Local Anesthesia for Endovascular Repair of Abdominal Aortic Aneurysm Allows for Accurate Graft Deployment with Durable Results.

BACKGROUND: Local anesthesia (LA) is sparsely used in endovascular aneurysm repair (EVAR) despite short-term benefit, likely secondary to concerns over patient movement preventing accurate endograft deployment. The objective of this study is to examine the association between anesthesia type and endoleak, sac regression, reintervention, and mortality. METHODS: The Vascular Quality Initiative database was queried for all EVAR cases from 2014 to 2022. Patients were included if they underwent percutaneous elective EVAR with anatomical criteria within instructions for use of commercially approved endografts. Multivariable logistic regression with propensity score weighting was used to determine the association between anesthesia type on the risk of any endoleak noted by intraoperative completion angiogram and sac regression. Multivariable survival analysis with propensity score weighting was used to determine the association between anesthesia type and endoleak at 1 year, long-term reintervention, and mortality. RESULTS: Thirteen thousand nine hundred thirty two EVARs met inclusion criteria: 1,075 (8%) LA and 12,857 (92%) general anesthesia (GA). On completion angiogram, LA was associated with fewer rates of any endoleaks overall (16% vs. 24%, P < 0.001). On multivariable analysis with propensity score weighting, LA was associated with similar adjusted odds of any endoleak on intraoperative completion angiogram (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.47-0.68) as well as combined type 1a and type 1b endoleaks (OR 0.72, 95% CI 0.47-1.09). Follow-up computed tomography imaging at 1 year was available for 4,892 patients, 377 (8%) LA and 4,515 (92%) GA. At 1 year, LA was associated with similar rate of freedom from any endoleaks compared to GA (0.66 [95% CI 0.63-0.69] vs. 0.71 [95% CI 0.70-0.72], P = 0.663) and increased rates of sac regression (50% vs. 45%, P = 0.040). On multivariable analysis with propensity score weighting, LA and GA were associated with similar adjusted odds of sac regression (OR 1.22, 95% CI 0.97-1.55). LA and GA had similar rates of endoleak at 1 year (hazard ratio [HR] 0.14, 95% CI 0.63-1.07); however, LA was associated with decreased hazards of combined type 1a and 1b endoleaks at 1 year (HR 0.87, 95% CI 0.80-0.96). LA and GA had similar adjusted long-term reintervention rate (HR 0.77, 95% CI 0.44-1.38) and long-term mortality (HR 1.100, 95% CI 079-1.25). CONCLUSIONS: LA is not associated with increased adjusted rates of any endoleak on completion angiogram or at 1-year follow-up compared to GA. LA is associated with decreased adjusted rates of type 1a and type 1b endoleak at 1 year, but similar rates of sac regression, long-term reintervention, and mortality. Concerns for accurate graft deployment should not preclude use of LA and LA should be increasingly considered when deciding on anesthetic type for standard elective EVAR.

Effect of after-hours presentation in ruptured abdominal aortic aneurysm.

OBJECTIVE: Ruptured abdominal aortic aneurysms (RAAAs) are surgical emergencies that require immediate and expert treatment. It has been unclear whether presentation during evenings and weekends, when "on call" teams are primarily responsible for patient care, is associated with worse outcomes. Our objective was to evaluate the outcomes of patients presenting with RAAAs after-hours vs during the workday. METHODS: A retrospective cohort study of all RAAAs in Nova Scotia between 2005 and 2015 was performed through linkage of administrative databases. Patients who had presented to the hospital with RAAAs during the workday (Monday through Friday, 6 am to 6 pm) were compared with those who had presented after-hours (6 pm to 6 am during the week and on weekends). The baseline and operative characteristics were identified for all patients through the available databases and a review of the medical records. Mortality before surgery, 30-day mortality, and operative mortality were compared between groups using multivariable logistic regression, adjusting for factors clinically significant on univariable analysis. RESULTS: A total of 390 patients with RAAAs were identified from 2005 to 2015, of whom 205 (53%) had presented during the workday and 185 (47%) after-hours. The overall chance of survival (OCS) was 45% overall, 49% if admitted to hospital, and 64% if surgery had been performed. During the workday, the OCS was 43% overall, 48% if admitted to hospital, and 67% if surgery had been performed. After-hours, the OCS was 46% overall, 49% if admitted to hospital, and 61% if surgery had been performed. Mortality before surgery was increased for patients who had presented to the hospital during the workday compared with after-hours (36% vs 26%; P = .04). The 30-day mortality (57% vs 54%; P = .62), rates of operative management (63% vs 72%; P = .06), and operative mortality (33% vs 39%; P = .33) were similar between the workday and after-hours groups (57% vs 54%; P = .06). After adjusting for significant clinical variables, the patients who had presented with RAAAs after-hours had had a similar odds of dying before surgery (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.41-1.03), operative management (OR, 1.47; 95% CI, 0.93-2.31), 30-day mortality (OR, 0.98; 95% CI, 0.63-1.51), and operative mortality (OR, 1.33; 95% CI, 0.78-2.26). In the subgroup of patients presenting to a hospital with endovascular capabilities, patients presenting after-hours had had similar odds of 30-day mortality (OR, 1.07; 95% CI, 0.57-2.02), and operative mortality (OR, 1.14; 95% CI, 0.58-2.23). CONCLUSIONS: We found that patients presenting to the hospital with RAAAs after-hours did not have increased adjusted odds of mortality before surgery, operative management, 30-day mortality, or operative mortality.

