Association between perioperative non-steroidal anti-inflammatory drug use and cardiovascular complications after non-cardiac surgery in older adult patients.

BACKGROUND: We investigated in older adult non-cardiac surgical patients whether receipt of perioperative non-steroidal anti-inflammatory drugs (NSAIDs) is associated with increased incidence of postoperative cardiovascular complications. METHODS: We retrospectively extracted the information for patients with age ≥  65 years who had inpatient non-cardiac surgery with a duration of ≥  1 h from the American College of Surgeons-National Surgical Quality Improvement Program registry data acquired at the University of Washington Medical Center. We compared patients who received NSAIDs perioperatively to those who did not receive NSAIDs, on the two composite outcomes: (1) the incidence of postoperative cardiovascular complications within 30 days of the surgery, and (2) the incidence of combined postoperative gastrointestinal and renal complications, and length of postoperative hospital stay. We used separate multivariable logistic regression models to analyze the two composite outcomes and a Poisson regression model for the length of hospital stay. RESULTS: The receipt of perioperative NSAIDs was not associated with postoperative cardiovascular complications (estimated odds ratio (OR), 1.78; 95% confidence interval (CI), 0.97 to 3.25; P =  0.06), combined renal and gastrointestinal complications (estimated OR, 1.30; 95% CI, 0.53 to 3.20; P =  0.57), and length of postoperative hospital stay in days (incidence rate ratio, 1.06; 95% CI, 0.93 to 1.21; P =  0.39). CONCLUSIONS: In older adult non-cardiac surgical patients, receipt of perioperative NSAIDs was not associated with increased incidences of postoperative cardiovascular complications, and renal and gastrointestinal complications within 30 days after surgery, or length of postoperative hospital stay.

Association Between Postoperative Methocarbamol and Postoperative Pain Opioid Dose Requirements: A Retrospective Cohort Study.

OBJECTIVES: We tested the hypothesis that patients who received methocarbamol postoperatively experience less severe pain and require smaller doses of opioids than those who did not receive methocarbamol. MATERIALS AND METHODS: This is a retrospective cohort study of patients undergoing surgery involving the musculoskeletal system. Of 9089 patients, 704 received methocarbamol during 48 hours postoperatively, while 8385 did not receive methocarbamol. The patients who received methocarbamol postoperatively and the patients who did not receive methocarbamol were compared on the time-weighted average (TWA) pain score and opioid dose requirements in morphine milligram equivalents (MME) during the first 48 hours postoperatively, using propensity score-weighted regression models to adjusting for preoperative and intraoperative covariates. RESULTS: Postoperative 48-hour TWA pain scores were 5.5±1.7 (mean±SD), and 4.3±2.1 for methocarbamol and non-methocarbamol patients. Postoperative 48-hour opioid dose requirements in MME were 276 [170-347] (median [interquartile range (IQR)]) mg, and 190 [60-248] mg for methocarbamol and non-methocarbamol patients. In propensity score-weighted regression models, receiving methocarbamol postoperatively was associated with 0.97-point higher postoperative TWA pain score (95% CI, 0.83-1.11; P <0.001), and 93.6-MME higher postoperative opioid dose requirements (95% CI, 79.9 to 107.4; P <0.001), compared with not receiving methocarbamol postoperatively. DISCUSSION: Postoperative methocarbamol was associated with significantly higher acute postoperative pain burden and opioid dose requirements. Although the results of the study are influenced by residual confounding, they suggest a limited-if any-benefit of methocarbamol as an adjunct of postoperative pain management.

Postoperative respiratory depression in patients on sublingual buprenorphine: a retrospective cohort study for comparison between postoperative continuation and discontinuation of buprenorphine.

BACKGROUND: We tested the hypothesis that patients who continued buprenorphine postoperatively experience postoperative respiratory depression less frequently than those who discontinued buprenorphine. METHODS: This is a retrospective cohort study of patients who were on buprenorphine preoperatively. The primary outcome was postoperative respiratory depression as defined by respiratory rate < 10/minute, oxygen saturation (SpO2) < 90%, or requirement of naloxone for 48 h postoperatively. The secondary outcome was the composite of postoperative respiratory complications. The associations between postoperative buprenorphine continuation and respiratory depression and respiratory complications were estimated using separate multivariable logistic regression models, including demographic, intraoperative characteristics, and preoperative buprenorphine dose as covariates. RESULTS: Postoperative buprenorphine continuation was not associated with postoperative respiratory depression (adjusted odds ratio (OR), 1.11, 95% confidence interval (CI), 0.61 to 1.99, P=0.72). In subanalysis stratified by the preoperative buprenorphine dose, buprenorphine continuation was not associated with postoperative respiratory depression either when preoperative buprenorphine dose was high (≥16 mg daily) or low (<16 mg daily). Postoperative buprenorphine continuation was associated with lower incidence of postoperative respiratory complications (adjusted OR, 0.43, 95% CI, 0.21 to 0.86, P=0.02). CONCLUSIONS: Continuing buprenorphine was not associated with respiratory depression, but it was associated with a lower incidence of respiratory complications.

