Publications by authors named "Ryan Howard"

57 Publications

Postoperative Opioid Prescription and Use After Outpatient Vascular Access Surgery.

J Surg Res 2021 Apr 6;264:173-178. Epub 2021 Apr 6.

Michigan Opioid Prescribing and Engagement Network, Ann Arbor, Michigan; Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan.

Background: Larger opioid prescriptions are associated with increased consumption without improvements in pain, and the majority of opioids prescribed go unused. We examined postoperative opioid prescription and use in patients undergoing vascular access surgery, where preoperative opioid exposure is common.

Methods: A retrospective analysis was conducted in adult CKD patients who underwent outpatient vascular access surgery. Patients were surveyed by telephone >2 weeks after surgery to assess pain level and opioid and non-opioid medication use.

Results: Of 117 patients contacted, 76 responded (65% response rate), with a median (interquartile range) age of 56 (42-69) years. Sixty-three patients (83%) were prescribed an opioid postoperatively. Respondents were prescribed 60 (38-75) oral morphine equivalents (OMEs) and consumed 0 (0-15) OMEs over 1 day with a pain score of 5 out of 10. Thirty-nine patients (>50%) used no opioids. There were no differences in postoperative opioid prescribing or use in patients with recent opioid exposure compared to patients without. Patients who underwent arteriovenous fistula (AVF) creation (short surgical incision procedure) were prescribed 60 (38-75) OMEs, compared with 75 (56-111) OMEs for patients who underwent AVF superficialization, AVG, or BVT (long surgical incision procedure; P < 0.01) and consumed 0 (0-15) OMEs compared with 10 (0-43) OMEs, respectively (P = 0.07).

Conclusion: Regardless of preoperative opioid exposure, CKD patients undergoing vascular access surgery consumed fewer opioids than prescribed, with a median of <10% of opioids used. Therefore, we've reduced our institutional prescribing recommendations to 4 and 6 oxycodone 5mg pills for short and long surgical incision procedures, respectively.
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http://dx.doi.org/10.1016/j.jss.2021.02.005DOI Listing
April 2021

The Impact of Surgeon Adherence to Preoperative Optimization of Hernia Repairs.

J Surg Res 2021 Mar 18;264:8-15. Epub 2021 Mar 18.

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan. Electronic address:

Background: At the patient level, optimizing risk factors before surgery is a proven approach to improve patient outcomes after hernia repair. However, nearly 25% of patients are not adequately optimized before surgery. It is currently unknown how surgeon-level adherence to preoperative optimization impacts postoperative outcomes. In this context, we evaluated the association between surgeon adherence to optimization practices and surgeon-level postoperative outcomes.

Materials And Methods: Michigan Surgical Quality Collaborative data from 2014 to 2018 was analyzed to examine rates of surgeon adherence to preoperative optimization when performing elective ventral and incisional hernia repair. Adherence was defined as operating on patients who were nontobacco users with a body mass index >18.5 kg/m2 and <40 kg/m2. Surgeons were assigned a risk- and reliability-adjusted adherence rate which was used to divide surgeons into tertiles. Outcomes were compared between adherence tertiles.

Results: Across 70 hospitals in Michigan, 15,016 patients underwent ventral and incisional hernia repair, cared for by 454 surgeons. Surgeon adherence to preoperative optimization ranged from 51% to 76%. Surgeons in the lowest optimization tertile had higher rates of emergency department visits (8.78% versus 7.05% versus 7.03%, P < 0.001), serious complications (2.12% versus 1.56% versus 1.84%, P = 0.041), and any complication (4.08% versus 3.37% versus 4.04%, P = 0.043), than middle and high optimization tertiles.

Conclusions: Surgeons' clinical outcomes, including complication rates, are affected by the proportion of their patients who are preoperatively optimized with regard to obesity and tobacco use. These results suggest that surgeons can improve their postoperative outcomes by addressing these issues before surgery.
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http://dx.doi.org/10.1016/j.jss.2021.01.044DOI Listing
March 2021

Prevalence and Trends in Smoking Among Surgical Patients in Michigan, 2012-2019.

JAMA Netw Open 2021 Mar 1;4(3):e210553. Epub 2021 Mar 1.

Department of Surgery, University of Michigan, Ann Arbor.

Importance: Surgery is a teachable moment, and smoking cessation interventions that coincide with an episode of surgical care are especially effective. Implementing these interventions at a large scale requires understanding the prevalence and characteristics of smoking among surgical patients.

Objectives: To describe the prevalence of smoking in a population of patients undergoing common surgical procedures and to identify any clinical or demographic characteristics associated with smoking.

Design, Setting, And Participants: This cross-sectional study included all adult patients (aged ≥18 years) in a statewide registry who underwent general and vascular surgical procedures from 2012 to 2019 at 70 hospitals in Michigan. Data analysis was conducted from August to October 2020.

Exposures: Undergoing a surgical procedure in any of the following categories: appendectomy, cholecystectomy, colon procedures, gastric or esophageal procedures, hepatopancreatobiliary procedures, hernia repair, small-bowel procedures, hysterectomy, vascular procedures, thyroidectomy, and other unspecific abdominal procedures.

Main Outcomes And Measures: The prevalence of smoking prior to surgery, defined as cigarette use in the year prior to surgery, obtained from medical record review. Multivariable logistic regression was performed to analyze smoking prevalence based on insurance type and year of surgery while adjusting for demographic and clinical factors, including age, sex, race/ethnicity (determined from the medical record), insurance type, geographic region, comorbidities (ie, hypertension, diabetes, congestive heart failure, chronic obstructive pulmonary disease, chronic steroid use, and obstructive sleep apnea), American Society of Anesthesiologists classification, admission status, surgical priority, procedure type, and year of surgery.