Trends in Incidence of Abdominal Aortic Aneurysm Rupture, Repair, and Mortality in Nova Scotia.

BACKGROUND: The purpose of this study was to examine sex-based trends in incidence of elective abdominal aortic aneurysm (AAA), ruptured AAA, ruptured AAA repair, and AAA-related mortality. METHODS: A retrospective analysis of patients presenting with AAA from 2005 to 2015 was conducted. Rates of elective AAA repair, ruptured AAA, ruptured AAA repair, and mortality were obtained from linking provincial administrative data using medical services insurance billing number. The age-adjusted incidence of elective AAA repair, overall rate of ruptured AAA, ruptured AAA repair, and AAA-related mortality was calculated for each sex based on Canadian census estimates, adjusted to the Canadian standard population. Weighted linear regression was performed to analyze trends in incidence over time. RESULTS: One thousand nine hundred eighty-six elective AAA repairs were identified, of which 1,098 were repaired open and 898 underwent endovascular abdominal aneurysm repair (EVAR). Five hundred and seventy ruptured AAAs were identified, of which 295 (52%) were repaired: 259 open and 36 EVAR. The proportion of ruptured AAA that was repaired did not change over time (P = 0.54). The proportion repairs performed using EVAR increased significantly in both elective (P < 0.001) and rupture repairs (P < 0.001). During the study period, 662 patients died of AAA-associated mortality. The average incidence of elective AAA repair in men was 29.3 (95% confidence interval (CI): 27.8 to 30.8) per 100,000 and decreased over time (P = 0.04), whereas the average incidence in women was 9.2 [8.3 to 10.0] and stable (P = 0.07). The incidence of open elective AAA repair was 10.5 [9.9-11.1] with a decreasing trend over time (P < 0.001) and EVAR was 9.0 (8.5-9.6) with an increasing trend over time (P < 0.001). A decreasing trend of overall ruptured AAA (5.4 [5.0-5.9], P < 0.001), ruptured AAA repair (2.9 [2.5-3.2], P = 0.02), and of AAA-related mortality (6.2 [5.8-6.8], P < 0.001) was found, with consistent trends in both sexes. The incidence of open ruptured AAA repair decreased over time (P = 0.001) whereas the incidence of ruptured EVAR remained stable (P = 0.23). CONCLUSIONS: The incidence of elective AAA repair is decreasing in males but not females, whereas the incidence of rupture has decreased in both sexes. This has translated into reduced incidence of AAA-related mortality. Increased adoption of EVAR for ruptured AAA should continue these trends.

Dying to Get There: Patients Who Reside at Increased Distance from Tertiary Center Experience Increased Mortality Following Abdominal Aortic Aneurysm Rupture.

