Perioperative factors associated with Hospital Consumer Assessment of Healthcare Providers and Systems responses of total hip arthroplasty patients.

OBJECTIVE: To determine perioperative treatments and events associated with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) responses among patients who undergo total hip arthroplasties (THAs) and total knee arthroplasties (TKAs). DESIGN: Retrospective analysis. SETTING: Single tertiary care, academic, urban, level 1 trauma center. PARTICIPANTS: Final cohort represents 301 consecutive surgical inpatients meeting criteria for evaluation by HCAHPS survey. EXPOSURES: Responses to 4 HCAHPS questions were analyzed against perioperative treatments and events. MEASURES: Positive and negative responses to HCAHPS questions. RESULTS: THA patients responding affirmatively to both pain specific and general satisfaction were associated with preoperative use of chronic nonsteroidal anti-inflammatory drugs. In addition, THA patients responding affirmatively "how often was your pain well controlled" were also associated decreased postanesthesia care unit (PACU) opioid requirement. TKA patients responding affirmatively to "what number would you use to rate this hospital" were associated with shorter PACU stays and lower final pain scores. TKA patients responding affirmatively to "would you recommend this hospital to your family" were associated with shorter lengths of stay in the hospital and in the PACU. TKA patients responding affirmatively to "How often did the hospital staff do everything to help with your pain" were not associated with any measured perioperative event. TKA patients responding affirmatively to "how often was your pain well controlled" were associated with older age, decreased use of preoperative chronic benzodiazepines, and increased use of preoperative midazolam. CONCLUSIONS: These data suggest that chronic use of nonsteroidal anti-inflammatory drugs is associated with improved overall satisfaction and satisfaction with pain in THA patients. Furthermore, increased PACU opioid use was negatively associated satisfaction with pain management. Age, lengths of stay preadmission medications, anxiolytic medications, and PACU pain scores are associated with patient satisfaction with regards to both pain management and overall satisfaction in TKA patients.

Increased dose of betamethasone for transforaminal epidural steroid injections is not associated with superior pain outcomes at 4 weeks.

BACKGROUND: Fluoroscopically guided transforaminal epidural steroid injections (FG-TFESIs) have been shown to provide both immediate and long-term improvement in patient's self-reported pain. Administration of the lowest possible dose of epidural betamethasone is desired to minimize side effects while maintaining efficacy. We hypothesize that a 3 mg or a 6 mg dose of betamethasone will demonstrate equivalent analgesic properties. OBJECTIVES: To compare the analgesic efficacy of 3 mg and a 6 mg dose of betamethasone for use in FG-TFESI. STUDY DESIGN: Retrospective evaluation. SETTING: Academic outpatient pain center. METHODS: One hundred fifty-eight patients underwent FG-TFESI for lumbar back pain between 2012 and 2013. Depending on the date of service, a dose of 3 mg or a dose of 6 mg betamethasone was used in the single level unilateral TFESI. Opioid consumption and NRS pain score were analyzed pre-procedurally and at a clinic visit 4 weeks post-procedurally. RESULTS: Changes in numerical rating scale (NRS) pain score (-1.21 +' 2.61 vs. -0.81 +' 2.40 respectively, P = 0.17) and changes in opioid consumption as measured in oral morphine equivalents (-2.94 +' 16.4 mg vs. -2.93 +' 14.8 mg, P = 0.17) were statistically equivalent between both groups. Intergroup sub-analysis of those with > 50% reduction in baseline VRS {sp} pain score was not different (15.2% vs. 34%, P = 0.56), and the proportion with a VRS pain score < 3 were similar (24.5% vs. 23.8%, P = 0.92). LIMITATIONS: Potential selection bias inherent with study design. CONCLUSIONS: Reduction in NRS pain scores and narcotic usage at 4 weeks after FG-TFESI were statistically equivalent between patients who received 3 mg or 6 mg of betamethasone, suggesting that a lower steroid dose has similar analgesic efficacy. IRB Number: Cedars Sinai Medical Center Institutional Review Board Pro00031594

Perioperative factors associated with HCAHPS responses of 2,758 surgical patients.

OBJECTIVE: To determine perioperative treatments and events associated with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey responses. DESIGN: Retrospective analysis. SETTING: Single tertiary care, academic, urban, level-1 trauma center. PARTICIPANTS: Final cohort represents 2,758 consecutive surgical inpatients meeting criteria for evaluation by HCAHPS. EXPOSURES: Responses to four HCAHPS questions were compared against 19 perioperative treatments and events. MEASURES: Positive and negative responses to HCAHPS questions. RESULTS: Patients responding affirmatively with a "9" or "10" to "what number would you use to rate this hospital" were associated with decreased lengths of hospitalization, greater lengths of surgery, decreased intraoperative opioid equianalgesic doses, greater preoperative midazolam doses, shorter post anesthesia care unit (PACU) lengths of stay and decreased last PACU numerical rating scale (NRS) pain scores. Patients responding affirmatively with "yes, definitely" to "would you recommend this hospital to your family" were associated with decreased last PACU NRS pain scores. Patients responding affirmatively with "yes, always" to "How often did the hospital staff do everything to help with your pain" were associated with decreased hospital lengths of stay, decreased chronic benzodiazepine use, greater chronic NSAID use, and decreased PACU lengths of stay. Patients responding affirmatively with "yes, always" to "how often was your pain well controlled" were associated with decreased chronic opioid use, decreased chronic benzodiazepine use, greater chronic NSAID use, increased length of surgery, decreased last PACU NRS pain score, and decreased first PACU NRS pain scores. Subgroup analysis of patients undergoing different types of surgery further characterized factors associated with HCAHPS responses among different surgical populations. CONCLUSIONS: These data suggest that demographic factors, preadmission medications, and PACU pain scores but not analgesic medications are associated with patient satisfaction with regards to both pain management and overall satisfaction.

