The impact of obstructive sleep apnea treatment on microvascular complications in patients with type 2 diabetes: a feasibility randomized controlled trial

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is associated with an increased risk of diabetes-related complications. Hence, it is plausible that Continuous Positive Airway Pressure (CPAP) could have a favorable impact on these complications. To assess the feasibility of conducting a randomized control trial (RCT) in patients with type 2 diabetes (T2D) and OSA over 2 years.

METHODS

An open-label multicenter feasibility RCT of CPAP vs no CPAP in patients with T2D and OSA. Patients with resting oxygen saturation <90%, central apnea index >15/hour or Epworth Sleepiness Scale (ESS) ≥11 were excluded. OSA was diagnosed using a multichannel portable device (ApneaLink Air, ResMed). The primary outcome measures were related to feasibility, and the secondary outcomes were changes in various clinical and biochemical parameters related to diabetes outcomes.

RESULTS

Eighty-three (40 CPAP vs 43 no CPAP) patients were randomized, with a median (IQR) follow-up of 645 [545, 861] days. CPAP compliance was inadequate, with a median usage of approximately 3.5 hours/night. Early CPAP use predicted longer-term compliance. The adjusted analysis showed a possible favorable association between being randomized to CPAP and several diabetes-related endpoints (chronic kidney disease (CKD), neuropathy, and quality of life (QoL)).

CONCLUSIONS

It was feasible to recruit, randomize, and achieve a high follow-up rate over 2 years in patients with OSA and T2D. CPAP compliance might improve by a run-in period before randomization. A full RCT is necessary to assess the observed favorable association between CPAP and CKD, neuropathy, and QoL in patients with T2D.

CLINICAL TRIAL REGISTRATION

Registry: ISRCTN; URL: https://www.isrctn.com/ISRCTN12361838; Title: The impact of sleep disorders in patients with type 2 diabetes; Identifier: ISRCTN12361838.

Diabetic retinopathy progression in patients under monitoring for treatment or vision loss: external validation and update of a multivariable prediction model

INTRODUCTION

The number of people with diabetes mellitus is increasing globally and consequently so too is diabetic retinopathy (DR). Most patients with diabetes are monitored through the diabetic eye screening programme (DESP) until they have signs of retinopathy and these changes progress, requiring referral into hospital eye services (HES). Here, they continue to be monitored until they require treatment. Due to current pressures on HES, delays can occur, leading to harm. There is a need to triage patients based on their individual risk. At present, patients are stratified according to retinopathy stage alone, yet other risk factors like glycated haemoglobin (HbA1c) may be useful. Therefore, a prediction model that combines multiple prognostic factors to predict progression will be useful for triage in this setting to improve care.We previously developed a Diabetic Retinopathy Progression model to Treatment or Vision Loss (DRPTVL-UK) using a large primary care database. The aim of the present study is to externally validate the DRPTVL-UK model in a secondary care setting, specifically in a population under care by HES. This study will also provide an opportunity to update the model by considering additional predictors not previously available.

METHODS AND ANALYSIS

We will use a retrospective cohort of 2400 patients with diabetes aged 12 years and over, referred from DESP to the NHS hospital trusts with referable DR between 2013 and 2016, with follow-up information recorded until December 2021.We will evaluate the external validity of the DRPTVL-UK model using measures of discrimination, calibration and net benefit. In addition, consensus meetings will be held to agree on acceptable risk thresholds for triage within the HES system.

ETHICS AND DISSEMINATION

This study was approved by REC (ref 22/SC/0425, 05/12/2022, Hampshire A Research Ethics Committee). The results of the study will be published in a peer-reviewed journal, presented at clinical conferences.

TRIAL REGISTRATION NUMBER

ISRCTN 10956293.

The association between inflammatory bowel disease and mental ill health: a retrospective cohort study using data from UK primary care

BACKGROUND

Patients with active inflammatory bowel disease (IBD) and mental illnesses experience worse IBD outcomes.

