Increasing Rates of RSV Hospitalization among Preterm Infants: A Decade of Data.

OBJECTIVE: In 2014, the American Academy of Pediatrics (AAP) changed its policy on the use of respiratory syncytial virus immunoprophylaxis (RSV-IP) so that RSV-IP was no longer recommended for use among infants without other medical conditions born >29 weeks of gestational age (wGA). This study examines 10-year trends in RSV-IP and RSV hospitalizations among term infants and preterm infants born at 29 to 34 wGA, including the 5 RSV seasons before and 5 RSV seasons after the AAP guidance change. STUDY DESIGN: A retrospective observational cohort study of a convenience sample of infants less than 6 months of age during RSV season (November-March) born between July 1, 2008, and June 30, 2019, who were born at 29 to 34 wGA (preterm) or >37 wGA (term) in the IBM MarketScan Commercial and Multi-State Medicaid databases. We excluded infants with medical conditions that would independently qualify them for RSV-IP. We identified RSV-IP utilization along with RSV and all-cause bronchiolitis hospitalizations during each RSV season. A difference-in-difference model was used to determine if there was a significant change in the relative rate of RSV hospitalizations following the 2014 policy change. RESULTS: There were 53,535 commercially insured and 85,099 Medicaid-insured qualifying preterm infants and 1,111,670 commercially insured and 1,492,943 Medicaid-insured qualifying term infants. Following the 2014 policy change, RSV-IP utilization decreased for all infants, while hospitalization rates tended to increase for preterm infants. Rate ratios comparing preterm to term infants also increased. The relative rate for RSV hospitalization for infants born at 29 to 34 wGA increased significantly for both commercially and Medicaid-insured infants (1.95, 95% CI: 1.67-2.27, p <0.001; 1.70, 95% CI: 1.55-1.86, p <0.001, respectively). Findings were similar for all-cause bronchiolitis hospitalizations. CONCLUSION: We found that the previously identified increase in RSV hospitalization rates among infants born at 29 to 34 wGA persisted for at least 5 years following the policy change. KEY POINTS: · Immunoprophylaxis rates decreased after the 2014 American Academy of Pediatrics guidelines update.. · Rate of RSV hospitalization increased among preterm infants after the 2014 AAP guidelines update.. · Increase in RSV hospitalization persisted for at least 5 years after AAP guidelines update..

Comparison of two-year treatment adherence, persistence, discontinuation, reinitiation, and switching between psoriasis patients treated with ixekizumab or secukinumab in real-world settings.

BACKGROUND: Real-world data on long-term treatment patterns associated with interleukin-17A inhibitors in plaque psoriasis are lacking. OBJECTIVE: To compare ixekizumab or secukinumab treatment patterns over a 24-month period among plaque psoriasis patients. METHODS: Adult patients with psoriasis who had 1 or more claims for ixekizumab or secukinumab between March 1, 2016, and October 31, 2019, and with 24 months of follow-up after starting treatment were identified from IBM MarketScan claims databases. Inverse probability of treatment weighting and multivariable models were employed to balance cohorts and estimate the risks of nonpersistence, discontinuation, and switching and odds of highly adherent treatment (proportion of days covered ≥ 80%). RESULTS: A total of 471 ixekizumab and 990 secukinumab users were included. Compared to secukinumab, ixekizumab use was associated with a 20% lower risk of nonpersistence (hazard ratio, 0.80; 95% CI, 0.70-0.92), a 17% lower risk of discontinuation (hazard ratio, 0.83; 95% CI, 0.72-0.96), and a 42% higher odds of being highly adherent to treatment (odds ratio, 1.42; 95% CI, 1.12-1.80). No difference in risk of switching was observed (hazard ratio, 0.83; 95% CI, 0.68-1.01). LIMITATIONS: Disease severity and clinical outcomes were unavailable. CONCLUSION: Over 24 months, ixekizumab users exhibited better persistence and adherence, and a lower risk of discontinuation than secukinumab users in real-world settings.

Exploration of machine learning techniques to examine the journey to neuroendocrine tumor diagnosis with real-world data.

Aim: Machine learning reveals pathways to neuroendocrine tumor (NET) diagnosis. Patients & methods: Patients with NET and age-/gender-matched non-NET controls were retrospectively selected from MarketScan claims. Predictors (e.g., procedures, symptoms, conditions for which NET is misdiagnosed) were examined during a 5-year pre-period to understand presence of and time to NET diagnosis using conditional inference trees. Results: Among 3460 patients with NET, 70% had a prior misdiagnosis. 10,370 controls were included. Decision trees revealed combinations of factors associated with a high probability of being a patient with NET (e.g., abdominal pain, an endoscopic/biopsy procedure, vomiting) or longer times to diagnosis (e.g., asthma diagnosis with visits to >6 providers). Conclusion: Decision trees provided a unique examination of the journey to NET diagnosis.

