Current Trends in Mortality Attributable to Racial or Ethnic Disparities in Post-Surgical Population in The United States: A Population-Based Study

Background

No study has contextualized the excess mortality attributable to racial and ethnic disparities in surgical outcomes. Further, not much effort has been made to quantify the effort needed to eliminate these disparities.

Objective

We examined the current trends in mortality attributable to racial or ethnic disparities in the US postsurgical population. We then identified the target for mortality reduction that would be necessary to eliminate these disparities by 2030.

Methods

We performed a population-based study of 1,512,974 high-risk surgical procedures among adults (18-64 years) performed across US hospitals between 2000 and 2020.

Results

Between 2000 and 2020, the risk-adjusted mortality rates declined for all groups. Nonetheless, Black patients were more likely to die following surgery (adjusted relative risk 1.42; 95% CI, 1.39-1.46) driven by higher Black mortality in the northeast (1.60; 95% CI, 1.52-1.68), as well as the West (1.53; 95% CI, 1.43-1.62). Similarly, mortality risk remained consistently higher for Hispanics compared with White patients (1.21; 95% CI, 1.19-1.24), driven by higher mortality in the West (1.26; 95% CI, 1.21-1.31). Overall, 8364 fewer deaths are required for Black patients to experience mortality on the same scale as White patients. Similar figures for Hispanic patients are 4388. To eliminate the disparity between Black and White patients by 2030, we need a 2.7% annualized reduction in the projected mortality among Black patients. For Hispanics, the annualized reduction needed is 0.8%.

Conclusions

Our data provides a framework for incorporating population and health systems measures for eliminating disparity in surgical mortality within the next decade.

A Multi-Site Survey Study on the Association Between the COVID-19 Pandemic and United States Anesthesiology Residents' Mental Health

BACKGROUND

 At the onset of the coronavirus disease 2019 (COVID-19) pandemic, anesthesiology residency programs were impacted differently due to various factors such as the local severity of COVID-19, exposure to patient suffering, and inability to complete rotations. We sought to investigate the impact of local-level pandemic severity on the well-being of anesthesiology residents.

METHODS

 This multi-site study surveyed postgraduate year two residents from 15 United States (US) anesthesiology programs using the Perceived Stress Scale, Mini-Z, Patient Health Questionnaire-9,WHO-5 Well-Being Index,and the Multidimensional Scale of Perceived Social Support before the pandemic (baseline survey) and during the first COVID-19 surge (post survey).

RESULTS

 A total of 144 (65%) residents responded to the initial baseline survey; 73 (33%) responded to the post survey, and 49 (22%) completed both surveys. There was not a statistically significant difference in any well-being outcomes of participants between the surveys, nor was there a significant difference based on the severity of COVID-19 impact at the program's hospital. Male participants had higher perceived stress scores (β = 4.05, 95%CI: 0.42, 7.67, P = 0.03) and lower social support from family (β = -6.57, 95%CI: -11.64, -1.51, P = 0.01) at the post survey compared to female participants after controlling for baseline scores. Additionally, married participants or those with domestic partners reported higher perceived social support in the post survey (β = 5.79, 95%CI: -0.65, 12.23, P = 0.03).

CONCLUSION

 The local COVID-19 severity at a residency program did not disproportionately impact well-being scores among anesthesiology residents. Those most vulnerable to diminished well-being appeared to be male and single participants. As a result, targeted well-being interventions, including those aiming to increase social support, to higher-risk resident groups may be indicated. Future work is needed to assess the longstanding COVID-19 pandemic impacts on resident well-being.

Association of Severe Obesity and Chronic Obstructive Pulmonary Disease With Pneumonia Following Non-Cardiac Surgery

Background

Pneumonia is the third most common surgical complication after urinary tract infection and wound infections. In addition to increased mortality, patients who develop postoperative pneumonia have a higher risk of prolonged hospital stay, intensive care unit (ICU) admissions, and higher healthcare costs. Obesity and chronic obstructive pulmonary disease (COPD) are both independent risk factors for the development and severity of postoperative pneumonia, although the combined effect of these comorbidities is unknown. Therefore, we evaluated whether the combination of severe obesity and COPD is associated with an increased risk of postoperative pneumonia.