AIM

To describe the incidence of mental illnesses, including deliberate self-harm, in IBD patients.

METHODS

A population-based retrospective cohort study using IQVIA medical research data of a primary care database covering the whole UK, between January 1995 and January 2021. IBD patients of all ages were matched 4:1 by demographics and primary care practice to unexposed controls. Following exclusion of patients with mental ill health at study entry, adjusted hazard ratios (HR) of developing depression, anxiety, deliberate self-harm, severe mental illness and insomnia were calculated using a Cox proportional hazards model.

RESULTS

We included 48,799 incident IBD patients: 28,352 with ulcerative colitis and 20,447 with Crohn's disease. Incidence rate ratios of mental illness were higher in IBD patients than controls (all p < 0.001): deliberate self-harm 1.31 (95% CI 1.16-1.47), anxiety 1.17 (1.11-1.24), depression 1.36 (1.31-1.42) and insomnia 1.62 (1.54-1.69). Patients with Crohn's disease were more likely to develop deliberate self-harm HR 1.51 (95% CI 1.28-1.78), anxiety 1.38 (1.16-1.65), depression 1.36 (1.26-1.47) and insomnia 1.74 (1.62-1.86). Patients with IBD are at increased risk of deliberate self-harm (HR 1.20 [1.07-1.35]). The incidence rate ratios of mental illnesses were particularly high during the first year following IBD diagnosis: anxiety 1.28 (1.13-1.46), depression 1.62 (1.48-1.77) and insomnia 1.99 (1.78-2.21).

CONCLUSION

Deliberate self-harm, depression, anxiety and insomnia were more frequent among patients with IBD. IBD is independently associated with an increased risk of deliberate self-harm.

Preventing unscheduled hospitalisations from asthma: a retrospective cohort study using routine primary and secondary care data in the UK (The PUSH-Asthma Study)-protocol paper

INTRODUCTION

Asthma is the most common chronic respiratory disease in children and adults. Asthma results in significant disease-related morbidity, healthcare costs and, in some cases, death. Despite efforts through implementation of national guidelines to improve asthma care, the UK has one of the highest asthma-related morbidity and mortality rates in the western world. New approaches are necessary to prevent asthma attacks in children and adults. The objectives of this study are to assess the association between demographic and clinical factors and asthma-related hospital admissions in children and adults, describe the epidemiology of asthma phenotypes among hospital attenders, and externally validate existing asthma risk prediction models.

METHODS AND ANALYSIS

This is a retrospective cohort study of children and adults with asthma. Data will be extracted from the Clinical Practice Research Datalink (CPRD) Aurum database, which holds anonymised primary care data for over 13 million actively registered patients and covers approximately 19% of the UK population. The primary outcome will be asthma-related hospital admissions. The secondary outcomes will be prescriptions of short courses of oral corticosteroids (as a surrogate measure for asthma exacerbations), a composite outcome measure including hospital admissions and prescriptions of short courses of oral corticosteroids and delivery of asthma care management following hospital discharge. The primary analysis will use a Poisson regression model to assess the association between demographic and clinical risk factors and the primary and secondary outcomes. Latent class analysis will be used to identify distinct subgroups, which will further our knowledge on potential phenotypes of asthma among patients at high risk of asthma-related hospital admissions. A Concordance statistic (C-statistic) and logistic regression model will also be used to externally validate existing risk prediction models for asthma-related hospitalisations to allow for the optimal model to be identified and evaluated provide evidence for potential use of the optimal performing risk prediction model in primary care.

ETHICS AND DISSEMINATION

This study was approved by the CPRD Independent Scientific Advisory Committee (reference number: 21_000512). Findings from this study will be published in a peer-reviewed journal and disseminated at national and international conferences.

