A Virtual Tumor Board Platform: A Way to Enhance Decision-Making for Complex Malignancies.

INTRODUCTION: Multidisciplinary tumor boards (TBs) are crucial for decision-making and management of patients diagnosed with complex malignancies. The social distancing conditions imposed by coronavirus disease 2019 presented an opportunity to compare virtual versus in-person TBs. METHODS: A retrospective analysis of attendance data from an National Cancer Institute-designated cancer center's gastrointestinal (GI) TB participant data from September 2019 to October 2020. In addition, an online survey assessing the virtual TB experience was sent to participants of all TBs. Interrupted time series analyses were performed to evaluate preintervention and postintervention GI TB attendance only. RESULTS: The overall mean attendance for GI TB was 30 participants; turnout was higher for virtual format compared to in-person (32 versus 23 attendees, P < 0.001). This increase was seen across all participant categories: attending physicians (15 versus 11 attendees, P < 0.001), trainees (11 versus 8, P < 0.001), and support staff (6 versus 3, P < 0.001). There was no significant difference in the mean number of cases discussed between TB formats. The majority of the 141 survey respondents (across all TB) were attending physicians with >20-year experience. Most supported a permanent virtual or hybrid TB format, 72.5% found this format to be more time efficient and with similar productivity, and 85.8% found it easier to attend. The majority (89.9%) felt confident that the decision-making process was not affected by virtual interactions. CONCLUSIONS: A virtual platform for multispecialty TBs allows for greater attendance without sacrificing the decision-making process. This survey supports continuing with a virtual or hybrid format, which may increase attendance and facilitate access to multidisciplinary discussions leading to improved patient care.

Real-world frequency of BRAF testing and utilization of therapies in patients with advanced melanoma.

Both BRAF/MEK targeted agents and immunotherapy are approved for the treatment of advanced melanoma. BRAF testing is recommended at the time of advanced melanoma diagnosis. In addition, little is known regarding the treatment trends for patients with BRAF mutated tumors. This investigation aims to assess the real-world prevalence of molecular testing and treatment trends for patients with BRAF mutated tumors. Using a de-identified database, patients of age ≥18 years with advanced melanoma from 2013 to 2018 were examined. Molecular testing performed within 3 months of advanced diagnosis was considered to have the test performed at the time of diagnosis. Test prevalence was calculated and compared in groups stratified by the patient, tumor and treatment factors. In total 4459 patients were included; 1936 (43.4%) stage III, 1191 (26.7%) stage IV and 1332 (29.9%) recurrent. Totally 50.4% of patients received systemic treatment; 76.4% stage IV, 71% recurrent patients and 26.7% stage III patients. However, 73.5% received first-line immunotherapy. In total 73.8% of patients had molecular testing, and 50.5% had tested at the time of advanced diagnosis. Of those tested 42% had a BRAF mutated tumor. In total 48% of these patients received first-line immunotherapy whereas 43% received a BRAF inhibitor, with increasing immunotherapy use seen over time. The majority of patients with advanced melanoma undergo molecular testing at the time of advanced diagnosis. Immunotherapy is the most commonly prescribed treatment regardless of BRAF mutational status. These results provide real-world data on the frequency of molecular testing and treatment trends for patients with advanced melanoma.

Tumor mutational burden and somatic mutation status to predict disease recurrence in advanced melanoma.

Tumor mutational burden (TMB) has recently been identified as a biomarker of response to immune checkpoint inhibitors in many cancers, including melanoma. Co-assessment of TMB with inflammatory markers and genetic mutations may better predict disease outcomes. The goal of this study was to evaluate the potential for TMB and somatic mutations in combination to predict the recurrence of disease in advanced melanoma. A retrospective review of 85 patients with stage III or IV melanoma whose tumors were analyzed by next-generation sequencing was conducted. Fisher's exact test was used to assess differences in TMB category by somatic mutation status as well as recurrence locations. Kaplan-Meier estimates and Cox-proportional regression model were used for survival analyses. The most frequently detected mutations were TERT (32.9%), CDKN2A (28.2%), KMT2 (25.9%), BRAF V600E (24.7%), and NRAS (24.7%). Patients with TMB-L + BRAFWT status were more likely to have a recurrence [hazard ratio (HR), 3.43; confidence interval (CI), 1.29-9.15; P = 0.01] compared to TMB-H + BRAF WT. Patients with TMB-L + NRASmut were more likely to have a recurrence (HR, 5.29; 95% CI, 1.44-19.45; P = 0.01) compared to TMB-H + NRAS WT. TMB-L tumors were associated with local (P = 0.029) and in-transit (P = 0.004) recurrences. Analysis of TMB alone may be insufficient in understanding the relationship between melanoma's molecular profile and the body's immune system. Classification into BRAFmut, NRASmut, and tumor mutational load groups may aid in identifying patients who are more likely to have disease recurrence in advanced melanoma.

