RESUMEN
BACKGROUND: The objective was to assess changes over time in prescriptions filled for nonopioid analgesics for older postoperative patients in the immediate postdischarge period. The authors hypothesized that the number of patients who filled a nonopioid analgesic prescription increased during the study period. METHODS: The authors performed a population-based cohort study using linked health administrative data of 278,366 admissions aged 66 yr or older undergoing surgery between fiscal year 2013 and 2019 in Ontario, Canada. The primary outcome was the percentage of patients with new filled prescriptions for nonopioid analgesics within 7 days of discharge, and the secondary outcome was the analgesic class. The authors assessed whether patients filled prescriptions for a nonopioid only, an opioid only, both opioid and nonopioid prescriptions, or a combination opioid/nonopioid. RESULTS: Overall, 22% (n = 60,181) of patients filled no opioid prescription, 2% (n = 5,534) filled a nonopioid only, 21% (n = 59,608) filled an opioid only, and 55% (n = 153,043) filled some combination of opioid and nonopioid. The percentage of patients who filled a nonopioid prescription within 7 days postoperatively increased from 9% (n = 2,119) in 2013 to 28% (n = 13,090) in 2019, with the greatest increase for acetaminophen: 3% (n = 701) to 20% (n = 9,559). The percentage of patients who filled a combination analgesic prescription decreased from 53% (n = 12,939) in 2013 to 28% (n = 13,453) in 2019. However, the percentage who filled both an opioid and nonopioid prescription increased: 4% (n = 938) to 21% (n = 9,880) so that the overall percentage of patients who received both an opioid and a nonopioid remained constant over time 76% (n = 18,642) in 2013 to 75% (n = 35,391) in 2019. CONCLUSIONS: The proportion of postoperative patients who fill prescriptions for nonopioid analgesics has increased. However, rather than a move to use of nonopioids alone for analgesia, this represents a shift away from combination medications toward separate prescriptions for opioids and nonopioids.
Asunto(s)
Analgésicos no Narcóticos , Humanos , Anciano , Analgésicos no Narcóticos/uso terapéutico , Estudios de Cohortes , Ontario , Cuidados Posteriores , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/inducido químicamente , Pautas de la Práctica en Medicina , Alta del Paciente , Analgésicos/uso terapéutico , Analgésicos Opioides/uso terapéutico , Prescripciones , Estudios RetrospectivosRESUMEN
PURPOSE: Patients with impaired functional capacity who undergo major surgery are at increased risk of postoperative morbidity including complications and increased length of stay. These outcomes have been associated with increased hospital and health system costs. We aimed to assess whether common preoperative risk indices are associated with postoperative cost. METHODS: We conducted a health economic analysis focused on the subset of Measurement of Exercise Tolerance before Surgery (METS) study participants in Ontario, Canada. Participants were scheduled for major elective noncardiac surgery and underwent several preoperative assessments of cardiac risk, including physicians' subjective assessment, Duke Activity Status Index (DASI) questionnaire, peak oxygen consumption, and N-terminal pro-B-type natriuretic peptide concentration. Using linked health administrative data, postoperative costs were calculated for both one year and in-hospital. Using multiple regression models, we tested for association between the preoperative measures of cardiac risk and postoperative costs. RESULTS: Our study included 487 patients (mean [standard deviation] age 68 [11] yr and 47.0% female) who underwent noncardiac surgery between 13 June 2013 and 8 March 2016. Overall, the median [interquartile range] cost incurred within one year postoperatively was CAD 27,587 [13,902-32,590], of which CAD 12,928 [10,253-12,810] were incurred in-hospital and CAD 14,497 [10,917-15,017] were incurred by 30 days. None of the four preoperative measures of cardiac risk assessment were associated with costs incurred in hospital or at one year postoperatively. This lack of strong association persisted in sensitivity analyses considering type of surgical procedure, burden of preoperative cost, and when costs were categorized as quantiles. CONCLUSION: In patients undergoing major noncardiac surgery, common measures of functional capacity are not consistently associated with total postoperative cost. Until further data exist that differ from this analysis, clinicians and health care funders should not assume that preoperative measures of cardiac risk are associated with annual health care or hospital costs for such surgeries.