Risk of a subsequent diagnosis of inflammatory bowel disease in subjects with ophthalmic disorders associated with inflammatory bowel disease: a retrospective cohort analysis of UK primary care data

OBJECTIVES

Ophthalmic conditions including anterior uveitis (AU), episcleritis and scleritis may occur in association with the inflammatory bowel diseases (IBD) as ophthalmic extraintestinal manifestations. The aim of this study was to assess the risk of a later IBD diagnosis in those presenting with IBD associated ocular inflammation (IAOI).

DESIGN

Retrospective cohort study.

SETTING

Primary care UK database.

PARTICIPANTS

38 805 subjects with an IAOI were identified (median age 51 (38-65), 57% women) and matched to 153 018 subjects without IAOI.

MEASURES

The risk of a subsequent diagnosis of IBD in subjects with IAOIs compared with age/sex matched subjects without IAOI. HRs were adjusted for age, sex, body mass index, deprivation, comorbidity, smoking, baseline axial arthropathy, diarrhoea, loperamide prescription, anaemia, lower gastrointestinal bleeding and abdominal pain.Logistic regression was used to produce a prediction model for a diagnosis of IBD within 3 years of an AU diagnosis.

RESULTS

213 (0.6%) subsequent IBD diagnoses (102 ulcerative colitis (UC) and 111 Crohn's disease (CD)) were recorded in those with IAOIs and 329 (0.2%) (215 UC and 114 CD) in those without. Median time to IBD diagnosis was 882 (IQR 365-2043) days in those with IAOI and 1403 (IQR 623-2516) in those without. The adjusted HR for a subsequent diagnosis of IBD was 2.25 (95% CI 1.89 to 2.68), p<0.001; for UC 1.65 (95% CI 1.30 to 2.09), p<0.001; and for CD 3.37 (95% CI 2.59 to 4.40), p<0.001 in subjects with IAOI compared with those without.Within 3 years of an AU diagnosis, 84 (0.5%) subjects had a recorded diagnosis of IBD. The prediction model performed well with a C-statistic of 0.75 (95% CI 0.69 to 0.80).

CONCLUSIONS

Subjects with IAOI have a twofold increased risk of a subsequent IBD diagnosis. Healthcare professionals should be alert for potential signs and symptoms of IBD in those presenting with ophthalmic conditions associated with IBD.

The Impact of Bariatric Surgery on Incident Microvascular Complications in Patients With Type 2 Diabetes: A Matched Controlled Population-Based Retrospective Cohort Study

OBJECTIVE

To assess the impact of bariatric surgery (BS) on incident microvascular complications of diabetes-related foot disease (DFD), sight-threatening diabetic retinopathy (STDR), and chronic kidney disease (CKD) in patients with type 2 diabetes and obesity.

RESEARCH DESIGN AND METHODS

A retrospective matched, controlled population-based cohort study was conducted of adults with type 2 diabetes between 1 January 1990 and 31 January 2018 using IQVIA Medical Research Data (IMRD), a database of primary care electronic records. Each patient with type 2 diabetes who subsequently had BS (surgical group) was matched on the index date with up to two patients with type 2 diabetes who did not have BS (nonsurgical group) within the same general practice by age, sex, preindex BMI, and diabetes duration.

RESULTS

Included were 1,126 surgical and 2,219 nonsurgical participants. In the study population 2,261 (68%) were women. Mean (SD) age was 49.87 (9.3) years vs. 50.12 (9.3) years and BMI was 46.76 (7.96) kg/m² vs. 46.14 (7.49) kg/m² in the surgical versus nonsurgical group, respectively. In the surgical group, 22.1%, 22.7%, 52.2%, and 1.1% of patients had gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB), and duodenal switch, respectively. Over a median follow-up of 3.9 years (interquartile range 1.8-6.4), BS was associated with reduction in incident combined microvascular complications (adjusted hazard ratio 0.53, 95% CI 0.43-0.66, P < 0.001), DFD (0.61, 0.50-0.75, P < 0.001), STDR (0.66, 0.44-1.00, P = 0.048), and CKD (0.63, 0.51-0.78, P < 0.001). Analysis based on the type of surgery showed that all types of surgery were associated with a favorable impact on the incidence of composite microvascular complications, with the greatest reduction for RYGB.