Total neoadjuvant therapy for pancreatic adenocarcinoma increases probability for a complete pathologic response.

BACKGROUND: Multiple neoadjuvant therapy protocols have been proposed in the treatment of pancreatic adenocarcinoma, including chemotherapy (CT), chemoradiation (CRT), and total neoadjuvant therapy (TNT), defined as a CT plus CRT. A pathologic complete response (pCR) can be achieved in a minority of cases. We hypothesize that TNT is more likely to confer pCR than other neoadjuvant therapies, which may improve overall survival (OS). METHODS: A retrospective review of the National Cancer Database (NCDB) from 2006 to 2016 was performed, identifying patients who underwent any neoadjuvant therapy followed by definitive pancreatic resection for locally advanced or borderline resectable pancreatic adenocarcinoma. A pathologic complete response was defined as down-staging from any clinical stage to pathologic stage 0. RESULTS: A total of 5402 patients who received neoadjuvant therapy followed by resection were identified. 177 patients (3.3%) achieved a pCR. Of the patients who achieved a pCR, 57 received CT, 41 CRT and 79 received TNT. On multivariate analysis, TNT was more likely to confer a pCR than CRT (OR 1.67, CI 1.13-2.46, p = 0.0103) or CT (OR 2.61, CI 1.83-3.71, p < 0.0001). Patients who achieved pCR had a significantly higher OS, with median survival of 64.9 months, compared to 21.6 months in patients who did not achieve pCR (p < 0.0001). CONCLUSION: TNT may be more likely to achieve a pCR than CT or CRT. Patients who achieve a pCR have a significant OS benefit as compared to those who have residual disease. TNT should be considered for patients requiring neoadjuvant therapy, as it may increase the likelihood of achieving a pCR, thus potentially improving OS.

A tool to predict disparities in the timeliness of surgical treatment for breast cancer patients in the USA.

PURPOSE: Breast cancer outcomes are impaired by both delays and disparities in treatment. This study was performed to assess their relationship and to provide a tool to predict patient socioeconomic factors associated with risk for delay. METHODS: The National Cancer Database was reviewed between 2004 and 2017 for patients with non-metastatic breast cancer managed with upfront surgery. Times to treatment were measured from the date of diagnosis. Patient, tumor, and treatment factors were assessed with attention paid to sociodemographic variables. RESULTS: 514,187 patients remained after exclusions, with 84.3% White, 10.8% Black, 3.7% Asian, and Hispanics comprising 5.6% of the cohort. Medicaid and uninsured patients had longer mean adjusted time to surgery (≥ 46 days) versus private (36.7 days), Medicare (35.9 days), or other governmental insurance (39.8 days). After adjustment, Black race and Hispanic ethnicity were most impactful, adding 6.0 and 6.4 preoperative days, 10.9 and 11.5 days to chemotherapy, 11.1 and 9.1 days to radiation, and 12.5 and 8.9 days to endocrine therapy, respectively. Income, education, and insurance, among other factors, also affected delay. A nomogram, including race and sociodemographic factors, was created to predict the risk of preoperative delay. CONCLUSION:  Significant disparities exist in timeliness of care for factors, including but not limited to, race and ethnicity. Although exact causes cannot be discerned, these data indicate population subsets whose intervals of care risk being longer than those specified by national quality standards. The nomogram created here may help direct resources to those at highest risk of incurring a treatment delay.

Harnessing choice architecture in urologic practice: Implementation of an opioid-sparing protocol grounded in cognitive behavioral theory.