BACKGROUND: Centralization of vascular surgery care for Ruptured Abdominal Aortic Aneurysms (RAAAs) to high-volume tertiary centers may hinder access to timely surgical intervention for patients in remote areas. The objective of this study was to determine the association between distance from vascular care and mortality from RAAAs in the province of Nova Scotia, Canada. METHODS: A retrospective cohort study of all RAAAs in Nova Scotia between 2005 and 2015 was performed through linkage of administrative databases. Patients were divided into groups by estimated travel time from their place of residence to the tertiary center (<1 hr and ≥1 hr) using geographic information software. Baseline and operative characteristics were identified for all patients through available databases and completed through chart review. Mortality at home, during transfer to the vascular center, and overall 30-day mortality were compared between groups using t-test and chi-squared test, as appropriate. Multivariable logistic regression analysis was used to calculate the independent effect of travel time on survival outcomes. RESULTS: A total of 567 patients with RAAA were identified from 2005-2015, of which 250 (44%) resided <1 hr travel time to the tertiary center and 317 (56%) resided ≥1 hr. On multivariable analysis, travel time ≥1 hr from vascular care was an independent predictor of mortality at home (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.07-2.63, P = 0.02), mortality prior to operation (OR 2.64, 95% CI 1.81-3.83, P < 0.001), and overall 30-day mortality (OR 1.61, 95% CI 1.10-2.37, P = 0.02). In patients who received an operation (n = 294), there was no association between increased travel time and mortality (OR 1.02, 95% CI 0.60-1.73, P = 0.94). CONCLUSIONS: Travel time ≥1 hr to the tertiary center is associated with significantly higher mortality from ruptured abdominal aortic aneurysm (AAA). However, there was no difference in overall chance of survival between groups for patients that underwent AAA repair. Therefore, strategies to facilitate early detection, and timely transfer to a vascular surgery center may improve outcomes for patients with RAAA.

Effect of socioeconomic status on patients undergoing elective abdominal aortic aneurysm repair in a publicly funded health care system.

BACKGROUND: The association between socioeconomic status (SES) and outcomes after abdominal aortic aneurysm (AAA) repair in publicly funded health care systems is poorly described. The purpose of this study was to determine the effect of SES on postoperative outcomes in patients who underwent AAA repair in Nova Scotia, Canada. METHODS: We performed a retrospective analysis of all elective AAA repairs in Nova Scotia between November 2005 and March 2015 using administrative data sources. We compared postoperative 30-day outcomes and long-term survival across socio-economic quintiles, defined as the Pampalon Material Deprivation Index (MDI) and Social Deprivation Index (SDI). We also compared the relation between baseline characteristics, MDI quintile, SDI quintile and 30-day mortality. We used multivariable logistic regression and survival analysis to calculate adjusted 30-day mortality and long-term survival, respectively. RESULTS: A total of 1913 patients underwent AAA repair during the study period. The overall 30-day mortality rate was 2.6% (50 patients). Thirty-day outcomes including death (p = 0.8), stroke (p = 0.7), myocardial infarction (p = 0.06), length of stay (p = 0.3) and discharge disposition other than home (p = 0.8) were similar across MDI quintiles. Similarly, there was no statistically significant association between SDI quintile and postoperative outcomes. Multivariable analysis showed that age greater than 70 years (odds ratio [OR] 3.06, 95% confidence interval [CI] 1.55-6.06) and open repair (OR 3.22, 95% CI 1.59-6.52) but not MDI quintile (p = NS) or SDI quintile (p = NS) were associated with increased 30-day mortality. There was no effect of MDI or SDI quintile on long-term survival on univariable or multivariable analysis. CONCLUSION: Socioeconomic status does not appear to affect short- or long-term mortality after AAA repair in a publicly funded health care system. Further research is needed to address any existing gaps in screening and referral before repair.

Cross-cultural adaptation of the SWAL-QOL and the Sydney Swallow Questionnaire (SSQ) into French-Canadian and preliminary assessment for their use in an oculopharyngeal muscular dystrophy (OPMD) population.

PURPOSE: Patient-reported outcomes (PRO) assessing dysphagia are an essential component of clinical trials to consider how patients feel and function in response to treatments. The selected PRO needs to be translated in several languages using a systematic process ensuring its validity and equivalence for use in multicenter clinical trials. The main objectives were to translate the SWAL-QOL and the Sydney Swallow Questionnaire (SSQ) into French Canadian (SWAL-QOL-FC and SSQ-FC) and to assess their appropriateness for patients with oculopharyngeal muscular dystrophy (OPMD). METHODS: A forward- and back-translation process was followed including independent mother-tongue translators followed by committee review. Known-groups validity was assessed by comparing scores of OPMD French-Canadian participants (n = 21) known to differ in dysphagia severity according to the 80-ml drinking test score. A Mann-Whitney test was used to compare the mean scores. Cognitive interviews were conducted later on to ensure a posteriori cultural equivalence among French-Canadian participants (n = 28). RESULTS: Evidences of adequate known-groups validity was shown for the SSQ-FC. Only two domains out of 10 of the SWAL-QOL-FC (burden and eating duration) showed adequate known-groups validity. In addition, the difference in the mean composite score was not significant. Several conceptual equivalence issues were found in both questionnaires as a result of the cognitive interviews. CONCLUSION: This study provided evidence that the SSQ-FC presents better validity than the SWAL-QOL-FC in a small sample size of OPMD participants. The findings of the cognitive interviews suggest the need to develop an OPMD-specific questionnaire to capture better the whole spectrum of disease severity.

