Performance of administrative database frailty instruments in predicting clinical outcomes and cost for patients undergoing transcatheter aortic valve implantation: a historical cohort study.

PURPOSE: Frailty instruments may improve prognostic estimates for patients undergoing transcatheter aortic valve implantation (TAVI). Few studies have evaluated and compared the performance of administrative database frailty instruments for patients undergoing TAVI. This study aimed to examine the performance of administrative database frailty instruments in predicting clinical outcomes and costs in patients who underwent TAVI. METHODS: We conducted a historical cohort study of 3,848 patients aged 66 yr or older who underwent a TAVI procedure in Ontario, Canada from 1 April 2012 to 31 March 2018. We used the Johns Hopkins Adjusted Clinical Group (ACG) frailty indicator and the Hospital Frailty Risk Score (HFRS) to assign frailty status. Outcomes of interest were in-hospital mortality, one-year mortality, rehospitalization, and healthcare costs. We compared the performance of the two frailty instruments with that of a reference model that adjusted baseline covariates and procedural characteristics. Accuracy measures included c-statistics, Akaike information criterion (AIC), Bayesian information criterion (BIC), integrated discrimination improvement (IDI), net reclassification index (NRI), bias, and accuracy of cost estimates. RESULTS: A total of 863 patients (22.4%) were identified as frail using the Johns Hopkins ACG frailty indicator and 865 (22.5%) were identified as frail using the HFRS. Although agreement between the frailty instruments was fair (Kappa statistic = 0.322), each instrument classified different subgroups as frail. Both the Johns Hopkins ACG frailty indicator (rate ratio [RR], 1.13; 95% confidence interval [CI], 1.06 to 1.20) and the HFRS (RR, 1.14; 95% CI, 1.07 to 1.21) were significantly associated with increased one-year costs. Compared with the reference model, both the Johns Hopkins ACG frailty indicator and HFRS significantly improved NRI for one-year mortality (Johns Hopkins ACG frailty indicator: NRI, 0.160; P < 0.001; HFRS: NRI, 0.146; P = 0.001) and rehospitalization (Johns Hopkins ACG frailty indicator: NRI, 0.201; P < 0.001; HFRS: NRI, 0.141; P = 0.001). These improvements in NRI largely resulted from classification improvement among those who did not experience the event. With one-year mortality, there was a significant improvement in IDI (IDI, 0.003; P < 0.001) with the Johns Hopkins ACG frailty indicator. This improvement in performance resulted from an increase in the mean probability of the event among those with the event. CONCLUSION: Preoperative frailty assessment may add some predictive value for TAVI outcomes. Use of administrative database frailty instruments may provide small but significant improvements in case-mix adjustment when profiling hospitals for certain outcomes.

RéSUMé: OBJECTIF: L'utilisation d'indicateur de fragilité pourrait améliorer l'évaluation pronostique des patients bénéficiant d'un remplacement valvulaire aortique par voie percutanée (procédure TAVI). Peu d'études ont évalué et comparé la performance des instruments d'évaluation de la fragilité développés à partir de données administratives chez les patients bénéficiant d'un TAVI. Nous avions pour objectif d'examiner la performance des instruments d'évaluation de la fragilité développés à partir de données administratives dans la prédiction des issues cliniques et des coûts chez les patients ayant bénéficié d'un TAVI. MéTHODE: Nous avons réalisé une étude de cohorte historique auprès de 3848 patients âgés de 66 ans ou plus qui ont bénéficié d'une procédure TAVI en Ontario, Canada, du 1er avril 2012 au 31 mars 2018. Nous avons utilisé l'indicateur de fragilité ACG (Adjusted Clinical Group) de Johns Hopkins et le score de risque de fragilité à l'hôpital (HFRS) pour définir la fragilité. Les critères d'évaluation étaient la mortalité hospitalière, la mortalité à un an, la réhospitalisation et les coûts des soins de santé. Nous avons comparé la performance des deux instruments d'évaluation de la fragilité à celle d'un modèle de référence qui ajustait les covariables de base et les caractéristiques procédurales. Les mesures d'exactitude comprenaient l'analyse statistique c, le critère d'information d'Akaike (AIC), le critère d'information bayésien (BIC), l'amélioration de la discrimination intégrée (IDI), l'indice NRI (net reclassification index), le biais et l'exactitude des estimations de coûts. RéSULTATS: Au total, 863 patients (22,4 %) ont été identifiés comme fragiles à l'aide de l'indicateur de fragilité ACG de Johns Hopkins, et 865 (22,5 %) ont été identifiés comme fragiles à l'aide du HFRS. Bien que l'agrément entre les instruments d'évaluation de la fragilité ait été acceptable (statistique de Kappa = 0,322), chaque instrument a classé des sous-groupes différents comme étant fragiles. L'indicateur de fragilité ACG de Johns Hopkins (rapport de taux [RR], 1,13; intervalle de confiance à 95 % [IC], 1,06 à 1,20) et le HFRS (RR, 1,14; IC 95 %, 1,07 à 1,21) étaient associés de façon significative à une augmentation des coûts sur un an. Par rapport au modèle de référence, l'indicateur de fragilité ACG de Johns Hopkins améliorent de façon significative le NRI pour la mortalité (l'indicateur de fragilité ACG de Johns Hopkins: NRI, 0.160; P < 0.001; HFRS: NRI, 0.146; P = 0.001) et la réhospitalisation (l'indicateur de fragilité ACG: NRI, 0.201; P < 0.001; HFRS: NRI, 0.141; P = 0.001) à un an. Ces améliorations du NRI résultent en grande partie de l'amélioration de la classification chez ceux qui n'ont pas bénéficié d'un TAVI. En ce qui a trait à la mortalité à un an, il y a eu une amélioration significative de l'IDI (IDI, 0,003; P < 0,001) avec l'indicateur de fragilité ACG de Johns Hopkins. Cette amélioration de la performance résultait d'une augmentation de la probabilité moyenne de TAVI chez les personnes ayant vécu l'événement. CONCLUSION: L'évaluation préopératoire de la fragilité peut ajouter une certaine valeur prédictive aux issues cliniques suivant une procédure de TAVI. L'utilisation d'instruments d'évaluation de la fragilité développés à partir de données administratives peut apporter des améliorations mineures mais significatives pour l'ajustement de risque lors de l'évaluation des hôpitaux en fonction de certaines issues cliniques.

