Narcotic requirements after shoulder arthroplasty are low using a multimodal approach to pain.

BACKGROUND: Recent "multimodal" approaches to pain, although understudied, have shown promise in reducing reliance on narcotics in shoulder arthroplasty (SA). Many surgeons report being unsure of how many narcotic pills to prescribe after the surgery. As result, patients are prescribed upwards of 60 oxycodone 5-mg pills for a 6-to-12-week treatment period despite studies showing postoperative pain can be managed without any medication at all. PURPOSE: The purpose of this multicenter study was to prospectively determine the number of opiate pills required after SA to develop generalizable, evidence-based prescription guidelines for surgeons. We hypothesized that opioid prescription would be low using a multimodal approach to pain management. METHODS: The study enrolled 63 patients undergoing SA. Subjects received either an interscalene nerve block with liposomal bupivacaine, standard bupivacaine, or a local infiltration standard bupivacaine field block based on preference. All subjects were provided with postoperative "Pain Journals" to document their daily pain on a Numerical Rating Scale and daily opioid consumption during the 14-day postoperative period. RESULTS: Overall, patients consumed an average of 8.6 oxycodone 5-mg pills (64.5 morphine milligram equivalents) after SA. Seventy-nine percent of patients required 15 or fewer oxycodone 5-mg pills, and 27% successfully managed their postoperative pain with zero opioids. Average pain remained low for patients in all groups. CONCLUSION: With a multimodal approach, most patients undergoing SA can manage postoperative pain with 15 or fewer oxycodone 5-mg tablets, or 112.5 morphine milligram equivalents. The addition of a liposomal bupivacaine interscalene nerve block may further reduce the consumption of postoperative narcotics compared with a standard interscalene nerve block. This study provides evidence that may be used for surgeon guidelines in the effort to reduce opioid prescriptions after SA.

How do Crocodylian embryos process yolk? Morphological evidence from the American alligator, Alligator mississippiensis.

Recent studies have demonstrated a mechanism of embryonic yolk processing in lizards, snakes and turtles that differs markedly from that of birds. In the avian pattern, cells that line the inside of the yolk sac take up products of yolk digestion and deliver nutrients into the vitelline circulation. In contrast, in squamates and turtles, proliferating endodermal cells invade and fill the yolk sac cavity, forming elongated strands of yolk-filled cells that surround small blood vessels. This arrangement provides a means by which yolk material becomes cellularized, digested, and transported for embryonic use. Ultrastructural observations on late-stage Alligator mississippiensis eggs reveal elongated, vascular strands of endodermal cells within the yolk sac cavity. The strands of cells are intermixed with free yolk spheres and clumps of yolk-filled endodermal cells, features that reflect early phases in the yolk-processing pattern. These observations indicate that yolk processing in Alligator is more like the pattern of other reptiles than that of birds.