Patients with prior exposure are more likely to be prescribed more opiates after femoral shaft fracture treatment. We recommend a protocol of prescribing half the mean of MMEs currently prescribed by orthopedists equating to 47 (711 MMEs) pills of oxycodone 10 mg in up to 3 prescriptions.

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The Model for End Stage Liver (MELD) score is validated to predict pretransplant mortality. However, as a predictor of postoperative outcomes, its utility has proven inconsistent. Recently developed MELD-Lactate models better predict 30-day survival as compared with the MELD and MELD-Sodium scores. We compared the MELD-Lactate, original MELD, and MELD-Sodium formulae and the initial postoperative lactate as predictors of 30-day and in-hospital mortality following liver transplantation.Adult patients (n = 989) undergoing orthotopic liver transplant between 2002 to 2013 were included. In addition to the previous models, the first postoperative lactate value and a newly derived Mount Sinai MELD-Lactate score and associated c-statistics were compared.The Mount Sinai MELD-Lactate model yielded the highest c-statistic value (0.749), followed by the original MELD-Lactate (0.740), initial lactate value (0.729), postoperative MELD (0.653), and MELD-Sodium (0.641) models in predicting survival at 30 days following liver transplantation. For in-hospital mortality, the original MELD-Lactate model had slightly higher c-statistic (0.739) compared with the Mount Sinai MELD-Lactate model (0.734). Despite the distribution differences in the MELD-Lactate models, the model validation results, both from cross-validation and bootstrap methods, were similar.Postoperative MELD-Lactate and isolated postoperative lactate values were moderately predictive of 30-day and in-hospital mortality following liver transplantation in this patient cohort.

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Objective: This retrospective study aimed at identifying opiate prescribing practices, the number of morphine milligram equivalents (MMEs) prescribed by orthopaedic and nonorthopaedic providers in patients with operatively treated isolated lower extremity fractures, and provide opiate prescribing recommendations. Methods: Patients older than 18 years with isolated lower extremity (unicondylar, bicondylar, tibial shaft, pilon, and ankle) fractures between 2005 and 2016 were identified. Prescribing information was obtained from the State Controlled Substance Monitoring Database. Descriptive statistics were calculated for each injury and plotted for MME use. Mann–Whitney and Wilcoxon tests were used for data analysis. To aid in clinical relevance, MMEs were converted to number of pills of oxycodone 10 mg (OC 10 mg). Results: Three hundred forty-one patients met our inclusion criteria. Mean age was 45 years; 56% (192/341) were men. Forty-seven percent (159/341) were prescribed opiates before their injury. Orthopaedic providers prescribed more opiates to patients with pilon fractures compared with unicondylar (P = 0.010), tibial shaft (P < 0.001), and ankle (P < 0.001) fractures. Bicondylar plateau fracture patients also received more opiates when compared with unicondylar (P = 0.001), tibial shaft (P < 0.001), and ankle (P < 0.001) fractures. Nonorthopaedic providers prescribed more opiates to patients with pilon fractures when compared with unicondylar (P = 0.006), bicondylar (P < 0.001), tibial shaft (P < 0.001), and ankle fractures (P = 0.006). Differences between orthopaedic and nonorthopaedic MMEs prescribed are significantly different for each injury type (<0.05). Conclusions: Patients with pilon or bicondylar tibial plateau fractures are currently being prescribed more opiates when compared with other isolated fractures. We have developed an opiate prescription guideline based on what is being prescribed by orthopaedic providers.

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Background Under Section 1557 of the Affordable Care Act, introduced in 2016, increased access to gender-affirming surgeries for transgender and gender diverse (TGD) individuals. Masculinizing chest reconstruction (e.g., mastectomy) and feminizing chest reconstruction (e.g., augmentation mammaplasty), often outpatient procedures, are the most frequently performed GAS. However, there is a paucity of information about the demographics of patients who undergo gender-affirming chest reconstruction. Objective The authors sought to investigate the incidence, demographics, and spending for ambulatory gender-affirming chest reconstruction using nationally representative data from 2016-2019. Methods Using the Nationwide Ambulatory Surgery Sample, the authors identified patients with an International Classification of Diseases diagnosis code of gender dysphoria who underwent chest reconstruction between 2016 and 2019. Demographic and clinical characteristics were recorded for each encounter. Results A weighted estimate of 21,293 encounters for chest reconstruction were included (17,480 [82.1%] masculinizing and 3,813 [27.9%] feminizing). Between 2016 and 2019, the number of chest surgeries per 100,000 encounters increased by 143.2% from 27.3 to 66.4 (P&lt;.001). 12,751 (59.9%) chest surgeries were covered by private health insurance, 6,557 (30.8%) were covered by public health insurance, 1,172 (5.5%) were self-pay, and 813 (3.8%) had other means of payment. The median total charges were $29,887 (IQR, $21,778-$43,785) for chest reconstruction overall. Age, expected primary payer, patient location, and median income varied significantly by race (P&lt;.001). Conclusions Gender-affirming chest reconstructions are on the rise, and surgeons must understand the background and needs of TGD patients who require and choose to undergo surgical transitions.