Efficacy of Liposomal Bupivacaine for Sternotomy Pain After Cardiac Surgery: A Retrospective Analysis.

BACKGROUND: Multimodal analgesia is a cornerstone of postoperative pain management. Different formulations of local anesthetics are available. Data to support these treatment options are limited. OBJECTIVE: To determine the efficacy of liposomal bupivacaine compared with bupivacaine or ropivacaine in patients undergoing sternotomy for coronary artery bypass graft (CABG) and/or valve surgery. METHODS: Single-center, retrospective, observational study at a community teaching hospital. Patients included were 18 years of age or older undergoing CABG and/or valve surgery via median sternotomy and received either liposomal bupivacaine or an active comparator. The primary outcome was opioid utilization in morphine milligram equivalent (MME) from 0 to 72 hours. RESULTS: A total of 376 patients were included, 223 in the liposomal bupivacaine arm and 153 in the active comparator arm. There was no difference in the MME use from 0 to 72 hours among patients in the liposomal bupivacaine group compared with the comparator group (114.2 mg [75.55] vs 107.6 mg [68.4], P = 0.38). After Bonferroni correction, there was no difference in pain scores at individual time points. At 24- and 48-hour post-op, pain scores were higher with liposomal bupivacaine at 4.4 (2.7) vs 3.5 (2.8) (P = 0.01) and 3.1 (2.9) vs 2.4 (2.6) (P = 0.02). CONCLUSION AND RELEVANCE: Based on these findings and previous studies, liposomal bupivacaine should not be routinely used for CABG and/or valve surgery through a median sternotomy given lack of superiority. This helps inform surgical practice to the role of anesthetics as part of the multimodal analgesia regimen.

Wearable gait device for stroke gait rehabilitation at home.

BACKGROUND: Hemiparesis is a common disabling consequence of stroke that leads to abnormal gait patterns marked by asymmetries in step length, stance, and swing phases. Asymmetric gait patterns are correlated with decreased gait velocity and increased susceptibility to falls that can lead to serious injuries and hospitalizations. OBJECTIVE: In this single group, before and after study, treatment with the iStrideTM gait device, designed to improve the gait patterns of individuals with hemiparesis, is adapted to the home environment. Previously tested in clinical settings, this study investigates if using the iStrideTM gait device within the home environment can provide safe and effective gait treatment for individuals with hemiparetic gait impairments caused by stroke. METHODS: Twelve 30-minute sessions of walking on the device were administered in each participant's home environment. Twenty-one participants who were more than one-year post-stroke received the treatment. The Ten-Meter Walk Test, Timed Up and Go Test, Berg Balance Scale, Functional Gait Assessment, and Stroke Specific Quality of Life Scale were performed before and one week after treatment. Safety, treatment plan compliance, and subjective responses were also recorded during the study period. RESULTS: Results demonstrate statistically significant improvement on all five outcome measures from before treatment to one week after the last treatment session (p < 0.01) using two-tailed paired t-tests. 76% of participants improved beyond the small meaningful change or minimal detectable change on three or more outcome measures. 67% of participants improved clinically in gait speed and on at least one of the fall risk assessment inventories. 81% of the participants were able to perform the treatment in their home without assistance before the end of week three. CONCLUSIONS: The results indicate that the iStrideTM gait device can facilitate effective, safe, and home-accessible gait treatment opportunities for individuals with hemiparesis from stroke.

Impact of Evidence-Based Guidelines on Outcomes of Hospitalized Patients With Clostridium difficile Infection.

OBJECTIVES: Clostridium difficile infection (CDI) is the most common healthcare-associated infection in the United States. Clinical practice guidelines for the treatment of CDI were updated in 2010 by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. An institutional guideline for the classification and management of CDI in accordance with the 2010 Society for Healthcare Epidemiology of America/Infectious Diseases Society of America guideline was developed and provided to attending physicians and medical residents in multiple formats. METHODS: We sought to determine the impact of an evidence-based guideline for the treatment of CDI at a community teaching hospital. A retrospective chart review was conducted to identify length of stay (LOS), readmission rates, direct cost, mortality, and physician adherence to guidelines in patients with International Classification of Diseases, Ninth Edition codes and laboratory confirmation of CDI between February 1, 2013 and January 31, 2014. Endpoints included LOS after diagnosis of CDI, 30-day readmission rates, direct cost after diagnosis of CDI, and mortality. RESULTS: A total of 351 patient encounters were included in the study. Although not statistically significant, it was found that guideline-based therapy (n = 131) was associated with a lower median LOS (6 days vs 8 days; P = 0.06). Thirty-day hospital readmission (25.2% vs 29.5%; P = 0.39) and median cost after diagnosis of CDI ($7238.48 vs $8794.81; P = 0.10) also were lower but not statistically significant. Patients with mild-to-moderate infection were found to have a significantly lower median LOS (5 days vs 7 days; P = 0.03) and median cost after diagnosis ($5257.85 vs $7680.56; P = 0.03) when treated with guideline-based therapy. Overall physician adherence to guidelines was low, at 38%. CONCLUSIONS: Treatment with guideline-based therapy for CDI was associated with a trend toward a significantly lower LOS and cost. Barriers to physician adherence to guidelines still exist, despite education and guideline availability. Electronic health record-based order sets or clinical decision tools may improve recognition of and adherence to guidelines.