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Science, Medicine, and the Anesthesiologist  |   December 2017
Science, Medicine, and the Anesthesiologist
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Science, Medicine, and the Anesthesiologist
Science, Medicine, and the Anesthesiologist   |   December 2017
Science, Medicine, and the Anesthesiologist
Anesthesiology 12 2017, Vol.127, A15-A18. doi:10.1097/ALN.0000000000001971
Anesthesiology 12 2017, Vol.127, A15-A18. doi:10.1097/ALN.0000000000001971
Incidence of myocardial infarction after high-risk vascular operations in adults. JAMA Surg 2017 Sep 6 [Epub ahead of print].
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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With recent advances in perioperative cardiac care and growth in the number of high-risk vascular procedures being performed endovascularly, there is interest in whether these modifications have led to changes in the incidence of postoperative myocardial infarction and its associated mortality. This study utilized the American College of Surgeons National Surgical Quality Improvement Program database to retrospectively evaluate temporal changes in mortality associated with high-risk vascular procedures between 2005 and 2013. Data from 90,303 vascular surgery patients demonstrated that the incidence of myocardial infarction remained stable during the majority of the study period. In patients undergoing open aortic procedures, the risk of myocardial infarction was higher than in patients undergoing infrainguinal bypass procedures (3% vs. 1.9%, respectively; P < 0.001). Myocardial infarction was consistently associated with a 3.01-fold (95% CI, 2.08 to 4.36) to 6.66-fold (95% CI, 4.66 to 9.52) increase in 30-day mortality (P < 0.001).
Take home message: The risk of myocardial infarction and related mortality after high-risk vascular procedures does not appear to have changed over the past decade despite an increase in the use of endovascular procedures and advanced diagnostic techniques for myocardial infarction.
Wide variation and overprescription of opioids after elective surgery. Ann Surg 2017; 266:564–73.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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Some have suggested that a maximum of a 7-day supply or 200 mg of oral morphine equivalents should be prescribed to opioid-naive patients when being discharged after a surgical procedure. This study used data from the American College of Surgeons National Surgical Quality Improvement Program database to retrospectively evaluate opioid prescribing at discharge after a surgical procedure. Among the 7,651 patients included in the analysis, 94% received an opioid prescription at discharge from the hospital. Among these patients, a median of 375 (interquartile range, 225 to 750) oral morphine equivalents were prescribed. Multivariable logistic regression demonstrated that patients over the age of 80 (odds ratio [OR] 0.47; 95% CI, 0.33 to 0.66) and females (OR 0.86; 95% CI, 0.75 to 0.96) were predictors of not receiving a top-quartile prescription. Predictors of receiving a refill on their opioid prescription include female sex (OR 1.39; 95% CI, 1.19 to 1.61), not having cancer (OR 0.27; 95% CI, 0.21 to 0.33), and prolonged hospital length of stay (OR 1.30; 95% CI, 1.03 to 1.65).
Take home message: This study suggests that most patients receive more oral morphine equivalents than are recommended at the time of discharge from their surgical procedure.
Risk associated with complications and mortality after urgent surgery vs elective and emergency surgery: Implications for defining “quality” and reporting outcomes for urgent surgery. JAMA Surg 2017; 152:768–74.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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Complication and mortality rates among patients having urgent general surgical procedures, unlike elective and emergent surgical procedures, are poorly described in the literature. This study utilized the American College of Surgeons National Surgical Quality Improvement Program database to retrospectively evaluate morbidity and mortality among 173,643 patients having elective, urgent, and emergent general surgical procedures in 2013. Patients were considered to have had an urgent surgical procedure if the surgery was not coded as either emergent or elective in the database. The risk of postoperative morbidity was increased for both urgent (odds ratio [OR] 1.38; 95% CI, 1.30 to 1.45; P < 0.001) and emergent (OR 1.65; 95% CI, 1.55 to 1.76) surgical procedures when compared to elective surgical procedures. Similarly, 30-day mortality was higher for patients having both urgent (OR 2.32; 95% CI, 2.00 to 2.68) and emergent (OR 2.91; 95% CI, 2.48 to 3.41) surgical procedures when compared to elective surgical procedures.