PURPOSE: Opioids are prescribed excessively following surgery. As many urologic oncology procedures are performed minimally invasively, an opportunity exists to push forward initiatives to minimize postoperative opioid use. MATERIALS AND METHODS: A quality improvement initiative to reduce inpatient opioid prescribing was launched at a tertiary cancer center. In Phase I (December 2019-July 2020), providers were instructed to start standing acetaminophen. In Phase II (beginning August 2020), education was provided to the entire care team and ordersets were modified to an opioid sparing protocol (OSP). We analyzed the proportion of minimally invasive surgery (MIS) prostatectomy and nephrectomy patients that adhered to an OSP during each phase and compared them to controls from the preceding 2 years. RESULTS: A total of 303, 153, and 839 patients underwent MIS during the Phase I, Phase II, and control periods respectively. The proportion of patients adhering to an OSP increased from 16% at the beginning of Phase I to 76% at the end of Phase II (p-trend < 0.001). The median total oral morphine equivalents for oral opioids declined from 20 mg and 40 mg at baseline for prostatectomy and nephrectomy patients respectively to 0 mg for both groups (p-trends < 0.001). Multivariable analysis found that patients received 22% and 81% less oral morphine equivalents during Phase I and II respectively compared to the control period (P < 0.001). CONCLUSIONS: Adherence to an OSP is most effective when initiatives incorporate the entire team and are supported by nudge theory-based structural changes. Using these strategies, most patients following urologic MIS can dramatically reduce opioid use postoperatively.

Neoadjuvant Endocrine Therapy and Delays in Surgery for Ductal Carcinoma in Situ: Implications for the Coronavirus Pandemic.

BACKGROUND: Surgical delays are associated with invasive cancer for patients with ductal carcinoma in situ (DCIS). During the Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) pandemic, neoadjuvant endocrine therapy (NET) was used as a bridge until postponed surgeries resumed. This study sought to determine the impact of NET on the rate of invasive cancer for patients with a diagnosis of DCIS who have a surgical delay compared with those not treated with NET. METHODS: Using the National Cancer Database, the study identified women with hormone receptor-positive (HR+) DCIS. The presence of invasion on final pathology was evaluated after stratifying by receipt of NET and by intervals based on time from diagnosis to surgery (≤30, 31-60, 61-90, 91-120, or 121-365 days). RESULTS: Of 109,990 women identified with HR+ DCIS, 276 (0.3%) underwent NET. The mean duration of NET was 74.4 days. The overall unadjusted rate of invasive cancer was similar between those who received NET ((15.6%) and those who did not (12.3%) (p = 0.10). In the multivariable analysis, neither the use nor the duration of NET were independently associated with invasion, but the trend across time-to-surgery categories demonstrated a higher rate of upgrade to invasive cancer in the no-NET group (p < 0.001), but not in the NET group (p = 0.97). CONCLUSIONS: This analysis of a pre-COVID cohort showed evidence for a protective effect of NET in HR+ DCIS against the development of invasive cancer as the preoperative delay increased, although an appropriately powered prospective trial is needed for a definitive answer.

A Retrospective, Observational Analysis of Tumor Infiltrating Lymphocytes and Tumor Regression in Melanoma.

BACKGROUND: Tumor infiltrating lymphocytes (TILs) and regression are thought to be distinct markers of the immune response to melanoma. OBJECTIVE: This study sought to analyze the relationship of TIL grade and presence of regression to each other and to other prognostic histopathologic and clinical values in melanoma. MATERIALS AND METHODS: A retrospective analysis was conducted using patients diagnosed with melanoma between 2013 and 2019 whose complete histopathologic reports were available. RESULTS: Regression was seen in 48.9%, 30.1% and 37.9% of patients with brisk, non-brisk, and absent TILs respectively (P=0.019). Melanoma tumors with brisk TILs were found to have a lower Breslow thickness than those with non-brisk or absent (P= 0.001). Tumors with regression were also found to have lower Breslow thickness (P<0.001). Neither TIL grade nor regression were protective of nodal metastasis or associated with improved survival. CONCLUSION: Brisk TILs have a positive association with thinner tumors and the presence of tumor regression relative to non-brisk or absent TILs. This may suggest a more robust immune response in tumors with brisk TILs. Further exploration of the interplay between TIL grade, lymphocyte cell subtype and lymphocyte density may help explain this finding.

Feasibility of Fitness Tracker Usage to Assess Activity Level and Toxicities in Patients With Colorectal Cancer.

