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BACKGROUND: Intrathecal drug delivery systems (IDDS) have been utilized for over 3 decades for management of chronic pain and spasticity. Patients with IDDS may present for surgical procedures unrelated to the IDDS device, although data are limited regarding perioperative outcomes. METHODS: This is a historical matched cohort study conducted between January 1, 2007 and December 31, 2016 of patients with an opioid-based IDDS versus matched control patients undergoing surgery excluding interventional pain procedures. Patients in the IDDS group were matched with up to 2 patients without an IDDS. Multivariable regression analyses were utilized to assess differences in the primary outcome of cumulative perioperative opioid consumption (ie, intraoperative and postanesthesia care unit [PACU] opioid consumption), and opioid consumption during the first 24 and 72 postoperative hours. Postoperative clinical outcomes were also assessed including escalating oxygen requirements, naloxone administration, pain-sedation mismatch, and perioperative pain service consultation. RESULTS: A total of 321 surgeries were included, 112 with IDDS and 209 controls, with median (interquartile range [IQR]) age of 57 (49–64) years. Compared to matched controls, patients with an IDDS had greater perioperative opioid consumption (median [IQR] oral morphine milligram equivalents [OME] of 110 [60–163] vs 93 [IQR, 53–142]; adjusted multiplicative increase 1.28 [95% confidence interval {CI}, 1.03–1.59]; P = .026). IDDS patients also had greater opioid consumption in the first 24 and 72 postoperative hours (multiplicative increases of 2.23 [95% CI, 1.36–3.63], P = .001, and 2.46 [95% CI, 1.41–4.32], P = .002, respectively). There were no significant differences in postoperative oxygen requirements, naloxone administration, or pain-sedation mismatch. Inpatient pain medicine consultation was more frequent in IDDS patients compared to controls (51.8% vs 6.2%; P < .001). CONCLUSIONS: Patients with opioid-based IDDS received more perioperative opioids and were more likely to receive postoperative pain service consultation compared to matched controls. There were no significant differences in clinical safety outcomes, suggesting tolerance for higher opioid doses. Further research is warranted to optimize perioperative outcomes in those with IDDS.

The Gly allele of the Arg16/Gly β 2 ‐adrenergic receptor polymorphism has been associated with hypertension in a linkage analysis in Rochester, MN. Gly homozygotes have greater forearm β 2 ‐receptor mediated vasodilation than Arg after a normal Na + diet (150 mmol/day), and the difference is mediated by endothelial NO. To test the hypothesis that dietary Na + restriction affects β 2 ‐mediated dilation in these groups, we measured forearm blood flow (FBF, plethysmography) during brachial arterial infusion of isoproterenol (ISO) after 5 days of low dietary Na + (10 mmol/day), in healthy subjects homozygous for Arg (n=15, 8 women, 29 ± 8 yrs, mean ± SD) vs. Gly (n=17, 7 women, 31 ± 7 yrs). Baseline FBF did not differ between groups. ISO caused a significant increase in FBF that was not different based on genotype (P = 0.51, main effect of genotype; P = 0.72, genotype‐by‐ISO‐interaction). For example, the highest response to ISO was 10.3 ± 5.5 in Arg and 12.0 ± 4.4 ml/100 ml forearm vol/min in Gly (P t‐test = 0.33). NO inhibition with L‐NMMA decreased baseline FBF, and significantly blunted the response to ISO, but there was no evidence to suggest the responses were influenced by genotype (P = 0.89, genotype‐by‐ISO‐by‐L‐NMMA interaction). We conclude that greater NO‐mediated β 2 ‐receptor vasodilation in Gly homozygotes is no longer apparent following dietary Na + restriction, suggesting that greater dilator function in Gly homozygotes during normal Na + intake may be a protective vascular mechanism in a population where the Gly allele is associated with hypertension. Support: HL‐63328, GCRC RR‐00585, NCRR K23‐17520.