Lay abstract We present the novel analytic approach of machine learning using real-world data to describe patient pathways to neuroendocrine tumor (NET) diagnosis. Due to the rarity and presentation of the disease, NET diagnosis is commonly inaccurate and delayed. We aimed to demonstrate the potential of analytics using conditional inference trees. Decision trees revealed specific combinations of characteristics associated with a high probability of being a patient with NET (e.g., abdominal pain, an endoscopic/biopsy procedure, vomiting) or longer times to diagnosis (e.g., asthma diagnosis with visits to >6 providers). Results from this study support prior literature and add advanced analyses that take initial steps toward developing tools aimed to help clinicians with early and accurate NET diagnosis. The methodology can be improved upon and translated to other diseases.

Effect of Aerobic Exercise on Cardiopulmonary Responses and Predictors of Change in Individuals With Parkinson's Disease.

OBJECTIVE: To determine the effect of aerobic exercise on maximal and submaximal cardiopulmonary responses and predictors of change in individuals with Parkinson's disease (PD). DESIGN: Single-center, parallel-group, rater-blind study. SETTING: Research laboratory. PARTICIPANTS: Individuals with mild to moderate PD (N=100). INTERVENTION: Participants were enrolled in a trial evaluating the effect of cycling on PD and randomized to either voluntary exercise (VE), forced exercise (FE), or a no exercise control group. The exercise groups were time and intensity matched and exercised 3×/wk for 8 weeks on a stationary cycle. MAIN OUTCOME MEASURES: Cardiopulmonary responses were collected via gas analysis during a maximal graded exercise test at baseline and post intervention. RESULTS: Exercise attendance was 97% and 93% for the FE and VE group, respectively. Average exercise heart rate reserve was 67%±11% for FE and 70%±10% for VE. No significant difference was present for change in peak oxygen consumption (VO2peak) post intervention, even though the FE group had a 5% increase in VO2peak. Both the FE and VE groups had significantly higher percentage oxygen consumption per unit time (V˙o2) at ventilator threshold (VT) than the control group compared with baseline values (P=.04). Mean V˙O2 at VT was 5% (95% CI, 0.1%-11%) higher in the FE group (P=.04) and 7% (2%, 12%) higher in VE group compared with controls. A stepwise linear regression model revealed that lower age, higher exercise cadence, and lower baseline VO2peak were most predictive of improved VO2peak. The overall model was found to be significant (P<.01). CONCLUSIONS: Peak and submaximal cardiopulmonary function may improve after aerobic exercise in individuals with PD. Lower age, higher exercise cadence, and lower baseline VO2peak were most predictive of improved VO2peak in this exercise cohort. The improvements observed in aerobic capacity were gained after a relatively short aerobic cycling intervention.

Comparison of real-world treatment patterns among patients with psoriasis prescribed ixekizumab or secukinumab.

BACKGROUND: Real-world data on treatment patterns associated with use of interleukin-17A inhibitors in psoriasis are lacking. OBJECTIVE: To compare treatment patterns between ixekizumab or secukinumab users in clinical practice. METHODS: A retrospective cohort study included patients with psoriasis aged ≥18 years treated with ixekizumab or secukinumab between March 1, 2016, and May 31, 2018 in IBM MarketScan (IBM Corp, Armonk, NY) databases. Inverse probability of treatment weighting and multivariable models were used to address cohort imbalances and estimate the risks of nonpersistence (60-day gap), discontinuation (≥90-day gap), switching, and the odds of adherence. RESULTS: The study monitored 645 ixekizumab users for 13.7 months and 1152 secukinumab users for 16.3 months. Ixekizumab users showed higher persistence rate (54.8% vs 45.1%, P < .001) and lower discontinuation rate (37.8% vs 47.5%, P < .001) than secukinumab. After multivariable adjustment, ixekizumab users had lower risks of nonpersistence (hazard ratio, 0.82; 95% confidence interval, 0.71-0.95) and discontinuation (hazard ratio, 0.82; 95% confidence interval, 0.70-0.96), and higher odds of high adherence to treatment measured by a medication possession ratio ≥80% (hazard ratio, 1.31; 95% confidence interval, 1.07-1.60). The risk of switching was similar between cohorts. LIMITATIONS: Disease severity and clinical outcomes were unavailable. CONCLUSION: Ixekizumab users demonstrated longer drug persistence, lower discontinuation rate and risk of discontinuation, higher likelihood of adherence, and similar risk of switching compared with secukinumab users in clinical practices.

Combined Aerobic Exercise and Task Practice Improve Health-Related Quality of Life Poststroke: A Preliminary Analysis.