Results: From 2012 to 2019, 328 578 patients underwent surgery and were included in analysis. Mean (SD) age was 54.0 (17.0) years, and 197 501 patients (60.1%) were women. The overall prevalence of smoking was 24.1% (79 152 patients). Prevalence varied regionally from 21.5% (95% CI, 21.0%-21.9%; 6686 of 31 172 patients) in southeast Michigan to 28.0% (95% CI, 27.1%-28.9%; 2696 of 9614 patients) in northeast Michigan. When adjusting for clinical and demographic factors, there were greater odds of smoking among patients with Medicaid (odds ratio [OR], 2.75; 95% CI, 2.69-2.82) and patients without insurance (OR, 2.21; 95% CI, 2.10-2.33) compared with patients with private insurance. Among procedure categories, patients undergoing vascular surgery had greater odds of smoking (OR, 3.24; 95% CI, 3.11-3.38) than those undergoing cholecystectomy. Compared with 2012, the adjusted odds of smoking decreased significantly each year (eg, 2019: OR, 0.78; 95% CI, 0.74-0.81). In 2019, the adjusted prevalence of smoking was 22.3% (95% CI, 22.0%-22.7%) among all patients, 43.0% (95% CI, 42.4%-43.6%) among patients with Medicaid, and 36.3% (95% CI, 35.2%-37.4%) among patients without insurance.

Conclusions And Relevance: In a statewide population of surgical patients, nearly one-quarter of patients smoked cigarettes, which is higher than the national average. The prevalence of smoking was especially high among patients without insurance and among those receiving Medicaid. Given the established association between undergoing a major surgical procedure and health behavior change, targeted smoking cessation interventions at the time of surgery may be an effective strategy to improve population health, especially among at-risk patient groups.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.0553DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930923PMC
March 2021

Post-Acute Care Utilization and Episode of Care Payments Following Common Elective Operations.

Ann Surg 2021 Feb 12. Epub 2021 Feb 12.

*Department of Surgery, University of Michigan, Ann Arbor, MI, USA †Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA ‡University of Michigan Medical School, Ann Arbor, MI, USA.

Objective: To describe post-acute care (PAC) utilization and associated payments for patients undergoing common elective procedures.

Summary Background Data: Utilization and costs of PAC are well described for benchmarked conditions and operations but remain understudied for common elective procedures.

Methods: Cross-sectional study of adult patients in a statewide administrative claims database undergoing elective cholecystectomy, ventral or incisional hernia repair (VIHR), and groin hernia repair from 2012-2019. We used multivariable logistic regression to estimate the odds of PAC utilization, and multivariable linear regression to determine the association of 90-day episode of care payments and PAC utilization.

Results: Among 34,717 patients undergoing elective cholecystectomy, 0.7% utilized PAC resulting in significantly higher payments ($19,047 vs $7,830, p < 0.001). Among 29,826 patients undergoing VIHR, 1.7% utilized PAC resulting in significantly higher payments ($19,766 vs $9,439, p < 0.001). Among 37,006 patients undergoing groin hernia repair, 0.3% utilized PAC services resulting in significantly higher payments ($14,886 vs $8,062, p < 0.001). We found both modifiable and non-modifiable risk factors associated with PAC utilization. Morbid obesity was associated with PAC utilization following VIHR (OR 1.61, 95% CI 1.29-2.02, p < 0.001). Male sex was associated with lower odds of PAC utilization for VIHR (OR 0.43, 95% CI 0.35-0.51, p < 0.001) and groin hernia repair (OR 0.62, 95% CI 0.39-0.98, p = 0.039).

Conclusions: We found both modifiable (e.g. obesity) and non-modifiable (e.g. female sex) patient factors that were associated with PAC. Optimizing patients to reduce PAC utilization requires an understanding of patient risk factors as well as systems and processes to address these factors.
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http://dx.doi.org/10.1097/SLA.0000000000004814DOI Listing
February 2021

Association of Postoperative Opioid Prescription Size and Patient Satisfaction.

Ann Surg 2021 Feb 1. Epub 2021 Feb 1.

Department of Surgery, University of Michigan, Ann Arbor, MI Michigan Surgical Quality Collaborative, Ann Arbor, MI Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI.

Objective: To evaluate the association between postoperative opioid prescription size and patient-reported satisfaction among surgical patients.

Summary Background Data: Opioids are overprescribed after surgery, which negatively impacts patient outcomes. The assumption that larger prescriptions increase patient satisfaction has been suggested as an important driver of excessive prescribing.

Methods: This prospective cohort study evaluated opioid-naïve adult patients undergoing laparoscopic cholecystectomy, laparoscopic appendectomy, and minor hernia repair between January 1 and May 31, 2018. The primary outcome was patient satisfaction, collected via a 30-day postoperative survey. Satisfaction was measured on a scale of 0-10 and dichotomized into "highly satisfied" (9-10) and "not highly satisfied" (0-8). The explanatory variable of interest was size of opioid prescription at discharge from surgery, converted into milligrams of oral morphine equivalents (OME). Hierarchical logistic regression was performed to evaluate the association between prescription size and satisfaction while adjusting for clinical covariates.

Results: 1520 patients met the inclusion criteria. Mean age was 53 years and 43% of patients were female. 1279 (84.1%) patients were highly satisfied and 241 (15.9%) were not highly satisfied. After multivariable adjustment, there was no significant association between opioid prescription size and satisfaction (OR 1.00, 95% CI 0.99-1.00). The predicted probability of being highly satisfied ranged from 83% for the smallest prescription (25 mg OME) to 85% for the largest prescription (750 mg OME).

