Effect of a national guideline on postoperative troponin surveillance: a retrospective cohort study.

PURPOSE: We aimed to evaluate the effect of the 2017 Canadian Cardiovascular Society (CCS) guidelines on troponin surveillance after noncardiac surgery. METHODS: This was a single-centre, retrospective, observational study. Patients aged 40 yr or older undergoing intermediate- to high-risk elective noncardiac surgery between 2016 and 2021 were included. We compared the number and percentage of troponin tests ordered before and after the guidelines were published and compared patient characteristics, specifically cardiovascular comorbidity, using odds ratio's (OR) with 95% confidence intervals (CIs). Outcomes were myocardial injury, myocardial infarction (MI), and in-hospital mortality. RESULTS: The cohort included 36,386 patients and the median age was 63 yr. Between 2016 and 2018, troponin surveillance was done in 2,461 (13%) of the 19,046 patients, compared with 2,398 (14%) of the 17,340 patients who had surgery between 2019 and 2021 (OR, 1.08; 95% CI, 1.02 to 1.15). Patients who had surgery in the second period had less cardiovascular comorbidity; the adjusted OR for troponin surveillance was 1.14 (95% CI, 1.07 to 1.21). In the two periods, troponin was elevated in 561 (2.9%) and 470 (2.7%) patients, an MI was documented in 54 (0.3%) and 36 (0.2%) patients, and 95 (0.5%) and 73 (0.4%) patients died, respectively. After adjustment for baseline differences in the two periods, the ORs for MI and mortality were 0.83 (95% CI, 0.54 to 1.27) and 0.88 (95% CI, 0.64 to 1.19), respectively. CONCLUSION: Although the odds of troponin ordering were slightly but significantly higher after publication of the CCS guidelines, the odds for detecting an MI and for mortality did not change.

RéSUMé: OBJECTIF: Notre objectif était d'évaluer l'effet des lignes directrices 2017 de la Société canadienne de cardiologie (SCC) sur le monitorage de la troponine après une chirurgie non cardiaque. MéTHODE: Il s'agissait d'une étude observationnelle rétrospective monocentrique. Les patient·es âgé·es de 40 ans ou plus bénéficiant d'une chirurgie non cardiaque non urgente à risque intermédiaire à élevé entre 2016 et 2021 ont été inclus·es. Nous avons comparé le nombre et le pourcentage de tests de troponine prescrits avant et après la publication des lignes directrices et comparé les caractéristiques des patient·es, en particulier la comorbidité cardiovasculaire, en utilisant le rapport de cotes (RC) avec des intervalles de confiance (IC) à 95 %. Les critères d'évaluation comprenaient les lésions myocardiques, l'infarctus du myocarde (IM) et la mortalité hospitalière. RéSULTATS: La cohorte comprenait 36 386 personnes et l'âge médian était de 63 ans. Entre 2016 et 2018, le monitorage de la troponine a été réalisé chez 2461 (13 %) des 19 046 patient·es, contre 2398 (14 %) des 17 340 patient·es opéré·es entre 2019 et 2021 (RC, 1,08; IC 95%, 1,02 à 1,15). Les patient·es qui ont bénéficié d'une intervention chirurgicale au cours de la deuxième période présentaient moins de comorbidité cardiovasculaire; le RC ajusté pour le monitorage de la troponine était de 1,14 (IC 95 %, 1,07 à 1,21). Au cours des deux périodes, la troponine était élevée chez 561 (2,9 %) et 470 (2,7 %) patient·es, un IM a été documenté chez 54 (0,3 %) et 36 (0,2 %) patient·es, et 95 (0,5 %) et 73 (0,4 %) patient·es sont décédé·es, respectivement. Après ajustement pour tenir compte des différences initiales au cours des deux périodes, les RC pour l'IM et la mortalité étaient de 0,83 (IC 95 %, 0,54 à 1,27) et de 0,88 (IC 95 %, 0,64 à 1,19), respectivement. CONCLUSION: Bien que les probabilités de commande de troponine aient été légèrement mais significativement plus élevées après la publication des lignes directrices de la SCC, les probabilités de détection d'un IM et de mortalité n'ont pas changé.