Emergency Medical Services and Syndromic Surveillance: A Comparison With Traditional Surveillance and Effects on Timeliness.

OBJECTIVE: Traditional public health surveillance of nonfatal opioid overdose relies on emergency department (ED) billing data, which can be delayed substantially. We compared the timeliness of 2 new data sources for rapid drug overdose surveillance-emergency medical services (EMS) and syndromic surveillance-with ED billing data. METHODS: We used data on nonfatal opioid overdoses in Kentucky captured in EMS, syndromic surveillance, and ED billing systems during 2018-2019. We evaluated the time-series relationships between EMS and ED billing data and syndromic surveillance and ED billing data by calculating cross-correlation functions, controlling for influences of autocorrelations. A case example demonstrates the usefulness of EMS and syndromic surveillance data to monitor rapid changes in opioid overdose encounters in Kentucky during the COVID-19 epidemic. RESULTS: EMS and syndromic surveillance data showed moderate-to-strong correlation with ED billing data on a lag of 0 (r = 0.694; 95% CI, 0.579-0.782; t = 9.73; df = 101; P < .001; and r = 0.656; 95% CI, 0.530-0.754; t = 8.73; df = 101; P < .001; respectively) at the week-aggregated level. After the COVID-19 emergency declaration, EMS and syndromic surveillance time series had steep increases in April and May 2020, followed by declines from June through September 2020. The ED billing data were available for analysis 3 months after the end of a calendar quarter but closely followed the trends identified by the EMS and syndromic surveillance data. CONCLUSION: Data from EMS and syndromic surveillance systems can be reliably used to monitor nonfatal opioid overdose trends in Kentucky in near-real time to inform timely public health response.

Public Health Surveillance of Youth Suicide Attempts: Challenges and Opportunities.

BACKGROUND: Surveillance of youth suicide attempts presents many challenges. To assess common data sources that capture information about youth suicidal behavior, we compared counts of high school students who reported (a) a suicide attempt and (b) an injurious suicide attempt, requiring medical treatment in the previous twelve months, with counts of suicide deaths and intentional self-injuries obtained from administrative data sources. METHOD: Youth Risk Behavior Surveillance System (YRBSS), high school enrollments, and vital statistics were used to estimate the ratio of suicide attempts to suicide deaths among Kentucky high school students. YRBSS and enrollment data were used to estimate the number of Kentucky high school students who received medical treatment following a suicide attempt, which was compared with hospital and emergency department (ED) discharges for intentional self-injury from administrative claim records. RESULTS: We estimated 943 students reporting a suicide attempt for every suicide death, a result that is higher than previous estimates for youth. Self-reported suicide attempts resulting in medical treatment were 7.5 times higher than self-injuries reported in claims records. CONCLUSION: Future research should address concerns about undocumented cases of intentional self-injury in administrative claims systems; patient encounters in nonhospital settings for injuries resulting from a suicide attempt; and validity of Youth Risk Behavior Survey questions on suicidal behavior.

Effect of Chronic Low Back Pain and Post-Traumatic Stress Disorder on the Risk for Separation from the US Army.

INTRODUCTION: Co-morbid post-traumatic stress disorder (PTSD) and low back pain (LBP) are common reasons for increased disability in the Veteran communities. Medical discharge from the military represents a considerable financial cost to society. Little is currently known about the impact of LBP and PTSD as longitudinal risk factors for medical discharge from Active Duty military service. MATERIALS AND METHODS: A retrospective analysis of US Army Active Duty Soldiers from 2002 to 2012 was performed to determine the risk for medical discharge. Four levels of exposure for were identified as independent variables: no chronic LBP or PTSD, chronic LBP only, PTSD only, and co-morbid PTSD present with chronic LBP. Statistical analysis utilized modified Poisson regression controlling for sex, age, rank, time in service, deployment, mental health, sleep disorders, alcohol use, tobacco use, obesity, and military occupation. This study was approved by a Department of Defense Institutional Review Board. RESULTS: After controlling for potential confounding variables, the RR for chronic LBP and PTSD independently was 3.65 (95% CI: 3.59-3.72) and 3.64 (95% CI: 3.53-3.75), respectively, and 5.17 (95% CI: 5.01-5.33) when both were present. CONCLUSIONS: This is the first study to identify a history of both chronic LBP and PTSD as substantial risk factors for medical discharge from the US Army. PTSD and chronic LBP may mutually reinforce one another and deplete active coping strategies, making Soldiers less likely to be able to continue military service. Future research should target therapies for co-morbid PTSD and chronic LBP as these conditions contribute a substantial increase in risk of medical discharge from the US Army.