Conclusions: In a large cohort of patients undergoing common surgical procedures, there was no association between opioid prescription size at discharge after surgery and patient satisfaction. This implies that surgeons can provide significantly smaller opioid prescriptions after surgery without negatively affecting patient satisfaction.
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http://dx.doi.org/10.1097/SLA.0000000000004784DOI Listing
February 2021

Hospital and surgeon variation in 30-day complication rates after ventral hernia repair.

Am J Surg 2020 Dec 11. Epub 2020 Dec 11.

Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA; Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA; Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA. Electronic address:

Background: Ventral hernia repair is an extremely common operation, however the variability in patient outcomes between individual hospitals and surgeons is unclear. We analyzed variability in 30-day complication rates and identified specific complications that contributed to this variability.

Methods: Retrospective, cross-sectional analysis of 30-day complication rates following ventral hernia repair across 73 hospital and 978 surgeons between January 1, 2014 and December 31, 2018.

Results: Data were collected on 19,007 patients who underwent VIHR at 73 hospitals across 978 surgeons. Adjusted complication rate among hospitals was 6.2% (range 4.3%-12.8%) and among surgeons was 6.2% (range 3.5%-26.8%). Variation between lowest and highest quartile surgeons was greatest for acute kidney injury (0.12% vs. 1.71%, P < 0.001), superficial surgical site infection (0.33% vs. 3.62%, P < 0.001), sepsis (0.27% vs. 2.47%, P < 0.001), and catheter-associated urinary tract infection (0.02% vs. 0.30%, P < 0.001).

Conclusion: After adjusting for a number of patient-specific clinical variables, there is significant variation in 30-day complication rates after ventral hernia repair. This represents a significant opportunity to improve patient outcomes.
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http://dx.doi.org/10.1016/j.amjsurg.2020.12.021DOI Listing
December 2020

Excessive Opioid Prescribing After Surgery - A Uniquely American Problem.

Ann Surg 2020 12;272(6):887-888

Michigan Opioid Prescribing and Engagement Network, Ann Arbor, Michigan.

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http://dx.doi.org/10.1097/SLA.0000000000004392DOI Listing
December 2020

Opioid prescribing exceeds consumption following common surgical oncology procedures.

J Surg Oncol 2021 Jan 30;123(1):352-356. Epub 2020 Oct 30.

Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.

Background And Objectives: Surgical oncology patients are vulnerable to persistent opioid use. As such, we aim to compare opioid prescribing to opioid consumption for common surgical oncology procedures.

Methods: We prospectively identified patients undergoing common surgical oncology procedures at a single academic institution (August 2017-March 2018). Patients were contacted by telephone within 6 months of surgery and asked to report their opioid consumption and describe their discharge instructions and opioid handling practices.

Results: Of the 439 patients who were approached via telephone, 270 completed at least one survey portion. The median quantity of opioid prescribed was significantly larger than consumed following breast biopsy (5 vs. 2 tablets of 5 mg oxycodone, p < .001), lumpectomy (10 vs. 2 tablets of 5 mg oxycodone, p < .001), and mastectomy or wide local excision (20 tablets vs. 2 tablets of 5 mg oxycodone, p < .001). The majority of patients reported receiving education on taking opioids, but only 27% received instructions on proper disposal; 82% of prescriptions filled resulted in unused opioids, and only 11% of these patients safely disposed of them.

Conclusions: This study demonstrates that opioid prescribing exceeds consumption following common surgical oncology procedures, indicating the potential for reductions in prescribing.
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http://dx.doi.org/10.1002/jso.26272DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7770117PMC
January 2021

New Persistent Opioid Use After Inguinal Hernia Repair.

Ann Surg 2020 Oct 15. Epub 2020 Oct 15.

Department of Surgery, Michigan Medicine, Ann Arbor, MI.

Objective: Describe the incidence of new persistent opioid use after inguinal hernia repair as well as its associated risk factors.

Summary Background Data: The development of new persistent opioid use after surgery is a common complication, however its incidence following inguinal hernia repair has not been described. Given that roughly 800,000 inguinal hernia repairs are performed annually in the United States, any incidence could have profound implications for patients.

Methods: Retrospective cross-sectional study of the incidence of new persistent opioid use after inguinal hernia repair using a national database of de-identified administrative health claims of opioid-naïve patients undergoing surgery from 2008-2016.

Results: During the study period, 59,795 opioid-naïve patients underwent inguinal hernia repair and met inclusion criteria. Mean (SD) age was 57.8 (16.1) years old and 55,014 (92%) patients were male. 922 (1.5%) patients continued filling opioids prescriptions for at least 3 months after surgery. The most significant risk factor for developing new persistent opioid use after surgery was filling an opioid prescription in the 30 days prior to surgery (OR 4.34, 95% CI 3.75-5.01). These prescriptions were provided by surgeons in 52% of cases and primary care physicians in 16% of cases. Other risk factors for new persistent opioid use included receiving a larger opioid prescription, having more comorbidities, having a major postoperative complication, and certain mental health disorders and pain disorders.

Conclusion: After undergoing inguinal hernia repair, 1.5% of patients developed new persistent opioid use. Filling an opioid prescription in the 30 days prior to surgery had the strongest association with this complication.
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http://dx.doi.org/10.1097/SLA.0000000000004560DOI Listing
October 2020

Let Us Not Be Silent.

Ann Surg 2020 12;272(6):915-916

Department of Surgery, Michigan Medicine, Ann Arbor, Michigan.

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http://dx.doi.org/10.1097/SLA.0000000000004458DOI Listing
December 2020

Assessment of a quality improvement intervention to decrease opioid prescribing in a regional health system.

BMJ Qual Saf 2021 Mar 16;30(3):251-259. Epub 2020 Sep 16.

Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.

Background: Opioids are prescribed in excess after surgery. We leveraged our continuous quality improvement infrastructure to implement opioid prescribing guidelines and subsequently evaluate changes in postoperative opioid prescribing, consumption and patient satisfaction/pain in a statewide regional health system.

