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Research and Discovery Pathways Programs
Medical Student Research Program Overview

Anesthesiology 2020 Projects

Project Title: Geospatial Disparities in Postoperative Outcomes

Faculty Mentor’s Name: Patrick Tighe
Email: ptighe@anest.ufl.edu

Student Name: Erin Locey
Email: erinlocey@ufl.edu

Research Project Description:

Goal: To integrate environmental, geospatial,, clinical, and psychosocial considerations on outcomes related to acute and persistent postsurgical pain, opioid and substance use disorder, and function-oriented patient-reported outcomes in patients undergoing a variety of surgical procedures.

Rationale: Our recent findings have uncovered important geospatial factors associated with perioperative pain-related outcomes. Patient location data (e.g. patient addresses) are commonly available, yet require unique data science techniques in order to extract relevant information (e.g. linkage with US census and public health data sources, sociodemographic and environmental characteristics, spatiotemporal statistical methods, etc.) It remains unclear how these geospatial factors interact with epigenetic, behavioral, socioeconomic, and clinical considerations previously associated with the perioperative pain outcome array. Identification of unique geospatial and environmental factors may point towards novel directions for intervention in the opioid use disorder crisis.

Mentees will learn key principles of epidemiological investigations using large spatiotemporal datasets. No prior experience in computer science, statistics, or geospatial analyses are required. This project is approved by the IRB.

Project Title: A Geospatial analysis of post-orthopedic surgical opioid prescriptions for elderly with and without dementia and associations with race

Faculty Mentor’s Name: Patrick Tighe
Email: ptighe@anest.ufl.edu

Student Name: Maria Juliana Pena 
Email: majulicat@ufl.edu

Research Project Description:

Studies have shown that elderly patients with a dementia diagnosis received less opioid orders compared to elderly without a dementia diagnosis (4,5,7), even when patients with dementia reported a greater pain intensity. However, there have been no clear studies that demonstrate that opioids lead to dementia agitation or significant cognitive decline (1,2). In addition to this variance in opioid prescribing practices, another trend that studies have demonstrated are differences in prescribing practices based on race. Studies show that whites are more likely to be prescribed opioids (10) and non-Hispanic Blacks were less likely (3,12). Finally, geography is a recognized factor in differences in opioid prescribing decisions in a great variety of surgeries (11). It has been found that opioid dose prescribing exhibit clustering of patients location of residence at both the global and local levels (9).

Historically, there has been little guidance offered to physicians on postoperative opioid prescribing at the time of discharge (8), this likely has lead to the high variability in opioid prescribing practice. This gap in opioid prescription could be causing unnecessary suffering from severe pain in vulnerable populations. Furthermore, inappropriate opioid prescription has contributed to the current epidemic of opioid use disorder (6). Therefore it is important to find these gaps in opioid prescription practices in order to address them and create more equitable guidelines

  1. Brown, R., Howard, R., Candy, B., & Sampson, E. L. (2015). Opioids for agitation in dementia. Cochrane Database of Systematic Reviews, (5).
  2. Dublin, S., Walker, R. L., Gray, S. L., Hubbard, R. A., Anderson, M. L., Yu, O., … & Larson, E. B. (2015). Prescription opioids and risk of dementia or cognitive decline: a prospective cohort study. Journal of the American Geriatrics Society, 63(8), 1519-1526
  3. Goyal, M. K., Kuppermann, N., Cleary, S. D., Teach, S. J., & Chamberlain, J. M. (2015). Racial disparities in pain management of children with appendicitis in emergency departments. JAMA pediatrics, 169(11), 996-1002.
  4. Husebo, B. S., Strand, L. I., Moe-Nilssen, R., BorgeHusebo, S., Aarsland, D., & Ljunggren, A. E. (2008). Who suffers most? Dementia and pain in nursing home patients: a cross-sectional study. Journal of the American Medical Directors Association, 9(6), 427-433.
  5. Jensen-Dahm, C., Palm, H., Gasse, C., Dahl, J. B., & Waldemar, G. (2016). Postoperative treatment of pain after hip fracture in elderly patients with dementia. Dementia and geriatric cognitive disorders, 41(3-4), 181-191
  6. 6.Makary MA, Overton HN, Wang P. Overprescribing is major contributor to opioid crisis. BMJ 2017;359:j4792
  7. Monroe, T. B., Misra, S. K., Habermann, R. C., Dietrich, M. S., Cowan, R. L., & Simmons, S. F. (2014). Pain reports and pain medication treatment in nursing home residents with and without dementia. Geriatrics & gerontology international, 14(3), 541-548.
  8. 8.Overton HN, Hanna MN, Bruhn WE, Hutfless S, Bicket MC, Makary MA. Opioid-prescribing guidelines for common surgical procedures: An expert panel consensus. J Am Coll Surg 2018; 227(4):411–8.
  9. Patrick Tighe, MD, MS, François Modave, PhD, MaryBeth Horodyski, EdD, Matthew Marsik, PhD, G Lipori, MBA, Roger Fillingim, PhD, Hui Hu, PhD, Jennifer Hagen, MD, Geospatial Analyses of Pain Intensity and Opioid Unit Doses Prescribed on the Day of Discharge Following Orthopedic Surgery, Pain Medicine, , pnz311,
  10. Pletcher, M. J., Kertesz, S. G., Kohn, M. A., & Gonzales, R. (2008). Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. Jama, 299(1), 70-78.
  11. Rabbitts JA, Groenewald CB, R€as€anen J. Geographic differences in perioperative opioid administration in children. Paediatr Anaesth 2012;22(7):676–81.
  12. Singhal, A., Tien, Y. Y., & Hsia, R. Y. (2016). Racial-ethnic disparities in opioid prescriptions at emergency department visits for conditions commonly associated with prescription drug abuse. PloS one, 11(8).