Dietary sodium influences intermediate physiological traits in healthy young adults independent of changes in blood pressure. The purpose of this study was to test the hypothesis that dietary sodium affects cardiac autonomic function. In prospective, randomized cross‐over design separated by 1 month or more between diets, 69 normotensive healthy young adults (M/F: 26/43, ages 18–38 yr) consumed a 5‐day low (10 mmol/day), normal (150 mmol), and high sodium (400mmol) diet prior to a protocol examining cardiovascular traits including heart rate variability (HRV) by time domain and frequency domain analysis (Nevrokard). All women were studied in the low hormone phase of the menstrual cycle. Diet did not affect blood pressure, but HR (mean ± SE) was 68±1, 65±1, and 64±1 in low, normal, and high sodium conditions, resp. (RM ANOVA p < 0.01). For HRV there was a main effect of sodium on SDNN, RMSSD, HF, LFnu, HFnu, and LF/HF ratio (p < 0.01 for all). The response to low sodium was most marked and consistent with sympathetic activation, with increased LFnu and LF/HF ratio, and decreased SDNN, RMSSD, and HFnu compared to both normal and high sodium conditions (p ≤ 0.05 for all). These findings suggest that autonomic control of HRV is altered through changes in dietary sodium without changes in blood pressure. Support: UL1 TR000135 , HL‐89331

This analysis tested the hypothesis that current e-cigarette use was associated with an increased risk of SARS-CoV-2 infection in patients seeking medical care. E-cigarette and conventional cigarette use were ascertained using a novel electronic health record tool, and COVID-19 diagnosis was ascertained by a validated institutional registry. Logistic regression models were fit to assess whether current e-cigarette use was associated with an increased risk of COVID-19 diagnosis. A total of 69,264 patients who were over the age of 12 years, smoked cigarettes or vaped, and were sought medical care at Mayo Clinic between September 15, 2019 and November 30, 2020 were included. The average age was 51.5 years, 62.1% were females and 86.3% were white; 11.1% were currently smoking cigarettes or using e-cigarettes and 5.1% tested positive for SARS-CoV-2. Patients who used only e-cigarettes were not more likely to have a COVID-19 diagnosis (OR 0.93 [0.69-1.25], P = .628), whereas those who used only cigarettes had a decreased risk (OR 0.43 [0.35-0.53], P < .001). The OR for dual users fell between these 2 values (OR 0.67 [0.49-0.92], P = .013). Although e-cigarettes have the well-documented potential for harm, they do not appear to increase susceptibility to SARS-CoV-2 infection. This result suggests the hypothesis that any beneficial effects of conventional cigarette smoking on susceptibility are not mediated by nicotine.

Background: Nondepolarizing neuromuscular blockade is reversed with neostigmine/glycopyrrolate or sugammadex. Anticholinergic glycopyrrolate decreases bladder detrusor muscle contractility, potentially leading to postoperative urinary retention (POUR). POUR commonly complicates inguinal herniorrhaphy. In this study we assess association between reversal technique and POUR. Methods: Records of adult patients undergoing unilateral inguinal herniorrhaphy with neuromuscular blockade from January 2013 to September 2020 were reviewed for POUR (unplanned postoperative insertion of urinary catheter). A propensity-adjusted analysis was performed to assess POUR in neostigmine/glycopyrrolate versus sugammadex using inverse probability of treatment weighting (IPTW) to adjust for potential confounding. Results: We identified 181 patients who underwent herniorrhaphy with amnio-steroidal neuromuscular blockers, 75 (41.4%) who received sugammadex and 106 (58.6%) neostigmine/glycopyrrolate. Compared with sugammadex, neostigmine/glycopyrrolate group had longer surgical course [unweighted standardized difference (USTD)=0.38, P=0.004], received more intraoperative opioids (USTD=0.704, P<0.001), more often performed via laparoscopic approach (USTD=0.407, P=0.012), and less often with periprocedural urinary catheter insertion (USTD=0.452, P=0.003). POUR was observed in 2 (3%) of patients in the sugammadex group, and 16 (15%) in neostigmine/glycopyrrolate [unadjusted odds ratio (OR)=0.15; 95% confidence interval (CI): 0.03-0.69; P=0.015, and IPTW OR=0.13; 95% CI: 0.03-0.64; P=0.012]. Results remained similar with further analysis adjusted for opioid administration in the postanesthesia care unit (adjusted IPTW OR=0.18; 95% CI: 0.04-0.88; P=0.034). Of the POUR patients, 9 required unplanned overnight admission and 4 emergency room visit. Conclusion: These results suggest that neuromuscular blockade reversal with sugammadex is associated with lower rates of POUR following unilateral inguinal herniorrhaphy. Our results need to be reconfirmed in a randomized prospective study.