OBJECTIVE: The aim of this project was to determine the effects of lower extremity aerobic exercise coupled with upper extremity repetitive task practice (RTP) on health-related quality of life (HRQOL) and depressive symptomology in individuals with chronic stroke. DESIGN: Secondary analysis of data from 2 randomized controlled trials. SETTING: Research laboratory. PARTICIPANTS: Individuals (N=40) with chronic stroke. INTERVENTIONS: Participants received one of the following interventions: forced exercise+RTP (FE+RTP, n=16), voluntary exercise+RTP (VE+RTP, n=16), or stroke education+RTP (EDU+RTP, n=8). All groups completed 24 sessions, each session lasting 90 minutes. MAIN OUTCOME MEASURES: The Center for Epidemiological Studies-Depression Scale (CES-D) and Stroke Impact Scale (SIS) were used to assess depressive symptomology and HRQOL. RESULTS: There were no significant group-by-time interactions for any of the SIS domains or composite scores. Examining the individual groups following the intervention, those in the FE+RTP and VE+RTP groups demonstrated significant improvements in the following SIS domains: strength, mobility, hand function, activities of daily living, and the physical composite. In addition, the FE+RTP group demonstrated significant improvements in memory, cognitive composite, and percent recovery from stroke. The HRQOL did not change in the EDU+RTP group. Although CES-D scores improved predominantly for those in the FE+RTP group, these improvements were not statistically significant. Overall, results were maintained at the 4-week follow-up. CONCLUSION: Aerobic exercise, regardless of mode, preceding motor task practice may improve HRQOL in patients with stroke. The potential of aerobic exercise to improve cardiorespiratory endurance, motor outcomes, and HRQOL poststroke justifies its use to augment traditional task practice.

A Comparison of Global Longitudinal, Circumferential, and Radial Strain to Predict Outcomes After Cardiac Surgery.

OBJECTIVE: Myocardial strain measured by speckle-tracking echocardiography detects subtle regional and global left ventricular dysfunction. Myocardial strain is measured in the longitudinal, circumferential, and radial dimensions; however, it is unclear which dimension of strain is the best predictor of postoperative outcomes. DESIGN: A secondary analysis of prospectively collected data from a clinical trial (NCT01187329). SETTING: The cardiothoracic surgical operating rooms of an academic tertiary-care center. PARTICIPANTS: Cardiothoracic surgery patients with aortic stenosis having aortic valve replacement (AVR) with or without coronary artery bypass grafting enrolled in a clinical trial. INTERVENTIONS: Myocardial deformation analysis from standardized investigative transesophageal echocardiographic examinations performed after induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: The authors compared the ability of intraoperative global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) strain to predict adverse postoperative outcomes, including prolonged hospitalization and the need for pharmacologic hemodynamic support after cardiac surgery. The association of GLS, GCS, and GRS with prolonged hospitalization (>7 days) and the need for pharmacologic hemodynamic support, with epinephrine or norepinephrine after cardiopulmonary bypass, were assessed using separate multivariable logistic regression models with adjustment for multiple comparisons. Of 100 patients, 86 had acceptable measurements for GLS analysis, 73 for GCS, and 72 for GRS. Worse GLS was associated with prolonged hospitalization [odds ratio [OR] (98.3% confidence interval [CI]) of 1.21 (1.01-1.46) per-unit worsening in strain (p = 0.01, significance criterion <0.0167)] and the need for inotropic support with epinephrine [OR (99.2% CI) of 1.81 (1.10-2.97) per-unit worsening in strain (p = 0.002, significance criterion <0.0083)], but not norepinephrine. GCS and GRS were not associated with adverse outcomes. CONCLUSION: GLS, but not GCS or GRS, predicts prolonged hospitalization and the requirement for inotropic support with epinephrine after AVR.

Intra-operative tachycardia is not associated with a composite of myocardial injury and mortality after noncardiac surgery: A retrospective cohort analysis.

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) is a major contributor to peri-operative morbidity and mortality with a reported incidence of about 8%. Tachycardia increases myocardial oxygen demand, and decreases oxygen supply, and is therefore a potential cause of MINS. OBJECTIVE: We tested the hypothesis that there is an association between intra-operative area above a heart rate (HR) of 90 bpm and a composite of MINS and in-hospital all-cause mortality. DESIGN: Retrospective analyses. SETTING: Major tertiary care hospital, Cleveland, USA. PATIENTS: Adults having elective or nonelective noncardiac surgery and scheduled troponin monitoring during the first 3 postoperative days between 2010 and 2015. MAIN OUTCOME MEASURES: All-or-none composite of myocardial injury (MINS), defined by a peak postoperative generation 4 troponin T concentration at least 0.03 ng ml, and in-hospital all-cause mortality. RESULTS: Among 2652 eligible patients, 123 (4.6%) experienced MINS within 7 days after surgery and 6 (0.2%) died before discharge. Intra-operative area above HR more than 90 bpm was not associated with the all-or-none composite of MINS and in-hospital mortality, with an estimated odds ratio (95% confidence interval) of 0.99 (0.97 to 1.01) per 1 h bpm increase in area above HR more than 90 bpm. Secondary outcomes were also unrelated to the composite, with estimated odds ratios (98.3% confidence interval) of 0.99 (0.98 to 1.00) for area above HR more than 80, 0.98 (0.92 to 1.04) for area above HR more than 100 bpm, and 0.96 (0.88 to 1.05) for maximum HR. CONCLUSION: There was no apparent association between various measures of tachycardia and a composite of MINS and death, a result that contradicts previously reported associations between other measures of intra-operative tachycardia and MINS/mortality.