Project Title: Enhanced Recovery After Surgery Clinical Pathway for Transforaminal Lumbar Interbody Fusion Surgery Patients and Perioperative Outcome

Faculty Mentor’s Name: Basma Mohamed 
Email: bmohamed@anest.ufl.edu 

Student Name: Ronny Samra
Email: Ronnys@ufl.edu 

Research Project Description:

Transforaminal Lumbar Interbody Fusion (TLIF) is an invasive spinal surgery used to treat lower back pain caused by conditions that cause spinal instability and weakness such as degenerative disc disease, disc herniation, and spondylolisthesis (1). The transforaminal approach of this surgery has been shown to decrease operation time, blood loss, and incidence of dural tear and nerve root injury compared to the posterior approach (2). However, it remains that lumbar fusion procedures can lead to complications, post-operative pain, and prolonged recovery which may deter patients from undergoing the procedure (3). Thus, implementation of strategies to reduce complication rates is necessary to improve patient outcomes.
Enhanced Recovery After Surgery (ERAS) is a multimodal protocol consisting of evidence-based preoperative, intraoperative, and postoperative interventions that aim to reduce complications and enhance recovery (4). This protocol was first implemented to improve outcomes in colorectal procedures but is now used in many surgical subspecialties, such as cardiothoracic, and oncologic surgery (4). There is sufficient evidence to expand the use of this protocol to spinal surgeries based on the recent increase in demand and the variable rate of complications associated with these surgeries (5). Thus, the ERAS protocol was implemented in TLIF procedures at UF to standardize patient care and minimize post-operative complications.

  1. Figueiredo N, Martins JWG, Arruda AA, et al. TLIF–transforaminal lumbar interbody fusion. Arq Neuropsiquiatr. 2004;62(3B):815-820. doi:10.1590/s0004-282×2004000500014
  2. Lan T, Hu S-Y, Zhang Y-T, et al. Comparison Between Posterior Lumbar Interbody Fusion and Transforaminal Lumbar Interbody Fusion for the Treatment of Lumbar Degenerative Diseases: A Systematic Review and Meta-Analysis. World Neurosurg. 2018;112:86-93. doi:10.1016/j.wneu.2018.01.021
  3. Mazur MD, Dailey AT. Editorial. Reducing the burden of spine fusion. Neurosurg Focus. 2019;46(4):E15. doi:10.3171/2019.1.FOCUS1945
  4. Cooper SL, Panesar P. Preoperative optimization and enhanced recovery after surgery. Surgery (Oxford). November 2019. doi:10.1016/j.mpsur.2019.10.006
  5. Wainwright TW, Immins T, Middleton RG. Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery. Best Pract Res Clin Anaesthesiol. 2016;30(1):91-102. doi:10.1016/j.bpa.2015.11.001
  6. Soffin EM, Wetmore DS, Barber LA, et al. An enhanced recovery after surgery pathway: association with rapid discharge and minimal complications after anterior cervical spine surgery. Neurosurg Focus. 2019;46(4):E9. doi:10.3171/2019.1.FOCUS18643
  7. Tarıkçı Kılıç E, Demirbilek T, Naderi S. Does an enhanced recovery after surgery protocol change costs and outcomes of single-level lumbar microdiscectomy? Neurosurg Focus. 2019;46(4):E10. doi:10.3171/2019.1.FOCUS18665