Implementation of Virtual Interactive Cases for Pharmacy Education: A Single-Center Experience.

Patient case simulation software are described in pharmacy education literature as useful tools to improve skills in patient assessment (including medication history-taking and physical assessment), clinical reasoning and communication, and are typically well-received by students and instructors. The virtual interactive case (VIC) system is a web-based software developed to deliver deliberate practice opportunities in simulated patient encounters across a spectrum of clinical topics. This article describes the implementation and utilization of VIC in the undergraduate curriculum at one Canadian pharmacy school. Methods: At our facility, the use of VIC was integrated across the training spectrum in the curriculum, including core and elective didactic courses and practice labs, experiential learning, interprofessional education, and continuing education. Its use was evaluated through student and instructor surveys and qualitative student interviews). VIC is easy to navigate and created a positive and realistic learning environment. Students identified that it enhanced their ability to identify relevant patient information, accurately simulated hospital pharmacy practice and thereby helped them to prepare for their upcoming experiential courses. The use of VIC has expanded beyond its original intended purpose for individual student practice to become a valuable addition to pharmacy undergraduate education. Future plans include ongoing development of cases and exploration of further uses of VIC within the didactic curriculum, for remediation in experiential courses, and for pharmacist continuing education.

An online immunohematology educational resource for post-graduate hematology trainees: LearnSerology.ca.

BACKGROUND: Canadian hematology residents are required to demonstrate competencies in transfusion medicine by the end of their 2-year training. Prior evaluation of final year trainees revealed significant variation in knowledge. To address the lack of standardization in serology teaching, an online educational immunohematology resource was created and evaluated. STUDY DESIGN AND METHODS: All Canadian post-graduate trainees completing a residency program in adult hematology during the 2018/2019 academic year were invited to participate. Only trainees from one university were exposed to the program curriculum. A validated exam was administered to trainees at both exposed and unexposed sites at the start of the academic year as a pre-test and in the following year as a post-test. The effectiveness of the program was assessed by both comparing the degree of improvement from pre- to post-test, and by comparing performance on the post-test. RESULTS: 57 trainees from 13 universities completed the pre-test, and 45 trainees from 14 universities completed the post-test. A strong trend towards better performance in the exposed vs non-exposed trainees on the post-test was observed, and the difference was more pronounced, and statistically significant, when analysis was limited to two questions relating to interpretation of an antibody investigation panel. DISCUSSION: LearnSerology.ca is effective and may be potentially superior to traditional immunohematology teaching. The interactive capability of the platform can improve skills related to the resolution of red cell antibody panels.

Albumin use for fluid resuscitation in cardiac surgical patients: a survey of Canadian perioperative care providers.

PURPOSE: To evaluate the perceptions and practices of Canadian cardiovascular anesthesiologists and intensivists towards intravenous albumin as a resuscitation fluid in patients undergoing cardiac surgery. METHODS: We conducted a cross-sectional survey of cardiac anesthesiologists and intensivists involved in the care of cardiac surgical patients. The 22-item survey included seven open-ended questions and assessed practice patterns and attitudes towards albumin. Descriptive statistics were analyzed using counts and proportions. Qualitative data were analyzed to identify themes describing albumin use patterns in Canada. RESULTS: A total of 133 respondents from seven provinces participated, with 83 (62%) using albumin perioperatively. The majority of respondents (77%) felt a low fluid balance in cardiac surgical patients was important, and that supplementing crystalloids with albumin was helpful for this objective (67%). There was poor agreement among survey respondents regarding the role of albumin for faster vasopressor weaning or intensive care discharge, and ≥ 90% did not feel albumin reduced mortality, renal injury, or coagulopathy. Nevertheless, cardiac surgical patients were identified as a distinct population where albumin may help to minimize fluid balance. There was an acknowledged paucity of formal evidence supporting possible benefits. Fewer than 10% of respondents could identify institutional or national guidelines for albumin use. A lack of evidence supporting albumin use in cardiac surgical patients, especially those at highest risk of complications, was a frequently identified concern. CONCLUSIONS: The majority of Canadian anesthesiologists and intensivists (62%) use albumin in cardiac surgical patients. There is clinical equipoise regarding its utility, and an acknowledged need for higher quality evidence to guide practice.