CONCLUSIONS

BS was associated with a significant reduction in incident diabetes-related microvascular complications.

The impact of bariatric surgery on incident microvascular complications in patients with type 2 diabetes: A matched controlled population-based retrospective cohort study.. [DOI: 10.2337/figshare.13075748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Aim: To assess the impact of bariatric surgery (BS) on incident microvascular complications [diabetes-related foot disease (DFD), sight threatening diabetic retinopathy (STDR), chronic kidney disease (CKD)] in patients with type 2 diabetes and obesity. <p>Methods: <a>A retrospective matched, controlled population-based cohort study of adults with type 2 diabetes between 1/1/1990 and 31/1/2018 using </a><a>IQVIA Medical Research Data (IMRD), </a>a database of primary care electronic records. <a>Each patient with type2 diabetes who subsequently had BS (surgical) was matched on index date with up to 2 patients with type 2 diabetes did not have BS (non-surgical) within the same general practice by age, sex, pre-index body mass index and diabetes duration</a>.</p> <p>Results: 1126 surgical and 2219 non-surgical participants were included. In the study population, 2261 (68%) were women; Mean (SD) age was 49.87 (9.3) vs 50.12 (9.3) years and BMI was 46.76 (7.96) kg/m² vs 46.14 (7.49) kg/m² in surgical vs non-surgical group respectively. In surgical group, 22.1%, 22.7%, 52.2% and 1.1% patients had gastric band, sleeve gastrectomy, gastric bypass & duodenal switch respectively.</p> <p>Over median (IQR) follow-up was 3.9 years (1.8-6.4), BS was associated with reduction in incident combined microvascular complications (adjusted HR 0.63, 95% CI 0.51 to 0.78, p<0.001), DFD (0.61, 0.50 to 0.75, p<0.001), STDR (0.66, 0.44 to 1.00, p<0.001), CKD (0.63, 0.51 to 0.78, p<0.001). Analysis based on the type of surgery showed that all types of surgery were associated with favourable impact on the incident of composite microvascular complications, greatest reduction RYGB.</p> <p>Conclusions: BS was associated with a significant reduction in incident diabetes-related microvascular complications. </p>

The impact of bariatric surgery on incident microvascular complications in patients with type 2 diabetes: A matched controlled population-based retrospective cohort study.. [DOI: 10.2337/figshare.13075748.v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Aim: To assess the impact of bariatric surgery (BS) on incident microvascular complications [diabetes-related foot disease (DFD), sight threatening diabetic retinopathy (STDR), chronic kidney disease (CKD)] in patients with type 2 diabetes and obesity. <p>Methods: <a>A retrospective matched, controlled population-based cohort study of adults with type 2 diabetes between 1/1/1990 and 31/1/2018 using </a><a>IQVIA Medical Research Data (IMRD), </a>a database of primary care electronic records. <a>Each patient with type2 diabetes who subsequently had BS (surgical) was matched on index date with up to 2 patients with type 2 diabetes did not have BS (non-surgical) within the same general practice by age, sex, pre-index body mass index and diabetes duration</a>.</p> <p>Results: 1126 surgical and 2219 non-surgical participants were included. In the study population, 2261 (68%) were women; Mean (SD) age was 49.87 (9.3) vs 50.12 (9.3) years and BMI was 46.76 (7.96) kg/m² vs 46.14 (7.49) kg/m² in surgical vs non-surgical group respectively. In surgical group, 22.1%, 22.7%, 52.2% and 1.1% patients had gastric band, sleeve gastrectomy, gastric bypass & duodenal switch respectively.</p> <p>Over median (IQR) follow-up was 3.9 years (1.8-6.4), BS was associated with reduction in incident combined microvascular complications (adjusted HR 0.63, 95% CI 0.51 to 0.78, p<0.001), DFD (0.61, 0.50 to 0.75, p<0.001), STDR (0.66, 0.44 to 1.00, p<0.001), CKD (0.63, 0.51 to 0.78, p<0.001). Analysis based on the type of surgery showed that all types of surgery were associated with favourable impact on the incident of composite microvascular complications, greatest reduction RYGB.</p> <p>Conclusions: BS was associated with a significant reduction in incident diabetes-related microvascular complications. </p>