Methods: We collected data regarding postoperative prescription size, opioid consumption and patient-reported outcomes from February 2017 to May 2019, from a 70-hospital surgical collaborative. Three iterations of prescribing guidelines were released. An interrupted time series analysis before and after each guideline release was performed. Linear regression was used to identify trends in consumption and patient-reported outcomes over time.

Results: We included 36 022 patients from 69 hospitals who underwent one of nine procedures in the guidelines, of which 15 174 (37.3%) had complete patient-reported outcomes data following surgery. Before the intervention, prescription size was decreasing over time (slope: -0.7 tablets of 5 mg oxycodone/month, 95% CI -1.0 to -0.5 tablets, p<0.001). After the first guideline release, prescription size declined by -1.4 tablets/month (95% CI -1.8 to -1.0 tablets, p<0.001). The difference between these slopes was significant (p=0.006). The second guideline release resulted in a relative increase in slope (-0.3 tablets/month, 95% CI -0.1 to -0.6, p<0.001). The third guideline release resulted in no change (p=0.563 for the intervention). Overall, mean (SD) prescription size decreased from 25 (17) tablets of 5 mg oxycodone to 12 (8) tablets. Opioid consumption also decreased from 11 (16) to 5 (7) tablets (p<0.001), while satisfaction and postoperative pain remained unchanged.

Conclusions: The use of procedure-specific prescribing guidelines reduced statewide postoperative opioid prescribing by 50% while providing satisfactory pain care. These results demonstrate meaningful impact on opioid prescribing using evidence-based best practices and serve as an example of successful utilisation of a regional health collaborative for quality improvement.
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http://dx.doi.org/10.1136/bmjqs-2020-011295DOI Listing
March 2021

Interhospital variation of inpatient versus outpatient pediatric burn treatment after emergency department evaluation.

J Pediatr Surg 2020 Oct 17;55(10):2134-2139. Epub 2020 Apr 17.

Division of Pediatric Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC.

Background: Approaches to burn care in the pediatric population are highly variable and can be targeted as a potential measure in cost-reduction. We hypothesized that institutions vary significantly in treatment allocation of nonsevere burns to either inpatient or outpatient care.

Methods: We queried the PHIS database for fiscal year 2017 to quantify small pediatric burn admissions and Emergency Department visits (ED). The ICD-10 code T31.0 was used to identify burns involving <10% of total body surface area (TBSA). Centers were categorized by burn center status and length of stay, readmissions, and charges were compared.

Results: Inpatient versus outpatient management distribution was significantly different across the included pediatric children's hospitals (n = 34, p < 0.00001). When data were analyzed with respect to outpatient care, a bimodal distribution distinguished two groups: high hospital utilizers with an average of 30% outpatient burn care and low-utilizers averaging 87%. Median inpatient charge per patient was greater than 31-fold compared to ED burn management (p < 0.0001).

Conclusions: Variability of inpatient versus outpatient pediatric burn management in small burns was significant. Compared to outpatient burn care, inpatient care is significantly more costly. Implementing protocols and personnel to provide adequate attention to small burns in the ED could be an important cost-saving measure.

Type Of Study: Retrospective analysis.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.03.018DOI Listing
October 2020

Ruptured ulnar artery aneurysm in vascular Ehlers-Danlos syndrome.

J Vasc Surg Cases Innov Tech 2020 Mar 12;6(1):71-74. Epub 2020 Feb 12.

Section of Vascular Surgery, Michigan Medicine, Ann Arbor, Mich.

Vascular Ehlers-Danlos syndrome (vEDS), also known as type IV Ehlers-Danlos syndrome, is a rare inherited connective tissue disease that affects 1 in 50,000 to 250,000 individuals. It is characterized by catastrophic vascular complications and hollow viscus rupture; 80% of patients with vEDS experience a vascular complication by the age of 40 years, and median life expectancy is 40 to 50 years. The central vasculature and visceral vasculature are most commonly affected; peripheral involvement is much less common. We describe the case of a 40-year-old woman with vEDS previously complicated by ruptured splenic and posterior tibial artery aneurysms who presented with a ruptured left ulnar artery aneurysm resulting in compartment syndrome.
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http://dx.doi.org/10.1016/j.jvscit.2019.11.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7016348PMC
March 2020

Structure-Guided Design and In-Cell Target Profiling of a Cell-Active Target Engagement Probe for PARP Inhibitors.

ACS Chem Biol 2020 02 10;15(2):325-333. Epub 2020 Feb 10.

Department of Chemistry, Molecular Sciences Research Hub , Imperial College London , London W12 0BZ , United Kingdom.

Inhibition of the poly(ADP-ribose) polymerase (PARP) family of enzymes has become an attractive therapeutic strategy in oncology and beyond; however, chemical tools to profile PARP engagement in live cells are lacking. Herein, we report the design and application of , the first photoaffinity probe (AfBP) for PARP enzymes based on triple PARP1/2/6 inhibitor , which induces multipolar spindle (MPS) formation in breast cancer cells. is a robust tool for profiling PARP1/2 and is used to profile clinical PARP inhibitor olaparib, identifying several novel off-target proteins. Surprisingly, while can enrich recombinant PARP6 spiked into cellular lysates and inhibits PARP6 in cell-free assays, it does not label PARP6 in intact cells. These data highlight an intriguing biomolecular disparity between recombinant and endogenous PARP6. provides a new approach to expand our knowledge of the targets of this class of compounds and the mechanisms of action of PARP inhibitors in cancer.
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http://dx.doi.org/10.1021/acschembio.9b00963DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146755PMC
February 2020

Spillover Effect of Opioid Reduction Interventions From Adult to Pediatric Surgery.