Long-term laryngotracheal complications following cardiac surgery.

BACKGROUND AND AIM OF THE STUDY: Long-term laryngotracheal complications have not been described in adult patients undergoing cardiac surgery. The purpose of this study was to determine the incidence of and risk factors for laryngotracheal complications following cardiac surgery. METHODS: A retrospective chart review of patients at high risk for laryngotracheal complications following cardiac surgery between 2006 and 2016 was performed. High-risk patients were reviewed to determine the presence of laryngotracheal complications including laryngotracheal stenosis, keyhole deformity, or vocal cord immobility. Logistic regression was used to identify predictors of long-term laryngotracheal complications. RESULTS: Of 11,417 patients who underwent cardiac surgery, 1099 were identified as at high risk. Of these, 24 (2.2%) developed laryngotracheal complications following their surgery and intensive care unit (ICU) stay. Laryngotracheal stenosis and keyhole deformity were present in 13 (1.2%) and 6 (0.5%) patients, respectively. Logistic regression demonstrated older age (age ≥ 70 odds ratio [OR] 0.31, 95% confidence interval [CI] 0.12-0.83) was protective, while readmission to ICU for ventilation (OR 3.11, 95% CI 1.17-8.25) and receiving a tracheostomy (OR 7.83, 95% CI 2.22-27.6) were associated with laryngotracheal complications. CONCLUSIONS: The incidence of long-term laryngotracheal complications following cardiac surgery was 2.2%. Readmission to ICU for ventilation and having a tracheostomy performed were associated with laryngotracheal complications.

Nutritional Risk in Oculopharyngeal Muscular Dystrophy: Beyond Dysphagia.

Purpose: To document the nutritional risk in adults with oculopharyngeal muscular dystrophy (OPMD) and its association with oropharyngeal dysphagia.Methods: In this cross-sectional study, 33 adults with molecular confirmation of OPMD between 50 and 75 years old were recruited from the registry of a university-affiliated neuromuscular clinic. Nutritional risk was assessed with the French version of Seniors in the Community: Risk Evaluation for Eating and Nutrition II (SCREEN II), whereas the severity of dysphagia was assessed using the French-Canadian version of the Sydney Swallow Questionnaire. Anthropometric measurements were performed with standardized procedures.Results: SCREEN II scores showed high nutritional risk for 81.8% of OPMD participants with 6 factors contributing to nutritional risk in at least 50% of the sample. Pearson's correlational analysis showed a significant moderate relationship between dysphagia and nutritional risk (r = -0.470; P = 0.006).Conclusion: To our knowledge, this study is the first to investigate the nutritional risk of adults with OPMD. Our results indicate that individuals with OPMD may be at high nutritional risk mostly associated with swallowing difficulty, in the absence of a low body mass index. The present study highlights the need for dietary counseling in OPMD.

Prediction of temporary epicardial pacing wire use in cardiac surgery.

BACKGROUND: Placement of temporary epicardial pacing wires (TEPW) at the end of open heart surgery cases is routine but can be associated with complications. Identification of patients who are high risk for requiring pacing would be beneficial on guiding selective TEPW placement. The purpose of this study was to identify predictors of temporary pacing immediately post cardiac surgery. METHODS: A retrospective analysis of patients undergoing cardiac surgery from 2005 to 2016 at the Maritime Heart Center was conducted. Analysis was performed of patients who require pacing on arrival to the cardiovascular intensive care unit (CVICU) compared with those who were not paced. Multivariable logistic regression was used to determine each variable's risk adjusted likelihood of pacing for the entire cohort. Subgroup analysis was performed in the isolated procedures. RESULTS: A total of 11 752 patient underwent surgery from the year 2005 to 2016. Two thousand and fifty-one (17.5%) required pacing on arrival to CVICU. Older age, female sex, preoperative renal failure, lower ejection fraction (EF), preoperative arrhythmia, preoperative use of calcium channel blockers, and longer cross-clamp times were risk factors for pacing. In the isolated coronary artery bypass grafting and aortic valve replacement groups, findings were similar to the overall cohort. Only age, obesity, and chronic obstructive pulmonary disease were risk factors for pacing in the isolated mitral valve (MV) repair group and only preoperative arrhythmia in the isolated MV replacement group. CONCLUSION: We have identified risk factors for TEPW use following cardiac surgery and in isolated procedure subgroups. These risk factors may help guide selective TEPW placement.