Project Title: Geospatial analysis of pre-op education for adults age 55 and older in relationship to postoperative pain-related outcomes

Faculty Mentor’s Name: Patrick Tighe
Email: ptighe@anest.ufl.edu

Student Name: Precious Ichite
Email: pcichite@ufl.edu

Research Project Description:

There is a substantial amount of data and literature suggesting a potential correlation between the education level of patients electing to undergo various surgical procedures and their post-operative pain management outcomes (1,3,5) . Many of these studies suggest that health literacy plays a profound role in the post-operative outcomes of these patients. Generally, patients who have had the opportunity to achieve a higher level of education tend to have better health and post-operative outcomes than patients that achieved lower levels of education. It is speculated that this may likely be due to an overall higher level of health literacy, as well as better access to health resources (1).

In addition to that, there is geospatial research showing that there is a relationship between dispersion of patient location of residence and postoperative pain intensity opioids prescribed on discharge following orthopedic surgery. These studies include data suggesting that opioid dose prescribing practices exhibit clustering of patient location at both the global and local levels (4). However, there is no research looking directly at how patient outcomes may vary based on geospatial locations, in addition to varying education levels. Being able to look closely at these specific factors in conjunction will aid clinicians in further understanding many of the underlying health disparities that may be unknowingly taking place within their practice. Knowledge of these health disparities is a vital component towards medical decision making, particularly among an increasingly diverse population (2).

  1. Kugelman, D. N., Haglin, J. M., Carlock, K. D., Konda, S. R., & Egol, K. A. (2019). The association between patient education level and economic status on outcomes following surgical management of (fracture) non-union. Injury, 50(2), 344–350. doi: 10.1016/j.injury.2018.12.013
  2. Pate, J. W., Veage, S., Lee, S., Hancock, M. J., Hush, J. M., & Pacey, V. (2019). Which Patients With Chronic Pain Are More Likely to Improve Pain Biology Knowledge Following Education? Pain Practice, 19(4), 363–369. doi: 10.1111/papr.12748
  3. Sany, S. B. T., Behzhad, F., Ferns, G., & Peyman, N. (2019). Communication Skills Training for Physicians Improves Health Literacy and Medical Outcomes among Patients with Hypertension: A Randomized Controlled Trial. doi: 10.21203/rs.2.13036/v1
  4. Tighe, P., Modave, F., Horodyski, M., Marsik, M., Lipori, G., Fillingim, R., … Hagen, J. (2019). Geospatial Analyses of Pain Intensity and Opioid Unit Doses Prescribed on the Day of Discharge Following Orthopedic Surgery. Pain Medicine. doi: 10.1093/pm/pnz311
  5. Yajnik, M., Hill, J. N., Hunter, O. O., Howard, S. K., Kim, T. E., Harrison, T. K., & Mariano, E. R. (2019). Patient education and engagement in postoperative pain management decreases opioid use following knee replacement surgery. Patient Education and Counseling, 102(2), 383–387. doi: 10.1016/j.pec.2018.09.001

Project Title: Postoperative Urinary Retention (POUR) in Patients with Parkinson’s Disease (PD)

Faculty Mentor’s Name: Steven Robicsek
Email: srobicsek@anest.ufl.edu 

Student Name: Victor Silva 
Email: victorsilva1108@ufl.edu 

Research Project Description:

POUR is a well-recognized potential complication for surgical patients undergoing anesthesia (1,4). Retention can often lead to urinary tract infection, urosepsis and hematuria, in acute cases with issues with incontinence, hydronephrosis, and renal failure being associated with chronic urinary retention (1). Urinary retention can prolong hospital stays and although catheterization can be used to treat POUR, its use presents increased risks for significant morbidities to the patient (2,5). Complications of catheterization secondary to POUR can include urinary tract infections, urethral strictures, and irreversible damage to the bladder nerves (2). Catheter associated complications can even result in the need for additional surgeries to correct (2).

In terms of surgically related risk factors, the type of procedure, operating room time, and the use of intravenous fluids have all been shown to increase the risk of urinary retention by varying degrees (1). Laparoscopic surgeries have been shown to present a higher risk for POUR with one study reporting that there was a 7.9% rate of retention for patients undergoing laparoscopic hernia repairs compared to a 1.1% rate in those who had open procedures (1). A separate prospective observational study also reported an increased rate of retention following laparoscopic surgery (40%) compared to open surgery (12%) but this time in patients undergoing colorectal surgery (1). A potential explanation for the increased risk could be possible nerve damage as a result of the increased need for retraction and instrument grasping in laparoscopic surgeries (1). Of note, anorectal surgeries carry a risk of POUR ranging anywhere from 1% to 52% due to injury of the pelvic nerves and increase in tone of the internal sphincter (3).