RéSUMé: OBJECTIF: Évaluer les perceptions et les pratiques des anesthésiologistes et intensivistes cardiovasculaires canadiens à l'égard de l'albumine intraveineuse comme liquide de réanimation pour les patients bénéficiant d'une chirurgie cardiaque. MéTHODE: Nous avons mené un sondage transversal auprès d'anesthésiologistes et d'intensivistes cardiaques impliqués dans les soins aux patients de chirurgie cardiaque. Le sondage en 22 éléments comprenait sept questions ouvertes et évaluait les habitudes de pratique et les attitudes des praticiens à l'égard de l'albumine. Les statistiques descriptives ont été analysées à l'aide de dénombrements et de proportions. Des données qualitatives ont été analysées pour identifier des thèmes décrivant les tendances d'utilisation de l'albumine au Canada. RéSULTATS: Au total, 133 répondants de sept provinces ont participé, et 83 (62 %) utilisent l'albumine en périopératoire. La majorité des répondants (77 %) estimaient qu'un bilan liquidien négatif était important chez les patients en chirurgie cardiaque et que la supplémentation en cristalloïdes par de l'albumine était utile pour atteindre cet objectif (67 %). Il y avait un faible accord parmi les répondants concernant le rôle de l'albumine pour accélérer le sevrage des vasopresseurs ou la sortie de soins intensifs, et ≥ 90 % ne pensaient pas que l'albumine réduisait la mortalité, les lésions rénales ou la coagulopathie. Néanmoins, les patients en chirurgie cardiaque ont été identifiés comme une population distincte pour laquelle l'albumine pourrait contribuer à minimiser le bilan liquidien. Il y avait un manque reconnu de données probantes formelles à l'appui des avantages possibles. Moins de 10 % des répondants ont pu trouver des lignes directrices institutionnelles ou nationales portant sur l'utilisation de l'albumine. Le manque de données probantes à l'appui de l'utilisation de l'albumine chez les patients en chirurgie cardiaque, en particulier chez ceux présentant le risque le plus élevé de complications, était une préoccupation fréquemment identifiée. CONCLUSION: La majorité des anesthésiologistes et intensivistes canadiens (62 %) utilisent l'albumine chez les patients en chirurgie cardiaque. Il existe un équilibre clinique quant à son utilité et un besoin reconnu de données probantes de meilleure qualité pour guider la pratique.

Early Adopters of Apple Health Records at a Large Academic Medical Center: Cross-sectional Survey of Users.

BACKGROUND: Mobile applications offer a new approach to personal health records, which are internet-based tools for patients to consolidate and manage their health information. The University of Pennsylvania Health System (UPHS) was one of the first health systems to participate in Apple Health Records (AHR), a prominent example of this new generation of personal health records. OBJECTIVE: This study aimed to characterize early adoption of AHR among UPHS patients and understand user perspectives. METHODS: An email-based survey with fixed answer, Likert scale, and open-ended questions was administered to all UPHS patients using AHR in the first 10 months of enrollment. Survey data linked to the UPHS electronic health record system were used to analyze responses. Multivariable logistic regression modeled the association of patient characteristics with user ratings. Content analysis was used to analyze open-ended questions. RESULTS: At the time of the survey, a total of 1458 patients had used AHR at least once. Mean age of AHR users was 47.5 years, 66.3% (967/1458) were male, 70.9% (1033/1458) were white, and 80.8% (1178/1458) had private insurance. Response rate was 26.8% (391/1458); 46.3% (180/389) were very satisfied with AHR, and 67.7% (264/390) described it as very easy to use. The most commonly utilized features were lab results (324/391, 82.9%), clinical vitals (264/391, 67.5%), and medications (253/391, 64.7%). No patient characteristics were associated with reporting high satisfaction or ease of use. The most common reason for using AHR was convenience/ease of use, and 58.2% (160/275) of users reported allowing no other apps to access their health information, citing privacy as one consideration. CONCLUSIONS: Early adopters of AHR were demographically white, male, and privately insured. Convenience was an important facilitator, and users were selective in which apps they allowed to access their health information.

Managing Families' Expectations in the Coronial Jurisdiction: Barriers to Enacting an Ethic of Care.