Incidence of tamponade following temporary epicardial pacing wire removal.

BACKGROUND AND AIM OF STUDY: Placement of temporary epicardial pacing wires (TEPW) is common practice in cardiac surgery. Removal of TEPW in the postoperative period can lead to serious bleeding necessitating surgical intervention and conferring high morbidity. The purpose of this study is to determine the incidence of TEPW removal complications. METHODS: A retrospective review of all major cardiac operations at our institution from 2005 to 2016 was conducted. Patients were identified using the Maritime Heart Center Database. We reviewed preoperative, intra-operative, and postoperative characteristics of patients who returned to the operating room more than or equal to 3 days after their index operation to identify those who had bleeding and/or tamponade as a consequence of TEPW removal and any subsequent morbidity. RESULTS: A total of 11 754 patients underwent cardiac surgery at our institution between 2005 and 2016. Of these patients, 88 (0.75%) went back to the operating theater for bleeding and/or tamponade more than or equal to 3 days from their initial index operation. Of these, 11 (0.09%) were secondary to TEPW removal where two (0.017%) suffered irreversible anoxic brain injury. All 11 patients were on antiplatelet therapy with the addition of either deep venous thrombosis (DVT) prophylaxis or therapeutic anticoagulation, which is the standard of care at our institution. CONCLUSIONS: Bleeding complications following TEPW removal are rare but have significant consequences including increased hospital length of stay, resource utilization, and morbidity. Standardized practice to address antiplatelet, DVT prophylaxis, and anticoagulation before removal may help further reduce the incidence of serious bleeding events.

Transcatheter vs surgical aortic valve replacement in patients with interstitial lung disease.

BACKGROUND: Patients with underlying interstitial lung disease (ILD) who undergo cardiac surgery are at high risk of postoperative pulmonary complications. It remains unclear if transcatheter aortic valve replacement (TAVR) offers any benefit over surgical aortic valve replacement (SAVR) in ILD patients with severe aortic stenosis. METHODS: All adult patients with a diagnosis of ILD who underwent either a TAVR or isolated SAVR between January 2002 and December 2017 were retrospectively reviewed. Operative mortality, 30-day readmissions, and adjusted 1-year survival were compared between the two cohorts. RESULTS: The overall cohort included 52 TAVR and 74 SAVR patients. While TAVR patients were significantly older (77.2 vs 72.9 years) with higher Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) scores compared with SAVR patients (6.29 vs 4.49; all P < .02), operative mortality was similar (5.8% vs 4.1%; P = .45). Rates of postoperative stroke, permanent pacemaker implantation, reintubation, and 30-day readmissions did not differ between the two groups (all P > .46). However, TAVR was associated with significantly shorter hospital and intensive care unit (ICU) length of stay, shorter ventilation times, and less requirement for ICU admission (all P < .05). Thirty-day readmissions and adjusted 1-year survival were also similar between the two groups (hazard ratio for TAVR vs SAVR = 1.34; 95% CI: 0.7-2.6). CONCLUSIONS: Among ILD patients with symptomatic aortic stenosis, TAVR was associated with comparable operative and risk-adjusted 1-year survival to SAVR. TAVR patients also had shorter ventilator times, ICU and hospital stay despite being at higher risk. Together, our findings suggest that TAVR may be a better option in this unique cohort.

Variability in opioid prescribing practices among cardiac surgeons and trainees.