Methods

We performed a multicenter retrospective cohort study of 365,273 patients aged 18 - 64 years who were either severely obese (body mass index (BMI) ≥ 40 kg/m²) or normal-weight (BMI between 18.6 and 24.9 kg/m²) and underwent general surgery, orthopedic surgery, neurosurgery, otolaryngology surgery, urology surgery, and vascular surgery in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) participating hospitals from 2014 to 2018. We evaluated the combined effect of COPD and severe obesity on the risk for postoperative pneumonia, unplanned tracheal reintubation, and extended length of stay.

Results

The co-occurrence of severe obesity and COPD appeared to have a protective effect on the risk of postoperative pneumonia. In the presence of COPD, patients with severe obesity were 14% less likely to develop pneumonia compared to their normal-weight counterparts (2.9% vs. 4.4%; adjusted relative risk (RR): 0.76; 95% confidence interval (CI): 0.60, 0.95). In addition, in the presence of COPD, severe obesity conferred a lower risk for requiring an extended length of stay (37.6% vs. 47.9%; adjusted RR: 0.83; 95% CI: 0.78, 0.89).

Conclusions

Counterintuitively, the co-occurrence of severe obesity with COPD appeared to buffer the negative impact of COPD on postoperative pneumonia, unplanned tracheal reintubation, and prolonged hospital stay after noncardiac surgery. These findings are consistent with the obesity paradox and warrant further investigations.

Caring for Parturients with Substance Use Disorders

Parturients with substance use disorder require expertise to manage the complexity of intoxication, withdrawal, and chronic use as well as ensure adequate analgesia throughout labor. Opioid use disorder in pregnancy has increased more than 4-fold in the past decade, with a 50-fold geographic variability that now dwarfs other substance use in this population. Understanding not only the medical but also the public health and criminal justice implications of substance use disorder is essential to providing optimal care to this at-risk population.

COVID-Activated Emergency Scaling of Anesthesiology Responsibilities Intensive Care Unit

In response to the rapidly evolving coronavirus disease 2019 (COVID-19) pandemic and the potential need for physicians to provide critical care services, the American Society of Anesthesiologists (ASA) has collaborated with the Society of Critical Care Anesthesiologists (SOCCA), the Society of Critical Care Medicine (SCCM), and the Anesthesia Patient Safety Foundation (APSF) to develop the COVID-Activated Emergency Scaling of Anesthesiology Responsibilities (CAESAR) Intensive Care Unit (ICU) workgroup. CAESAR-ICU is designed and written for the practicing general anesthesiologist and should serve as a primer to enable an anesthesiologist to provide limited bedside critical care services.

Be Active and Be Well? A Cross-sectional Survey of US Anesthesia Residents

BACKGROUND

Wellness among resident physicians is important to their well-being and ability to provide clinical care. The relationship between physical activity and wellness among anesthesia residents has not yet been evaluated. We surveyed anesthesia residents to evaluate their levels of physical activity and self-perceived wellness scores. We hypothesized that residents with high self-reported physical activity levels would be more likely to have higher wellness scores.

METHODS

Three hundred and twenty-three anesthesia residents were invited to participate in this cross-sectional survey study. The survey included questions regarding demographics (age, gender, clinical anesthesia year, work hours), physical activity (based off the US Department of Health and Human Services [USDHHS] guidelines), and wellness (using the Satisfaction With Life Scale). The relationship between wellness and physical activity levels was evaluated.

RESULTS

One hundred forty-one residents responded (43.6% response rate). Thirty-eight (27.1%) residents met our activity threshold for physically active. Eighty-six respondents (61.4%) were classified as having high wellness based on their survey answers. No significant associations were found between demographic data and wellness, including age or clinical anesthesia training year. Among those residents who described physical activity consistent with USDHHS guidelines, 29 (76.3%) had high wellness scores. After logistic regression analysis, residents who achieved the physical activity guidelines were more likely to have high wellness scores (odds ratio 2.54, 95% confidence interval 1.13-6.20, P value .03).