Take home message: Urgent surgical procedures may have morbidity and mortality rates intermediate between elective and emergent surgical procedures.
Perception of safety of surgical practice among operating room personnel from survey data is associated with all-cause 30-day postoperative death rate in South Carolina. Ann Surg 2017; 266:658–66.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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The perception that environment promotes a culture of perioperative safety among healthcare professionals has been associated with better perioperative outcomes. This study describes the results of a 35-item survey administered to operating room personnel to determine whether their perception of perioperative safety was associated with improved 30-day mortality rates in patients having inpatient surgical procedures in 31 hospitals in South Carolina. The response rate was 38% with 1,793 respondents. The overall 30-day postoperative mortality rate was 3.2% (interquartile range, 2.5% to 4.1%). Among the survey items that were significantly associated with 30-day mortality rates, mutual respect (relative risk [RR] 0.78; 95% CI, 0.65 to 0.93; P = 0.006), clinical leadership (RR 0.86; 95% CI, 0.74 to 0.99; P = 0.04), and assertiveness for patient safety (RR 0.71; 95% CI, 0.54 to 0.93; P < 0.01) were all associated with lower 30-day mortality rates. Higher 30-day mortality rates were associated with limited interest in checklist implementation (RR 1.17; 95% CI, 1.06 to 1.29; P < 0.002) and difficulty in implementing the Joint Commission Time Out (RR 1.17; 95% CI, 1.01 to 1.35; P < 0.04).
Take home message: The perception of operating room safety may be associated with decreased 30-day mortality rates.
Association of the Modified Frailty Index with 30-day surgical readmission. JAMA Surg 2017; 152:749–57.
Summary: Deborah J. Culley. Image: ©ThinkStock.
Summary: Deborah J. Culley. Image: ©ThinkStock.
Summary: Deborah J. Culley. Image: ©ThinkStock.
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Frailty has been associated with adverse perioperative outcomes. Less well studied are associations between frailty and unplanned 30-day hospital readmissions. This study utilized the Veterans Affairs Surgical Quality Improvement Program database to retrospectively evaluate the effect of frailty, identified by the Modified Frailty Index, on 30-day postoperative hospital readmission rates after 236,957 surgical procedures. Overall, 11% of the patients were readmitted to the hospital. Frailty was associated with an increased risk of an unplanned 30-day hospital readmission (odds ratio 1.11; 95% CI, 1.10 to 1.12; P < 0.001). Patients with no frailty components had a 7.9% risk of being readmitted to the hospital, whereas patients with the highest frailty burden had more than 40% likelihood that they would be readmitted to the hospital. On secondary analysis, frailty was also associated with in-hospital and postdischarge complications, emergency department use, and postdischarge mortality (P < 0.001).
Take home message: Frailty is associated with higher 30-day hospital readmission rates after surgery.
Readiness of US general surgery residents for independent practice. Ann Surg 2017; 266:582–94.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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There is a growing concern that not all general surgery residents can independently perform 132 procedures that are core to the practice of general surgery. This study investigated this question by enrolling faculty and residents from 15 general surgical programs into a multiinstitutional trial that used a smart phone application that allowed both attendings and residents to answer three questions immediately after a surgical procedure on guidance provided by the attending, ability to independently perform the surgical procedure, and complexity of the surgical procedure. Resident performance improved during the course of their residency such that at the end of training the predicted probability that a trainee would be rated as competent after performing a core procedure was 91% (95% CI, 86 to 94%) and the predicted probability that a trainee had meaningful autonomy for a typical core procedure was 91% (95% CI, 88 to 94%).