Purpose The purpose of the present study was to investigate body mass index, multi-morbidity, and COVID-19 Risk Score as predictors of severe COVID-19 outcomes. Patients Patients from this study are from a well-characterized patient cohort collected at Mayo Clinic between January 1, 2020 and May 23, 2020; with confirmed COVID-19 diagnosis defined as a positive result on reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assays from nasopharyngeal swab specimens. Measures Demographic and clinical data were extracted from the electronic medical record. The data included: date of birth, gender, ethnicity, race, marital status, medications (active COVID-19 agents), weight and height (from which the Body Mass Index (BMI) was calculated, history of smoking, and comorbid conditions to calculate the Charlson Comorbidity Index (CCI) and the U.S Department of Health and Human Services (DHHS) multi-morbidity score. An additional COVID-19 Risk Score was also included. Outcomes included hospital admission, ICU admission, and death. Results Cox proportional hazards models were used to determine the impact on mortality or hospital admission. Age, sex, and race (white/Latino, white/non-Latino, other, did not disclose) were adjusted for in the model. Patients with higher COVID-19 Risk Scores had a significantly higher likelihood of being at least admitted to the hospital (HR = 1.80; 95% CI = 1.30, 2.50; P < .001), or experiencing death or inpatient admission (includes ICU admissions) (HR = 1.20; 95% CI = 1.02, 1.42; P = .028). Age was the only statistically significant demographic predictor, but obesity was not a significant predictor of any of the outcomes. Conclusion Age and COVID-19 Risk Scores were significant predictors of severe COVID-19 outcomes. Further work should examine the properties of the COVID-19 Risk Factors Scale.

Objective The purpose of this study was to determine self-reported knowledge, attitudes, prior experience, and perceived needs for the management of overweight and obese patients within a General Internal Medicine Practice. Patients and Methods An emailed cross-sectional survey was sent between June 20, 2019 and September 12, 2019 to 194 healthcare workers (93 primary care providers (PCPs) and 101 nurses) which focused on management of patients with weight issues. Results In total, 80 of the eligible 194 participants completed the survey (nurses = 42, PCPs = 38). Up to 87% were white, 74.7% female (74.7%). Most of the responders were either in the age group of 30’s (30%) or 50’s (30%). Among the responders, 48.8% reported some type of specialty training in weight management since their medical training with lectures being the most common form of training (36%). When asked about their interest in either weight management training or strategies to initiate weight conversations, 79% of the respondents reported an interest in education on weight management or strategies to initiate weight conversations, while 65.8% indicated they would be interested in both topics. Conclusion Our study suggests that healthcare workers have a self-reported need for further training in management of overweight and obese patients, irrespective of previous training in this area.