The coronial jurisdiction is different in function, character and procedure to most other legal processes in Australia, being inquisitorial rather than adversarial. It is also, by virtue of its focus on the circumstances of death, situated at the intersection of trauma and grief on the one hand, and legal exploration and evidence-gathering, on the other. For families a coronial investigation offers the potential for resolution about a death, but it can also exacerbate grief and trauma, particularly in the public forum of an inquest. This article utilises interviews with legal professionals engaged in the coronial jurisdiction to explore their understanding of the issues that impact upon families during a death investigation. Our findings indicate that an ethics of care is evident in the court but that this remains contingent on adequate resourcing of the sector, and that this is increasingly the case as the jurisdiction becomes more specialised.

Visualising a rare and complex case of advanced hilar cholangiocarcinoma.

The Toronto Video Atlas of Liver, Pancreas, Biliary, and Transplant Surgery (TVASurg) is a free online library of three-dimensional (3D) animation-enhanced surgical videos, designed to instruct surgical fellows in hepato-pancreato-biliary (HPB) and transplant procedures. The video 'Klatskin tumours: Extended left hepatectomy with complex portal vein reconstruction and in situ cold perfusion of the liver', which is available to watch at http://TVASurg.ca , is a unique and valuable visual resource for surgeons in training to assist them in learning this rare procedure. This paper describes the methodologies used in producing this 3D animation-enhanced surgical video.

Decision-making in a death investigation: Emotion, families and the coroner.

The role of the coroner in common law countries such as Australia, England, Canada and New Zealand is to preside over death investigations where there is uncertainty as to the manner of death, a need to identify the deceased, a death of unknown cause, or a violent or unnatural death. The vast majority of these deaths are not suspicious and thus require coroners to engage with grieving families who have been thrust into a legal process through the misfortune of a loved one's sudden or unexpected death. In this research, 10 experienced coroners discussed how they negotiated the grief and trauma evident in a death investigation. In doing so, they articulated two distinct ways in which legal officers engaged with emotions, which are also evident in the literature. The first engages the script of judicial dispassion, articulating a hierarchical relationship between reason and emotion, while the second introduces an ethic of care via the principles of therapeutic jurisprudence, and thus offers a challenge to the role of emotion in the personae of the professional judicial officer. By using Hochschild's work on the sociology of emotions, this article discusses the various ways in which coroners manage the emotion of a death investigation through emotion work. While emotional distance may be an understandable response by coroners to the grief and trauma experienced by families and directed at cleaner coronial decision-making, the article concludes that coroners may be better served by offering emotions such as sympathy, consideration and compassion directly to the family in those situations where families are struggling to accept, or are resistant to, coroners' decisions.

Creating an animation-enhanced video library of hepato-pancreato-biliary and transplantation surgical procedures.

The potential for integrating real-time surgical video and state-of-the art animation techniques has not been widely applied to surgical education. This paper describes the use of new technology for creating videos of liver, pancreas and transplant surgery, annotating them with 3D animations, resulting in a freely-accessible online resource: The Toronto Video Atlas of Liver, Pancreas and Transplant Surgery ( http://tvasurg.ca ). The atlas complements the teaching provided to trainees in the operating room, and the techniques described in this study can be readily adapted by other surgical training programmes.

Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery.

BACKGROUND: Intraoperative hypotension (IOH) may be associated with postoperative acute kidney injury (AKI), but the duration of hypotension for triggering harm is unclear. The authors investigated the association between varying periods of IOH with mean arterial pressure (MAP) less than 55, less than 60, and less than 65 mmHg with AKI. METHODS: The authors conducted a retrospective cohort study of 5,127 patients undergoing noncardiac surgery (2009 to 2012) with invasive MAP monitoring and length of stay of 1 or more days. Exclusion criteria were preoperative MAP less than 65 mmHg, dialysis dependence, urologic surgery, and surgical duration less than 30 min. The primary exposure was IOH. The primary outcome was AKI (50% or 0.3 mg/dl increase in creatinine) during the first 2 postoperative days. Multivariable logistic regression was used to model the exposure-outcome relationship. RESULTS: AKI occurred in 324 (6.3%) patients and was associated with MAP less than 60 mmHg for 11 to 20 min and MAP less than 55 mmHg for more than 10 min in a graded fashion. The adjusted odds ratio of AKI for MAP less than 55 mmHg was 2.34 (1.35 to 4.05) for 11- to 20-min exposure and 3.53 (1.51 to 8.25) for more than 20 min. For MAP less than 60 mmHg, the adjusted odds ratio for AKI was 1.84 (1.11 to 3.06) for 11- to 20-min exposure. CONCLUSIONS: In this analysis, postoperative AKI is associated with sustained intraoperative periods of MAP less than 55 and less than 60 mmHg. This study provides an impetus for clinical trials to determine whether interventions that promptly treat IOH and are tailored to individual patient physiology could help reduce the risk of AKI.