Period-dependent Associations between Hypotension during and for Four Days after Noncardiac Surgery and a Composite of Myocardial Infarction and Death: A Substudy of the POISE-2 Trial.

BACKGROUND: The relative contributions of intraoperative and postoperative hypotension to perioperative morbidity remain unclear. We determined the association between hypotension and a composite of 30-day myocardial infarction and death over three periods: (1) intraoperative, (2) remaining day of surgery, and (3) during the initial four postoperative days. METHODS: This was a substudy of POISE-2, a 10,010-patient factorial-randomized trial of aspirin and clonidine for prevention of myocardial infarction. Clinically important hypotension was defined as systolic blood pressure less than 90 mmHg requiring treatment. Minutes of hypotension was the exposure variable intraoperatively and for the remaining day of surgery, whereas hypotension status was treated as binary variable for postoperative days 1 to 4. We estimated the average relative effect of hypotension across components of the composite using a distinct effect generalized estimating model, adjusting for hypotension during earlier periods. RESULTS: Among 9,765 patients, 42% experienced hypotension, 590 (6.0%) had an infarction, and 116 (1.2%) died within 30 days of surgery. Intraoperatively, the estimated average relative effect across myocardial infarction and mortality was 1.08 (98.3% CI, 1.03, 1.12; P < 0.001) per 10-min increase in hypotension duration. For the remaining day of surgery, the odds ratio was 1.03 (98.3% CI, 1.01, 1.05; P < 0.001) per 10-min increase in hypotension duration. The average relative effect odds ratio was 2.83 (98.3% CI, 1.26, 6.35; P = 0.002) in patients with hypotension during the subsequent four days of hospitalization. CONCLUSIONS: Clinically important hypotension-a potentially modifiable exposure-was significantly associated with a composite of myocardial infarction and death during each of three perioperative periods, even after adjustment for previous hypotension.

Patients at High Risk for Obstructive Sleep Apnea Are at Increased Risk for Atrial Fibrillation After Cardiac Surgery: A Cohort Analysis.

BACKGROUND: Patients with obstructive sleep apnea (OSA) experience intermittent hypoxia, hypercarbia, and sympathetic activation during sleep, which increases risk for paroxysmal atrial fibrillation and other cardiac arrhythmias. Whether patients with OSA experience increased episodes of atrial fibrillation after cardiac surgery is unclear. We examined whether patients at increased risk for OSA, assessed by the STOP-BANG (snoring, tired during the day, observed stop breathing during sleep, high blood pressure, body mass index more than 35 kg/m, age more than 50 years, neck circumference more than 40 cm, and male gender) questionnaire, had a higher incidence of new-onset postoperative atrial fibrillation after cardiac surgery. Because both postoperative atrial fibrillation and OSA increase resource utilization, we secondarily examined whether patients at increased OSA risk had longer duration of postoperative mechanical ventilation and intensive care unit (ICU) length of stay. METHODS: With institutional review board approval, this retrospective observational study evaluated adult patients who underwent elective cardiac surgery requiring cardiopulmonary bypass between 2014 and 2015 with preoperative assessment of OSA risk using the STOP-BANG questionnaire. Patients with a history of atrial fibrillation were excluded. The association between the STOP-BANG score and postoperative atrial fibrillation was examined using a multivariable logistic regression model. Secondarily, we estimated the association between the STOP-BANG score and duration of initial intubation using multivariable linear regression and ICU length of stay using Cox proportional hazards regression. We also descriptively summarized the percentage of patients requiring tracheal reintubation for mechanical ventilation. RESULTS: Of 4228 cardiac surgery patients, 1593 met inclusion and exclusion criteria. An increased STOP-BANG score was associated with higher odds of postoperative atrial fibrillation (odds ratio [95% confidence interval {CI}], 1.16 [1.09-1.23] per-point increase in the STOP-BANG score; P < .001). The STOP-BANG score was not associated with ICU length of stay (estimated hazard ratio [97.5% CI], 0.99 [0.96-1.03] per-point increase in the STOP-BANG score; P = .99) or duration of initial intubation (ratio of geometric means [97.5% CI], 1.01 [1.00-1.04]; P = .03; significance criterion [Bonferroni correction] < 0.025). One percent of patients required reintubation. DISCUSSION: Increasing risk for OSA, assessed by STOP-BANG, was associated with higher odds of postoperative atrial fibrillation, but not prolonged duration of mechanical ventilation or ICU length of stay.