Bronchoalveolar lavage fluid lymphocytosis in chronic hypersensitivity pneumonitis: a systematic review and meta-analysis

Background

The role of bronchoalveolar lavage fluid (BALF) lymphocyte percentage in diagnosing chronic hypersensitivity pneumonitis (CHP) is unclear. We conducted a systematic review and meta-analysis of bronchoalveolar lavage (BAL) lymphocyte percentage in the diagnosis of CHP.

Methods

We searched Medline, Embase and the Cochrane Library from inception to August 2019. Individual patient data were obtained to test performance characteristics of BAL lymphocyte percentage at different thresholds. Random-effects models were used for pooled estimates, with comparisons made between CHP and non-CHP interstitial lung diseases (ILDs).

Results

Fifty-three studies were included in the systematic review and 42 in the meta-analysis. The pooled estimate for BAL lymphocyte percentage was 42.8% (95% CI 37.7–47.8, I2=95.3%) in CHP, 10.0% (95% CI 6.9–13.1, I2=91.2%) in idiopathic pulmonary fibrosis (IPF), 23.1% (95% CI 3.0–43.2, I2=85.2%) in non-IPF idiopathic interstitial pneumonia (IIP), 23.4% (95% CI 11.0–35.9, I2=45.7%) in connective-tissue disease associated ILD (CTD-ILD) and 31.2% (95% CI 17.6–44.8, I2=95.2%) in sarcoidosis. Results differed between CHP and IPF (p<0.0001), non-IPF IIP (p=0.0309) or CTD-ILD (p=0.0824), but not between CHP and sarcoidosis (p=0.0966). Using individual patient data from eight studies, a lymphocyte percentage threshold of >20% provided a sensitivity of 68.1% and a specificity of 64.8% for CHP. Higher thresholds provided lower sensitivity with higher specificity. Older age and ever having smoked were associated with lower lymphocyte percentage in CHP.

Conclusions

BAL lymphocyte percentage is higher in CHP compared to IPF and other IIPs, with higher thresholds providing improved specificity at the cost of sensitivity. However, the parent studies are at risk of incorporation bias and prospective studies should evaluate the additive discriminate value of BAL lymphocyte percentage to accurately diagnose CHP.

Impact of bariatric surgery on cardiovascular outcomes and mortality: a population-based cohort study

Background

Cohort studies have shown that bariatric surgery may reduce the incidence of and mortality from cardiovascular disease (CVD), but studies using real-world data are limited. This study examined the impact of bariatric surgery on incident CVD, hypertension and atrial fibrillation, and all-cause mortality.

Methods

A retrospective, matched, controlled cohort study of The Health Improvement Network primary care database (from 1 January 1990 to 31 January 2018) was performed (approximately 6 per cent of the UK population). Adults with a BMI of 30 kg/m2 or above who did not have gastric cancer were included as the exposed group. Each exposed patient, who had undergone bariatric surgery, was matched for age, sex, BMI and presence of type 2 diabetes mellitus (T2DM) with two controls who had not had bariatric surgery.