Operating room times have been associated with increased risk of urinary retention with one institutional review reporting an 11% increase for every 10-minute increase (1). As reported by Kowalik et al., operating times greater than 120 minutes presented a 3-fold increase in the risk for POUR (1). The general rule is that indwelling urinary catheters should be used for operations expected to last longer than 3 hours (1). Another study evaluated patients undergoing bariatric surgery found that factors such as decreased neostigmine dosing in the reversal of anesthesia correlated with an increase in POUR in patients (5). Increased use of intraoperative intravenous fluids has also been shown to increase the risk for retention (3,4). One study found that the administration of IV fluids greater than 750 mL perioperatively increased the risk of urinary retention by 2.3 times in patients undergoing hernia repair and anorectal surgery (3). The idea is that overdistension of the bladder caused by excessive infusion of IV fluids inhibits detrusor function and thus micturition (3).

Bladder dysfunction (excessive urinary urgency/frequency, incontinence) is one of the most common autonomic disorders in PD. The pathophysiology has been extensively reviewed by Sakakibaraa and colleagues in 2012 and 2016. (6,7) The neural circuitry involved is illustrated in Figure 1. (Figure included in the proposal that was emailed to the MSRP office)

DBS is a surgical procedure that involves implanting electrodes in the midbrain, which deliver electrical impulses that block or change the abnormal activity. Initially indicated for movement disorders such as PD and essential tremor, DBS has been used to treat a number of disorders including dystonia, epilepsy, essential tremor, obsessive-compulsive disorder, and Tourette syndrome. At the University of Florida, DBS is performed by a single surgeon and as two separate surgeries. In the first surgery the patient is awake, receives local anesthetic for electrode placement. Battery implantation is a second surgery and is performed under general anesthesia.

(1) Kowalik, Urszula, and Mark K. Plante. “Urinary Retention in Surgical Patients.” Surgical Clinics of North America, vol. 96, no. 3, June 2016, pp. 453–467., doi:10.1016/j.suc.2016.02.004.

(2) Darrah, Daniela M., et al. “Postoperative Urinary Retention.” Anesthesiology Clinics, vol. 27, no. 3, Sept. 2009, pp. 465–484., doi:10.1016/j.anclin.2009.07.010.

(3) Baldini, Gabriele, et al. “Postoperative Urinary Retention: Anesthetic and Perioperative Considerations.” Anesthesiology, vol. 110, no. 5, May 2009, pp. 1139–1157., doi:10.1097/aln.0b013e31819f7aea.

(4) Altschul, David, et al. “Postoperative Urinary Retention in Patients Undergoing Elective Spinal Surgery.” J Neurosurgery: Spine, vol. 26, no. 2, 2017, pp. 229–234., doi:10.3171/2016.8.spine151371.

(5) Roadman, Daniel, et al. “Postoperative Urinary Retention After Bariatric Surgery: An Institutional Analysis.” J Surgical Res, vol. 243, 2019, pp. 83–89., doi:10.1016/j.jss.2019.05.005.

(6) Sakakibaraa R, Tatenoa F, Kishia M, Tsuyuzakia Y, Uchiyamab T, Yamamoto T. Pathophysiology of bladder dysfunction in Parkinson’s disease. Neurobiology of Disease
Volume 46, Issue 3, June 2012, Pages 565-571 https://doi.org/10.1016/j.nbd.2011.10.002

(7) Sakakibara R, Panicker J, Finazzi-Agro E, Iacovelli V, Bruschini H, et al. A Guideline for the Management of Bladder Dysfunction in Parkinson’s Disease and Other Gait Disorders. Neurourology Urodynamics 35:551–563 (2016).

Project Title: Prehabilitation for Frail Patients Undergoing Spine Surgery

Faculty Mentor: Basma Mohamed
Email: BMohamed@anest.ufl.edu

Student:Jesse Caron 
Email: jesse.caron@ufl.edu 

Research Project Description:

Frailty is a multidimensional syndrome characterizing diminished strength, endurance, and physiologic function. Such a clinical state leaves patients vulnerable to different stressors, particularly surgical, throughout the perioperative period. Perioperative outcomes are therefore affected by frailty, as frail patients have increased risk of morbidity and mortality, as well as longer recovery time. From the National Surgical Quality Improvement Program, increased frailty in patients was associated with increased risk of failure to rescue.1 Increased frailty, as measured by the modified frailty index, has been associated with higher risk of 30-day postoperative morbidity and mortality for spine surgery.2 Prehabilitation is a preoperative intervention designed to strengthen patients’ physical stamina, thereby bolstering physiological function and vitality ahead of surgery. By preparing patients’ physical condition, prehabilitation has the potential to address the physiological vulnerabilities and adverse perioperative outcomes associated with frailty.