Use of preoperative antidepressants is not associated with postoperative hospital length of stay.

PURPOSE: Antidepressant medications are commonly prescribed for the treatment of depression, anxiety, and chronic pain. Their use may lead to a number of side effects with important implications in the perioperative period. Our aim was to examine the effect of preoperative antidepressant administration on post-surgical hospital length of stay (LOS) in elective non-cardiac surgery patients. DESIGN: Historical cohort study. METHODS: Demographic and preoperative data were collected by chart review for all non-cardiac surgery patients who were assessed in the preoperative consult clinic from April 2008 through February 2009. Patients were grouped according to whether or not they were taking antidepressant medications. Median length of stay was compared between patients who took antidepressants preoperatively and those who did not. RESULTS: Data were collected for 3,692 patients. Two hundred eighty-nine (7.8%) patients were taking antidepressants preoperatively. Use of antidepressants was not associated with an increased hospital LOS. The median LOS was four days both for patients who took antidepressants preoperatively (95% confidence interval [CI] 4 to 4) and for those who did not (95% CI 3 to 5) (P = 0.13). CONCLUSIONS: The preoperative use of antidepressant medications was not associated with increased postoperative hospital LOS following elective non-cardiac surgery.

Selective ß1-antagonism with bisoprolol is associated with fewer postoperative strokes than atenolol or metoprolol: a single-center cohort study of 44,092 consecutive patients.

BACKGROUND: Perioperative metoprolol increases postoperative stroke. Animal studies indicate that the mechanism may be related to attenuated ß(2)-adrenoreceptor-mediated cerebral vasodilatation. The authors therefore conducted a cohort to study whether the highly ß(1)-specific ß-blocker (bisoprolol) was associated with a reduced risk of postoperative stroke compared with less selective ß-blockers (metoprolol or atenolol). METHODS: The authors conducted a single-center study on 44,092 consecutive patients with age 50 yr or more having noncardiac, nonneurologic surgery. The primary outcome was stroke within 7 days of surgery. The secondary outcome was a composite of all-cause mortality, postoperative myocardial injury, and stroke. A propensity score-matched cohort was created to assess the independent association between bisoprolol and less ß(1)-selective agents metoprolol or atenolol. A secondary analysis using logistic regression, based on previously identified confounders, also compared selective ß(1)-antagonism. RESULTS: Twenty-four percent (10,756) of patients were exposed to in-hospital ß-blockers. A total of 88 patients (0.2%) suffered a stroke within 7 days of surgery. The matched cohort consisted of 2,462 patients, and the pairs were well matched for all variables. Bisoprolol was associated with fewer postoperative strokes than the less selective agents (odds ratio = 0.20; 95% CI, 0.04-0.91). Multivariable risk-adjustment in the ß-blockers-exposed patients comparing bisoprolol with the less selective agents was associated with a similarly reduced stroke rate. CONCLUSIONS: The use of metoprolol and atenolol is associated with increased risks of postoperative stroke, compared with bisoprolol. These findings warrant confirmation in a pragmatic randomized trial.

Hyperchloremia after noncardiac surgery is independently associated with increased morbidity and mortality: a propensity-matched cohort study.