Reduced Left Ventricular Global Longitudinal Strain Predicts Prolonged Hospitalization: A Cohort Analysis of Patients Having Aortic Valve Replacement Surgery.

BACKGROUND: Left ventricular ejection fraction (LVEF) is often preserved in patients with aortic stenosis and thus cannot distinguish between normal myocardial contractile function and subclinical dysfunction. Global longitudinal strain and strain rate (SR), which measure myocardial deformation, are robust indicators of myocardial function and can detect subtle myocardial dysfunction that is not apparent with conventional echocardiographic measures. Strain and SR may better predict postoperative outcomes than LVEF. The primary aim of our investigation was to assess the association between global longitudinal strain and serious postoperative outcomes in patients with aortic stenosis having aortic valve replacement. Secondarily, we also assessed the associations between global longitudinal SR and LVEF and the outcomes. METHODS: In this post hoc analysis of data from a randomized clinical trial (NCT01187329), we examined the association between measures of myocardial function and the following outcomes: (1) need for postoperative inotropic/vasopressor support; (2) prolonged hospitalization (>7 days); and (3) postoperative atrial fibrillation. Standardized transesophageal echocardiographic examinations were performed after anesthetic induction. Myocardial deformation was measured using speckle-tracking echocardiography. Multivariable logistic regression was used to assess associations between measures of myocardial function and outcomes, adjusted for potential confounding factors. The predictive ability of global longitudinal strain, SR, and LVEF was assessed as area under receiver operating characteristics curves (AUCs). RESULTS: Of 100 patients enrolled in the clinical trial, 86 patients with aortic stenosis had acceptable images for global longitudinal strain analysis. Primarily, worse intraoperative global longitudinal strain was associated with prolonged hospitalization (odds ratio [98.3% confidence interval], 1.22 [1.01-1.47] per 1% decrease [absolute value] in strain; P = .012), but not with other outcomes. Secondarily, worse global longitudinal SR was associated with prolonged hospitalization (odds ratio [99.7% confidence interval], 1.68 [1.01-2.79] per 0.1 second(-1) decrease [absolute value] in SR; P = .003), but not other outcomes. LVEF was not associated with any outcomes. Global longitudinal SR was the best predictor for prolonged hospitalization (AUC, 0.72), followed by global longitudinal strain (AUC, 0.67) and LVEF (AUC, 0.62). CONCLUSIONS: Global longitudinal strain and SR are useful predictors of prolonged hospitalization in patients with aortic stenosis having an aortic valve replacement.

Postoperative Hypotension and Surgical Site Infections After Colorectal Surgery: A Retrospective Cohort Study.

BACKGROUND: Hypotension compromises local tissue perfusion, thereby reducing tissue oxygenation. Hypotension might thus be expected to promote infection. Hypotension on surgical wards, while usually less severe than intraoperative hypotension, is common and often prolonged. In this retrospective cohort study, we tested the hypotheses that there is an association between surgical site infections and low postoperative time-weighted average mean arterial pressure and/or postoperative minimum mean arterial pressure. METHODS: We considered patients who had colorectal surgery lasting ≥1 hour at the Cleveland Clinic between 2009 and 2013. We defined blood pressure exposures as time-weighted average (primary) and minimum mean arterial pressure (secondary) within 72 hours after surgery. We assessed associations between continuous blood pressure exposures with a composite of deep and superficial surgical site infection using separate severity-weighted average relative effect generalized estimating equations models, each using an unstructured correlation structure and adjusting for potentially confounding variables. RESULTS: A total of 5896 patients were eligible for analysis. Time-weighted mean arterial pressure and surgical site infection were not significantly associated, with an estimated odds ratio (95% CI) of 1.03 (0.99-1.08) for a 5-mm Hg decrease (P = .16). However, there was a significant inverse association between minimum postoperative mean arterial pressure and infection, with an estimated odds ratio of 1.08 (1.03-1.12) per 5-mm Hg decrease (P = .001). CONCLUSIONS: Postoperative time-weighted mean arterial pressure was not associated with surgical site infection, but lowest postoperative mean arterial pressure was. Whether the relationship is causal remains to be determined.

Biochemically diagnosed hypothyroidism and postoperative complications after cardiac surgery: a retrospective cohort analysis.