Take home message: Approximately 9% of general surgery residents are not able to independently perform core surgical procedures at the time they complete their residency.
Twin Peaks? No evidence of bimodal distribution of outcomes in clinical trials of nonsurgical interventions for spinal pain: An exploratory analysis. J Pain 2017; 18:964–72.
Summary: David J. Clark. Image: J. P. Rathmell.
Summary: David J. Clark. Image: J. P. Rathmell.
Summary: David J. Clark. Image: J. P. Rathmell.
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Randomized controlled trials are considered to be the gold standard when evaluating the efficacy of clinical interventions, yet randomized controlled trials have failed to demonstrate beneficial effects for many candidate pain management interventions over the past several years. One explanation for the apparent failure of the trials may be a bimodal distribution of response in which a significant subset of patients shows benefit that is not detected in the overall analysis. This has led to calls for a conversion to using so-called “responder analysis” rather than the comparison of mean group responses when interpreting outcomes. This study examined outcomes from 10 published randomized controlled trials looking at interventions for spine pain in an effort to discover bimodal patterns in the outcome data. Despite diversity in terms of treatments and patient populations, strong evidence for bimodal outcomes was not identified.
Take home message: This study identified no strong indication for the use of responder analysis in place of between-group differences in pain intervention trials.
Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. N Engl J Med 2017; 377:613–22.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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Preeclampsia is associated with adverse patient outcomes. This prospective, multicenter, placebo-controlled study was designed to determine whether administration of 150 mg of aspirin per day decreased premature delivery associated with preeclampsia when compared to placebo in high-risk patients. A total of 1,620 patients completed the study. Preeclampsia was noted in 1.6% of patients in the aspirin group and 4.3% of patients in the placebo group (odds ratio 0.38; 95% CI, 0.20 to 0.74; P = 0.04). There were no significant baseline differences between the groups or differences in the incidence of other secondary outcomes. Similarly, there were no differences in the incidence of serious adverse event between the aspirin group (1.6%) and the placebo group (3.2%). These data suggest that aspirin administration may decrease the risk of preterm preeclampsia in high-risk patients.
Take home message: Aspirin may reduce the risk of preeclampsia in high-risk patients.
Changing resident physician studying behaviors: A randomized, comparative effectiveness trial of goal setting versus use of WOOP. J Grad Med Educ 2017; 9:451–7.
Summary: Dawn Dillman. Image: ©ThinkStock.
Summary: Dawn Dillman. Image: ©ThinkStock.
Summary: Dawn Dillman. Image: ©ThinkStock.
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A resident physician’s ability to etch out study time can be difficult due to both personal and clinical demands. This study was designed to determine whether a formalized self-regulation strategy using a four-step tool (Wish, Outcome, Obstacle, Plan) increased actual study when compared to a control group that set a goal to study more in a prospective randomized study involving 34 residents. While both sets of students had similar goals, residents randomized to the four-step tool studied significantly more than those randomized to the traditional goal-setting group (median 4.3 h/week [interquartile range, 2.5 to 6.3] vs. median 1.5 h/week [interquartile range, 2.5 to 6.3]; P = 0.021). On secondary analysis, the percentage of residents who reported any reading to achieve their learning goals by postintervention week 3 was 81% in the four-step tool group compared to 44% of those in the control group. In contrast, there were no differences in the amount of time spent reading nongoal medical topics between the two groups.
Take home message: Use of a brief, targeted tool for planning how to deal with obstacles to studying increased targeted reading time among residents.