RéSUMé: OBJECTIF: La patientèle présentant une capacité fonctionnelle dégradée qui bénéficie d'une intervention chirurgicale majeure court un risque accru de morbidité postopératoire, y compris de complications et de prolongation de la durée de séjour. Ces issues ont été associées à une augmentation des coûts hospitaliers et du système de santé. Notre objectif était d'évaluer si des indices de risque préopératoires communs étaient associés aux coûts postopératoires. MéTHODE: Nous avons effectué une analyse de l'économie de la santé axée sur le sous-ensemble des participant·es à l'étude METS (Measurement of Exercise Tolerance before Surgery) en Ontario, au Canada. Les participant·es devaient bénéficier d'une chirurgie non cardiaque et non urgente majeure et ont complété plusieurs évaluations préopératoires du risque cardiaque, notamment l'évaluation subjective des médecins, le questionnaire DASI (Duke Activity Status Index), la consommation maximale d'oxygène et la concentration de prohormone N-terminale du peptide natriurétique de type B (cérébral) (NT-proBNP). À l'aide de données administratives couplées de santé, les coûts postopératoires ont été calculés à la fois pour une année et à l'hôpital. À l'aide de modèles de régression multiples, nous avons testé l'association entre les mesures préopératoires du risque cardiaque et les coûts postopératoires. RéSULTATS: Notre étude a inclus 487 personnes (âge moyen [écart type] 68 [11] ans et 47,0 % de femmes) ayant bénéficié d'une chirurgie non cardiaque entre le 13 juin 2013 et le 8 mars 2016. Dans l'ensemble, le coût médian [écart interquartile] engagé dans l'année qui a suivi l'opération était de 27 587 CAD [13 90232 590], dont 12 928 CAD [10 25312 810] ont été encourus à l'hôpital et 14 497 CAD [10 91715 017] ont été encourus dans les premiers 30 jours. Aucune des quatre mesures préopératoires de l'évaluation du risque cardiaque n'était associée aux coûts engagés à l'hôpital ou un an après l'opération. Cette absence d'association forte persistait dans les analyses de sensibilité tenant compte du type d'intervention chirurgicale, du fardeau des coûts préopératoires et lorsque les coûts étaient classés en quantiles. CONCLUSION: Chez la patientèle bénéficiant d'une chirurgie non cardiaque majeure, les mesures courantes de la capacité fonctionnelle ne sont pas systématiquement associées au coût postopératoire total. Jusqu'à ce qu'il existe d'autres données qui diffèrent de cette analyse, les cliniciens et cliniciennes et les organismes finançant les soins de santé ne devraient pas présumer que les mesures préopératoires du risque cardiaque sont associées aux coûts annuels des soins de santé ou des hôpitaux pour de telles chirurgies.
Asunto(s)
Procedimientos Quirúrgicos Electivos , Complicaciones Posoperatorias , Humanos , Femenino , Anciano , Masculino , Complicaciones Posoperatorias/epidemiología , Medición de Riesgo , Ontario/epidemiología , Costos de la Atención en Salud , Cuidados Preoperatorios/métodosRESUMEN
OBJECTIVE: To examine the association between Textbook Outcome (TO)-a new composite quality measurement-and long-term survival in gastric cancer surgery. BACKGROUND: Single-quality indicators do not sufficiently reflect the complex and multifaceted nature of perioperative care in patients with gastric adenocarcinoma. METHODS: All patients undergoing gastrectomy for nonmetastatic gastric adenocarcinoma registered in the Population Registry of Esophageal and Stomach Tumours of Ontario (PRESTO) between 2004 and 2015 were included. TO was defined according to negative margins; >15 lymph nodes sampled; no severe complications; no re-interventions; no unplanned ICU admission; length of stay ≤21 days; no 30-day readmission; and no 30-day mortality. Three-year survival was estimated using the Kaplan-Meier method. A marginal multivariable Cox proportional-hazards model was used to estimate the association between achieving TO metrics and long-term survival. E-value methodology was used to assess for risk of residual confounding. RESULTS: Of the 1836 patients included in this study, 402 (22%) achieved all TO metrics. TO patients had a higher 3-year survival rate compared to non-TO patients (75% vs 55%, log-rank P < 0.001). After adjustments for covariates and clustering within hospitals, TO was associated with a 41% reduction in mortality (adjusted hazards ratio 0.59, 95% confidence interval 0.48, 0.72, P < 0.001). These results were robust to potential residual confounding. CONCLUSIONS: Achieving TO is strongly associated with improved long-term survival in gastric cancer patients and merits further focus in surgical quality improvement efforts.
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Adenocarcinoma/mortalidad , Adenocarcinoma/cirugía , Evaluación de Resultado en la Atención de Salud , Neoplasias Gástricas/mortalidad , Neoplasias Gástricas/cirugía , Edad de Inicio , Anciano , Anciano de 80 o más Años , Cuidados Críticos , Femenino , Gastrectomía , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Escisión del Ganglio Linfático , Masculino , Márgenes de Escisión , Persona de Mediana Edad , Ontario/epidemiología , Readmisión del Paciente , Modelos de Riesgos Proporcionales , Sistema de Registros , Estudios RetrospectivosRESUMEN
PURPOSE: Many hospital and provincial-level recommendations now advise a tailored approach to postoperative opioid prescribing; recent trends in postoperative prescribing at the population level have not been well described. METHODS: This population-based cohort study included opioid-naïve patients ≥ 18 yr of age who underwent one of 16 surgical procedures with varying anticipated postoperative pain between July 2013 and March 2020. We evaluated the rate of filled opioid prescriptions within seven days postoperatively, the total morphine milligram equivalent (MME) dose, duration, and type of the first opioid prescription. We then compared the MMEs in initial opioid prescriptions with available procedure-specific recommendations. RESULTS: The sample included 900,989 opioid-naïve patients (mean [standard deviation (SD)] age of 50 [17] 31 yr; 66% women). The percentage of patients filling an opioid prescription within 7 days postoperatively increased from 65% in 2013 to 69% in 2016, and returned to the baseline (65%) in 2019. The mean (SD) MMEs dispensed increased until 2015/2016 and then declined (226 [176] MMEs in 2013, 240 [202] MMEs in 2016, and 175 [175] MMEs in 2019). The most frequently prescribed opioid in 2013 was oxycodone compared with hydromorphone in 2019. Among patients who filled an opioid prescription in 2013, 67% were prescribed an opioid dose higher than those in one set of available prescribing recommendations, while in 2019, 41% were prescribed doses above those stated in recommendations. CONCLUSION: While the proportion of patients filling an opioid prescription postoperatively remained s during the study period, MMEs decreased after 2016. Opioid prescribing remained significantly higher than available prescribing recommendations, particularly among low pain procedures. These findings highlight the need to identify strategies that improve adherence to surgery-specific prescribing guidelines in North America.