Establishment of a comprehensive drug overdose fatality surveillance system in Kentucky to inform drug overdose prevention policies, interventions and best practices.

BACKGROUND: According to the National Center for Health Statistics, Kentucky had the third highest drug overdose fatality rate in the nation in 2015 at 29.9 drug overdose fatalities per 100 000 population. OBJECTIVE: The elevated drug overdose fatality rate necessitated the development and implementation of a comprehensive multisource drug overdose fatality surveillance system (DOFSS). METHODS: DOFSS stakeholder work group members and data sources were identified, and memorandums of understanding were established. The following data sources were used to establish DOFSS: (1) death certificates; (2) autopsy reports; (3) toxicology result reports; (4) coroner reports; and (5) Kentucky All Schedule Prescription Electronic Reporting (KASPER) (prescription drug monitoring programme) data. Drug overdose poisonings were defined using Injury Surveillance Workgroup 7 definitions. Analyses were performed to investigate possible drug overdose-related health disparities for disabled drug overdose decedents and to characterise gabapentin in drug overdose deaths. RESULTS: DOFSS identified 2106 drug overdose poisoning fatalities in Kentucky for 2013-2014. Identification of specific drugs involved in drug overdose deaths increased from 75.8% using a single data source to 97.5% using multiple data sources. Disabled drug overdose decedents were significantly more likely to have an active prescription for drugs identified in their system compared with the non-disabled drug overdose decedents. Toxicology data showed increased gabapentin involvement in drug overdose deaths from 2.9% in 2013 to 17% in 2014. Alprazolam was found most often in combination with gabapentin (41%), along with various other benzodiazepines and prescription opioids. CONCLUSIONS: A comprehensive multisource DOFSS improved drug overdose fatality surveillance by increasing completeness of data and data quality. DOFSS is a model that can be considered by other states to enhance their efforts in tracking drug overdose fatalities, identifying new and emerging trends, and informing policies and best practices, to address and reduce drug overdoses.

Differential protective effects of motorcycle helmets against head injury.

BACKGROUND: Although numerous observational studies have demonstrated a protective effect of motorcycle helmets against head injury, the degree of protection against specific head injury types remains unclear. Experimental biomechanics studies involving cadavers, animals, and computer models have established that head injuries have varying etiologies. This retrospective cross-sectional study compared helmet protection against skull fracture, cerebral contusion, intracranial hemorrhage, and cerebral concussion in a consecutive series of motorcycle operators involved in recent traffic crashes in Kentucky. METHODS: Police collision reports linked to hospital inpatient and emergency department (ED) claims were analyzed for the period 2008 to 2012. Motorcycle operators with known helmet use who were not killed at the crash scene were included in the study. Helmet use was ascertained from the police report. Skull fracture, cerebral contusion, intracranial hemorrhage, and cerebral concussion were identified from International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes on the claims records. The relative risks of each type of head injury for helmeted versus unprotected operators were estimated using generalized estimating equations. RESULTS: Helmets offer substantial protection against skull fracture (relative risk [RR] = 0.31, 95% confidence interval [CI], 0.23, 0.34), cerebral contusion (RR = 0.29, 95% CI, 0.16, 0.53), and intracranial hemorrhage (RR = 0.47, 95% CI, 0.35, 0.63). The findings pertaining to uncomplicated concussion (RR = 0.80, 95% CI, 0.64, 1.01) were inconclusive. A modest protective effect (20% risk reduction) was suggested by the relative risk estimate, but the 95% confidence interval included the null value. CONCLUSIONS: Motorcycle helmets were associated with a 69% reduction in skull fractures, 71% reduction in cerebral contusion, and 53% reduction in intracranial hemorrhage. This study finds that current motorcycle helmets do not protect equally against all types of head injury. Efforts to improve rotational acceleration management in motorcycle helmets should be considered.

Nonlinear hierarchical modeling of experimental infection data.