J Surg Res 2020 05 6;249:18-24. Epub 2020 Jan 6.

Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan.

Background: Procedure-specific prescribing guidelines and trainee education have reduced opioid overprescribing in adult surgical patients, but tailored interventions do not yet exist for children. It is unknown what effect these adult interventions have had on postoperative opioid prescribing in children at the same institution, where trainees rotate across both adult and pediatric services.

Materials And Methods: This retrospective study of patients (<18 y) undergoing pediatric surgery (PS), pediatric otolaryngology (ENT), or pediatric urology (URO) procedures at a single tertiary academic center assessed opioid doses per patient before (January 01, 2015 to September 30, 2016) and after (January 01, 2017 to March 31, 2018) opioid prescribing guidelines and trainee education were instituted for adult laparoscopic cholecystectomy. Patient demographics, postoperative opioid prescribing, opioid refills, and emergency department (ED) visits <21 d after surgery were compared using chi-squared analyses and t-tests. Interrupted time-series analyses (ITSA) assessed changes in the rate of opioid prescribing pre- and postintervention for each subspecialty.

Results: There were 3371 patients preintervention and 2439 patients postintervention. After the intervention, fewer patients were prescribed opioids (ENT: 97% versus 93%, P < 0.001; URO: 98% versus 94%, P < 0.001; PS: 61% versus 25%, P < 0.001) and fewer opioid doses were prescribed in each prescription (ENT: 63.8 ± 26.1 versus 50.8 ± 22.0 doses, P < 0.001; URO: 33.5 ± 23.4 versus 22.1 ± 11.3, P < 0.001; PS: 20.4 ± 12.8 versus 13.8 ± 11.4 doses, P < 0.001). There were no changes in opioid refill or ED visit rates postintervention. A decreasing rate in ENT prescribing was seen preintervention, with no significant change postintervention (-2.3 ± 1.1 versus -3.3 ± 0.7; P = 0.24). Whereas, the rate of decrease in PS and URO prescribing significantly slowed postintervention (PS: -2.0 ± 0.1 versus -0.9 ± 0.1, P < 0.001; URO: -4.2 ± 0.2 versus -2.3 ± 0.5, P = 0.005).

Conclusions: Opioid prescribing rates are decreasing, but adult interventions did not achieve reductions in pediatric opioid prescribing at the same institution. There was no concomitant rise in postoperative ED visits or opioid refills as prescribing declined, indicating that the risks of reducing opioid prescriptions may be minimal. Development of evidence-based, procedure-specific prescribing guidelines that specifically address pediatric patients are needed to effectively minimize opioid overprescribing in this population.
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http://dx.doi.org/10.1016/j.jss.2019.11.021DOI Listing
May 2020

Costs Associated With Modifiable Risk Factors in Ventral and Incisional Hernia Repair.

JAMA Netw Open 2019 11 1;2(11):e1916330. Epub 2019 Nov 1.

Department of Surgery, University of Michigan Health System, Ann Arbor.

Importance: Ventral and incisional hernia repair (VIHR) is an extremely common operation, after which complications are also fairly common. A number of preoperative risk factors are known to contribute to increased complications after surgical repair; however, the individual relative association of these risk factors with adverse outcomes and increased spending is unclear. Quantifying the association of individual risk factors may help surgeons implement targeted surgical optimization, improve outcomes, and reduce spending.

Objective: To identify the attributable association of modifiable risk factors for adverse outcomes after VIHR on outcomes and episode-of-care payments.

Design, Setting, And Participants: This cross-sectional study was performed using a population-based sample of adult patients and episode spending data from January 1, 2012, to December 31, 2018, from a statewide multipayer registry. A multilevel mixed-effects logistic regression model was used to examine the contribution of patient-specific risk factors to adverse outcomes. Attributable risk and population attributable risk fraction were calculated to estimate the additional spending attributable to individual risk factors. Data were analyzed from April 2018 to September 2018.

Main Outcomes And Measures: Any complications, serious complication, discharge not to home, 30-day emergency department utilization, and 30-day readmission. Episode-of-care spending was calculated for these outcomes.

Results: This study included 22 664 patients (median [interquartile range] age, 55 [44-64] years; 10 496 [46.3%] women) undergoing VIHR with identified significant preoperative risk factors. Fourth-quartile body mass index (BMI), calculated as weight in kilograms divided by height in meters squared and defined as a mean (SD) BMI of 43 (6), was associated with increased risk of any complication (odds ratio [OR], 1.64; 95% CI, 1.30-2.06; P < .001) and serious complication (OR, 1.67; 95% CI, 1.22-2.31; P = .002). Insulin-dependent diabetes was associated with increased risk of any complication (OR, 1.34; 95% CI, 1.03-1.73; P = .03), serious complication (OR, 1.51; 95% CI, 1.08-2.12; P = .02), discharge not to home (OR, 1.49; 95% CI, 1.12-1.98; P = .005), and 30-day readmission (OR, 1.68; 95% CI, 1.32-2.14; P < .001). Median (interquartile range) additional episode spending for any complication was $9934 ($9224-$11 851), of which $1304 ($1208-$1552) was attributable to fourth-quartile BMI. Median (interquartile range) additional episode spending for a serious complication was $26 648 ($20 632-$33 166), of which $3638 ($2827-$4544) was attributable to fourth-quartile BMI, $650 ($495-$796) was attributable to insulin-dependent diabetes, and $567 ($433-$696) was attributable to unhealthy alcohol use.

Conclusions And Relevance: In this cross-sectional study, modifiable risk factors, such as obesity, insulin-dependent diabetes, and unhealthy alcohol use, were associated with adverse outcomes after VIHR. These factors were significantly associated with increased health care spending; therefore, preoperative optimization may improve outcomes and decrease episode-of-care costs.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.16330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902835PMC
November 2019

Current Practices in Hernia Screening-Evidence Based or Profit Driven?