RéSUMé: OBJECTIF: De nombreuses recommandations à l'échelle hospitalière et provinciale préconisent aujourd'hui une approche personnalisée de la prescription d'opioïdes postopératoires; les tendances récentes de la prescription postopératoire au niveau de la population n'ont pas été bien décrites. MéTHODE: Cette étude de cohorte basée sur la population englobait des patients naïfs aux opioïdes et âgés de ≥ 18 ans ayant bénéficié de l'une de 16 interventions chirurgicales entraînant une douleur postopératoire anticipée variable entre juillet 2013 et mars 2020. Nous avons évalué le taux d'ordonnances d'opioïdes remplies dans les sept jours suivant l'opération, la dose totale d'équivalent en milligrammes de morphine (EMM), ainsi que la durée et le type de la première ordonnance d'opioïdes. Nous avons ensuite comparé les EMM des ordonnances initiales d'opioïdes avec les recommandations spécifiques à l'intervention disponibles. RéSULTATS: L'échantillon comprenait 900 989 patients naïfs aux opioïdes (âge moyen [écart type (ET)] de 50 [17] ans; 66 % de femmes). La proportion de patients remplissant une ordonnance d'opioïdes dans les 7 jours suivant l'opération est passée de 65 % en 2013 à 69 % en 2016, et est revenue à la valeur de référence (65 %) en 2019. Les EMM moyens (ET) administrés ont augmenté jusqu'en 2015-2016, puis ont diminué (226 [176] EMM en 2013, 240 [202] EMM en 2016 et 175 [175] EMM en 2019). L'opioïde le plus fréquemment prescrit en 2013 était l'oxycodone par rapport à l'hydromorphone en 2019. Parmi les patients qui ont rempli une ordonnance d'opioïdes en 2013, 67 % se sont vu prescrire une dose d'opioïdes supérieure à celle d'un ensemble de recommandations de prescription disponibles, tandis qu'en 2019, 41 % se sont vu prescrire des doses supérieures à celles indiquées dans les recommandations. CONCLUSION: Alors que la proportion de patients remplissant une ordonnance d'opioïdes en période postopératoire est restée stable au cours de la période d'étude, les EMM ont diminué après 2016. La prescription d'opioïdes est demeurée beaucoup plus élevée que les recommandations de prescription disponibles, en particulier dans le cas d'interventions à faible douleur. Ces résultats soulignent la nécessité d'identifier des stratégies pour améliorer l'adhérence aux recommandations de prescription spécifiques au type de chirurgie en Amérique du Nord.
Asunto(s)
Analgésicos Opioides , Pautas de la Práctica en Medicina , Analgésicos Opioides/uso terapéutico , Estudios de Cohortes , Prescripciones de Medicamentos , Femenino , Humanos , Masculino , Ontario , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/epidemiología , Estudios RetrospectivosRESUMEN
OBJECTIVE: The aim of this study was to summarize strategies to reduce postsurgical opioid prescribing at discharge. SUMMARY BACKGROUND DATA: Current practices for the prescription of opioids at discharge after surgery are highly variable and often excessive. We conducted a systematic review to identify behavioral interventions designed to improve these practices. METHODS: We searched MEDLINE, EMBASE, CINAHL, and PsycINFO until December 14, 2018 to identify studies of behavioral interventions designed to decrease opioid prescribing at discharge among adults undergoing surgery. Behavioral interventions were defined according to the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy. We assessed the risk of bias of included studies using criteria suggested by Cochrane EPOC and the Newcastle-Ottawa scale. RESULTS: Of 8048 citations that were screened, 24 studies were included in our review. Six types of behavioral interventions were identified: local consensus-based processes (18 studies), patient-mediated interventions (2 studies), clinical practice guidelines (1 study), educational meetings (1 study), interprofessional education (1 study), and clinician reminder (1 study). All but one study reported a statistically significant decrease in the amount of opioid prescribed at discharge after surgery, and only 2 studies reported evidence of increased pain intensity. Reductions in prescribed opioids ranged from 34.4 to 212.3 mg morphine equivalents. All studies were found to have medium-to-high risks of bias. CONCLUSIONS: We identified 6 types of behavioral strategies to decrease opioid prescription at discharge after surgery. Despite the risk of bias, almost all types of intervention seemed effective in reducing opioid prescriptions at discharge after surgery without negatively impacting pain control.