CONCLUSIONS

Anesthesia resident physicians with high physical activity levels had higher self-perceived wellness scores.

Comparison of Phenylephrine and Ephedrine in Treatment of Spinal-Induced Hypotension in High-Risk Pregnancies: A Narrative Review

Purpose

To compare maternal and fetal effects of intravenous phenylephrine and ephedrine administration during spinal anesthesia for cesarean delivery in high-risk pregnancies.

Source

An extensive literature search was conducted using the US National Library of Medicine, MEDLINE search engine, Cochrane review, and Google Scholar using search terms “ephedrine and phenylephrine,” “preterm and term and spinal hypotension,” “preeclampsia and healthy parturients,” or “multiple and singleton gestation and vasopressor.” Society of Obstetric Anesthesia and Perinatology meeting abstracts for the past 4 years were also searched for relevant studies.

Principle findings

Both phenylephrine and ephedrine can be safely used to counteract hypotension after spinal anesthesia in patients with uteroplacental insufficiency, pregnancy-induced hypertension, and in non-elective cesarean deliveries. Vasopressor requirements before delivery in high-risk cesarean sections are reduced compared to healthy parturients. Among the articles reviewed, there were no statistically significant differences in umbilical arterial pH, umbilical venous pH, incidence of fetal acidosis, Apgar scores, or maternal hypotension when comparing maternal phenylephrine and ephedrine use.

Conclusion

From the limited existing data, phenylephrine and ephedrine are both appropriate selections for treating or preventing hypotension induced by neuraxial blockade in high-risk pregnancies. There is no clear evidence that either medication is more effective at maintaining maternal blood pressure or has a superior safety profile in this setting. Further investigations are required to determine the efficacy, ideal dosing regimens, and overall safety of phenylephrine and ephedrine administration in high-risk obstetric patients, especially in the presence uteroplacental insufficiency.

Preventing Ventilator-Associated Lung Injury: A Perioperative Perspective

Introduction

Research into the prevention of ventilator-associated lung injury (VALI) in patients with acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU) has resulted in the development of a number of lung protective strategies, which have become commonplace in the treatment of critically ill patients. An increasing number of studies have applied lung protective ventilation in the operating room to otherwise healthy individuals. We review the history of lung protective strategies in patients with acute respiratory failure and explore their use in patients undergoing mechanical ventilation during general anesthesia. We aim to provide context for a discussion of the benefits and drawbacks of lung protective ventilation, as well as to inform future areas of research.

Methods

We completed a database search and reviewed articles investigating lung protective ventilation in both the ICU and in patients receiving general anesthesia through May 2015.

Results

Lung protective ventilation was associated with improved outcomes in patients with acute respiratory failure in the ICU. Clinical evidence is less clear regarding lung protective ventilation for patients undergoing surgery.

Conclusion

Lung protective ventilation strategies, including low tidal volume ventilation and moderate positive end-expiratory pressure, are well established therapies to minimize lung injury in critically ill patients with and without lung disease, and may provide benefit to patients undergoing general anesthesia.

Complications of bronchoscopy: A concise synopsis

Flexible and rigid bronchoscopes are used in diagnosis, therapeutics, and palliation. While their use is widespread, effective, and generally safe; there are numerous potential complications that can occur. Mechanical complications of bronchoscopy are primarily related to airway manipulations or bleeding. Systemic complications arise from the procedure itself, medication administration (primarily sedation), or patient comorbidities. Attributable mortality rates remain low at < 0.1% for fiberoptic and rigid bronchoscopy. Here we review the complications (classified as mechanical or systemic) of both rigid and flexible bronchoscopy in hope of making practitioners who are operators of these tools, and those who consult others for interventions, aware of potential problems, and pitfalls in order to enhance patient safety and comfort.