JAMA Surg 2020 02;155(2):99-100

Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jamasurg.2019.4424DOI Listing
February 2020

The Impact of Complications and Pain on Patient Satisfaction.

Ann Surg 2019 Oct 28. Epub 2019 Oct 28.

Department of Surgery, Michigan Medicine, Ann Arbor, Michigan.

Objective: To measure the association between patient-reported satisfaction and regret and clinical outcomes.

Summary Of Background Data: Patient-reported outcomes are becoming an increasingly important marker of the quality of patient care. It is unclear however, how well patient-reported outcomes adequately reflect care quality and clinical outcomes in surgical patients.

Methods: Retrospective, population-based analysis of adults ages 18 and older undergoing surgery across 38 hospitals in Michigan between January 1, 2017 and May 31, 2018.

Results: In this study, 9953 patients (mean age 56 years; 5634 women (57%)) underwent 1 of 16 procedures. 9550 (96%) patients experienced no complication, whereas 240 (2%) and 163 (2%) patients experienced Grade 1 and Grade 2-3 complications, respectively. Postoperative pain scores were: none (908 (9%) patients), mild (3863 (40%) patients), moderate (3893 (40%) patients), and severe (1075 (11%) patients). Overall, 7881 (79%) patients were highly satisfied and 8911 (91%) had absolutely no regret after surgery. Patients were less likely to be highly satisfied if they experienced a Grade 1 complication [odds ratio (OR) 0.50, 95% confidence interval (CI) 0.37-0.66], Grade 2-3 complication (OR 0.44, 95% CI 0.31-0.62), minimal pain (OR 0.80, 95% CI 0.64-0.99, moderate pain (OR 0.39, 95% CI 0.32-0.49), or severe pain (OR 0.23, 95% CI 0.18-0.29). Patients were less likely to have no regret if they experienced a Grade 1 complication (OR 0.48, 95% CI 0.33-0.70), Grade 2-3 complication (OR 0.39, 95% CI 0.25-0.60), moderate pain (OR 0.55, 95% CI 0.40-0.76), or severe pain (OR 0.22, 95% CI 0.16-0.31). The predicted probability of being highly satisfied was 79% for patients who had no complications and 88% for patients who had no pain.

Conclusions: Patients who experienced postoperative complications and pain were less likely to be highly satisfied or have no regret. Notably, postoperative pain had a more significant effect on satisfaction and regret after surgery, suggesting focused postsurgical pain management is an opportunity to substantially improve patient experiences. More research and patient education are needed for managing expectations of postoperative pain, and use of adjuncts and regional anesthesia.
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http://dx.doi.org/10.1097/SLA.0000000000003621DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7303925PMC
October 2019

Early-life injury produces lifelong neural hyperexcitability, cognitive deficit and altered defensive behaviour in the squid .

Philos Trans R Soc Lond B Biol Sci 2019 11 23;374(1785):20190281. Epub 2019 Sep 23.

Department of Biology, San Francisco State University, 1600 Hollloway Avenue, San Francisco, CA 94132, USA.

Injury occurring in the neonatal period in mammals is known to induce plasticity in pain pathways that may lead to pain dysfunction in later life. Whether these effects are unique to the mammalian nervous system is not well understood. Here, we investigate whether similar effects of early-life injury are found in a large-brained comparative model, the cephalopod . We show that the peripheral nervous system of undergoes profound and permanent plasticity after injury of peripheral tissue in the early post-hatching period, but not after the same injury given in the later juvenile period. Additionally, both innate defensive behaviour and learning are impaired by injury in early life. We suggest that these similar patterns of nervous system and behavioural remodelling that occur in squid and in mammals indicate an adaptive value for long-lasting plasticity arising from early-life injury, and suggest that injuries inflicted in very early life may signal to the nervous system that the environment is highly dangerous. Thus, neonatal pain plasticity may be a conserved pattern whose purpose is to set the developing nervous system's baseline responsiveness to threat. This article is part of the Theo Murphy meeting issue 'Evolution of mechanisms and behaviour important for pain'.
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http://dx.doi.org/10.1098/rstb.2019.0281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6790388PMC
November 2019

Effects of Shared Decision Making on Opioid Prescribing After Hysterectomy.

Obstet Gynecol 2019 10;134(4):823-833

Departments of Obstetrics and Gynecology, Anesthesia, and Surgery, and the Section of Plastic Surgery, Department of Surgery, University of Michigan, the University of Michigan Medical School, and the University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan.

Objective: To evaluate the effects of shared decision making using a simple decision aid for opioid prescribing after hysterectomy.

Methods: We conducted a prospective quality initiative study including all patients undergoing hysterectomy for benign, nonobstetric indications between March 1, 2018, and July 31, 2018, at our academic institution. Using a visual decision aid, patients received uniform education regarding postoperative pain management. They were then educated on the department's guidelines regarding the maximum number of tablets recommended per prescription and the mean number of opioid tablets used by a similar cohort of patients in a previously published study at our institution. Patients were then asked to choose their desired number of tablets to receive on discharge. Structured telephone interviews were conducted 14 days after surgery. The primary outcome was total opioids prescribed before compared with after implementation of the decision aid. Secondary outcomes included opioid consumption, patient satisfaction, and refill requests after intervention implementation.