PURPOSE: Performance status (PS) is a subjective assessment of patients' overall health. Quantification of physical activity using a wearable tracker (Fitbit Charge [FC]) may provide an objective measure of patient's overall PS and treatment tolerance. MATERIALS AND METHODS: Patients with colorectal cancer were prospectively enrolled into two cohorts (medical and surgical) and asked to wear FC for 4 days at baseline (start of new chemotherapy [± 4 weeks] or prior to curative resection) and follow-up (4 weeks [± 2 weeks] after initial assessment in medical and postoperative discharge in surgical cohort). Primary end point was feasibility, defined as 75% of patients wearing FC for at least 12 hours/d, 3 of 4 assigned days. Mean steps per day (SPD) were correlated with toxicities of interest (postoperative complication or ≥ grade 3 toxicity). A cutoff of 5,000 SPD was selected to compare outcomes. RESULTS: Eighty patients were accrued over 3 years with 55% males and a median age of 59.5 years. Feasibility end point was met with 68 patients (85%) wearing FC more than predefined duration and majority (91%) finding its use acceptable. The mean SPD count for patients with PS 0 was 6,313, and for those with PS 1, it was 2,925 (122 and 54 active minutes, respectively) (P = .0003). Occurrence of toxicity of interest was lower among patients with SPD > 5,000 (7 of 33, 21%) compared with those with SPD < 5,000 (14 of 43, 32%), although not significant (P = .31). CONCLUSION: Assessment of physical activity with FC is feasible in patients with colorectal cancer and well-accepted. SPD may serve as an adjunct to PS assessment and a possible tool to help predict toxicities, regardless of type of therapy. Future studies incorporating FC can standardize patient assessment and help identify vulnerable population.

Program and candidate experience with virtual interviews for the 2020 Complex General Surgical Oncology interview season during the COVID pandemic.

BACKGROUND: The COVID crisis hit during the interview season for the Complex General Surgical Oncology (CGSO) fellowship. With minimal time to adapt, all programs transitioned to virtual interviews. Here we describe the experience of both program directors (PDs) and candidates with virtual interviews, and provide guidelines for implementation based on the results. METHODS: Surveys regarding interview day specifics and perceptions were created for CGSO fellowship PDs and candidates. They were distributed at the conclusion of the season, prior to match. RESULTS: Thirty (94%) PDs and 64 (79%) candidates responded. Eighty-three% of PDs and 79% of candidates agreed or strongly agreed that they felt comfortable creating a rank list. If given the choice, 60% of PDs and 45% of candidates would choose virtual interviews over in-person interviews. The majority of candidates found PD overviews, fellows only sessions and pre-interview materials helpful. CONCLUSION: Overall, the majority of PDs and candidates felt comfortable creating a rank list; however, more PDs preferred virtual interviews for the future. Our results also confirm key components of a virtual interview day.

A How-To Guide: Virtual Interviews in the Era of Social Distancing.

The coronavirus crisis hit at the beginning of the Complex General Surgical Oncology Fellowship (CGSO) and Breast Oncology Fellowship interview cycles. Within 2 weeks, nearly all programs, including ours, switched to a virtual platform for the remainder of the season. Given that social distancing will remain in place for the foreseeable future, it is possible that all residency and fellowship interviews will need to be conducted virtually. Our methods and shared experience can assist other programs faced with this task for their upcoming interview cycle. We recommend using a virtual meeting platform in which staff have the most comfort; we chose Zoom as our platform. Information on the program traditionally included in the welcome packet, research opportunities, details on the institution, hospital and staff, and detailed interview instructions were distributed prior to the interview day. A virtual "happy hour" was conducted to provide an opportunity for candidates and current trainees to interact. Our virtual interview day schedule mimicked our traditional in person interview day, and we always had a back-up plan for completing the interview if the virtual platform became unstable. While many programs would not choose to perform virtual interviews, we felt that by conducting them in the methods we describe, we were able to closely replicate our traditional interview day and appreciate the candidacy of the applicants.

A leopard never changes its spots: Development of colonic adenocarcinoma in an Indiana Pouch.

Colonic adenocarcinoma of a urinary diversion is rare. We report a case of a 70 year-old woman who developed such a malignancy 12 years after creation of an Indiana pouch urinary diversion for treatment of urothelial carcinoma of the bladder cancer.

A fluorescence-activatable reporter of flavivirus NS2B-NS3 protease activity enables live imaging of infection in single cells and viral plaques.