Prescription opioid use, misuse, and use disorders in U.S. adults: 2015 National Survey on Drug Use and Health. Ann Intern Med 2017; 167:293–301.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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The prevalence of opioid prescription use and misuse remains unknown. This study reports on the 2015 National Survey on Drug Use and Health. A total of 51,200 (71% of eligible adults) participated in this study. Overall, 38% (95% CI, 37 to 39%) of adults had used a prescription opioid within the previous year. Among patients that had used a prescription opioid within the previous year, 10% (95% CI, 10 to 11%) had misused their opioid and 2% (95% CI, 2 to 2%) had an opioid use disorder. Interestingly, 60% (95% CI, 57 to 63%) of adults reporting misuse of prescription opioids used them without a prescription. The motivation for misuse of prescription opioids was pain for 63% (95% CI, 61 to 66%) of patients. Forty-one percent of patients (95% CI, 38 to 43%) with opioid misuse had obtained prescription opioids free from friends or relatives.
Take home message: More than one third of adults living in the United States reported prescription opioid use in 2017, with many of them receiving prescription opioids from their relatives or friends.
Effect of obesity and underweight status on perioperative outcomes of congenital heart operations in children, adolescents, and young adults: An analysis of data from the Society of Thoracic Surgeons database. Circulation 2017; 136:704–18.
Summary: Deborah J. Culley. Image: ©ThinkStock.
Summary: Deborah J. Culley. Image: ©ThinkStock.
Summary: Deborah J. Culley. Image: ©ThinkStock.
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In adults undergoing cardiac surgery, very low and very high body mass index (BMI) is associated with an increased risk of adverse perioperative outcomes. This study used the Society of Thoracic Surgeons Congenital Heart Surgery Database to identify 18,377 patients between 10 and 25 yr of age who underwent a surgical procedure for heart disease between January 1, 2010, and December 31, 2015, to determine whether extremes of BMI were associated with adverse outcomes. On multivariate analysis, there was no association between BMI and operative mortality, although there was an association between being obese (odds ratio [OR] 1.21; 95% CI, 1.05 to 1.39; P = 0.008), severely underweight (OR 1.53; 95% CI, 1.31 to 1.79; P < 0.001), and underweight (OR 1.33; 95% CI, 1.11 to 1.60; P = 0.002) and composite adverse outcome scores.
Take home message: Obese and underweight patients between the ages of 10 and 35 yr may have an increased risk of composite adverse outcomes after cardiac surgery.
Delirium and catatonia in critically ill patients: The Delirium and Catatonia Prospective Cohort Investigation. Crit Care Med 2017; 45:1837–44.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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Delirium and catatonia share many features in common and both occur during critical illness, yet treatment differs between them. This study used a convenience cohort design from two ongoing randomized trials to understand relationships between delirium and catatonia. Among the 136 patients included in this analysis, 58 (43%) had only delirium identified using the Confusion Assessment Method for the intensive care unit administered by trained study personnel, 4 (3%) had catatonia identified by the Bush Francis Catatonia Rating Scale by two psychiatrists blinded to the results of the delirium screening tool, and 42 (31%) had both delirium and catatonia. The risk of delirium correlated with the number of catatonia signs. Patients with three or more catatonia signs were 28 times more likely to develop delirium (interquartile range, 13 to 61%). This study demonstrates that both catatonia and delirium are common and may occur concurrently in patients with critical illness.
Take home message: These data suggest a strong association between catatonia and delirium.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
×
Summary: Deborah J. Culley. Image: ©ThinkStock.
Summary: Deborah J. Culley. Image: ©ThinkStock.
Summary: Deborah J. Culley. Image: ©ThinkStock.
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Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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Summary: David J. Clark. Image: J. P. Rathmell.
Summary: David J. Clark. Image: J. P. Rathmell.
Summary: David J. Clark. Image: J. P. Rathmell.
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Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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Summary: Dawn Dillman. Image: ©ThinkStock.
Summary: Dawn Dillman. Image: ©ThinkStock.
Summary: Dawn Dillman. Image: ©ThinkStock.
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Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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Summary: Deborah J. Culley. Image: ©ThinkStock.
Summary: Deborah J. Culley. Image: ©ThinkStock.
Summary: Deborah J. Culley. Image: ©ThinkStock.
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Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
Summary: Deborah J. Culley. Image: J. P. Rathmell.
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