Results: Of 170 eligible patients, 159 (93.5%) used the decision aid (one patient who used the decision aid was subsequently excluded from the analysis owing to significant perioperative complications), including 110 (69.6%) laparoscopic, 40 (25.3%) vaginal, and eight (5.3%) abdominal hysterectomies. Telephone surveys were completed for 89.2% (n=141) of participants. Student's t-test showed that patients who participated in the decision aid (post-decision aid cohort) were discharged with significantly fewer oral morphine equivalents than patients who underwent hysterectomy before implementation of the decision aid (pre-decision aid cohort) (92±35 vs 160±81, P<.01), with no significant change in the number of requested refills (9.5% [n=15] vs 5.7% [n=14], P=.15). In the post-decision aid cohort, 76.6% of patients (n=121) chose fewer tablets than the guideline-allotted maximum. Approximately 76% of patients (n=102) reported having leftover tablets.

Conclusion: This quality improvement initiative illustrates that a simple decision aid can result in a significant decrease in opioid prescribing without compromising patient satisfaction or postoperative pain management.
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http://dx.doi.org/10.1097/AOG.0000000000003468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6945818PMC
October 2019

A Pathway for Developing Postoperative Opioid Prescribing Best Practices.

Ann Surg 2020 01;271(1):86-93

Department of Surgery, University of Michigan, Ann Arbor, MI.

Objective: Opioid prescriptions after surgery are effective for pain management but have been a significant contributor to the current opioid epidemic. Our objective is to review pragmatic approaches to develop and implement evidence-based guidelines based on a learning health system model.

Summary Background Data: During the last 2 years there has been a preponderance of data demonstrating that opioids are overprescribed after surgery. This contributes to a number of adverse outcomes, including diversion of leftover pills in the community and rising rates of opioid use disorder.

Methods: We conducted a MEDLINE/PubMed review of published examples and reviewed our institutional experience in developing and implementing evidence-based postoperative prescribing recommendations.

Results: Thirty studies have described collecting data regarding opioid prescribing and patient-reported use in a cohort of 13,591 patients. Three studies describe successful implementation of opioid prescribing recommendations based on patient-reported opioid use. These settings utilized learning health system principles to establish a cycle of quality improvement based on data generated from routine practice. Key components of this pathway were collecting patient-reported outcomes, identifying key stakeholders, and continual assessment. These pathways were rapidly adopted and resulted in a 37% to 63% reduction in prescribing without increasing requests for refills or patient-reported pain scores.

Conclusion: A pathway for creating evidence-based opioid-prescribing recommendations can be utilized in diverse practice environments and can lead to significantly decreased opioid prescribing without adversely affecting patient outcomes.
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http://dx.doi.org/10.1097/SLA.0000000000003434DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7106149PMC
January 2020

Advanced Glycation End-Products Can Activate or Block Bitter Taste Receptors.

Nutrients 2019 Jun 12;11(6). Epub 2019 Jun 12.

Manitoba Chemosensory Biology Research Group, Department of Oral Biology, University of Manitoba, Children's Hospital Research Institute of Manitoba (CHRIM), Winnipeg, MB R3E 0W4, Canada.

Bitter taste receptors (T2Rs) are expressed in several tissues of the body and are involved in a variety of roles apart from bitter taste perception. Advanced glycation end-products (AGEs) are produced by glycation of amino acids in proteins. There are varying sources of AGEs, including dietary food products, as well as endogenous reactions within our body. Whether these AGEs are T2R ligands remains to be characterized. In this study, we selected two AGEs, namely, glyoxal-derived lysine dimer (GOLD) and carboxymethyllysine (CML), based on their predicted interaction with the well-studied T2R4, and its physiochemical properties. Results showed predicted binding affinities () for GOLD and CML towards T2R4 in the nM and μM range, respectively. Calcium mobilization assays showed that GOLD inhibited quinine activation of T2R4 with IC 10.52 ± 4.7 μM, whilst CML was less effective with IC 32.62 ± 9.5 μM. To characterize whether this antagonism was specific to quinine activated T2R4 or applicable to other T2Rs, we selected T2R14 and T2R20, which are expressed at significant levels in different human tissues. A similar effect of GOLD was observed with T2R14; and in contrast, GOLD and CML activated T2R20 with an EC of 79.35 ± 29.16 μM and 65.31 ± 17.79 μM, respectively. In this study, we identified AGEs as novel T2R ligands that caused either activation or inhibition of different T2Rs.
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http://dx.doi.org/10.3390/nu11061317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628017PMC
June 2019

Patient Satisfaction and Pain Control Using an Opioid-Sparing Postoperative Pathway.

J Am Coll Surg 2019 09 30;229(3):316-322. Epub 2019 May 30.

Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI; Department of Surgery, University of Michigan Health System, Ann Arbor, MI.

Background: Opioids are overprescribed after surgical procedures, leading to dependence and diversion into the community. This can be mitigated by evidence-based prescribing practices. We investigated the feasibility of an opioid-sparing pain management strategy after surgical procedures.

Study Design: Patients undergoing 6 procedures were offered the opportunity to participate in an opioid-sparing pain management pathway. Patients were advised to use acetaminophen and ibuprofen, and were provided with a small "rescue" opioid prescription for breakthrough pain. They were then surveyed postoperatively about opioid use and patient-reported outcomes measures. Overall cohort characteristics and differences between opioid users and non-users were analyzed.

Results: A total of 190 patients were analyzed. Median prescription size was 5 (interquartile range [IQR] 4 to 6) pills and opioid use was 0 (IQR 0 to 4) pills. Fifty-two percent of patients used no opioids after procedures. Median number of leftover pills was 2 (IQR 0 to 5). Median pain score was 1 (IQR 1 to 2) and satisfaction score was 10 (IQR 8 to 10). Almost all (91%) patients agreed that their pain was manageable. Patients who used opioids were younger (52 ± 14 vs 59 ± 13 years; p = 0.001), reported higher pain scores (2 [IQR 1 to 2] vs 1 [1 to 2]; p = 0.014), received larger rescue prescriptions (6 ± 3 vs 4 ± 4 pills; p = 0.003), and were less likely to agree that their pain was manageable (82% vs 98%; p = 0.001). There were no other significant differences between opioid users and non-users.