The genus Flavivirus in the family Flaviviridae comprises many medically important viruses, such as dengue virus (DENV), Zika virus (ZIKV), and yellow fever virus. The quest for therapeutic targets to combat flavivirus infections requires a better understanding of the kinetics of virus-host interactions during infections with native viral strains. However, this is precluded by limitations of current cell-based systems for monitoring flavivirus infection in living cells. In the present study, we report the construction of fluorescence-activatable sensors to detect the activities of flavivirus NS2B-NS3 serine proteases in living cells. The system consists of GFP-based reporters that become fluorescent upon cleavage by recombinant DENV-2/ZIKV proteases in vitro A version of this sensor containing the flavivirus internal NS3 cleavage site linker reported the highest fluorescence activation in stably transduced mammalian cells upon DENV-2/ZIKV infection. Moreover, the onset of fluorescence correlated with viral protease activity. A far-red version of this flavivirus sensor had the best signal-to-noise ratio in a fluorescent Dulbecco's plaque assay, leading to the construction of a multireporter platform combining the flavivirus sensor with reporter dyes for detection of chromatin condensation and cell death, enabling studies of viral plaque formation with single-cell resolution. Finally, the application of this platform enabled the study of cell-population kinetics of infection and cell death by DENV-2, ZIKV, and yellow fever virus. We anticipate that future studies of viral infection kinetics with this reporter system will enable basic investigations of virus-host interactions and facilitate future applications in antiviral drug research to manage flavivirus infections.

A Nanopore Approach for Analysis of Caspase-7 Activity in Cell Lysates.

Caspases are an important protease family that coordinate inflammation and programmed cell death. Two closely related caspases, caspase-3 and caspase-7, exhibit largely overlapping substrate specificities. Assessing their proteolytic activities individually has therefore proven extremely challenging. Here, we constructed an outer membrane protein G (OmpG) nanopore with a caspase substrate sequence DEVDG grafted into one of the OmpG loops. Cleavage of the substrate sequence in the nanopore by caspase-7 generated a characteristic signal in the current recording of the OmpG nanopore that allowed the determination of the activity of caspase-7 in Escherichia coli cell lysates. Our approach may provide a framework for the activity-based profiling of proteases that share highly similar substrate specificity spectrums.

Cysteine Disulfide Traps Reveal Distinct Conformational Ensembles in Dengue Virus NS2B-NS3 Protease.

The dengue virus protease (NS2B-NS3pro) plays a critical role in the dengue viral life cycle, making it an attractive drug target for dengue-related pathologies, including dengue hemorrhagic fever. A number of studies indicate that NS2B-NS3pro undergoes a transition between two widely different conformational states: an "open" (inactive) conformation and a "closed" (active) conformation. For the past several years, the equilibrium between these states and the resting conformation of NS2B-NS3pro have been debated, although a strong consensus is emerging. To investigate the importance of such conformational states, we developed versions of NS2B-NS3pro that allow us to trap the enzyme in various distinct conformations. Our data from these variants suggest that the enzymatic activity appears to be dependent on the movement of NS2B and may rely on the flexibility of the protease core. Locking the enzyme into the "closed" conformation dramatically increased activity, strongly suggesting that the "closed" conformation is the active conformation. The observed resting state of the enzyme depends largely on the construct used to express the NS2B-NS3pro complex. In an "unlinked" construct, in which the NS2B and NS3 regions exist as independent, co-expressed polypeptides, the enzyme rests predominantly in a "closed", active conformation. In contrast, in a "linked" construct, in which NS2B and NS3 are attached by a nine-amino acid linker, NS2B-NS3pro adopts a more relaxed, alternative conformation. Nevertheless, even the unlinked construct samples both the "closed" and other alternative conformations. Given our findings, and the more realistic resemblance of NS2B-NS3pro to the native enzyme, these data strongly suggest that studies should focus on the "unlinked" constructs moving forward. Additionally, the results from these studies provide a more detailed understanding of the various poses of the dengue virus NS2B-NS3 protease and should help guide future drug discovery efforts aimed at this enzyme.

The Unique Cofactor Region of Zika Virus NS2B-NS3 Protease Facilitates Cleavage of Key Host Proteins.