Clinical impact of disinvestment in hydroxyethyl starch for patients undergoing coronary artery bypass surgery: a retrospective observational study.

PURPOSE: To examine the effect of discontinuing hydroxyethyl starch (HES) solutions on length of hospital stay, transfusion, risk of death, acute kidney injury (AKI), and dialysis. METHODS: We conducted a historical cohort study of linked administrative and clinical databases in patients undergoing coronary artery bypass surgery (CABG) on cardiopulmonary bypass. We used propensity scores to match patients who did not receive HES (after discontinuation) with patients exposed to HES (before discontinuation) and also controlled for albumin exposure. Hospital length of stay (the primary outcome) was analyzed using Fine-Gray proportional hazard regression, with hospital discharge as the outcome and death as a competing risk. Adverse outcomes were compared between matched patients using conditional logistic regression. RESULTS: We compared 1,085 propensity score-matched pairs (n = 2,170) from a pool of 2,757 patients. Discontinuation of HES was associated with shorter length of hospital stay, as evidenced by an increased probability of discharge (hazard ratio, 1.24; 95% confidence interval [CI], 1.14 to 1.35) and a reduced risk of red blood cell transfusion (odds ratio [OR], 0.68; 95% CI, 0.55 to 0.84), plasma transfusion (OR, 0.48; 95% CI, 0.34 to 0.66), and platelet transfusion (OR, 0.62; 95% CI, 0.44 to 0.87). Discontinuation of HES was not associated with in-hospital mortality (OR, 0.74; 95% CI, 0.36 to 1.54), AKI (OR, 0.84; 95% CI, 0.57 to 1.25), or dialysis (OR, 0.83; 95% CI, 0.25 to 2.73). CONCLUSIONS: For patients undergoing CABG on cardiopulmonary bypass, discontinuation of HES was associated with reduced hospital length of stay and reduced blood product transfusion, without measurable change in renal failure, dialysis rate, or in-hospital mortality. Our results should be interpreted with caution, though we found no evidence of harms associated with discontinuing HES. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02329158); registered 31 December, 2014.

Should Transfusion Trigger Thresholds Differ for Critical Care Versus Perioperative Patients? A Meta-Analysis of Randomized Trials.