PURPOSE: To determine whether hypothyroidism is associated with cardiovascular complications and surgical wound infections after cardiac surgery. METHODS: Patients were categorized as: (1) hypothyroid [patients with increased TSH concentrations (≧ 5.5 mIU/L) within 6 months prior to surgery]; (2) corrected hypothyroid [diagnosis of hypothyroidism any time before surgery or on preoperative thyroid supplementation and normal TSH concentration (0.4 [Formula: see text] TSH [Formula: see text] 5.5 mIU/L]; and (3) euthyroid [no hypothyroid diagnosis and not on preoperative thyroid supplementation and normal TSH concentrations (0.4-5.5 mIU/L)]. We conducted pairwise comparisons among the three groups using inverse probability of treatment weighting. We compared the groups on postoperative myocardial infarction, cardiac arrest, atrial fibrillation, and a composite of surgical wound infections and postoperative vasopressor use using multivariable logistic regression models. We compared the groups on ICU and hospital length of stay using Cox proportional hazards regression. RESULTS: Hypothyroidism was associated with a lower risk of atrial fibrillation than euthyroidism, with an estimated relative risk (99.4% CI) of 0.71 (0.56, 0.89); P < 0.001. However, none of the other pairwise comparisons on myocardial infarction, cardiac arrest, and atrial fibrillation were significant. Corrected hypothyroid patients were slightly more likely to be discharged from hospital at any given time than euthyroid patients (hazard ratios (99.6% CI), 1.18 (1.07, 1.30); P < 0.001), but no other pairwise comparisons for secondary outcomes were significant. CONCLUSIONS: Hypothyroidism was associated with lower risk of atrial fibrillation than euthyroidism, and corrected hypothyroidism was associated with a shorter length of stay than euthyroidism.

Systemic Lupus Erythematosus Is Associated With Increased Adverse Postoperative Renal Outcomes and Mortality: A Historical Cohort Study Using Administrative Health Data.

BACKGROUND: Systemic lupus erythematosus (SLE) is a common autoimmune connective tissue disease that mainly harms kidneys, heart, lungs, and nervous system. Effects of surgical stimulus and anesthesia combined with SLE-related pathologies may increase morbidity and mortality. Therefore, we aimed to evaluate the association between SLE (versus none) and postoperative renal, cardiac, and in-hospital mortality complications among patients undergoing major surgeries. METHODS: We obtained censuses of 2009 to 2011 inpatient hospital discharges across 7 states and conducted a retrospective cohort study by using International Classification of Diseases and Injuries, Version 9, diagnosis codes, procedure codes, and present-on-admission indicators. We included patients who had major surgery and matched each SLE discharge up to 4 control discharges for potential confounders. We assessed the association between matched SLE patients and controls on in-hospital renal complications, cardiovascular complications, and in-hospital mortality using separate logistic regression models. RESULTS: Among 8 million qualifying discharges, our sample contained 28,269 SLE patients matched with 13,269 controls. SLE was associated with a significantly higher risk of postoperative renal complications, with an estimated odds ratio (99% CI) of 1.33 (1.21, 1.46); P < .001. In addition, SLE was significantly associated with a higher risk of in-hospital mortality, with an estimated odds ratio (99% CI) of 1.27 (1.11, 1.47); P < .001. However, we found no significant association between SLE and cardiac complications, with an estimated odds ratio (99% CI) of 0.98 (0.83, 1.16), P = .79. CONCLUSIONS: This is, by far, the largest clinical study for postoperative outcomes of SLE patients with adequately powered statistical analyses. We concluded that SLE was associated with a higher risk of renal complications and in-hospital mortality but not cardiac events after major surgery. In SLE patients, more aggressive measures should be taken to prevent renal injury in the perioperative period.

Intravenous Acetaminophen Does Not Decrease Persistent Surgical Pain After Cardiac Surgery.

OBJECTIVE: The authors investigated the hypothesis that perioperative acetaminophen reduces incisional pain at 30 and 90 days. DESIGN: This was a prospective, randomized, double-blind trial. SETTING: Tertiary-care hospital (single center) cardiac surgery unit. PARTICIPANTS: Patients undergoing cardiac surgery via median sternotomy. INTERVENTIONS: Patients were assigned randomly to intravenous (IV) acetaminophen or IV placebo. Patients were given 4 doses of 1 g of IV acetaminophen or an equal volume of saline placebo over 15 minutes every 6 hours for 24 hours starting in the operating room after sternal closure. MEASUREMENTS AND MAIN RESULTS: Study participants were assessed by phone for incisional pain severity 30 and 90 days after surgery. Those reporting any incisional pain were asked to complete the Neuropathic Pain Questionnaire-Short Form and the modified Brief Pain Inventory. Patients were compared on 30- and 90-day incisional pain severity using separate multivariable linear regression models. IV acetaminophen had no effect on 30- and 90-day incisional pain, with an estimated difference in means (confidence interval) of 0.06 (-0.87 to 0.99) at 30 days (p = 0.88) and 0.07 (-0.71 to 0.86) at 90 days (p = 0.83). Low pain severity, neuropathic pain, and interference at both 30 and 90 days after surgery, regardless of treatment group, were observed. CONCLUSIONS: IV acetaminophen did not reduce the incidence or intensity of incisional pain at 30 days and 90 days after surgery.