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Analgésicos Opioides/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Pautas de la Práctica en Medicina/estadística & datos numéricos , Programas de Monitoreo de Medicamentos Recetados , Humanos , Trastornos Relacionados con Opioides/prevención & control , Alta del PacienteRESUMEN
BACKGROUND: While persistent opioid use after surgery has been the subject of a large number of studies, it is unknown how much variability in the definition of persistent use impacts the reported incidence across studies. The objective was to evaluate the incidence of persistent use estimated with different definitions using a single cohort of postoperative patients, as well as the ability of each definition to identify patients with opioid-related adverse events. METHODS: The literature was reviewed to identify observational studies that evaluated persistent opioid use among opioid-naive patients requiring surgery, and any definitions of persistent opioid use were extracted. Next, the authors performed a population-based cohort study of opioid-naive adults undergoing 1 of 18 surgical procedures from 2013 to 2017 in Ontario, Canada. The primary outcome was the incidence of persistent opioid use, defined by each extracted definition of persistent opioid use. The authors also assessed the sensitivity and specificity of each definition to identify patients with an opioid-related adverse event in the year after surgery. RESULTS: Twenty-nine different definitions of persistent opioid use were identified from 39 studies. Applying the different definitions to a cohort of 162,830 opioid-naive surgical patients, the incidence of persistent opioid use in the year after surgery ranged from 0.01% (n = 10) to 14.7% (n = 23,442), with a median of 0.7% (n = 1,061). Opioid-related overdose or diagnosis associated with opioid use disorder in the year of follow-up occurred in 164 patients (1 per 1,000 operations). The sensitivity of each definition to identify patients with the composite measure of opioid use disorder or opioid-related toxicity ranged from 0.01 to 0.36, while specificity ranged from 0.86 to 1.00. CONCLUSIONS: The incidence of persistent opioid use reported after surgery varies more than 100-fold depending on the definition used. Definitions varied markedly in their sensitivity for identifying adverse opioid-related event, with low sensitivity overall across measures.
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Trastornos Relacionados con Opioides/epidemiología , Estudios de Cohortes , Humanos , Incidencia , Estudios Observacionales como Asunto , Ontario/epidemiología , Periodo Posoperatorio , Factores de RiesgoRESUMEN
BACKGROUND: Although cannabis is known to have cardiovascular and psychoactive effects, the implications of its use before surgery are currently unknown. The objective of the present study was to determine whether patients with an active cannabis use disorder have an elevated risk of postoperative complications. METHODS: The authors conducted a retrospective population-based cohort study of patients undergoing elective surgery in the United States using the Nationwide Inpatient Sample from 2006 to 2015. A sample of 4,186,622 inpatients 18 to 65 yr of age presenting for 1 of 11 elective surgeries including total knee replacement, total hip replacement, coronary artery bypass graft, caesarian section, cholecystectomy, colectomy, hysterectomy, breast surgery, hernia repair, laminectomy, and other spine surgeries was selected. The principal exposure was an active cannabis use disorder, as defined by International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) diagnostic codes for cannabis dependence and cannabis abuse. The primary outcome was a composite endpoint of in-hospital postoperative myocardial infarction, stroke, sepsis, deep vein thrombosis, pulmonary embolus, acute kidney injury requiring dialysis, respiratory failure, and in-hospital mortality. Secondary outcomes included hospital length of stay, total hospital costs, and the individual components of the composite endpoint. RESULTS: The propensity-score matched-pairs cohort consisted of 27,206 patients. There was no statistically significant difference between patients with (400 of 13,603; 2.9%) and without (415 of 13,603; 3.1%) a reported active cannabis use disorder with regard to the composite perioperative outcome (unadjusted odds ratio = 1.29; 95% CI, 1.17 to 1.42; P < 0.001; Adjusted odds ratio = 0.97; 95% CI, 0.84 to 1.11; P = 0.63). However, the adjusted odds of postoperative myocardial infarction was 1.88 (95% CI, 1.31 to 2.69; P < 0.001) times higher for patients with a reported active cannabis use disorder (89 of 13,603; 0.7%) compared with those without (46 of 13,603; 0.3%) an active cannabis use disorder (unadjusted odds ratio = 2.88; 95% CI, 2.34 to 3.55; P < 0.001). CONCLUSIONS: An active cannabis use disorder is associated with an increased perioperative risk of myocardial infarction.
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Procedimientos Quirúrgicos Electivos/tendencias , Abuso de Marihuana/epidemiología , Abuso de Marihuana/cirugía , Complicaciones Posoperatorias/epidemiología , Adulto , Estudios de Cohortes , Procedimientos Quirúrgicos Electivos/efectos adversos , Femenino , Humanos , Masculino , Abuso de Marihuana/diagnóstico , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/epidemiología , Complicaciones Posoperatorias/diagnóstico , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: To determine the association between gastric cancer surgery case-volume and Textbook Outcome, a new composite quality measurement. BACKGROUND: Textbook Outcome included (a) negative resection margin, (b) greater than 15 lymph nodes sampled, (c) no severe complication, (d) no re-intervention, (e) no unplanned ICU admission, (f) length of stay of 21 days or less, (g) no 30-day readmission and (h) no 30-day mortality following surgery. METHODS: All patients undergoing gastrectomy for non-metastatic gastric adenocarcinoma registered in the Population Registry of Esophageal and Stomach Tumours of Ontario between 2004 and 2015 were included. We used multivariable generalized estimating equation (GEE) logistic regression modelling to estimate the association between gastrectomy volume (surgeon and hospital annual volumes) and Textbook Outcome. Volumes were considered as continuous variables and quintiles. RESULTS: Textbook Outcome was achieved in 378 of 1660 patients (22.8%). The quality metrics least often achieved were inadequate lymph node sampling and presence of severe complications, which occurred in 46.1% and 31.7% of patients, respectively. Accounting for covariates and clustering, neither surgeon volume nor hospital volume were significantly associated with Textbook Outcome. However, hospital volume was associated with adequate lymphadenectomy and fewer unplanned ICU admissions. CONCLUSIONS: Higher case volume can impact certain measures of quality of care but may not address all care structures necessary for ideal Textbook recovery. Future quality improvement strategies should consider using case-mix adjusted Textbook Outcome rates as a surgical quality metric.