OBJECTIVE: To address the significant uncertainty as to whether transfusion thresholds for critical care versus surgical patients should differ. DESIGN: Meta-analysis of randomized controlled trials. SETTING: Medline, EMBASE, and Cochrane Library searches were performed up to 15 June 2016. PATIENTS: Trials had to enroll adult surgical or critically ill patients for inclusion. INTERVENTIONS: Studies had to compare a liberal versus restrictive threshold for the transfusion of allogeneic packed RBCs. MEASUREMENTS AND MAIN RESULTS: The primary outcome was 30-day all-cause mortality, sub-grouped by surgical and critical care patients. Secondary outcomes included myocardial infarction, stroke, renal failure, allogeneic blood exposure, and length of stay. Odds ratios and weighted mean differences were calculated using random effects meta-analysis. To assess whether subgroups were significantly different, tests for subgroup interaction were used. Subgroup analysis by trials enrolling critically ill versus surgical patients was performed. Twenty-seven randomized controlled trials (10,797 patients) were included. In critical care patients, restrictive transfusion resulted in significantly reduced 30-day mortality compared with liberal transfusion (odds ratio, 0.82; 95% CI, 0.70-0.97). In surgical patients, a restrictive transfusion strategy led to the opposite direction of effect for mortality (odds ratio, 1.31; 95% CI, 0.94-1.82). The subgroup interaction test was significant (p = 0.04), suggesting that the effect of restrictive transfusion on mortality is statistically different for critical care (decreased risk) versus surgical patients (potentially increased risk or no difference). Regarding secondary outcomes, for critically ill patients, a restrictive strategy resulted in reduced risk of stroke/transient ischemic attack, packed RBC exposure, transfusion reactions, and hospital length of stay. In surgical patients, restrictive transfusion resulted in reduced packed RBC exposure. CONCLUSIONS: The safety of restrictive transfusion strategies likely differs for critically ill patients versus perioperative patients. Further trials investigating transfusion strategies in the perioperative setting are necessary.

Fibrinogen Concentrate in Cardiovascular Surgery: A Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Postoperative bleeding remains a frequent complication after cardiovascular surgery and may contribute to serious morbidity and mortality. Observational studies have suggested a relationship between low endogenous plasma fibrinogen concentration and increased risk of postoperative blood loss in cardiac surgery. Although the transfusion of fibrinogen concentrate has been increasing, potential benefits and risks associated with perioperative fibrinogen supplementation in cardiovascular surgery are not fully understood. METHODS: PubMed, Cochrane Library, Ovid MEDLINE, Embase, Web of Science, and China National Knowledge Infrastructure were searched on January 15, 2017, with automated updates searched until February 15, 2018, to identify all randomized controlled trials (RCTs) of fibrinogen concentrate, whether for prophylaxis or treatment of bleeding, in adults undergoing cardiovascular surgery. All RCTs comparing fibrinogen infusion versus any other comparator (placebo/standard of care or another active comparator) in adult cardiovascular surgery and reporting at least 1 predefined clinical outcome were included. The random-effects model was used to calculate risk ratios and weighted mean differences (95% confidence interval [CI]) for dichotomous and continuous variables, respectively. Subgroup analyses by fibrinogen dose and by baseline risk for bleeding were preplanned. RESULTS: A total of 8 RCTs of fibrinogen concentrate in adults (n = 597) of mixed risk or high risk undergoing cardiovascular surgery were included. Compared to placebo or inactive control, perioperative fibrinogen concentrate did not significantly impact risk of all-cause mortality (risk ratio, 0.41; 95% CI, 0.12-1.38; I = 10%; P = .15). Fibrinogen significantly reduced incidence of allogeneic red blood cell transfusion (risk ratio, 0.64; 95% CI, 0.49-0.83; I = 0%; P = .001). No significant differences were found for other clinical outcomes. Subgroup analyses were unremarkable when analyzed according to fibrinogen dose, time of infusion initiation, mean cardiopulmonary bypass time, and rotational thromboelastometry/fibrinogen temogram use (all P values for subgroup interaction were nonsignificant). CONCLUSIONS: Current evidence remains insufficient to support or refute routine perioperative administration of fibrinogen concentrate in patients undergoing cardiovascular surgery. Fibrinogen concentrate may reduce the need for additional allogeneic blood product transfusion in cardiovascular surgery patients at high risk or with evidence of bleeding. However, no definitive advantage was found for reduction in risk of mortality or other clinically relevant outcomes. The small number of clinical events within existing randomized trials suggests that further well-designed studies of adequate power and duration to measure all-cause mortality, stroke, myocardial infarction, reoperation, and thromboembolic events should be conducted. Future studies should also address cost-effectiveness relative to standard of care.

Drugs That May Cause or Exacerbate Heart Failure: A Scientific Statement From the American Heart Association.

Heart failure is a common, costly, and debilitating syndrome that is associated with a highly complex drug regimen, a large number of comorbidities, and a large and often disparate number of healthcare providers. All of these factors conspire to increase the risk of heart failure exacerbation by direct myocardial toxicity, drug-drug interactions, or both. This scientific statement is designed to serve as a comprehensive and accessible source of drugs that may cause or exacerbate heart failure to assist healthcare providers in improving the quality of care for these patients.

Postoperative Outcomes in Obstructive Sleep Apnea Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis of Comparative Studies.