Zika virus is an emerging mosquito-borne pathogen capable of severely damaging developing fetuses as well as causing neurological abnormalities in adults. The molecular details of how Zika virus causes pathologies that are unique among the flavivirus family remain poorly understood and have contributed to the lack of Zika antiviral therapies. To elucidate how Zika virus protease (ZVP) affects host cellular pathways and consequent pathologies, we used unbiased N-terminomics to identify 31 human proteins cleaved by the NS2B-NS3 protease. In particular, autophagy-related protein 16-1 (ATG16L1) and eukaryotic translation initiation factor 4 gamma 1 (eIF4G1) are dramatically depleted during Zika virus infection. ATG16L1 and eIF4G1 mediate type-II interferon production and host-cell translation, respectively, likely aiding immune system evasion and driving the Zika life cycle. Intriguingly, the NS2B cofactor region from Zika virus protease is essential for recognition of host cell substrates. Replacing the NS2B region in another flavivirus protease enabled recognition of novel Zika-specific substrates by hybrid proteases, suggesting that the cofactor is the principal determinant in ZVP substrate selection.

Association of the Use of a Mandatory Prescription Drug Monitoring Program With Prescribing Practices for Patients Undergoing Elective Surgery.

Importance: Most states have adopted the routine use of a prescription drug monitoring program (PDMP) to curb overprescribing of opioids. The American College of Surgeons promotes the use of these programs as a "guiding principle to curb the opioid epidemic." However, there is a paucity of data on the effects of the use of these programs for surgical patient populations. Objective: To determine the association of the mandatory use of a PDMP with the opioid prescribing practices for patients undergoing general surgery. Design, Setting, and Participants: A prospective observational cohort study was conducted at an academic hospital in New Hampshire among 1057 patients undergoing representative elective general surgical procedures from July 1, 2016, to June 30, 2017. Exposures: New state legislation mandated the use of a PDMP and opioid risk-assessment tool for all patients receiving an outpatient opioid prescription in New Hampshire beginning January 1, 2017. The electronic medical prescribing system was modified to facilitate and support compliance with the new requirements. Main Outcomes and Measures: Change in opioid prescribing practices after January 1, 2017, and time to complete PDMP requirements. Results: Among the 1057 patients (569 women [53.8%] and 488 men [46.2%]; mean [SD] age, 56.8 [15.4] years), the percentage of patients prescribed opioids after surgery did not decrease significantly (429 of 536 [80.0%] before the new requirements vs 401 of 521 [77.0%] after the requirements; P = .29). The mean number of opioid pills prescribed decreased from 30.8 to 24.0 (22.1%) in the 6 months prior to the mandatory PDMP requirement; the rate of decrease was actually less (from 22.8 to 21.9 pills [3.9%]) in the 6 months after the legislation. These new requirements did not identify any high-risk patients who subsequently were not prescribed opioids. The query and opioid abuse risk calculator together took a median time of 7 minutes (range, 2-17 minutes) to complete. Conclusions and Relevance: A mandatory PDMP query requirement was not significantly associated with the overall rate of opioid prescribing or the mean number of pills prescribed for patients undergoing general surgical procedures. In no cases was a high-risk patient identified, leading to avoidance of an opioid prescription. A PDMP can be a useful adjunct in certain settings, but this study found that it did not have the intended effect in a population undergoing elective surgical procedures. Legislative efforts to mandate PDMP use should be targeted to populations in which benefit can be demonstrated.

Patterns of opioid use and prescribing for outpatient anorectal operations.

BACKGROUND: Surgery for anorectal diseases is thought to cause significant pain postoperatively. There is little known regarding standardized opioid-prescribing trends and patient use following surgery for anorectal diseases. We aimed to evaluate and analyze opioid-prescribing trends and patient use for outpatient anorectal operations. MATERIALS AND METHODS: All patients who underwent outpatient anorectal surgery performed over a 1-y period at a single institution were eligible. Procedures included hemorrhoidectomy, anal fistula repair/seton, anal fissure treatment with sphincterotomy, and transanal excision of rectal tumors. Demographic, operative, and postoperative data were obtained. Patients were given a survey to determine postoperative pain control with opioid and non-narcotic analgesia use; respondents were included in analysis. RESULTS: Forty-two outpatient anorectal surgery patients were included: 13 had hemorrhoidectomy, 22 had anal fistula repair/seton, one had sphincterotomy, and six had transanal excisions. All patients had multimodality treatment with either an anal block and/or postoperative nonopioid analgesics. Ninety percent were prescribed opioids postoperatively with a median of 20 pills (range: 0-120 pills). Forty-three percent (18/42) did not fill their prescription. For those who used opioids, the median number of pills taken was four. Eighty percent of pills prescribed were not used. One patient required a refill. Greater than 60% of respondents reported good to excellent pain control on a five-point scale. CONCLUSIONS: Most patients had adequate pain control after anorectal surgery with little to no use of opioids and that more than 80% of opioid pills prescribed were not consumed. We intend to standardize our prescribing opioid quantities for outpatient anorectal operations to reflect this reduced use.