BACKGROUND AND AIM: The opioid epidemic has become a major public health crisis in recent years. Discharge opioid prescription following cardiac surgery has been associated with opioid use disorder; however, ideal practices remain unclear. Our aim was to examine current practices in discharge opioid prescription among cardiac surgeons and trainees. METHODS: A survey instrument with open- and closed-ended questions, developed through a 3-round Delphi method, was circulated to cardiac surgeons and trainees via the Canadian Society of Cardiac Surgeons. Survey questions focused on routine prescription practices including type, dosage and duration. Respondents were also asked about their perceptions of current education and guidelines surrounding opioid medication. RESULTS: Eighty-one percent of respondents reported prescribing opioids at discharge following routine sternotomy-based procedures, however, there remained significant variability in the type and dose of medication prescribed. The median (interquartile range) number of pills prescribed was 30 (20-30) with a median total dose of 135 (113-200) Morphine Milligram Equivalents. Informal teaching was the most commonly reported primary influence on prescribing habits and a lack of formal education regarding opioid prescription was associated with a higher number of pills prescribed. A majority of respondents (91%) felt that there would be value in establishing practice guidelines for opioid prescription following cardiac surgery. CONCLUSIONS: Significant variability exists with respect to routine opioid prescription at discharge following cardiac surgery. Education has come predominantly from informal sources and there is a desire for guidelines. Standardization in this area may have a role in combatting the opioid epidemic.

Patient-reported disease burden in oculopharyngeal muscular dystrophy.

INTRODUCTION: There is currently little evidence regarding oculopharyngeal muscular dystrophy (OPMD) disease burden reported by patients. In this study we aim to elicit direct patient input regarding OPMD disease burden. METHODS: We conducted semistructured interviews with 25 participants with genetically confirmed OPMD and a wide range of disease duration (15 ± 8 years). Using the Framework Technique, themes and categories were then extracted. RESULTS: Analyses revealed 7 themes (physical impact, mental impact, social impact, perception of progression, treatment perceptions, coping strategies, and access to disease information), encompassing 27 categories of OPMD disease burden. The most frequent categories were related to dysphagia, coping strategies for dysphagia, and impaired mobility. DISCUSSION: This study demonstrates the importance of considering, when providing clinical care, the broad range of coping strategies patients use to deal with OPMD symptoms, especially dysphagia, to properly assess limitations and monitor real disease progression.

The requirement for a disease-specific patient-reported outcome measure of dysphagia in oculopharyngeal muscular dystrophy.

INTRODUCTION: There is no patient-reported outcome (PRO) questionnaire specifically designed to assess oropharyngeal dysphagia in oculopharyngeal muscular dystrophy (OPMD). To select a suitable questionnaire, content validity of the existing questionnaires must be assessed. This study sought (1) to identify dysphagia-related symptoms in OPMD and (2) to assess content validity of currently available PRO for the assessment of dysphagia severity in OPMD. METHODS: A two-step literature review was conducted of dysphagia-related symptom identification and oropharyngeal dysphagia-related PRO. Symptoms were validated with an expert panel by using a Delphi survey. Content validity of PRO questionnaires was documented through content analysis. RESULTS: Ten PRO questionnaires were identified. None of the questionnaires cover the entire symptom spectrum in OPMD and thus lack content validity. DISCUSSION: The development and validation of a new PRO questionnaire to assess dysphagia in OPMD is required to establish the importance of symptomatic relief from new treatments. Muscle Nerve 59:445-450, 2019.

Chronic opioid use after coronary bypass surgery.

BACKGROUND: Opioid dependence has become a major health care issue. Pain management of invasive surgical procedures with opioids may potentially contribute to this epidemic. We sought to determine the association of opioid-prescribing patterns with chronic opioid use. METHODS: We retrospectively reviewed all patients undergoing isolated coronary artery bypass graft (CABG) procedures during 2016 at a single institution. Prescribing patterns and medication usage were compared between opioid-naïve and opioid-exposed patients (patients with reported opioid use within 30 days prior to surgery). Chronic opioid dependence was defined as opioid usage beyond 90 days after discharge. RESULTS: We included 284 opioid-naïve and 46 opioid-exposed patients. Although overall prescribing patterns were similar between groups, a higher proportion of opioid-exposed patients were prescribed a total dose >150 mg of oxycodone per discharge prescription (15.2% vs 4.9%; P = 0.024), and had a higher proportion of refills within 30 days (28.3% vs 10.9%; relative risk [RR] 3.2 [95% confidence interval (CI): 1.5-6.8]; all P < 0.05). The incidence of chronic opioid dependence was higher among opioid-exposed patients compared to opioid-naïve patients (21.7% vs 3.2%; RR 8.5 [95%CI: 3.2-22.3]; P = 0.001). CONCLUSIONS: Ongoing opioid use 3 months after CABG is present in 21.7% of opioid-exposed patients and 3.2% of opioid-naïve patients. These preliminary findings highlight the burden of prescribing patterns on the overall opioid epidemic and the need to develop alternative pain management strategies.

Efficacy of intraoperative cell salvage in decreasing perioperative blood transfusion rates in first-time cardiac surgery patients: a retrospective study.

