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Introduction Older adults are more vulnerable to opioid-associated morbidity. The purpose of this study was to determine the frequency and timing of acetaminophen and opioid use in the postoperative period. Methods Older adult trauma patients (≥65 years) with hip fractures requiring femur or hip fixation were reviewed (Premier Database 2008-2014). We examined rates of acetaminophen use on the day of surgery and prior to receipt of oral opioids. Mixed-effects linear regression models were used to examine the effects of an acetaminophen-first approach on opioid use the day prior to and on the day of discharge. Results Of the 192 768 patients, 81.6% were Caucasian; 74.0% were female; and the mean age was 82.0 years [± 7.0]. Only 16.8% (32 291) of patients received acetaminophen prior to being prescribed opioids. 27.4% (52 779) received an acetaminophen-opioid combination, and 9.2% (17 730) received opioids without acetaminophen first. Acetaminophen first was associated with reduced opioid use on the day prior to and on the day of discharge (3.52 parenteral morphine equivalent doses (PMEs) less [95% CI: 3.33, 3.70]; P < .0001). A statistically but not clinically significant reduction in length of stay was observed in the acetaminophen-first group. Conclusion Nearly 37% of older adult patients did not receive acetaminophen as first-line analgesia after hip surgery. Multimodal analgesia, including non-opioid medications as first-line, should be encouraged.

Staphylococcus aureus is an opportunistic human pathogen and a primary cause of nosocomial infections. Its biofilm forming capability is an adaptation strategy utilized by many species of bacteria to overcome stressful environmental conditions and provides both resistance to antimicrobial treatments and protection from the host immune system. This paper addresses a growing demand for an objective, fully automated method of biofilm structure description with standardized parameters that are independent of user input. In this study, we used watershed segmentation to analyze and compare confocal laser scanning microscopy (CLSM) images of two S. aureus strains with different biofilm-forming capabilities. Results are compared with manual calculations as well as the commonly used COMSTAT software.

Breast conserving therapy (BCT), lumpectomy followed by radiotherapy, is an effective treatment for a majority of breast cancers. According to the National Comprehensive Cancer Network, mammographic imaging should be completed at least six months after completion of radiation. This study evaluates the clinical significance and financial cost of postoperative breast imaging within one year of BCT. Patients treated with BCT between 2014 and 2016 at an academic center were identified retrospectively. The medical records were reviewed to identify the timing and type of the first imaging study after BCT. This study evaluated the clinical significance and the cost of postoperative imaging. A total of 128 patients were included into the study. Seventy-six patients received mammograms 3 to 12 months after BCT. Six of the 76 postoperative mammograms required additional imaging/intervention for a total of seven additional imaging studies and three procedures, all of which revealed benign findings. None of these patients had physical examination findings that were of clinical concern. The total cost of postoperative imaging and procedures performed less than a year after BCT was estimated to be $32,506. Postoperative imaging performed on breast cancer patients less than a year after BCT proved to be of no medical benefit and revealed no additional significant pathology. The mammographic surveillance in this study did not lead to the diagnosis of recurrent malignancy or second primary lesions and placed additional financial burden on the patient population. This study demonstrates that breast imaging within a year after BCT had no clinical impact and resulted in increased cost of care.

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Background: Surgical site infection (SSI) is one of the most common healthcare-associated infections. The use of negative pressure wound therapy (NPWT) has shown to decrease the overall rate of SSI, wound dehiscence, and length of hospital stay in surgical conditions. This study aims to determine the impact of NPWT applied on closed surgical incisions on patients with coexisting ostomy undergoing exploratory laparotomy.   Methods: A retrospective study on patients who underwent exploratory laparotomies from 2017 to 2019 was conducted. NPWT was compared to standard post-operative surgical wound dressing. A sub-analysis of patients with ostomies was performed.   Results: A total of 286 patients who underwent exploratory laparotomy were identified; 51 patients received NPWT and 235 received standard dressing. The NPWT group had a higher percentage of patients with an ostomy (37.3% vs 20.4%, P=.016), of which 25.5% were colostomies (vs 12.3%) and 11.8% were ileostomies (vs 8.1%) with P=.002. No significant difference in the overall rate of SSI (7.8% vs 5.5%, P= .517), wound dehiscence (7.8% vs 2.1 %, P=.057), and seroma formation (3.9% vs 2.1%, P=.612) were observed. The mean length of ICU stay (3.5 vs 7.0, P=.051) and unplanned reoperation (5.9% vs 16.6%, P=.051) were lower in the NPWT group compared to the control group. Sub analysis of patients with stoma found no significant difference in SSI.   Conclusions: In our study, the use of NPWT on closed surgical incision wound was not associated with the reduction of SSI in patients with ostomies. Large studies are needed to ascertain significant benefits in patients with ostomies.   Keywords: negative pressure wound therapy, surgical site infection, ostomy, exploratory laparotomy

Cholecystogastric and cholecystocolonic fistulae are rare sequelae of longstanding cholelithiasis and can complicate surgical management. Our case involves a male patient in his early 40s with a history of chronic cholelithiasis who presented to the emergency department with severe abdominal pain. Findings on imaging were consistent with acute calculous cholecystitis. During laparoscopic cholecystectomy, the presence of both cholecystogastric and cholecystocolonic fistulae was discovered. Fistula resection with cholecystectomy in a one-step approach using indocyanine green (ICG) angiography was performed. The patient improved and was discharged 3 days later. Laparoscopic management complemented by ICG angiography is a viable surgical approach in patients with cholecystogastric and cholecystocolonic fistulae.

It is customary for a postoperative chest radiograph to be obtained after fluoroscopic guided port insertion to exclude acute complications. In this review, we provide a cost-benefit analysis by examination of acute postoperative complications detected by postoperative port insertion chest films at our institution. We conducted a retrospective chart review of complications associated with port insertion procedures performed over a 5-year period. Our study included only ultrasound-assisted internal jugular venous or landmark guided subclavian ports placed with the assistance of fluoroscopy. A total of 519 port insertions were reviewed and there was noted to be a postoperative complication rate of 0.58 per cent. The operative note for each complication described a procedural abnormality that suggested a chest film would be of medical benefit. The total price of postoperative chest radiographs was $179,400. Performing chest X-ray films on asymptomatic patients after fluoroscopic guided placement of ports proved to be of no medical advantage to 516 out of 519 patients. Given the extremely low complication rate and financial burden placed on the patient population, we propose discontinuing routine use of postoperative port placement chest radiographs as a way to alleviate unwarranted medical cost.