Guideline for Discharge Opioid Prescriptions after Inpatient General Surgical Procedures.

BACKGROUND: There is a paucity of data to inform appropriate opioid prescribing for patients who are discharged after a hospital admission for a surgical procedure. STUDY DESIGN: We studied 333 inpatients discharged to home after bariatric, benign foregut, liver, pancreas, ventral hernia, and colon surgery. Chronic opioid users or patients who had complications were excluded. Home opioid usage was quantified in 90% of the remaining patients by questionnaires and phone surveys. RESULTS: Eighty-five percent of patients were prescribed an opioid and 38% of prescribed opioid pills were taken. Fifteen opioid pills satisfied the opioid needs of 88% of patients discharged on postoperative day (POD) 1. For patients discharged after POD 1, in multivariate analysis, the number of opioid pills used at home was associated with the number taken the day before discharge (p < 0.0001) and patient age (p = 0.006), but not the type of surgery. Forty-one percent of patients took no opioids the day before discharge, 33% took 1 to 3, and 26% took more than 4 pills. Eighty-five percent of patients' home opioid requirements would be satisfied using the following guideline: if no opioid pills are taken the day before discharge, no prescription is needed; if 1 to 3 opioid pills are taken the day before discharge, then a prescription for 15 opioid pills is given at discharge; and if 4 or more pills are taken the day before discharge, then a prescription for 30 opioid pills is given at discharge. If these guidelines were used, the number of opioid pills prescribed would decrease by 40%. CONCLUSIONS: For patients admitted after surgical procedures, post-discharge opioid use is best predicted by usage the day before discharge. Use of this guideline could decrease opioid prescriptions substantially and effectively treat patients' pain.

Mortality after emergency Hartmann's procedure in octogenarians: a propensity score-matched analysis.

BACKGROUND: Complicated diverticulitis is associated with a postoperative mortality rate of 20%. We hypothesized that age ≥80 was an independent risk factor for mortality after Hartmann's procedure for diverticular disease when controlling for baseline comorbidities. METHODS: Patients who underwent an urgent or emergent Hartmann's procedure (Current Procedural Terminology codes 44143 and 44206) for diverticular disease (International Classification of Diseases-9:562.xx) were identified using the American College of Surgeons National Surgical Quality Improvement Project 2005-2013 user file. Using propensity score matching to control for baseline comorbidities, a group of patients ≥80 years old was matched to a group of those <80 years old. Univariate and multivariable logistic regression were performed. A P value <0.05 was considered statistically significant with a confidence interval (CI) of 95%. RESULTS: From a total of 2986 patients, 464 patients (15.5%) were ≥80 years old. Two groups of 284 patients in each study arm were matched using propensity-matching. The mean age of the ≥80 group and <80 group was 84.4 ± 3.3 versus 63.77 ± 911.8; P < 0.0001, respectively. There was no statistical difference in baseline comorbidities or operative time between the groups. There was a significant difference in mortality with 19% and 9.2% in the >80 group versus <80 groups, respectively (P = 0.001). Factors associated with mortality included ascites (odds ratio [OR] 4.95, confidence interval [CI] 1.64-14.93, P = 0.005), previous cardiac surgery (OR 3.68, CI 1.46-9.26, P = 0.006), partially dependent or fully dependent functional status (OR 2.51, CI 1.12-5.56, P = 0.02), albumin <3 (OR 2.49, CI 1.18-5.29, P = 0.01), and American Society of Anesthesiologist class >3 (OR 2.10, CI 1.10-4.46, P = 0.05). CONCLUSIONS: Octogenarians presenting with complicated diverticulitis requiring an emergent Hartmann's procedure have a higher mortality rate compared to those <80, even after controlling for baseline comorbidities. STUDY TYPE: This is a retrospective, descriptive study.