BACKGROUND: Evidence regarding the safety and efficacy of intraoperative cell salvage (ICS) in transfusion reduction during cardiac surgery remains conflicting. We sought to evaluate the impact of routine ICS on outcomes following cardiac surgery. METHODS: We conducted a retrospective analysis of patients who underwent nonemergent, first-time cardiac surgery 18 months before and 18 months after the implementation of routine ICS. Perioperative transfusion rates, postoperative bleeding, clinical and hematological outcomes, and overall cost were examined. We used multivariable logistic regression modelling to determine the risk-adjusted effect of ICS on likelihood of perioperative transfusion. RESULTS: A total of 389 patients formed the final study population (186 undergoing ICS and 203 controls). Patients undergoing ICS had significantly lower perioperative transfusion rates of packed red blood cells (pRBCs; 33.9% v. 45.3% p = 0.021), coagulation products (16.7% v. 32.5% p < 0.001) and any blood product (38.2% v. 52.7%, p = 0.004). Patients receiving ICS had decreased mediastinal drainage at 12 h (mean 320 [range 230-550] mL v. mean 400 [range 260-690] mL, p = 0.011) and increased postoperative hemoglobin (mean 104.7 ± 13.2 g/L v. 95.0 ± 11.9 g/L, p < 0.001). Following adjustment for other baseline and intraoperative covariates, ICS emerged as an independent predictor of lower perioperative transfusion rates of pRBCs (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.31-0.87), coagulation products (OR 0.41, 95% CI 0.24-0.71) and any blood product (OR 0.47, 95% CI 0.29-0.77). Additionally, ICS was associated with a cost benefit of $116 per patient. CONCLUSION: Intraoperative cell salvage could represent a clinically cost-effective way of reducing transfusion rates in patients undergoing cardiac surgery. Further research on systematic ICS is required before recommending it for routine use.

CONTEXTE: Les résultats d'études portant sur l'innocuité et l'efficacité de l'autotransfusion peropératoire (ATPO) comme mesure de réduction du besoin de transfusion durant une chirurgie cardiaque sont contradictoires. Nous avons cherché à évaluer l'incidence du recours systématique à l'ATPO sur les issues de chirurgies cardiaques. MÉTHODES: Nous avons mené une analyse rétrospective portant sur des patients ayant subi une première chirurgie cardiaque non urgente 18 mois avant et 18 mois après l'introduction de l'ATPO systématique. Les taux de transfusion périopératoire et d'hémorragie postopératoire, les résultats cliniques et hématologiques et le coût total ont été analysés. Nous avons utilisé un modèle de régression logistique multivariée pour déterminer l'incidence ajustée en fonction du risque du recours à l'ATPO sur la probabilité qu'une transfusion périopératoire soit nécessaire. RÉSULTATS: L'échantillon à l'étude était composé de 389 patients (186 dans le groupe ATPO et 203 dans le groupe témoin). Par rapport au groupe témoin, les patients ayant reçu une ATPO ont eu besoin significativement moins souvent d'une transfusion de concentrés de globules rouges (33,9 % c. 45,3 %; p = 0,021), de produits coagulants (16,7 % c. 32,5 %; p < 0,001) et de produits sanguins, tous types confondus (38,2 % c. 52,7 %; p = 0,004). Chez les patients ayant reçu une ATPO, on a constaté un volume de drainage médiastinal après 12 h plus faible (moyenne : 320 mL [étendue de 230-550] c. 400 mL [étendue de 260-690]; p = 0,011) et une hémoglobine postopératoire plus élevée (moyenne : 104,7 ± 13,2 g/L c. 95,0 ± 11,9 g/L; p < 0,001). Après des ajustements pour tenir compte d'autres covariables des mesures de base et peropératoires, nous avons conclu que le recours à l'ATPO était un facteur prédicteur indépendant de taux de transfusion périopératoire plus faibles de concentré de globules rouges (rapport de cotes [RC] : 0,52; intervalle de confiance [IC] à 95 % : 0,31-0,87), de produits coagulants (RC : 0,41; IC à 95 % : 0,24-0,71) et de produits sanguins, tous types confondus (RC : 0,47; IC à 95 % : 0,29-0,77). De plus, l'ATPO a été associée à des économies de 116 $ par patient. CONCLUSION: L'autotransfusion peropératoire pourrait constituer un moyen cliniquement efficace en fonction des coûts de réduire les taux de transfusion des patients subissant une chirurgie cardiaque. D'autres recherches sur le recours systématique à l'ATPO devront être menées avant qu'on puisse recommander son utilisation de routine.

