A Multimodal Intervention Using Nonopioid Analgesics Is Associated With Reduced Intravenous Opioid Exposure Among Hospitalized Patients With Inflammatory Bowel Diseases.

INTRODUCTION: Opioid use in patients with inflammatory bowel disease (IBD) is associated with increased mortality. Previous interventions targeting reduced intravenous opioid (IVOPI) exposure for all patients admitted to a general medical unit have decreased total opioid use without compromising pain control. We therefore performed a prospective evaluation of a multimodal intervention encouraging the use of nonopioid alternatives to reduce IVOPI exposure among patients with IBD hospitalized at our institution. METHODS: This was a prospective evaluation of a multimodal intervention to reduce IVOPI use among patients with IBD aged ≥18 years admitted to a general medical unit at a large urban academic medical center from January 1, 2019, to June 30, 2019. Intravenous and total (all routes) opioid exposures were measured as proportions and intravenous morphine milligram equivalents/patient day and compared with preintervention (January 1, 2018, to December 31, 2018) data. Hospital length of stay (LOS), 30-day readmission rates (RRs), and pain scores (1-10 scale) were also assessed. RESULTS: Our study involved 345 patients with IBD with similar baseline characteristics in preintervention (n = 241) and intervention (n = 104) periods. Between study periods, we observed a significant reduction in the proportion of patients receiving IVOPIs (43.6% vs 30.8%, P = 0.03) and total opioid dose exposure (15.6 vs 8.5 intravenous morphine mg equivalents/d, P = 0.02). We observed similar mean pain scores (3.9 vs 3.7, P = 0.55) and significantly reduced mean LOS (7.2 vs 5.3 days, P = 0.03) and 30-day RRs (21.6% vs 11.5%, P = 0.03). DISCUSSION: A multimodal intervention was associated with reduced opioid exposure, LOS, and 30-day RRs for hospitalized patients with IBD. Additional research is needed to determine long-term benefits of reduced opioid exposure in this population.

Interprofessional Simulations to Inform Perioperative Facility Planning and Design.

OBJECTIVE: The purpose of this study is to report our experience with interprofessional simulations, executed in a mock-up of a proposed perioperative space, that were designed to elicit valuable end-user feedback on the design of the perioperative space. DESIGN: A styrofoam, life-sized model of a perioperative unit was constructed. Various medical professionals and support staff participated in interactive sessions, including workflow simulations, and provided feedback on the perioperative design. Based on participant feedback, the perioperative design was modified, and the styrofoam model was re-constructed. A second round of sessions was conducted, and the change in participant feedback was analyzed. SETTING: This study took place under the auspices of the University of Pennsylvania in Philadelphia, Pennsylvania, within Penn Medicine. PARTICIPANTS: One-hundred and ninety-three medical professionals and front line operating room staff participated in the initial round of interactive sessions, and 134 participated in the second round (after re-construction). RESULTS: In the first round of simulations and interactive sessions, participants spent 560 hours engaging with the space. Modifications were then made to the perioperative design based on participant feedback, and a second round was conducted, in which participants spent 403 hours in the space. Floor plans for round 2 show significant changes compared with round 1, and mean design satisfaction scores for round 2 (3.78 ± 0.41) were significantly higher than for round 1 (3.61 ± 0.49) (p = 0.02). The quality of feedback was associated with the type of interactive session the user participated in. CONCLUSIONS: This study suggests that simulations and other interactive sessions, when executed in a mock-up of a proposed perioperative space, can elicit valuable end-user feedback that impacts the final design of the perioperative space and that would traditionally be difficult to obtain until after construction and move-in.

Neuropathology of the olfactory mucosa in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is a complex heterogeneous inflammatory disease that affects the nasal cavity, but the pathological examination of the olfactory mucosa (OM) in this disease has been limited. METHODS: Nasal biopsy specimens were obtained from 20 control subjects and 50 CRS patients in conjunction with clinical assessments. Histopathology of these nasal biopsy specimens was performed and immunohistochemistry was used to characterize nonneuronal, neuronal, and inflammatory cells in the OM. These OM characteristics were then evaluated to determine the degree to which pathological features may be related to smell loss in CRS. RESULTS: Histopathological examination of control and CRS OM revealed changes in the normal pseudostratified olfactory epithelium (OE): intermixing of goblet cells, metaplasia to squamous-like cells, and erosion of the OE. Lower percentages of normal epithelium and olfactory sensory neurons were found in CRS OE compared with controls. Relative to other CRS patients, those with anosmia had the greatest amount of OE erosion, the highest density of eosinophils infiltrating the OE, and exhibited the most extensive abnormalities on CT and endoscopic examination, including being significantly more likely to exhibit nasal polyposis. CONCLUSION: Our results suggest that OM pathology observed in nasal biopsy specimens can assist in understanding the degree of epithelial change and sensorineural damage in CRS and the potential for olfactory loss.

Smoking-associated squamous metaplasia in olfactory mucosa of patients with chronic rhinosinusitis.

Few studies have examined the induction of squamous metaplasia in human olfactory nasal tissue caused by tobacco use and the implications it may have for olfaction, particularly when there are pre-existing insults, such as chronic rhinosinusitis (CRS). Quantitative histopathological analyses were performed on Alcian blue- and H&E-stained sections of nasal biopsies taken from the upper aspect of the middle turbinate of CRS patients. Chronic rhinosinusitis patients who were current smokers had a predominance of squamous metaplasia in the olfactory sensory epithelium, whereas CRS patients who were nonsmokers and were not exposed to secondhand cigarette smoke had a prevalence of goblet cell hyperplasia. In spite of this difference, the groups did not differ significantly in olfactory threshold sensitivity. The impact of primary cigarette smoke on olfaction and a possible role of squamous metaplasia in preserving olfactory neurogenesis are discussed.