In this paper, we propose a nonlinear hierarchical model (NLHM) for analyzing longitudinal experimental infection (EI) data. The NLHM offers several improvements over commonly used alternatives such as repeated measures analysis of variance (RM-ANOVA) and the linear mixed model (LMM). It enables comparison of relevant biological properties of the course of infection including peak intensity, duration and time to peak, rather than simply comparing mean responses at each observation time. We illustrate the practical benefits of this model and the insights it yields using data from experimental infection studies on equine arteritis virus. Finally, we demonstrate via simulation studies that the NLHM substantially reduces bias and improves the power to detect differences in relevant features of the infection response between two populations. For example, to detect a 20% difference in response duration between two groups (n=15) in which the peak time and peak intensity were identical, the RM-ANOVA test had a power of just 11%, and LMM a power of just 12%. By comparison, the nonlinear model we propose had a power of 58% in the same scenario, while controlling the Type I error rate better than the other two methods.

Emergency Department Visits Prior to Suicide and Homicide: Linking Statewide Surveillance Systems.

BACKGROUND: Emergency departments (EDs) serve a wide range of patients who present at risk of impending suicide and homicide. AIMS: Two statewide surveillance systems were probabilistically linked to understand who utilizes EDs and then dies violently within 6 weeks. METHOD: Each identified case was matched with four randomly selected controls on sex, race, date of birth, resident zip code, and date of ED visit vs. date of death. Matched-pair odds ratios were estimated by conditional logistic regression to assess differences between cases and controls on reported diagnoses and expected payment sources. RESULTS: Of 1,599 suicides and 569 homicides in the 3-year study period, 10.7% of decedents who died by suicide (mean = 13.6 days) and 8.3% who died by homicide (mean = 16.3 days) were seen in a state ED within 6 weeks prior to death. ED attendees who died by suicide were more likely to have a diagnosis of injury/ poisoning diagnosis or mental disorder and more likely to have Medicare. Those who died by homicide were more likely to have a diagnosis of injury/poisoning and less likely to have commercial insurance. CONCLUSION: It is essential for research to further explore risk factors for imminent suicide and homicide in ED patients who present for psychiatric conditions and general injuries.

Body mass index, asthma and exhaled nitric oxide in U.S. adults, 2007-2010.

OBJECTIVE: Increases in asthma and obesity over the past three decades have led to speculation about a causal link between the two diseases. However, investigations of the relationship between body mass index (BMI) and fractional exhaled nitric oxide (FeNO) - a marker of eosinophilic airway inflammation - have produced mixed results. The purpose of this study was to evaluate the relationship between body mass index (BMI), asthma and FeNO in a sample of U.S. adults using data from the National Health and Nutrition Examination Surveys (NHANES) for 2007-2010. METHODS: We assessed the relationship between FeNO and BMI in subjects with and without asthma using categorical and continuous models for BMI. All models controlled for age, gender, ethnicity, household income-to-poverty ratio, atopy and current smoking. RESULTS: Adjusted asthma prevalence was positively associated with BMI, and subjects with asthma had higher adjusted FeNO levels than subjects without asthma. However, no association between FeNO and BMI was observed in either those with (ß = 0.002, p = 0.74) or without (ß = 0.0014, p = 0.51) asthma after adjusting for covariates. CONCLUSIONS: Our results suggest that in the U.S. adult population, BMI is not associated with eosinophilic airway inflammation.

Comparison of incidence of hospital utilization for poisoning and other injury types.

OBJECTIVES: We investigated the incidence of hospital utilization for injuries and compared poisoning with other forms of injury. Previous studies have suggested poison control centers reduce health-care costs by decreasing hospital utilization. METHODS: We conducted a one-year retrospective study involving patients treated for injuries at acute-care hospitals in Kentucky in 2008. We also compared inpatient discharges with discharges directly from the emergency department (ED) to determine hospitalization rates. The primary data sources were the Kentucky Hospital Billing database and the Kentucky Regional Poison Control Center (KRPCC) database. RESULTS: In 2008, there were 377,642 hospital encounters for injuries in Kentucky. The most common mechanisms of injury were falls, struck by/against, motor vehicle traffic crashes, and overexertion. Three causes of injury were greater than one standard deviation above the mean in percentage of inpatient admissions: poisoning (41.3%), firearms (38.4%), and drowning (22.4%). During this same year, KRPCC reported 46,258 poisonings, with 76.5% of patients managed outside of a health-care facility, 11.4% of patients treated and released from the ED, 7.1% of patients admitted to inpatient care, 2.3% of patients admitted to psychiatric care, and 2.7% lost to follow-up. CONCLUSIONS: Three causes of injury had the greatest percentage of patients admitted for inpatient medical care--poisoning, firearms, and drowning--suggesting a high level of severity in these injuries presenting to the ED. We believe availability and use of a poison control center reduced hospital utilization for poisoning primarily by managing a large number of low-severity patients outside of the hospital system.