COPD comorbidities network.

Multimorbidity frequently affects the ageing population and their co-existence may not occur at random. Understanding their interactions and that with clinical variables could be important for disease screening and management.In a cohort of 1969 chronic obstructive pulmonary disease (COPD) patients and 316 non-COPD controls, we applied a network-based analysis to explore the associations between multiple comorbidities. Clinical characteristics (age, degree of obstruction, walking, dyspnoea, body mass index) and 79 comorbidities were identified and their interrelationships quantified. Using network visualisation software, we represented each clinical variable and comorbidity as a node with linkages representing statistically significant associations.The resulting COPD comorbidity network had 428, 357 or 265 linkages depending on the statistical threshold used (p≤0.01, p≤0.001 or p≤0.0001). There were more nodes and links in COPD compared with controls after adjusting for age, sex and number of subjects. In COPD, a subset of nodes had a larger number of linkages representing hubs. Four sub-networks or modules were identified using an inter-linkage affinity algorithm and their display provided meaningful interactions not discernible by univariate analysis.COPD patients are affected by larger number of multiple interlinked morbidities which clustering pattern may suggest common pathobiological processes or be utilised for screening and/or therapeutic interventions.

Prognostic evaluation of COPD patients: GOLD 2011 versus BODE and the COPD comorbidity index COTE.

BACKGROUND: The Global Obstructive Lung Disease (GOLD) 2011 revision recommends the multidimensional assessment of COPD including comorbidities and has developed a disease categories system (ABCD) attempting to implement this strategy. The added value provided by quantifying comorbidities and integrating them to multidimensional indices has not been explored. OBJECTIVE: Compare the prognostic value of the GOLD ABCD categories versus the BMI, Obstruction, Dyspnea, Exercise (BODE) index, and explore the added prognostic value of comorbidities evaluation to this multidimensional assessment. METHODS: From the patients who have been enrolled in the BODE study, we selected the most recent ones who had the available information needed to classify them by the ABCD GOLD categories. Cox proportional hazards ratios for all-cause mortality were performed for GOLD categories and BODE index. The added value of the comorbidity Copd cO-morbidity TEst (COTE) index was also explored using receiver operating curves (ROC) values. RESULTS: 707 patients were followed for 50±30 months including all degrees of airway limitation and BODE index severity. ABCD GOLD predicted global mortality (HR: 1.47; 95% CI 1.28 to 1.70) as did the BODE index (HR: 2.02; 95% CI 1.76 to 2.31). Area under the curve (AUC) of ROC for ABCD GOLD was 0.68; (95% CI 0.64 to 0.73) while for the BODE index was 0.71 (95% CI 0.67 to 0.76). The C statistics value was significantly higher for the observed difference. Adding the COTE index to the BODE index improved its AUC to 0.81 (95% CI 0.77 to 0.85), (χ(2)=40.28, p<0.001). CONCLUSIONS: In this population of COPD patients, the BODE index had a better survival prediction than the ABCD GOLD categories. Adding the COTE to the BODE index was complimentary and significantly improved outcome prediction.

Longitudinal assessment in COPD patients: multidimensional variability and outcomes.

The value and timing of multidimensional assessments in chronic obstructive pulmonary disease (COPD) remains unclear because there is little information about their variability and relationship to outcome. The aim of this study was to determine the progression of COPD using clinical and spirometric variability over time with mortality as the outcome. We determined the annual intra-individual variability of forced expiratory volume in 1 s (FEV1) and BODE (body mass index, airflow obstruction, dyspnoea, exercise capacity) index in 403 patients with at least five measurements. The pattern was defined as "stable" if the annual change remained constant in ≥66% of the observations and "unstable" if it did not meet that threshold. We explored the minimum number of yearly observations that related to mortality in the 704 patients of the cohort. The "unstable" pattern of FEV1 was seen in 53% and 40% of patients using a threshold of 40 mL·year(-1) and 100 mL·year(-1), respectively. There was a slightly more "stable" pattern in the BODE index (62% for 1 point). A profile associated with mortality was defined by a baseline measurement followed by annual measurements for 2 years of the BODE index, but not its individual components, including FEV1 (p<0.001). Progression of COPD measured using FEV1 is inconsistent and relates poorly to outcome. Monitoring the more stable BODE index better assesses disease progression.