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Neoplasias Esofágicas/cirugía , Esofagectomía/mortalidad , Gastrectomía/mortalidad , Hospitales de Alto Volumen/estadística & datos numéricos , Escisión del Ganglio Linfático/mortalidad , Sistema de Registros/estadística & datos numéricos , Neoplasias Gástricas/cirugía , Anciano , Anciano de 80 o más Años , Canadá/epidemiología , Neoplasias Esofágicas/epidemiología , Neoplasias Esofágicas/patología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Neoplasias Gástricas/epidemiología , Neoplasias Gástricas/patología , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Many patients use opioids chronically before surgery; it is unclear if surgery alters the likelihood of ongoing opioid consumption in these patients. METHODS: We performed a population-based matched cohort study of adults in Ontario, Canada undergoing one of 16 non-orthopaedic surgical procedures and who were chronically using opioids, defined as (1) an opioid prescription that overlapped the index date and (2) either a total of 120 or more cumulative calendar days of filled opioid prescriptions, or 10 or more prescriptions filled in the prior year. Each surgical patient was matched based on age, sex, Charlson comorbidity index, and daily preoperative opioid dose to three non-surgical patients who were also chronic opioid users. The primary outcome was time to opioid discontinuation. RESULTS: The cohort included 4755 surgical and 14 265 matched non-surgical patients. After adjustment for sociodemographic characteristics and comorbidities, surgery was associated with an increased likelihood of opioid discontinuation (adjusted hazard ratio: 1.34, 95% confidence interval [CI]: 1.27, 1.42). Among surgical patients, factors associated with a reduced odds of discontinuation included a mean preoperative opioid dose above 90 morphine milligram equivalents (adjusted odds ratio [aOR]: 0.39; 95% CI: 0.32, 0.49) or filling a prescription for oxycodone (aOR: 0.73; 95% CI: 0.56, 0.98). Receipt of an in-patient Acute Pain Service consultation (aOR: 1.34; 95% CI: 1.06, 1.69) or residing in the highest neighbourhood income quintile (aOR: 1.35; 95% CI: 1.04, 1.79) were associated with a greater odds of opioid discontinuation. CONCLUSIONS: For chronic opioid users, surgery was associated with an increased likelihood of discontinuation of opioids in the following year compared with non-surgical chronic opioid users.
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Analgésicos Opioides/administración & dosificación , Trastornos Relacionados con Opioides/epidemiología , Dolor Postoperatorio/tratamiento farmacológico , Procedimientos Quirúrgicos Operativos/métodos , Anciano , Analgésicos Opioides/uso terapéutico , Estudios de Casos y Controles , Enfermedad Crónica , Estudios de Cohortes , Esquema de Medicación , Prescripciones de Medicamentos/estadística & datos numéricos , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Ontario/epidemiología , Periodo Posoperatorio , Privación de Tratamiento/estadística & datos numéricosRESUMEN
IMPORTANCE: Recognizing patients in whom endotracheal intubation is likely to be difficult can help alert physicians to the need for assistance from a clinician with airway training and having advanced airway management equipment available. OBJECTIVE: To identify risk factors and physical findings that predict difficult intubation. DATA SOURCES: The databases of MEDLINE and EMBASE were searched from 1946 to June 2018 and from 1947 to June 2018, respectively, and the reference lists from the retrieved articles and previous reviews were searched for additional studies. STUDY SELECTION: Sixty-two studies with high (level 1-3) methodological quality that evaluated the accuracy of clinical findings for identifying difficult intubation were reviewed. DATA EXTRACTION AND SYNTHESIS: Two authors independently abstracted data. Bivariate random-effects meta-analyses were used to calculate summary positive likelihood ratios across studies or univariate random-effects models when bivariate models failed to converge. RESULTS: Among the 62 high-quality studies involving 33â¯559 patients, 10% (95% CI, 8.2%-12%) of patients were difficult to intubate. The physical examination findings that best predicted a difficult intubation included a grade of class 3 on the upper lip bite test (lower incisors cannot extend to reach the upper lip; positive likelihood ratio, 14 [95% CI, 8.9-22]; specificity, 0.96 [95% CI, 0.93-0.97]), shorter hyomental distance (range of <3-5.5 cm; positive likelihood ratio, 6.4 [95% CI, 4.1-10]; specificity, 0.97 [95% CI, 0.94-0.98]), retrognathia (mandible measuring <9 cm from the angle of the jaw to the tip of the chin or subjectively short; positive likelihood ratio, 6.0 [95% CI, 3.1-11]; specificity, 0.98 [95% CI, 0.90-1.0]), and a combination of physical findings based on the Wilson score (positive likelihood ratio, 9.1 [95% CI, 5.1-16]; specificity, 0.95 [95% CI, 0.90-0.98]). The widely used modified Mallampati score (≥3) had a positive likelihood ratio of 4.1 (95% CI, 3.0-5.6; specificity, 0.87 [95% CI, 0.81-0.91]). CONCLUSIONS AND RELEVANCE: Although several simple clinical findings are useful for predicting a higher likelihood of difficult endotracheal intubation, no clinical finding reliably excludes a difficult intubation. An abnormal upper lip bite test, which is easily assessed by clinicians, raises the probability of difficult intubation from 10% to greater than 60% for the average-risk patient.