BACKGROUND: Obstructive sleep apnea (OSA) is a common comorbidity in patients undergoing cardiac surgery and may predispose patients to postoperative complications. The purpose of this meta-analysis is to determine the evidence of postoperative complications associated with OSA patients undergoing cardiac surgery. METHODS: A literature search of Cochrane Database of Systematic Reviews, Medline, Medline In-process, Web of Science, Scopus, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL until October 2016 was performed. The search was constrained to studies in adult cardiac surgical patients with diagnosed or suspected OSA. All included studies must report at least 1 postoperative complication. The primary outcome is major adverse cardiac or cerebrovascular events (MACCEs) up to 30 days after surgery, which includes death from all-cause mortality, myocardial infarction, myocardial injury, nonfatal cardiac arrest, revascularization process, pulmonary embolism, deep venous thrombosis, newly documented postoperative atrial fibrillation (POAF), stroke, and congestive heart failure. Secondary outcome is newly documented POAF. The other exploratory outcomes include the following: (1) postoperative tracheal intubation and mechanical ventilation; (2) infection and/or sepsis; (3) unplanned intensive care unit (ICU) admission; and (4) duration of stay in hospital and ICU. Meta-analysis and meta- regression were conducted using Cochrane Review Manager 5.3 (Cochrane, London, UK) and OpenBUGS v3.0, respectively. RESULTS: Eleven comparative studies were included (n = 1801 patients; OSA versus non-OSA: 688 vs 1113, respectively). MACCEs were 33.3% higher odds in OSA versus non-OSA patients (OSA versus non-OSA: 31% vs 10.6%; odds ratio [OR], 2.4; 95% confidence interval [CI], 1.38-4.2; P = .002). The odds of newly documented POAF (OSA versus non-OSA: 31% vs 21%; OR, 1.94; 95% CI, 1.13-3.33; P = .02) was higher in OSA compared to non-OSA. Even though the postoperative tracheal intubation and mechanical ventilation (OSA versus non-OSA: 13% vs 5.4%; OR, 2.67; 95% CI, 1.03-6.89; P = .04) were significantly higher in OSA patients, the length of ICU stay and hospital stay were not significantly prolonged in patients with OSA compared to non-OSA. The majority of OSA patients were not treated with continuous positive airway pressure therapy. Meta-regression and sensitivity analysis of the subgroups did not impact the OR of postoperative complications for OSA versus non-OSA groups. CONCLUSIONS: Our meta-analysis demonstrates that after cardiac surgery, MACCEs and newly documented POAF were 33.3% and 18.1% higher odds in OSA versus non-OSA patients, respectively.

Cerebral Oximetry Monitoring to Maintain Normal Cerebral Oxygen Saturation during High-risk Cardiac Surgery: A Randomized Controlled Feasibility Trial.

BACKGROUND: Cerebral oxygen desaturation during cardiac surgery has been associated with adverse perioperative outcomes. Before a large multicenter randomized controlled trial (RCT) on the impact of preventing desaturations on perioperative outcomes, the authors undertook a randomized prospective, parallel-arm, multicenter feasibility RCT to determine whether an intervention algorithm could prevent desaturations. METHODS: Eight Canadian sites randomized 201 patients between April 2012 and October 2013. The primary outcome was the success rate of reversing cerebral desaturations below 10% relative to baseline in the intervention group. Anesthesiologists were blinded to the cerebral saturation values in the control group. Intensive care unit personnel were blinded to cerebral saturation values for both groups. Secondary outcomes included the area under the curve of cerebral desaturation load, enrolment rates, and a 30-day follow-up for adverse events. RESULTS: Cerebral desaturations occurred in 71 (70%) of the 102 intervention group patients and 56 (57%) of the 99 control group patients (P = 0.04). Reversal was successful in 69 (97%) of the intervention group patients. The mean cerebral desaturation load (SD) in the operating room was smaller for intervention group patients compared with control group patients (104 [217] %.min vs. 398 [869] %.min, mean difference, -294; 95% CI, -562 to -26; P = 0.03). This was also true in the intensive care unit (P = 0.02). There were no differences in adverse events between the groups. CONCLUSIONS: Study sites were successful in reversal of desaturation, patient recruitment, randomization, and follow-up in cardiac surgery, supporting the feasibility of conducting a large multicenter RCT.

Ketamine added to morphine or hydromorphone patient-controlled analgesia for acute postoperative pain in adults: a systematic review and meta-analysis of randomized trials.