BACKGROUND: The use of normal saline is associated with hyperchloremic metabolic acidosis. In this study, we sought to determine the incidence of acute postoperative hyperchloremia (serum chloride >110 mEq/L) and whether this electrolyte disturbance is associated with an increase in length of hospital stay, morbidity, or 30-day postoperative mortality. METHODS: Data were retrospectively collected on consecutive adult patients (>18 years of age) who underwent inpatient, noncardiac, nontransplant surgery between January 1, 2003 and December 31, 2008. The impact of postoperative hyperchloremia on patient morbidity and length of hospital stay was examined using propensity-matched and logistic multivariable analysis. RESULTS: The dataset consisted of 22,851 surgical patients with normal preoperative serum chloride concentration and renal function. Acute postoperative hyperchloremia (serum chloride >110 mmol/L) is quite common, with an incidence of 22%. Patients were propensity-matched based on their likelihood to develop acute postoperative hyperchloremia. Of the 4955 patients with hyperchloremia after surgery, 4266 (85%) patients were matched to patients who had normal serum chloride levels after surgery. These 2 groups were well balanced with respect to all variables collected. The hyperchloremic group was at increased risk of mortality at 30 days postoperatively (3.0% vs 1.9%; odds ratio = 1.58; 95% confidence interval, 1.25-1.98) (relative risk 1.6 or risk increase of 1.1%) and had a longer hospital stay (7.0 days [interquartile range 4.1-12.3] compared with 6.3 [interquartile range 4.0-11.3]) than patients with normal postoperative serum chloride levels. Patients with postoperative hyperchloremia were more likely to have postoperative renal dysfunction. Using all preoperative variables and measured outcome variables in a logistic regression analysis, hyperchloremia remained an independent predictor of 30-day mortality with an odds ratio of 2.05 (95% confidence interval, 1.62-2.59). CONCLUSION: This retrospective cohort trial demonstrates an association between hyperchloremia and poor postoperative outcome. Additional studies are required to demonstrate a causal relationship between these variables.

The relationship between fibrinogen levels after cardiopulmonary bypass and large volume red cell transfusion in cardiac surgery: an observational study.

BACKGROUND: Coagulopathy leading to excessive blood loss and large volume red cell transfusion is a frequent complication of cardiac surgery with cardiopulmonary bypass (CPB) that may be caused by low perioperative fibrinogen levels. We explored the relationship between post-CPB fibrinogen levels and large volume red cell transfusion. METHODS: Patients who underwent cardiac surgery with CPB from 2005 to 2011 at a single institution and had a fibrinogen level measured after CPB were included in this retrospective observational study. The relationship between post-CPB fibrinogen levels and large volume red cell transfusion (defined as ≥5 units transfused on the day of or the day after surgery) was assessed by cubic spline function and receiver operating characteristic analyses. The independent relationship between fibrinogen levels and large volume transfusion was assessed by multivariable logistic regression and propensity score analyses. RESULTS: In the 4606 patients included, the probability of large volume transfusion increased when fibrinogen levels decreased below approximately 2.0 g/L. Using <2.0 g/L as the threshold for low fibrinogen, 1918 (42%) were categorized into the low fibrinogen group, of whom 363 (18.9%) had large volume transfusion compared with 164 (13.5%) of the 2688 patients whose fibrinogen level was ≥2.0 g/L (P < 0.0001). In the low fibrinogen group, the unadjusted odds ratio (95% confidence interval) for large volume transfusion was 1.5 (1.3-1.7). The risk-adjusted odds ratio obtained by logistic regression was 1.8 (1.4-2.2) and by propensity score methods was 1.5 (1.2-2.0). CONCLUSIONS: While this study was not equipped to detect the critical fibrinogen level in bleeding patients, its results suggest that current recommendations that fibrinogen replacement not be initiated in bleeding patients unless fibrinogen levels decrease below 0.8 to 1.0 g/L may be too conservative. Randomized trials are needed to determine whether maintaining higher fibrinogen levels in bleeding patients can reduce blood loss and transfusions and by that means improve clinical outcomes in cardiac surgery.

The use of an online three-dimensional model improves performance in ultrasound scanning of the spine: a randomized trial.