There is extensive evidence of the effectiveness of prehabilitation programs in improving perioperative outcomes. A minimum-4-week prehabilitation program involving a personalized physical activity program (with supervised high-intensity endurance exercise training) for patients undergoing major abdominal surgery enhanced aerobic capacity and reduced perioperative complication rates, while also lowering the overall number of patients with postoperative complications by 51%.3 A two-week multimodal prehabilitation program involving aerobic and resistance exercises, respiratory training, and nutritional and psychological support for patients undergoing thoracoscopic lobectomy succeeded in increasing average 6-minute walk distance by 60.9 m.4 Although the data on lumbar and thoracolumbar spine surgery patients is limited, there is some evidence of prehabilitation efficacy. A 6-week personalized, exercise-based rehabilitation for patients undergoing lumbar spinal stenosis surgery produced improved preoperative outcomes such as active ranges of motion, leg pain intensity, lumbar extensor muscle endurance, and walking capacities; patients also had high satisfaction rates without adverse events.5 Through a quality improvement project which implemented preoperative assessment and prehabilitation protocol at our institution, we would like to build on the current body of research by evaluating the impact of prehabilitation on spine surgery patients’ functional capacity and ability to participate in physical therapy in the postoperative period.

We hypothesize that that the implementation of prehabilitaiton will:

  1. Decrease hospital length of stay
  2. Increase active participation in Physical Therapy/Occupational Therapy (PT/OT)
  3. Decrease any complications
  4. Prevent unplanned ICU admission
  5. Decrease readmission rate.
  6. Decrease admission to rehab facility: (social factors will need to be matched)

Specific Aims:

This is a retrospective analysis that aims to evaluate a prospectively implemented perioperative optimization and enhanced post-surgical recovery clinical pathway for patients who underwent spine surgery. The clinical pathway was implemented as a quality improvement project (QIPR project ID 179) to reduce variability among providers and increase quality of care by using the concepts of perioperative surgical home and enhanced recovery after surgery. The prehabilitation stage in this clinical pathway is of particular interest for improving postoperative outcome and patient wellbeing.

Therefore, we hypothesize that that the implementation of prehabilitaiton will:

  1. Decrease hospital length of stay
  2. Increase active participation in Physical Therapy/Occupational Therapy (PT/OT)
  3. Decrease any complications
  4. Prevent unplanned ICU admission
  5. Decrease readmission rate.
  6. Decrease admission to rehab facility: (social factors will need to be matched)

Evaluation of prehabilitation will entail outcome comparison of frail patients who underwent prehabilitation protocol to those who did not.

Primary outcomes:

  1. Length of hospital stay.
  2. Unexpected ICU admission
  3. Active Participation in PT/OT

Secondary outcome:

  1. Incidence of postoperative complications
  2. 30-day hospital re-admission rate
  3. Discharge to rehabilitation rate.

References:

  1. Shah R, Attwood K, Arya S, et al. Association of Frailty With Failure to Rescue After Low-Risk and High-Risk Inpatient Surgery. JAMA Surg 2018;153(5):e180214. doi:10.1001/jamasurg.2018.0214.
  2. Ali R, Schwalb JM, Nerenz DR, Antoine HJ, Rubinfeld I. Use of the modified frailty index to predict 30-day morbidity and mortality from spine surgery. J Neurosurg Spine 2016;25(4):537-541. doi:10.3171/2015.10.SPINE14582.
  3. Barberan-Garcia A, Ubré M, Roca J, et al. Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial. Ann. Surg. 2018;267(1):50-56. doi:10.1097/SLA.0000000000002293.
  4. Liu Z, Qiu T, Pei L, et al. Two-Week Multimodal Prehabilitation Program Improves Perioperative Functional Capability in Patients Undergoing Thoracoscopic Lobectomy for Lung Cancer: A Randomized Controlled Trial. Anesth. Analg. 2019. doi:10.1213/ANE.0000000000004342.
  5. Marchand A-A, Suitner M, O’Shaughnessy J, Châtillon C-É, Cantin V, Descarreaux M. Feasibility of conducting an active exercise prehabilitation program in patients awaiting spinal stenosis surgery: a randomized pilot study. Sci. Rep. 2019;9(1):12257. doi:10.1038/s41598-019-48736-7.