PURPOSE: To determine whether ketamine added to morphine or hydromorphone patient-controlled analgesia (PCA) provides clinically relevant reductions in postoperative pain, opioid requirements, and adverse events when compared with morphine or hydromorphone PCA in adults undergoing surgery. SOURCE: We systematically searched six databases up to June 2, 2015 for randomized controlled trials (RCTs) comparing ketamine plus morphine/hydromorphone PCA vs morphine/hydromorphone PCA for postoperative pain in adults. PRINCIPAL FINDINGS: Thirty-six RCTs including 2,502 patients proved eligible, and 22 of these were at low risk of bias. The addition of ketamine to morphine/hydromorphone PCA decreased postoperative pain intensity at six to 72 hr when measured at rest (weighted mean difference [WMD] on a 10-cm visual analogue scale ranged from -0.4 to -1.3 cm) and during mobilization (WMD ranged from -0.4 to -0.5 cm). Adjunctive ketamine also significantly reduced cumulative morphine consumption at 24-72 hr by approximately 5-20 mg. Predefined subgroup analyses and meta-regression did not detect significant differences across subgroups, including a dose-response relationship. There was no significant difference in patient satisfaction scores at 24 and 48 hr. Nevertheless, the addition of ketamine to morphine/hydromorphone PCA significantly reduced postoperative nausea and vomiting (relative risk, 0.71; 95% confidence interval [CI], 0.60 to 0.85; absolute risk reduction, 8.9%; 95% CI, 4.6 to 12.2). Significant effects on other adverse events (e.g., hallucinations, vivid dreams) were not detected, though only a few studies reported on them. CONCLUSIONS: Adding ketamine to morphine/hydromorphone PCA provides a small improvement in postoperative analgesia while reducing opioid requirements. Adjunctive ketamine also reduces postoperative nausea and vomiting without a detected increase in other adverse effects; however, adverse events were probably underreported.

Pain and inflammatory response following off-pump coronary artery bypass grafting.

PURPOSE OF REVIEW: Inflammation and pain are two common clinical issues following cardiac surgery, which are important to patient outcomes. This article reviews the literature regarding inflammation and pain following cardiac surgery with special emphasis on off-pump cardiac surgery. RECENT FINDINGS: Off-pump surgery is associated with decreased intraoperative inflammatory response compared with procedures using cardiopulmonary bypass; however, the postoperative pattern of inflammatory response is similar to on-pump procedures. Multimodal analgesic regimens and protocol-based approaches to pain management improve analgesia compared to conventional approaches. SUMMARY: Off-pump cardiac surgeries although known to decrease the inflammatory burden do not appear to impact the overall patient outcomes. Recent evidence indicates the prothrombotic tendency following off-pump procedures, which could be related to the time course of inflammation following off-pump cardiac surgery. There might be some benefit of off-pump procedures regarding neurological and renal function that needs further studies. Pain management following off-pump procedures is similar to that of patients undergoing on-pump cardiac surgery. Better caregiver and patient education is crucial for improving pain control following cardiac surgery. Analgesic regimens need to consider adjuvants and regional analgesic techniques and patient-controlled modalities while providing care.

Harnessing the potential of large language models in medical education: promise and pitfalls.

OBJECTIVES: To provide balanced consideration of the opportunities and challenges associated with integrating Large Language Models (LLMs) throughout the medical school continuum. PROCESS: Narrative review of published literature contextualized by current reports of LLM application in medical education. CONCLUSIONS: LLMs like OpenAI's ChatGPT can potentially revolutionize traditional teaching methodologies. LLMs offer several potential advantages to students, including direct access to vast information, facilitation of personalized learning experiences, and enhancement of clinical skills development. For faculty and instructors, LLMs can facilitate innovative approaches to teaching complex medical concepts and fostering student engagement. Notable challenges of LLMs integration include the risk of fostering academic misconduct, inadvertent overreliance on AI, potential dilution of critical thinking skills, concerns regarding the accuracy and reliability of LLM-generated content, and the possible implications on teaching staff.

A Multi-Country Survey on the Availability of Intraoperative Use of Echocardiography for Noncardiac Surgery.

BACKGROUND: This survey aimed to explore the availability and accessibility of echocardiography during noncardiac surgery worldwide. METHODS: An internet-based 45-item survey was sent, followed by reminders from August 30, 2021, to August 20, 2022. RESULTS: 1189 responses were received from 62 countries. Nearly seventy-one percent of respondents had intraoperatively used transesophageal or transthoracic echocardiography (TEE and TTE, respectively) for monitoring or examination. The unavailability of echocardiography machines (30.3%), lack of trained personnel (30.2%), and absence of clinical indications (22.6%) were the top 3 reasons for not using intraoperative echocardiography in noncardiac surgery. About 61.5% of participants had access to at least one echocardiography machine. About 41% had access to at least 1 TEE probe, and 62.2% had access to at least 1 TTE probe. Seventy-four percent of centers had a procedure to request intraoperative echocardiography if needed for noncardiac cases. Intraoperative echocardiography service was immediately available in 58% of centers. CONCLUSIONS: Echocardiography machines and skilled echocardiographers are still unavailable at many centers worldwide. National societies should aim to train a critical mass of certified TEE/TTE anesthesiologists and provide all anesthesiologists access to perioperative TEE/TTE machines in anesthesiology departments, considering the increasing number of older and sicker surgical patients scheduled for noncardiac surgery.

Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis.

BACKGROUND: The magnitude of risk of death related to surgery and anaesthesia is not well understood. We aimed to assess whether the risk of perioperative and anaesthetic-related mortality has decreased over the past five decades and whether rates of decline have been comparable in developed and developing countries. METHODS: We did a systematic review to identify all studies published up to February, 2011, in any language, with a sample size of over 3000 that reported perioperative mortality across a mixed surgical population who had undergone general anaesthesia. Using standard forms, two authors independently identified studies for inclusion and extracted information on rates of anaesthetic-related mortality, perioperative mortality, cardiac arrest, American Society of Anesthesiologists (ASA) physical status, geographic location, human development index (HDI), and year. The primary outcome was anaesthetic sole mortality. Secondary outcomes were anaesthetic contributory mortality, total perioperative mortality, and cardiac arrest. Meta-regression was done to ascertain weighted event rates for the outcomes. FINDINGS: 87 studies met the inclusion criteria, within which there were more than 21·4 million anaesthetic administrations given to patients undergoing general anaesthesia for surgery. Mortality solely attributable to anaesthesia declined over time, from 357 per million (95% CI 324-394) before the 1970s to 52 per million (42-64) in the 1970s-80s, and 34 per million (29-39) in the 1990s-2000s (p<0·00001). Total perioperative mortality decreased over time, from 10,603 per million (95% CI 10,423-10,784) before the 1970s, to 4533 per million (4405-4664) in the 1970s-80s, and 1176 per million (1148-1205) in the 1990s-2000s (p<0·0001). Meta-regression showed a significant relation between risk of perioperative and anaesthetic-related mortality and HDI (all p<0·00001). Baseline risk status of patients who presented for surgery as shown by the ASA score increased over the decades (p<0·0001). INTERPRETATION: Despite increasing patient baseline risk, perioperative mortality has declined significantly over the past 50 years, with the greatest decline in developed countries. Global priority should be given to reducing total perioperative and anaesthetic-related mortality by evidence-based best practice in developing countries. FUNDING: University of Western Ontario.

Role of the anesthesiologist in the wider governance of healthcare and health economics.

PURPOSE: Healthcare resources will always be limited, and as a result, difficult decisions must be made about how to allocate limited resources across unlimited demands in order to maximize health gains per resource expended. Governments and hospitals now in severe financial deficits recognize that reengagement of physicians is central to their ability to contain the runaway healthcare costs. Health economic analysis provides tools and techniques to assess which investments in healthcare provide good value for money vs which options should be forgone. Robust decision-making in healthcare requires objective consideration of evidence in order to balance clinical and economic benefits vs risks. PRINCIPAL FINDINGS: Surveys of the literature reveal very few economic analyses related to anesthesia and perioperative medicine despite increasing recognition of the need. Now is an opportune time for anesthesiologists to become familiar with the tools and methodologies of health economics in order to facilitate and lead robust decision-making in quality-based procedures. For most technologies used in anesthesia and perioperative medicine, the responsibility to determine cost-effectiveness falls to those tasked with the governance and stewardship of limited resources for unlimited demands using best evidence plus economics at the local, regional, and national levels. Applicable cost-effectiveness, cost-utility, and cost-benefits in health economics are reviewed in this article with clinical examples in anesthesia. CONCLUSIONS: Anesthesiologists can make a difference in the wider governance of healthcare and health economics if we advance our knowledge and skills beyond the technical to address the "other" dimensions of decision-making--most notably, the economic aspects in a value-based healthcare system.

Malnutrition risk, outcomes, and costs among older adults undergoing elective surgical procedures: A retrospective cohort study.