PURPOSE: The use of ultrasound for neuraxial blockade is a new application of technology that is rapidly becoming accepted as a standard of care. This new skill has shown to improve success, but it is a challenge to teach. To assist with teaching the use of ultrasound in regional anesthesia of the lumbar spine, we have developed an interactive educational model ( http://pie.med.utoronto.ca/vspine or http://www.usra.ca/vspine.php ). In this study, we aimed to determine whether use of this model for a two-week period would improve the performance of novice operators in determining defined landmarks during real-time ultrasound imaging of the lumbar spine. METHODS: We evaluated the educational benefit of the ultrasound module by randomly assigning 16 postgraduate first-year (PGY1) anesthesia residents to either a control group with password-protected access to only the lumbar anatomy module or to an intervention group with access to the complete module. All residents had access to the module for two weeks following a full-day workshop that is part of the university teaching program which consists of a didactic lecture on ultrasound-facilitated neuraxial anesthesia, mentored teaching on cadaveric spine dissections, and hands-on ultrasound scanning of live models. At the end of the two weeks, the performance of the residents was evaluated using a 12-item task-specific checklist while carrying out a scout scan on a live model. RESULTS: The control group had a median score of 5.5 (25(th) percentile: 4, 75(th) percentile: 18), while the intervention group had a median score of 11.5 (25(th) percentile: 8, 75(th) percentile: 12) in the task-specific checklist, with a significant difference of 6 (confidence interval 1.5 to 10.5) between groups (P = 0.021). CONCLUSION: Our results show superior performance by the residents who had access to both components of the module, indicating that access to the interactive ultrasound spine module improves knowledge and skills prior to clinical care.

The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients.

PURPOSE: Cardiac complications following non-cardiac surgery are major causes of morbidity and mortality. The Revised Cardiac Risk Index (RCRI) has become a standard for predicting post-surgical cardiac complications. This study re-examined the original six risk factors to confirm their validity in a large modern prospective database. METHODS: Using the definitions in the original risk index, this study included 9,519 patients aged ≥ 50 undergoing elective non-cardiac surgery with an expected length of stay ≥ two days at two major tertiary-care teaching hospitals. The validity of the original predictors was tested in this population using binomial logistic regression modelling, area under the receiver operator curve (ROC) analysis, and the net reclassification index. RESULTS: Rates of major cardiac complications with 0, 1, 2, ≥ 3 of the predictors were 0.5%, 2.6%, 7.2%, and 14.4%, respectively, in our patient cohort compared with 0.4%, 1.1%, 4.6%, and 9.7%, respectively, in the original cohort. Similar to the original report, binary logistic regression analysis showed that both preoperative treatment with insulin (odds ratio [OR] 1.4; 95% confidence interval [CI] 0.7 to 2.6) and preoperative creatinine > 176.8 mmol·L(-1) (OR 1.7; 95% CI 0.8 to 3.6) did not improve the predictive ability of the index. Analysis of the remaining four factors resulted in an area under the curve (AUC) identical to that seen for the reconstructed six-factor RCRI (AUC = 0.79). We found that a glomerular filtration rate (GFR) < 30 mL·min(-1) was a better predictor of major cardiac complications (OR 2.2; 95% CI 1.2 to 4.3) than creatinine > 176.8 mmol·L(-1). The receiver operating characteristic analysis of this resultant 5-Factor model resulted in an AUC of 0.79, with 0, 1, 2, ≥ 3 of the predictors representing 0.5%, 2.9%, 7.4%, and 17.0% risk, respectively, among our patient cohort. CONCLUSION: Compared with the RCRI, a simplified 5-Factor model using a high-risk type of surgery, a history of ischemic heart disease, congestive heart failure, cerebrovascular disease, and a preoperative GFR < 30 mL·min(-1) results in superior prediction of major cardiac complications following elective non-cardiac surgery.

Impact of online transesophageal echocardiographic simulation on learning to navigate the 20 standard views.