Background Postoperative falls are preventable complications. The study aims were to describe the rate and circumstances surrounding postoperative falls and explore potential associations with patient and procedural characteristics with emphasis on the use of sedative medications. Methods Medical records of hospitalized patients undergoing non-lower extremity surgery under general anesthesia from January 1, 2010, through April 30, 2018 were reviewed for falls within 72 postoperative hours. Perioperative use of sedatives, sleep aids, gabapentinoids, and opioids were abstracted. Each fall case was matched with two controls on age, sex, and procedure type. Descriptive statistics and multivariable analysis accounting for the matched design were performed. Results There were 343 falls among 200 186 hospitalized surgical patients (incidence of 17.1 [95% CI: 15.4, 19.0] falls per 10 000 procedures) with largest proportion of falls occurring on postoperative day 2 (n = 134, 39.1%). Most falls occurred in the general hospital wards (n = 304, 88.6%) and were unwitnessed (n = 186, 55.9%). The incidence of major injuries was 1.0 (95% CI: .1 – 3.6) per 100 000 procedures. Home use of non-benzodiazepine hypnotics (odds ratio 2.68, 95% CI: 1.47, 4.88, P=.001) and blood transfusions were associated with increased fall risk. Hospital stay was longer in patients who fall (7 [4, 15] vs. 5 [3, 9] days, P < .001). Conclusions The rate of postoperative falls in our institution was low and frequently unwitnessed. The use of non-benzodiazepine hypnotics is a modifiable risk factor associated with postoperative falls. Serious complications after falls were rare.

Objective To describe the process and outcome of creating a patient cohort in the early stages of the COVID-19 pandemic in order to better understand the process of and predict the outcomes of COVID-19. Patients and Methods A total of 1169 adults aged 18 years of age or older who tested positive in Mayo Clinic Rochester or the Mayo Clinic Midwest Health System between January 1 and May 23 of 2020. Results Patients were on average 43.9 years of age and 50.7% were female. Most patients were white (69.0%), and Blacks (23.4%) and Asians (5.8%) were also represented in larger numbers. Hispanics represented 16.3% of the sample. Just under half of patients were married (48.4%). Common comorbid conditions included: cardiovascular diseases (25.1%), dyslipidemia (16.0%), diabetes mellitus (11.2%), chronic obstructive pulmonary disease (6.6%), asthma (7.5%), and cancer (5.1%). All other comorbid conditions were less the 5% in prevalence. Data on 3 comorbidity indices are also available including the: DHHS multi-morbidity score, Charlson Comorbidity Index, and Mayo Clinic COVID-19 Risk Factor Score. Conclusion In addition to managing the ever raging pandemic and growing death rates, it is equally important that we develop adequate resources for the investigation and understanding of COVID-19-related predictors and outcomes.

Objective To estimate the health care workers (HCWs) self-reported stress, resilience, and coping during the COVID-19 pandemic, and to determine inter-professional differences. Participants and Methods An email survey was sent to 474 HCW at a Midwestern HealthCare facility between April 9, 2020 and April 30, 2020. A total of 311 (65.6%) responses were received by May 31, 2020. The survey utilized 3 validated instruments: Perceived Stress Scale (PSS), Brief Resilience Scale (BRS), Brief Resilience Coping Scale (BRCS). Results Of the 311 responses, 302 were evaluated: 97 from nonmedical staff with patient contact (NMPC); 86 from nonmedical staff with no patient contact (NMNPC); 62 from medical doctors (MD), physician assistants (PA) and nurse practitioners (NP); and 57 from nurses. Significant differences were noted across job categories for stress and resilience, with nurses reporting highest PSS scores (effect estimates: −2.72, P = .009 for NMNPC; −2.50, P = .015 for NMPC; −3.21, P = .006 for MD/NP/PA respectively), and MD/NP/PA group with highest BRS scores: nurses (−0.31, P = .02); NMPC (−0.3333, P = .01); and NMNPC (−0.2828, P = .02). Younger personnel had higher stress (−1.59 per decade of age, P < .01) and more resilience (0.11 per decade of age, P = .002). Conclusion These self-reported data indicate that MD/NP/PA had the highest resilience scores and the nurses had highest stress levels. Efforts are warranted to include all HCWs in systematic stress mitigating interventions with particular attention to understand specific factors contributing to stress for the nursing team.