Determination of the effective dose of pregabalin on human experimental pain using the sequential up-down method.

UNLABELLED: The intradermal capsaicin pain model has been used to evaluate analgesic effects of a variety of drugs. Using the sequential up-down method, we examined the analgesic effects of pregabalin on intradermal capsaicin pain. Using a double-blind, placebo-controlled, crossover study, healthy adult men were randomized to oral pregabalin or placebo on the first visit and returned for the opposite treatment after a washout period. Dosing was set by the Dixon sequential up-down method; that is, a greater or less than 30% reduction in capsaicin pain decreased or increased the dose, respectively, by a fixed interval for the next subject. The median effective dose (ED50) was derived once 7 changes in dose direction occurred. Secondary outcome measures included secondary hyperalgesia and tactile and thermal allodynia, and their respective areas (cm(2)). Thirteen subjects were required to derive the pregabalin ED50: 252 mg (95% confidence interval 194, 310 mg). Most common side effects were drowsiness (46%), euphoria (31%), and dizziness (7%). Those with ≥30% pain reduction as compared to placebo also had similar reductions in secondary outcome measures. The intradermal capsaicin pain model can be used to efficiently derive the pregabalin ED50, but well-powered dose-response curve studies are needed for comparison and validation. PERSPECTIVE: Using the Dixon sequential up-down method, the ED50 of pregabalin on intradermal capsaicin induced pain was successfully calculated (252 mg) using only 13 subjects.

The effect of cross-training with adjustable airway model anatomies on laryngoscopy skill transfer.

BACKGROUND: A problem with learning endotracheal intubation on airway mannequins is poor transfer of direct laryngoscopy skills from model to patient. We developed an airway model with adjustable anatomic features and investigated whether practicing on a model with frequent adjustments improved laryngoscopy skills transfer. METHODS: Fifty-one paramedic students and 18 medical students with minimal previous experience practiced laryngoscopy 25 times with either the novel model with static features, the novel model with variable features, or a Laerdal Adult Intubation mannequin. For the variable group, the configuration changed after every 5 attempts. After training, all subjects performed 10 laryngoscopies on 2 new mannequins to test their competence at skills transfer. A mixed linear model analyzed various predictors of success as a binary outcome, including training group and change in laryngoscopy model. RESULTS: The odds ratio for success after a recent change in mannequin was 0.69 (0.49, 0.96 [95% confidence interval]). Compared with the Laerdal group, subjects with the static trainer did worse (odds ratio 0.46 [0.23, 0.94]), and subjects in the variable group were no different (0.74 [0.36, 1.52]). Change in laryngoscopy model decreased success rate by approximately 30% for all training groups. CONCLUSION: The results verify that proficiency on one model does not guarantee success on another. However, subjects who trained with a laryngoscopy mannequin in multiple configurations did not show better skill transfer than subjects practicing on fixed configuration airway models.

Cellular localization and stimulation-associated distribution dynamics of syntaxin-1 and syntaxin-3 in gastric parietal cells.

Syntaxins are differentially localized in polarized cells and play an important role in vesicle trafficking and membrane fusion. These soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) proteins are believed to be involved in tubulovesicle trafficking and membrane fusion during the secretory cycle of the gastric parietal cell. We examined the cellular localization and distribution of syntaxin-1 and syntaxin-3 in rabbit parietal cells. Fractionation of gastric epithelial cell membranes showed that syntaxin-1 was more abundant in a fraction enriched in apical plasma membranes, whereas syntaxin-3 was found predominantly in the H,K-ATPase-rich tubulovesicle fraction. We also examined the cellular localization of syntaxins in cultured parietal cells. Parietal cells were infected with CFP-syntaxin-1 and CFP-syntaxin-3 adenoviral constructs. Fluorescence microscopy of live and fixed cells demonstrated that syntaxin-1 was primarily on the apical membrane vacuoles of infected cells, but there was also the expression of syntaxin-1 in a subadjacent cytoplasmic compartment. In resting, non-secreting parietal cells, syntaxin-3 was distributed throughout the cytoplasmic compartment; after stimulation, syntaxin-3 translocated to the apical membrane vacuoles, there co-localizing with H,K-ATPase, syntaxin-1 and F-actin. The differential location of these syntaxin isoforms in gastric parietal cells suggests that these proteins may be critical for maintaining membrane compartment identity and that they may play important, but somewhat different, roles in the membrane recruitment processes associated with secretory activation.