OBJECTIVE: To overcome a challenge in transesophageal echocardiographic (TEE) training, an online virtual TEE simulation was developed that allows the user to navigate among the 20 standard views. The TEE probe position and ultrasound plane movements on a 3-dimensional heart model were displayed with the corresponding TEE video recording as the probe was moved among the views. DESIGN: This study evaluated the educational benefit of the virtual TEE application using a pretest/post-test design. SETTING: Single academic teaching hospital. PARTICIPANTS: Ten postgraduate physician volunteers who were novice echocardiographers. INTERVENTIONS: In a controlled environment, 10 study subjects completed a 20 multiple-choice question pretest, used the simulation for 1 hour, and then completed a 20 multiple-choice question post-test. Percentages of correct answers for each test were recorded for each subject. MEASUREMENTS AND MAIN RESULTS: The hypothesis that the median improvement in the number of questions correctly answered was different from 0 was tested with a related-samples Wilcoxon signed-rank test. A p value <0.05 was considered significant. A 1-hour exposure to the virtual TEE simulation produced a significant improvement (p = 0.005) in the post-test score (median 80%) compared with the pretest score (median 20%). CONCLUSIONS: Using the virtual TEE simulation for 1 hour significantly improves the trainees' knowledge of navigation among the 20 standard TEE views. This application freely is available on the Internet and will be a useful adjunct to TEE training programs.

Gender differences in mortality following non-cardiovascular surgery: an observational study.

PURPOSE: Although inequality between males and females in cardiovascular surgery is well recognized, few studies have examined the influence of sex on mortality following non-cardiovascular surgery. The objective of the study was to determine whether there are differences in mortality between males and females following non-cardiovascular surgery and to ascertain to what extent preoperative risk factors explain these differences. METHODS: This was an observational study of 39,433 consecutive non-cardiovascular inpatient surgical cases from non-sex-biased surgical services from 2003 to 2009. Data on the surgical procedure, patient risk factors, and outcomes was retrieved from the institutional Electronic Data Warehouse. The primary outcome was in-hospital mortality within 30 days of surgery. Multivariate analysis using logistic regression was conducted to determine the role of risk factors for mortality. RESULTS: The 30-day mortality was 2.76% for males and 1.89% for females (odds ratio, 1.47; 95% confidence interval [CI], 1.29 to 1.69). Logistic regression showed that age, number of Charlson comorbidities, American Society of Anesthesiologists (ASA) classification, and emergent/urgent status were independent predictors of mortality (receiver operating characteristic area, 0.90). After adjustment for these factors, the odds ratio for male mortality was reduced to 1.31 (95% CI, 1.14 to 1.52). CONCLUSION: Males present for non-cardiovascular surgery with a higher ASA classification, with more comorbidities, and more often emergently than females, providing a partial explanation of the observed difference in mortality.

Use of clinically based troponin underestimates the cardiac injury in non-cardiac surgery: a single-centre cohort study in 51,701 consecutive patients.

PURPOSE: Postoperative myocardial infarction causes hundreds of thousands of deaths annually, and "failure to rescue" is a leading cause of hospital mortality. Strategies to recognize cardiac injury are important to reduce the burden of cardiac-related morbidity. For these reasons, we chose to assess the association between postoperative troponin I elevations and 30-day in-hospital mortality and, secondarily, to compare the predictive value of regularly scheduled troponin estimates with troponin ordered in response to clinical indications. METHODS: We carried out a retrospective cohort analysis of 51,701 consecutive patients throughout 2003 to 2009. All patients were from a single university referral hospital and included all non-cardiac non-transplant surgery patients requiring overnight admission. Logistic regression was used to assess the risk-adjusted associations between troponin I and 30-day in-hospital mortality. RESULTS: The multivariable predictive model for death improved after troponin I was included. The receiver operating characteristic was 0.902 before troponin I vs 0.934 after troponin I (P<0.0001). The likelihood ratio for troponin was 3.0 (95% confidence interval 2.8 to 3.2) and evident in each surgical service. Increasing troponin I showed a dose-response associated with increased mortality, and compared with clinically based measurements, a regularly scheduled postoperative troponin protocol showed a threefold increase in the probability of detecting myocardial injury. However, troponin I was not found to improve the risk prediction model in the lowest risk patients (n=18,953; probability of death<0.02%) with one cardiac death. CONCLUSIONS: Postoperatively elevated troponin I is associated with 30-day in-hospital mortality in a dose-dependent manner. A postoperative measurement protocol provides a threefold increase in the ability to detect myocardial injury. Conversely, in patients with a low mortality risk, cardiac injury is low; there is minimal improvement in the ability to detect cardiac injury, and the rescue rates from cardiac injury are excellent. These findings suggest that a surveillance protocol of troponin I would be optimal when limited to moderate to high-risk patients.