Results

A total of 5170 exposed and 9995 control participants were included; their mean(s.d.) age was 45·3(10·5) years and 21·5 per cent (3265 of 15 165 participants) had T2DM. Median follow-up was 3·9 (i.q.r. 1·8– 6·4) years. Mean(s.d.) percentage weight loss was 20·0(13·2) and 0·8(9·5) per cent in exposed and control groups respectively. Overall, bariatric surgery was not associated with a significantly lower CVD risk (adjusted hazard ratio (HR) 0·80; 95 per cent c.i. 0·62 to 1·02; P = 0·074). Only in the gastric bypass group was a significant impact on CVD observed (HR 0·53, 0·34 to 0·81; P = 0·003). Bariatric surgery was associated with significant reduction in all-cause mortality (adjusted HR 0·70, 0·55 to 0·89; P = 0·004), hypertension (adjusted HR 0·41, 0·34 to 0·50; P &lt; 0·001) and heart failure (adjusted HR 0·57, 0·34 to 0·96; P = 0·033). Outcomes were similar in patients with and those without T2DM (exposed versus controls), except for incident atrial fibrillation, which was reduced in the T2DM group.

Conclusion

Bariatric surgery is associated with a reduced risk of hypertension, heart failure and mortality, compared with routine care. Gastric bypass was associated with reduced risk of CVD compared to routine care.

Temporal variation in the diagnosis of resolved atrial fibrillation and the influence of performance targets on clinical coding: cohort study

OBJECTIVES

To investigate whether the introduction of performance targets for anticoagulation in atrial fibrillation (AF) was associated with a change in use of the 'resolved AF' code.

DESIGN

Retrospective cohort studies.

SETTING

Data from The Health Improvement Network, a UK database of electronic patient records, from 2000 to 2016.

PARTICIPANTS

250 788 adult patients aged ≥18 years with a diagnosis of AF, including 14 757 with an incident diagnosis of 'resolved AF'.

MAIN OUTCOME MEASURES

Annual and monthly incidence of 'resolved AF' from 2000 to 2016. Among patients with 'resolved AF', for each year we calculated median duration of the preceding AF diagnosis and the proportion prescribed anticoagulants prior to 'resolved AF'.

RESULTS

Incidence of 'resolved AF' increased from 5.7 to 26.3 per 1000 person-years between 2005 and the introduction of AF performance targets in 2006. Compared with the years prior to the introduction of the performance targets, incidence has remained higher in every year since their implementation. Since 2007, monthly incidence has been highest between January and March. Between 2005 and 2006, median duration between AF and 'resolved AF' diagnoses increased from 276 days (9 months) to 1343 days (3 years 8 months). Among 'resolved AF' patients with CHA₂DS₂-VASc score ≥1, 81.9% (95% CI 81.1 to 82.6) had no current anticoagulant prescription, and 62.3% (95% CI 61.4 to 63.2) had no record of any anticoagulant prescription.

CONCLUSION

The introduction of AF performance targets was followed by a large increase in use of the 'resolved AF' code, particularly in the months immediately before practices make their anticoagulant performance target submissions. Although most AF patients are prescribed anticoagulants, few patients diagnosed with 'resolved AF' are prescribed anticoagulants and most have never been prescribed them. Untreated patients are much more likely to be coded as having 'resolved AF'.

Patients' and health professionals' attitudes and perceptions towards the initiation of preventive drugs for primary prevention of cardiovascular disease: protocol for a systematic review of qualitative studies

INTRODUCTION

Lipid-lowering drugs and antihypertensive agents can be prescribed for the primary prevention of cardiovascular disease. In some cases, patients eligible for primary prevention of cardiovascular disease according to the European guidelines are not always started on preventive drugs. Existing research explores the attitudes of health professionals and patients towards cardiovascular preventive drugs but does not always differentiate between the attitudes towards drug initiation for primary or secondary prevention. We aim to systematically review qualitative studies assessing health professionals' and patients' attitudes and perceptions towards drug initiation for primary prevention of cardiovascular disease.

METHODS AND ANALYSIS

MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, CINAHL, Applied Social Sciences Index and Abstracts, Conference Proceedings Citation Index (Web of Science), Healthcare Management Information Consortium, and Open Grey will be searched without restrictions on date or language of publication. Searches will be limited to studies of qualitative design, standalone or in the context of a mixed-method design, focusing on cardiovascular drug initiation for primary prevention. The primary outcome is the attitudes of health professionals and patients towards drug initiation for primary prevention of cardiovascular disease. Two reviewers will independently carry out the study selection, data extraction and quality assessment. The Critical Appraisal Skills Programme Qualitative Research Checklist will be used to assess the quality of included studies. The findings will be analysed using Thomas and Harden's thematic synthesis approach.