BACKGROUND: We examine here the association between malnutrition risk and adverse health outcomes among older adult patients undergoing elective surgical procedures. METHODS: We conducted a retrospective study using linked clinical and administrative databases. Malnutrition risk was assessed prior to surgery, defined by unintentional weight loss and decreased food intake. We performed a logistic regression analysis of the primary outcome, a composite adverse outcome measure, including death, bleeding, pneumonia, and other surgical complications. We conducted Fine-Gray proportional hazard regression analysis of hospital length of stay (LOS). We performed a generalized linear regression analysis of in-hospital cost data. All regression analyses controlled for frailty, age, sex, surgical category, and comorbidities. RESULTS: Of a total of 3457 older adult elective surgical patients (65-102 years), 310 (9.0%) screened positive for malnutrition risk. In multivariable regression analyses, malnutrition risk was associated with an increased risk of the composite adverse outcome (odds ratio [OR] = 1.74; 95% CI = 1.25-2.39), higher hospitalization costs (relative cost = 1.84; 95% CI = 1.59-2.13), and a decreased risk of discharge from the hospital (hazard ratio = 0.67; 95% CI = 0.59-0.77) compared with those who screened negative. CONCLUSION: Older adult patients with malnutrition risk were at an increased risk of adverse surgical outcomes, had longer LOS in the hospital, and incurred higher costs of care. It is important to screen for malnutrition risk and refer older adults for dietetic consults prior to elective surgery.

Magnitude of COVID-19 deaths relative to other leading causes of death: a global analysis.

OBJECTIVES: To quantify the burden of death that COVID-19 contributes relative to the top three causes of death for all countries. DESIGN: We performed uncertainty analyses and created contour plots for COVID-19 mortality to place the number of COVID-19 deaths in context relative to the top three causes of death in each country, across a plausible range of values for two key parameters: case fatality rate and magnitude of under-reporting. SETTING: All countries that have reported COVID-19 cases to the WHO and are included in the Global Burden of Disease Study by the Institute of Health Metrics and Evaluation. MAIN OUTCOMES AND MEASURES: Monthly number of deaths caused by COVID-19 and monthly number of deaths caused by the top three causes of death for every country. RESULTS: For countries that were particularly hard hit during the outbreak in 2020, most combinations of model parameters resulted in COVID-19 ranking within the top three causes of death. For countries not as hard hit on a per-capita basis, such as China and India, COVID-19 did not rank higher than the third leading cause of death at any combination of the model parameters within the given ranges. Up-to-date ranking of COVID-19 deaths relative to the top three causes of death for all countries globally is provided in an interactive online application. CONCLUSIONS: Estimating the country-level burden of death that COVID-19 contributes relative to the top three causes of death is feasible through contour graphs, even when the actual number of deaths or cases is unknown. This method can help convey importance by placing the magnitude of COVID-related deaths in context relative to more familiar causes of death by communicating when COVID-related deaths rank among the top three causes of death.

N-acetylcysteine in cardiac surgery: do the benefits outweigh the risks? A meta-analytic reappraisal.

OBJECTIVE: N-acetylcysteine (NAC) reduces proinflammatory cytokines, oxygen free-radical production, and ameliorates ischemia reperfusion injury; therefore, it may theoretically reduce postoperative complications in cardiac surgery. The aim of this study was to determine, through systematic review and meta-analysis of all relevant randomized trials, whether NAC reduces mortality, morbidity, or resource utilization in cardiac surgery. DESIGN: Meta-analysis. SETTING: University hospitals. PARTICIPANTS: A total of 1,407 patients from 15 randomized studies were included in the analysis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All randomized trials searched up to May 2009 comparing the use of NAC versus placebo during cardiac surgery in any language and reporting at least 1 predefined outcome were included. The random effect model was used to calculate odds ratios (ORs, 95% confidence intervals [CIs]) and weighted mean differences (WMD, 95% CI) for dichotomous and continuous variables, respectively. During cardiac surgery, the use of NAC did not significantly decrease acute renal failure requiring renal replacement therapy (OR = 1.05; 95% CI, 0.52-2.11; p = 0.90), new atrial fibrillation (OR = 0.67; 95% CI, 0.37-1.22; p = 0.19), or mortality (OR = 0.81; 95% CI, 0.39-1.68; p = 0.57). There were no differences in the incidence of incremental increase in serum creatinine concentration greater than 25% above baseline (OR = 0.86; 95% CI, 0.66-1.12; p = 0.26), acute myocardial infarction (OR = 0.69; 95% CI, 0.29-1.61, p =0.39), stroke (OR = 0.78; 95% CI, 0.30-2.03; p = 0.61), red blood cell transfusion requirement (OR = 0.77; 95% CI, 0.45-1.31; p = 0.33), re-exploration (OR = 1.33; 95% CI, 0.70-2.26; p = 0.29), or postoperative drainage (WMD = 33 mL; 95% CI,-125 to 191 mL; p = 0.69) between NAC and placebo. CONCLUSION: Current evidence shows that the perioperative use of NAC has no proven benefit or risk on clinically important outcomes in patients undergoing cardiac surgery.

Prognosis of diabetic patients undergoing coronary artery bypass surgery compared with nondiabetics: a systematic review and meta-analysis.