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Obstrucción de las Vías Aéreas/diagnóstico , Intubación Intratraqueal , Humanos , Intubación Intratraqueal/efectos adversos , Maxilares/anatomía & histología , Funciones de Verosimilitud , Boca/anatomía & histología , Faringe/anatomía & histología , Factores de Riesgo , Sensibilidad y EspecificidadRESUMEN
OBJECTIVES: The use of clinical staging in the fatal neurodegenerative disease amyotrophic lateral sclerosis would have value in optimising future therapeutic trials. We aimed to use previous clinical trial data to determine the length of time patients spend in each of four proposed stages, its range and transition patterns to subsequent stages. METHODS: Using databases from two multicentre clinical trials, patients were retrospectively staged through the trial course. At each stage we assessed whether patients then progressed to an earlier, consecutive or later stage or death. Duration spent in each stage before progression to a later stage was calculated. RESULTS: There were 725 patients. No patients moved to an earlier stage. More patients at stages 1, 2 and 3 progressed to the consecutive stage rather than skipping a stage. 59.3% of patients at Stage 1 progressed to Stage 2, 54.0% of patients at Stage 2 progressed to Stage 3, 42.3% of patients at Stage 3 progressed to Stage 4 and 47.0% of Stage 4 patients progressed to death. Transition times between stages had a median duration of 3 to 7â months for stages 2 to 4. DISCUSSION: We have shown using trial data that transition times between stages are short. Use of stage duration as an endpoint might allow a shorter trial duration. We have shown face validity in this system as most patients progress through consecutive stages, and none revert to earlier stages. Furthermore, we have shown the system is reliable across populations and therefore has content validity.
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Esclerosis Amiotrófica Lateral/diagnóstico , Ensayos Clínicos Fase III como Asunto/métodos , Progresión de la Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ensayos Clínicos Controlados Aleatorios como Asunto/estadística & datos numéricos , Factores de TiempoRESUMEN
Myocardial infarction (MI), and subsequent heart failure, remains a major healthcare problem in the western and developing world and leads to substantial morbidity and mortality. After MI, the ability of the myocardium to recover is closely associated with a complex immune response that often leads to adverse remodeling of the ventricle, and poor prognosis. Currently used clinical imaging modalities allow the assessment of anatomy, perfusion, function, and viability but do not provide insights into specific biological processes. In contrast, novel non-invasive imaging methods, using targeted imaging agents, allow imaging of the molecular processes underlying the post-MI immune cell response, and subsequent remodeling. Therefore, this may have significant diagnostic, prognostic, and therapeutic value, and may help to improve our understanding of post-infarct remodeling, in vivo. Imaging modalities such as magnetic resonance imaging, single-photon emission computed tomography, and positron emission tomography have been used in concert with radiolabelled and (super) paramagnetic probes to image each phase of the immune response. These probes, which target apoptosis, necrosis, neutrophils, monocytes, enzymes, angiogenesis, extracellular matrix, and scar formation have been assessed and validated pre-clinically. Translating this work to the bedside in a cost-effective, clinically beneficial manner remains a significant challenge. This article reviews these new imaging techniques as well as the corresponding pathophysiology.
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Imagen Molecular/métodos , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/fisiopatología , Animales , HumanosRESUMEN
Optimisation of oxygenation strategies in patients with hypoxaemic respiratory failure is a top priority for acute care physicians, as hypoxaemic respiratory failure is one of the leading causes of admission. Various oxygenation methods range from non-invasive face masks to high flow nasal cannulae, which have advantages and disadvantages for this heterogeneous patient group. Focus has turned toward examining the benefits of non-invasive ventilation, as this was heavily researched in resource-limited settings during the COVID-19 pandemic. The oxygenation strategy should be determined on an individualised basis for patients, and with new evidence from the COVID-19 pandemic, providers may now consider placing further emphasis on non-invasive approaches. As non-invasive ventilation continues to be used in increasing frequency, new methods of monitoring patient response, including when to escalate ventilation strategy, will need to be validated.
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COVID-19 , Ventilación no Invasiva , Insuficiencia Respiratoria , Humanos , Pandemias , COVID-19/complicaciones , Hipoxia/etiología , Hipoxia/terapia , Insuficiencia Respiratoria/terapia , Ventilación no Invasiva/efectos adversos , Terapia por Inhalación de OxígenoRESUMEN
OBJECTIVE: Recent Canadian data show that the prescribing of opioids has declined while the number of opioid deaths continues to rise. This study aimed to assess the relationship between neighborhood-level opioid prescription rates and opioid-related mortality among individuals without an opioid prescription. METHOD: This was a nested case-control study using data in Ontario from 2013 to 2019. Neighborhood-level data were analyzed by using dissemination areas that consist of 400-700 people. Cases were defined as individuals who had an opioid-related death without an opioid prescription filled in the year prior. Cases and controls were matched using a disease risk score. After matching, there were 2,401 cases and 8,813 controls. The primary exposure was the total volume of opioids dispensed within the individual's dissemination area in the 90 days before the index date. Conditional logistic regression was used to examine the association between opioid prescriptions and the risk of overdose. RESULTS: There was no significant association between the total volume of opioid prescriptions dispensed in a dissemination area and opioid-related mortality. In subgroup analyses stratifying the cohort into prescription and nonprescription opioid-related mortality, the number of prescriptions dispensed was positively associated with prescription opioid-related mortality. There was also a significant inverse association between the increased total volume of opioids dispensed and nonprescription opioid mortality. CONCLUSIONS: Our results suggest that prescription opioids dispensed within a neighborhood can have both potential benefits and harms. The opioid epidemic requires a nuanced approach that ensures appropriate pain care for patients while also creating a safer environment for opioid use through harm-reduction strategies.