Novel needle guide reduces time to perform ultrasound-guided femoral nerve catheter placement: A randomised controlled trial.

BACKGROUND: Ultrasound-guided nerve blocks have become the standard when performing regional nerve blocks in anaesthesia. Infiniti Plus (CIVCO Medical Solutions, Kalona, Iowa, USA) is a needle guide that has been recently developed to help clinicians in performing ultrasound-guided nerve blocks. OBJECTIVES: We tested the hypothesis that femoral nerve catheter placement carried out with the Infiniti Plus needle guide will be quicker to perform than without the Infiniti Plus. Secondary aims were to assess whether the Infiniti Plus needle guide decreased the number of block attempts and also whether it improved needle visibility. DESIGN: A randomised, controlled trial. SETTING: Cleveland Clinic, Cleveland, Ohio, USA. PATIENTS: We enrolled adult patients having elective total knee arthroplasty with a femoral nerve block and femoral nerve catheter. Patients, who were pregnant or those who had preexisting neuropathy involving the surgical limb, coagulopathy, infection at the block site or allergy to local anaesthetics were excluded. INTERVENTIONS: Patients were randomised into two groups to receive the ultrasound-guided femoral nerve catheter placement with or without the Infiniti Plus needle guide. MAIN OUTCOME MEASURES: The time taken to place the femoral nerve catheter, the number of attempts, the success rate and needle visibility were recorded. We used an overall α of 0.05 for both the primary and secondary analyses; the secondary analyses were Bonferroni corrected to control for multiple comparisons. RESULT: The median (interquartile range Q1 to Q3) time to perform the femoral nerve catheter placement was 118 (100 to 150) s with Infiniti Plus and 177 (130 to 236) s without Infiniti Plus. Infiniti Plus significantly reduced the time spent performing femoral nerve catheterisation, with estimated ratio of means [(95% confidence interval), P value] of 0.67 [(0.60 to 0.75), P < 0.001] with Infiniti Plus compared with no Infiniti Plus. However, Infiniti Plus had no effect on the odds of a successful femoral nerve catheter placement, number of attempts or percentage of perfect needle visibility. CONCLUSION: We found that the use of Infiniti Plus decreased the median time to successfully place a femoral nerve catheter by 33% compared with not using Infiniti Plus. This difference may be more apparent to clinicians undertaking this procedure less often or by those in training as our team was very experienced, had been trained in the technique and was working in a hospital with a large caseload. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02080481.

Association Between Intraoperative Low Blood Pressure and Development of Surgical Site Infection After Colorectal Surgery: A Retrospective Cohort Study.

OBJECTIVE: We tested the primary hypothesis that surgical site infections (SSIs) are more common in patients who had longer periods of intraoperative low blood pressure. Our secondary hypothesis was that hospitalization is prolonged in patients experiencing longer periods of critically low systolic blood pressure (SBP) and/or mean arterial pressure (MAP). BACKGROUND: Hypotension compromises local tissue perfusion, thereby reducing tissue oxygenation. Hypotension might thus be expected to promote infection, but the extent to which low blood pressure contributes remains unclear. METHODS: We considered patients who had colorectal surgery lasting at least 1 hour at the Cleveland Clinic between 2009 and 2013. The duration of hypotensive exposure and development of SSI was assessed with logistic regression; the association between hypotensive exposure and duration of hospitalization was assessed with Cox proportional hazard regression. RESULTS: A total of 2521 patients were eligible for analysis. There was no adjusted association between SBP hypotension < 80 mm Hg and SSI, with an estimated odds ratio (95% confidence interval) of 0.97 (0.81, 1.17) per 5-minute increase in SBP hypotension (P = 0.54). There was also no adjusted association between MAP hypotension time and SSI, with estimated odds ratio of 0.97 (0.81, 1.17) for a 5-minute increase in MAP hypotension < 55 mm Hg time (P = 0.71). There was no association between duration of hypotension and time to discharge. CONCLUSIONS: Intraoperative hypotension does not seem to be a clinically important predictor of SSI after colorectal surgery, probably because the outcomes are overwhelmingly determined by other baseline and surgical factors-and perhaps postoperative hypotension.

