia otitidiscaviarum by sequencing the 16S rRNA. The patient was treated with meropenem plus rifampicin intravenously for 6 weeks followed by oral ciprofloxacin and rifampicin for 2 months. Due to pharmacokinetic interaction with rifampicin, the prednisolone dose was doubled, and the dose of tacrolimus had to be tripled for maintenance of adequate trough concentrations. Five months following cessation of antibiotic treatment, the patient has regained normal strength and function in her left-sided extremities and has a serum creatinine level of about 160 micromol/l (1.8 mg/dl).