ETHICS AND DISSEMINATION

This systematic review does not require ethical approval as primary data will not be collected. The results of the study will be published in a peer-reviewed journal and presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42018095346.

The role of contraindications in prescribing anticoagulants to patients with atrial fibrillation: a cross-sectional analysis of primary care data in the UK

BACKGROUND

Underuse of anticoagulants in atrial fibrillation (AF) is an international problem, which has often been attributed to the presence of contraindications to treatment. No studies have assessed the influence of contraindications on anticoagulant prescribing in the UK.

AIM

To determine the influence of contraindications on anticoagulant prescribing in patients with AF in the UK.

DESIGN AND SETTING

Cross-sectional analysis of primary care data from 645 general practices contributing to The Health Improvement Network, a large UK database of electronic primary care records.

METHOD

Twelve sequential cross-sectional analyses were carried out from 2004 to 2015. Patients with a diagnosis of AF aged ≥35 years and registered for at least 1 year were included. Outcome measure was prescription of anticoagulant medication.

RESULTS

Over the 12 study years, the proportion of eligible patients with AF with contraindications who were prescribed anticoagulants increased from 40.1% (95% confidence interval [CI] = 38.3 to 41.9) to 67.2% (95% CI = 65.6 to 68.8), and the proportion of those without contraindications prescribed anticoagulants increased from 42.1% (95% CI = 41.6 to 42.6) to 67.7% (95% CI = 67.2 to 68.1). In patients with a recent history of major bleeding or aneurysm, prescribing rates increased from 44.3% (95% CI = 42.2 to 46.5) and 34.8% (95% CI = 29.4 to 40.6) in 2004 to 71.7% (95% CI = 69.9 to 73.5) and 63.2% (95% CI = 58.3 to 67.8) in 2015, respectively, comparable with rates in patients without contraindications.

CONCLUSION

The presence or absence of recorded contraindications has little influence on the decision to prescribe anticoagulants for the prevention of stroke in patients with AF. The study analysis suggests that, nationally, 38 000 patients with AF with contraindications are treated with anticoagulants. This has implications for patient safety.

Does intrathecal morphine alter the stress response following coronary artery bypass grafting surgery?

PURPOSE

Intrathecal morphine administered prior to coronary artery revascularization (CABG) surgery was studied to determine its effects on the stress response.

METHODS

In a single centre, open, randomized clinical trial, first time elective CABG surgery patients, < 75 yr, were studied. Control subjects (n=12) received a standardized anesthetic consisting of fentanyl (maximum cumulative dose of 35 microg x kg(-1)), propofol, and pancuronium. In addition, spinal subjects (n=13) received 1.0 mg (age > 60 yr) or 1.5 mg (age < or = 59 yr) intrathecal morphine prior to induction of anesthesia. Control subjects received continuous i.v. morphine at 2 mg x hr(-1) on arrival in the ICU with i.v. bolus morphine supplementation as required while spinal subjects received bolus i.v. morphine as required. Changes in plasma cortisol and catecholamine concentrations were measured preoperatively, poststernotomy, on admission to ICU, following tracheal extubation, at 0800 hr on the first postoperative day, and 24 and 48 hr after ICU admission.

RESULTS

No differences between groups were detected for demographic variables. The percent change in cortisol concentration relative to preoperative values (control vs spinal; (38 (87) vs -41 (46)%: P < 0.05)) was lower in the spinal group on admission to ICU. The percent change in plasma epinephrine levels (control vs spinal) on admission to ICU (285 (337) vs -10 (37)%) and 0800 hr after surgery (314 (341) vs -4 (37)%) was also significantly different.

CONCLUSION

Intrathecal morphine only partially attenuated the postsurgical stress response in CABG surgical patients.