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Sobredosis de Droga , Trastornos Relacionados con Opioides , Humanos , Analgésicos Opioides/uso terapéutico , Ontario/epidemiología , Estudios de Casos y Controles , Pautas de la Práctica en Medicina , Sobredosis de Droga/epidemiología , Trastornos Relacionados con Opioides/tratamiento farmacológicoRESUMEN
Importance: The ability to provide invasive mechanical ventilation (IMV) is a mainstay of modern intensive care; however, whether rates of IMV vary among countries is unclear. Objective: To estimate the per capita rates of IMV in adults across 3 high-income countries with large variation in per capita intensive care unit (ICU) bed availability. Design, Setting, and Participants: This cohort study examined 2018 data of patients aged 20 years or older who received IMV in England, Canada, and the US. Exposure: The country in which IMV was received. Main Outcomes and Measures: The main outcome was the age-standardized rate of IMV and ICU admissions in each country. Rates were stratified by age, specific diagnoses (acute myocardial infarction, pulmonary embolus, upper gastrointestinal bleed), and comorbidities (dementia, dialysis dependence). Data analyses were conducted between January 1, 2021, and December 1, 2022. Results: The study included 59â¯873 hospital admissions with IMV in England (median [IQR] patient age, 61 [47-72] years; 59% men, 41% women), 70â¯250 in Canada (median [IQR] patient age, 65 [54-74] years; 64% men, 36% women), and 1â¯614â¯768 in the US (median [IQR] patient age, 65 [54-74] years; 57% men, 43% women). The age-standardized rate per 100â¯000 population of IMV was the lowest in England (131; 95% CI, 130-132) compared with Canada (290; 95% CI, 288-292) and the US (614; 95% CI, 614-615). Stratified by age, per capita rates of IMV were more similar across countries among younger patients and diverged markedly in older patients. Among patients aged 80 years or older, the crude rate of IMV per 100â¯000 population was highest in the US (1788; 95% CI, 1781-1796) compared with Canada (694; 95% CI, 679-709) and England (209; 95% CI, 203-214). Concerning measured comorbidities, 6.3% of admitted patients who received IMV in the US had a diagnosis of dementia (vs 1.4% in England and 1.3% in Canada). Similarly, 5.6% of admitted patients in the US were dependent on dialysis prior to receiving IMV (vs 1.3% in England and 0.3% in Canada). Conclusions and Relevance: This cohort study found that patients in the US received IMV at a rate 4 times higher than in England and twice that in Canada in 2018. The greatest divergence was in the use of IMV among older adults, and patient characteristics among those who received IMV varied markedly. The differences in overall use of IMV among these countries highlight the need to better understand patient-, clinician-, and systems-level choices associated with the varied use of a limited and expensive resource.
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Demencia , Respiración Artificial , Masculino , Humanos , Femenino , Anciano , Persona de Mediana Edad , Estudios de Cohortes , Diálisis Renal , Hospitalización , Estudios RetrospectivosRESUMEN
Identification of epigenetically affected genes has become an important tool for understanding both normal and aberrant gene expression in cancer. Here we report a whole-genome analysis of DNA methylation profiles in fresh-frozen oropharyngeal squamous cell carcinoma (OPSCC) tissues and normal mucosa samples using microarray technology with patient genomic DNA. We initially compared whole-genome patterns of DNA methylation among 24 OPSCC primary tumors and 24 matched normal mucosal samples. From a survey of 27,578 CpG dinucleotide loci spanning more than 14,000 genes, we identified 958 CpG loci in which measurements of DNA methylation were altered in the primary tumors relative to the normal mucosal samples. These alterations were validated in an independent set of 21 OPSCC patients. A survey of these loci by chromosomal location revealed an abnormally high number of differentially methylated loci on chromosome 19. Many of the loci on chromosome 19 are associated with genes belonging to the Krüppel-type zinc finger protein genes. Hypermethylation was accompanied by a significant decrease in expression of these genes in OPSCC primary tumors relative to adjacent mucosa. This study reports the epigenetic silencing of Krüppel-type zinc finger protein genes on chromosome 19q13 in oropharyngeal cancer. The aberrant methylation of these genes represents a new avenue of exploration for pathways affected in this disease.