Pharyngeal Oxygen Insufflation During AirTraq Laryngoscopy Slows Arterial Desaturation in Infants and Small Children.

BACKGROUND: The extent to which insufflation of oxygen into the posterior pharynx during laryngoscopy prolongs adequate saturation in infants and small children remains unknown. Therefore, we compared oxygen saturation over time in preoxygenated small children with and without posterior pharynx oxygen insufflation. METHODS: After induction of anesthesia with sevoflurane and propofol, infants and small children were preoxygenated with 100% oxygen for 3 minutes. An AirTraq laryngoscope size 0 or 1 with an appropriately sized cuffed endotracheal tube positioned in the side channel was prepared. Oxygen tubing was connected to the endotracheal U-shaped tube. However, oxygen at a flow of 4 L/min was provided only to half of the randomly selected participating patients. The trachea was intubated, the tube cuff was inflated, and the laryngoscope was removed from the mouth. The oxygen tubing was disconnected from the endotracheal tube and left exposed to ambient air until oxygen saturation decreased to 95%. Thereafter, patients' lungs were manually ventilated with 100% oxygen until SpO2 returned to 100%. Subsequent anesthetic management was at the discretion of the attending anesthesiologist. RESULTS: Laryngoscopy took a median of 60 (Q1-Q3, 40-90) seconds. The mean time to 95% oxygen saturation was (mean ± SD) 166 ± 47 seconds in the oxygen insufflation group and 131 ± 39 seconds in small children without insufflation. Oxygen insufflation prolonged the mean time for saturation to decrease from 100% to 95% by an estimated 35 (95% confidence interval, 10-60) seconds, P = 0.01. CONCLUSIONS: Adding posterior pharyngeal oxygen insufflation to conventional preoxygenation prolonged the period of adequate oxygen saturation in infants and small children by an amount that is potentially clinically important.

Clonidine Does Not Reduce Pain or Opioid Consumption After Noncardiac Surgery.

BACKGROUND: Clonidine is an α2-adrenoceptor agonist, which has analgesic properties. However, the analgesic efficacy of perioperative clonidine remains unclear. We, therefore, tested the hypothesis that clonidine reduces both pain scores and cumulative opioid consumption during the initial 72 hours after noncardiac surgery. METHODS: Six hundred twenty-four patients undergoing elective noncardiac surgery under general and spinal anesthesia were included in this substudy of the PeriOperative ISchemia Evaluation-2 trial. Patients were randomly assigned to 0.2 mg oral clonidine or placebo 2 to 4 hours before surgery, followed by 0.2 mg/d transdermal clonidine patch or placebo patch, which was maintained until 72 hours after surgery. Postoperative pain scores and opioid consumption were assessed for 72 hours after surgery. RESULTS: Clonidine had no effect on opioid consumption compared with placebo, with an estimated ratio of means of 0.98 (95% confidence interval, 0.70-1.38); P = 0.92. Median (Q1, Q3) opioid consumption was 63 (30, 154) mg morphine equivalents in the clonidine group, which was similar to 60 (30, 128) mg morphine equivalents in the placebo group. Furthermore, there was no significant effect on pain scores, with an estimated difference in means of 0.12 (95% confidence interval, -0.02 to 0.26); 11-point scale; P = 0.10. Mean pain scores per patient were 3.6 ± 1.8 for clonidine patients and 3.6 ± 1.8 for placebo patients. CONCLUSIONS: Clonidine does not reduce opioid consumption or pain scores in patients recovering from noncardiac surgery.

Plant trait expression responds to establishment timing.

Trait divergence between co-occurring individuals could decrease the strength of competition between these individuals, thus promoting their coexistence. To test this hypothesis, we manipulated establishment timing for four congeneric pairs of perennial plants and assessed trait plasticity. Because soil conditions can affect trait expression and competition, we grew the plants in field-collected soil from each congener. Competition was generally weak across species, but the order of establishment affected divergence in biomass between potmates for three congeneric pairs. The type of plastic response differed among genera, with trait means of early-establishing individuals of Rumex and Solanum spp. differing from late-establishing individuals, and trait divergence between potmates of Plantago and Trifolium spp. depending on which species established first. Consistent with adaptive trait plasticity, higher specific leaf area (SLA) and root-shoot ratio in Rumex spp. established later suggest that these individuals were maximizing their ability to capture light and soil resources. Greater divergence in SLA correlated with increased summed biomass of competitors, which is consistent with trait divergence moderating the strength of competition for some species. Species did not consistently perform better in conspecific or congener soil, but soil type influenced the effect of establishment order. For example, biomass divergence between Rumex potmates was greater in R. obtusifolius soil regardless of which species established first. These results suggest that plant responses to establishment timing act in a species-specific fashion, potentially enhancing coexistence in plant communities.