Conclusions: Patients reported minimal or no opioid use after implementation of an opioid-sparing pathway, and still reported high satisfaction and pain control. These results demonstrate the effectiveness and acceptability of major reduction and even elimination of opioids after discharge from minor surgical procedures.
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http://dx.doi.org/10.1016/j.jamcollsurg.2019.04.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7596906PMC
September 2019

Opioid Prescription After Surgery-Reply.

JAMA Surg 2019 07;154(7):675-676

Department of Surgery, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jamasurg.2019.0574DOI Listing
July 2019

Gender Matters: Mandating Sex as a Biologic Variable in Hernia Research.

Ann Surg 2019 07;270(1):10-11

Department of Surgery, University of Michigan, Ann Arbor, MI.

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http://dx.doi.org/10.1097/SLA.0000000000003323DOI Listing
July 2019

Association of Opioid Prescribing With Opioid Consumption After Surgery in Michigan.

JAMA Surg 2019 01 16;154(1):e184234. Epub 2019 Jan 16.

Department of Surgery, University of Michigan, Ann Arbor.

Importance: There is growing evidence that opioids are overprescribed following surgery. Improving prescribing requires understanding factors associated with opioid consumption.

Objective: To describe opioid prescribing and consumption for a variety of surgical procedures and determine factors associated with opioid consumption after surgery.

Design, Setting, And Participants: A retrospective, population-based analysis of the quantity of opioids prescribed and patient-reported opioid consumption across 33 health systems in Michigan, using a sample of adults 18 years and older undergoing surgery. Patients were included if they were prescribed an opioid after surgery. Surgical procedures took place between January 1, 2017, and September 30, 2017, and were included if they were performed in at least 25 patients.

Exposures: Opioid prescription size in the initial postoperative prescription.

Main Outcomes And Measures: Patient-reported opioid consumption in oral morphine equivalents. Linear regression analysis was used to calculate risk-adjusted opioid consumption with robust standard errors.

Results: In this study, 2392 patients (mean age, 55 years; 1353 women [57%]) underwent 1 of 12 surgical procedures. Overall, the quantity of opioid prescribed was significantly higher than patient-reported opioid consumption (median, 30 pills; IQR, 27-45 pills of hydrocodone/acetaminophen, 5/325 mg, vs 9 pills; IQR, 1-25 pills; P < .001). The quantity of opioid prescribed had the strongest association with patient-reported opioid consumption, with patients using 0.53 more pills (95% CI, 0.40-0.65; P < .001) for every additional pill prescribed. Patient-reported pain in the week after surgery was also significantly associated with consumption but not as strongly as prescription size. Compared with patients reporting no pain, patients used a mean (SD) 9 (1) more pills if they reported moderate pain and 16 (2) more pills if they reported severe pain (P < .001). Other significant risk factors included history of tobacco use, American Society of Anesthesiologists class, age, procedure type, and inpatient surgery status. After adjusting for these risk factors, patients in the lowest quintile of opioid prescribing had significantly lower mean (SD) opioid consumption compared with those in the highest quintile (5 [2] pills vs 37 [3] pills; P < .001).

Conclusions And Relevance: The quantity of opioid prescribed is associated with higher patient-reported opioid consumption. Using patient-reported opioid consumption to develop better prescribing practices is an important step in combating the opioid epidemic.
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http://dx.doi.org/10.1001/jamasurg.2018.4234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439853PMC
January 2019

Taking Control of Your Surgery: Impact of a Prehabilitation Program on Major Abdominal Surgery.

J Am Coll Surg 2019 01 22;228(1):72-80. Epub 2018 Oct 22.

Department of Surgery, Michigan Medicine, Ann Arbor, MI. Electronic address:

Background: Surgery is a major physiologic stress comparable to intense exercise. Diminished cardiopulmonary reserve is a major predictor of poor outcomes. Current preoperative workup focuses mainly on identifying risk factors; however, little attention is devoted to improving cardiopulmonary reserve beyond counseling. We propose that patients could be optimized for a "surgical marathon" similar to the preparation of an athlete.

Study Design: The Michigan Surgical and Health Optimization Program (MSHOP) is a formal prehabilitation program that engages patients in 4 activities before surgery: physical activity, pulmonary rehabilitation, nutritional optimization, and stress reduction. We prospectively collected demographic, intraoperative (first hour), and postoperative data for patients enrolled in MSHOP undergoing major abdominal surgery. Statistical analysis was performed using 2:1 propensity score matching to compare the MSHOP group (n = 40) to emergency (n = 40) and elective, non-MSHOP (n = 76) patients.

Results: Overall, 70% of MSHOP patients complied with the program. Age, sex, American Society of Anesthesiologists (ASA) classification, and BMI did not differ significantly between groups. One hour intraoperatively, MSHOP patients showed improved systolic and diastolic blood pressures and lower heart rate (Figure). There was a significant reduction in Clavien-Dindo class 3 to 4 complications in the MSHOP group (30%) compared with the nonprehabilitation (38%) and emergency (48%) groups (p = 0.05). This translated to total hospital charges averaging $75,494 for the MSHOP group, $97,440 for the nonprehabilitation group, and $166,085 for the emergency group (p < 0.001).

Conclusions: Patients undergoing prehabilitation before colectomy showed positive physiologic effects and experienced fewer complications. The average savings of $21,946 per patient represents a significant cost offset for a prehabilitation program, and should be considered for all patients undergoing surgery.
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http://dx.doi.org/10.1016/j.jamcollsurg.2018.09.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309718PMC
January 2019