OBJECTIVE: The influence of diabetes mellitus (DM) on mortality and morbidity in patients undergoing coronary artery bypass graft (CABG) surgery has remained uncertain due to conflicting conclusions from clinical trials measuring the association between diabetes and perioperative risk. Therefore, a quantitative meta-analysis was undertaken to evaluate the available evidence from prospective and historic cohort clinical trials. The purpose of this study was to determine the significance and magnitude of impact of DM on mortality, morbidity and resource-related outcomes for patients undergoing CABG over the past few decades and in the contemporary setting. METHODS: MEDILINE, EMBase, BIOSIS Preview, CBMDisc, CNKI and WanFang databases were searched, supplemented by hand search, without language limitations, for studies published from January 1981 to October 2008. Data extraction included study design, setting, inclusion/exclusion criteria, population characteristics, statistical method, length of follow-up and clinical outcomes. Eligible studies were assessed for quality. RESULTS: Of the 132 identified studies, 24 cohort studies with a median follow-up of 4.3 years were selected for analysis. A total of 100,217 patients (28,168 with DM and 72,049 without DM), were included in the meta-analysis. The pooled RR (95% CI) for mortality of diabetic versus non-diabetic patients was significantly increased at 30 days (RR 1.64, 95% CI 1.39, 1.93), 1 year (RR 1.83, 95% CI 1.56, 2.15), 3 years (RR 1.81, 95% CI 1.58, 2.09), 5 years (RR 1.66, 95% CI 1.53, 1.79) and 10 years (RR 1.55, 95% CI 1.43, 1.68) after CABG. Significant differences were also found for DM versus non-DM patients post-CABG for perioperative cerebrovascular accidents (RR 1.52; 95% CI 1.31, 1.77), postoperative acute renal failure (RR 1.63; 95% CI 1.48, 1.79), sternal infection (RR; 1.70, 95% CI 1.41-2.04) and blood transfusion (RR 1.15; 95% CI 1.08, 1.21). No significant differences were found for postoperative atrial fibrillation (AF), postoperative myocardial infarction (MI) and re-exploration for bleeding. Insufficient and/or heterogeneous data did not allow for pooled analysis of ventilator time, ICU stay, angina recurrence, repeat revascularization, hospital stay and hospital costs. CONCLUSIONS: Current evidence suggests that patients with DM who are undergoing CABG are at increased risk of mortality, stroke, renal failure, sternal infection and blood transfusion when compared to those without DM. This increased relative risk for perioperative mortality and complications has remained, despite evolving definitions of DM and practice patterns. Future randomized studies should focus on interventions targeted toward these complications to mitigate the risk for patients with DM.

The effect of nasogastric tube application during cardiac surgery on postoperative nausea and vomiting--a randomized trial.

OBJECTIVE: Postoperative nausea and vomiting (PONV) are significant morbidities following cardiac surgery. The purpose of this study was to determine if application of a nasogastric (NG) tube during cardiac surgery can reduce the prevalence of postoperative PONV. DESIGN: This study was a prospective randomized controlled trial. SETTING: University tertiary referral center. PARTICIPANTS: Two hundred two patients undergoing elective cardiac procedures. INTERVENTIONS: Patients were prospectively enrolled and randomized to either receive or not receive an NG tube after induction of anesthesia. Standard anesthetic technique and postoperative care were employed in all patients. Preoperative demographic data, pain score, nausea score and incidence of vomiting were recorded early (0-8 hours) and late (8-16 hours) following extubation. Antiemetic and analgesic medications were compared between the 2 groups. MEASUREMENTS AND MAIN RESULTS: One hundred three patients were randomized to no an NG tube (controls) and 99 received an NG tube as part of their perioperative management. Demographic data and surgical characteristics were similar between the 2 groups. However, the control group had more smokers. Incidence and severity of nausea, pain scores, and analgesic requirements were similar between the 2 groups. Prevalence of vomiting was more frequent in the control group (24%) than in the NG tube group (10%, p = 0.007), and was more frequent in patients who underwent valve and redo procedures. CONCLUSIONS: Use of an NG tube during cardiac surgery may reduce the incidence of postoperative vomiting.

Impact of COVID-19 on excess mortality, life expectancy, and years of life lost in the United States.

This paper quantifies the net impact (direct and indirect effects) of the pandemic on the United States population in 2020 using three metrics: excess deaths, life expectancy, and total years of life lost. The findings indicate there were 375,235 excess deaths, with 83% attributable to direct, and 17% attributable to indirect effects of COVID-19. The decrease in life expectancy was 1.67 years, translating to a reversion of 14 years in historical life expectancy gains. Total years of life lost in 2020 was 7,362,555 across the USA (73% directly attributable, 27% indirectly attributable to COVID-19), with considerable heterogeneity at the individual state level.