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Carcinoma de Células Escamosas/genética , Cromosomas Humanos Par 19/genética , Metilación de ADN/genética , Factores de Transcripción de Tipo Kruppel/genética , Neoplasias Orofaríngeas/genética , Adulto , Anciano , Islas de CpG/genética , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis de Secuencia por Matrices de Oligonucleótidos , Reacción en Cadena de la Polimerasa de Transcriptasa InversaRESUMEN
While early empiric antibiotic therapy is beneficial for patients presenting with sepsis, the presentation of sepsis from Clostridioides difficile (formerly Clostridium difficile) infection (CDI) has not been well studied in large cohorts. We sought to determine whether the combination of extreme leukocytosis and diarrhea was strongly predictive of CDI in a cohort of 8659 patients admitted to the intensive care unit. We found that CDI was present in 15.0% (95% CI, 12.1-18.3%) of patients with extreme leukocytosis and diarrhea and that mortality for those with CDI, diarrhea, and extreme leukocytosis was 33.8% (95% CI, 23.2-44.3%). These data support consideration of empiric treatment for CDI in unstable critically ill patients with extreme leukocytosis and diarrhea, along with treatment of other possible sources of sepsis as appropriate. Empiric treatment for CDI can usually be discontinued promptly, along with narrowing of other broad-spectrum antimicrobial coverage, if a sensitive C. difficile test is negative.
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OBJECTIVES: In traumatically injured patients, excessive blood loss necessitating the transfusion of red blood cell (RBC) units is common. Indicators of early RBC transfusion in the pre-hospital setting are needed. This study aims to evaluate the association between hypothermia (<36°C) and transfusion risk within the first 24 hours after arrival to hospital for a traumatic injury. METHODS: We completed an audit of all traumatically injured patients who had emergent surgery at a single tertiary care center between 2010 and 2014. Using multivariable logistic regression analysis, we evaluated the association between pre-hospital hypothermia and transfusion of ≥1 unit of RBC within 24 hours of arrival to the trauma bay. RESULTS: Of the 703 patients included to evaluate the association between hypothermia and RBC transfusion, 203 patients (29%) required a transfusion within 24 hours. After controlling for important confounding variables, including age, sex, coagulopathy (platelets and INR), hemoglobin, and vital signs (blood pressure and heart rate), hypothermia was associated with a 68% increased odds of transfusion in multivariable analysis (OR: 1.68; 95% CI: 1.11-2.56). CONCLUSIONS: Hypothermia is strongly associated with RBC transfusion in a cohort of trauma patients requiring emergent surgery. This finding highlights the importance of early measures of temperature after traumatic injury and the need for intervention trials to determine if strategies to mitigate the risk of hypothermia will decrease the risk of transfusion and other morbidities.
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Hipotermia , Heridas y Lesiones , Trastornos de la Coagulación Sanguínea , Transfusión Sanguínea , Hospitales , Humanos , Hipotermia/etiología , Estudios Retrospectivos , Reacción a la TransfusiónRESUMEN
Purpose Effective clinical leadership is crucial to avoid failings in the delivery of safe health care, particularly during a period of increasing scrutiny and cost-constraints for the National Health Service (NHS). However, there is a paucity of leadership training for health-care students, the future leaders of the NHS, which is due in part to overfilled curricula. The purpose of this study was to assess the impact of student-led leadership training for the benefit of fellow students. Design/methodology/approach To address this training gap, a group of multiprofessional students organised a series of large-group seminars and small-group workshops given by notable health-care leaders at a London university over the course of two consecutive years. Findings The majority of students had not previously received any formal exposure to leadership training. Feedback post-events were almost universally positive, though students expressed a preference for experiential teaching of leadership. Working with university faculty, an inaugural essay prize was founded and student members were given the opportunity to complete internships in real-life quality improvement projects. Originality/value Student-led teaching interventions in leadership can help to fill an unmet teaching need and help to better equip the next generation of health-care workers for future roles as leaders within the NHS.
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Curriculum , Liderazgo , Grupo Paritario , Adulto , Educación en Odontología , Educación de Pregrado en Medicina , Bachillerato en Enfermería , Educación en Farmacia , Femenino , Humanos , Londres , Masculino , Ciencias de la Nutrición/educación , Especialidad de Fisioterapia/educación , Medicina EstatalRESUMEN
INTRODUCTION: The prevalence of diabetic nephropathy is increasing as a consequence of the global epidemic of diabetes, and the complications of diabetic nephropathy are unsurprisingly legion. Blockade of the renin-angiotensin-aldosterone system (RAAS) has formed the mainstay of management, but despite this, most individuals will suffer premature cardiovascular events, and many will progress to end-stage renal disease. Given the heterogeneity of pathologies, it is perhaps naïve to hope that blocking a single neurohormonal pathway will protect against the myriad of pathogenetic mechanisms that conspire to cause the injuries seen with diabetes. Chronic hyperglycaemia and resulting advanced glycation end products form a mechanistic axis, which appears central to many of the pathways that lead to diabetic nephropathy. Treatment with pyridoxamine (an inhibitor of advanced glycation end-products) may represent a strategy to counter these injurious pathways. AREAS COVERED: In this review, the authors explore pyridoxamine and other emerging therapeutic agents in the battle against diabetic nephropathy. The authors also provide their perspectives on the field and potential future directions. EXPERT OPINION: Although issues around validity of surrogate markers and clinical end points have complicated trial data in the field, currently available evidence is not persuasive as regards the clinical application of these agents. There remains a clear and growing need for emerging therapeutics to be used in combination with RAAS blocking agents.