Effects of parecoxib on analgesia benefit and blood loss following open prostatectomy: a multicentre randomized trial

Background

This multi-centre, prospective, randomized, double-blind, placebo-controlled study was designed to test the hypotheses that parecoxib improves patients’ postoperative analgesia without increasing surgical blood loss following radical open prostatectomy.

Methods

105 patients (64 ± 7 years old) were randomized to receive either parecoxib or placebo with concurrent morphine patient controlled analgesia. Cumulative opioid consumption (primary objective) and the overall benefit of analgesia score (OBAS), the modified brief pain inventory short form (m-BPI-sf), the opioid-related symptom distress scale (OR-SDS), and perioperative blood loss (secondary objectives) were assessed.

Results

In each group 48 patients received the study medication for 48 hours postoperatively. Parecoxib significantly reduced cumulative opioid consumption by 24% (43 ± 24.1 mg versus 57 ± 28 mg, mean ± SD, p=0.02), translating into improved benefit of analgesia (OBAS: 2(0/4) versus 3(1/5.25), p=0.01), pain severity (m-BPI-sf: 1(1/2) versus 2(2/3), p < 0.01) and pain interference (m-BPI-sf: 1(0/1) versus 1(1/3), p=0.001), as well as reduced opioid-related side effects (OR-SDS score: 0.3(0.075/0.51) versus 0.4(0.2/0.83), p=0.03). Blood loss was significantly higher at 24 hours following surgery in the parecoxib group (4.3 g⋅dL⁻¹ (3.6/4.9) versus (3.2 g⋅dL⁻¹ (2.4/4.95), p=0.02).

Conclusions

Following major abdominal surgery, parecoxib significantly improves patients’ perceived analgesia. Parecoxib may however increase perioperative blood loss. Further trials are needed to evaluate the effects of selective cyclooxygenase-2 inhibitors on blood loss.

Trial registration

ClinicalTrials.gov Identifier: NCT00346268

Meniscal fixation with an absorbable staple. An experimental study in dogs

An absorbable staple for meniscal fixation was developed and evaluated in an in vivo canine study. The staple consisted of two rigid barbed legs, made of a copolymer of polyglycolic acid and polylactic acid, connected by a flexible suture made of the same absorbable material. The staple was developed for arthroscopic use, eliminating the risk of nerve or vascular injuries associated with suture fixation. Eighty-two mongrel dogs underwent meniscal repair in this study, which was performed in two sequential parts. An incision was made in the medial meniscus at the peripheral third and was fixed with either the staple or with a single 3-0 PDS suture. The animals from the first part of the study, in which the biocompatibility of a prototype staple design, was evaluated were sacrificed at 3 days, 2 weeks, 6 weeks, 3 months, and 9 months. Those from the second part of the study, in which an improved staple design of the same material, was evaluated were sacrificed at 6 weeks, 4 months, and 1 year. The operated menisci were either examined histologically or were mechanically tested for tensile strength. Absorption of the staple began by 3 months and was almost complete by 1 year. Mechanically, the staple provided greater tensile strength augmentation of the meniscus than suture fixation for up to 4 months. In the long term, there was no difference between the staple and suture in enhancement of healing.

The effect of estrogen usage on the subsequent hormone receptor status of primary breast cancer

In order to determine if prior use of exogenous estrogens was related to the estrogen receptor (ER) content of primary breast cancers, a retrospective analysis was performed from 536 patients with invasive breast cancer. The patient's age, menopausal status, oral contraceptive or estrogen replacement therapy usage, and the ER and progesterone receptor (PR) content of the breast cancer were recorded for all patients. Hormone usage in premenopausal and postmenopausal patients was compared to ER and PR levels in primary breast cancers using non-parametric testing. Complete information was available from 508 (193 premenopausal and 315 postmenopausal) patients. Breast cancers were ER positive in 72% of postmenopausal patients and 57% of premenopausal patients. The majority of patients received 'Some' form of hormone therapy (111 of 193 premenopausal patients and 233 of 315 postmenopausal patients). Significantly more estrogen receptors were detected in tumors from patients receiving 'some' estrogen therapy compared to 'never' users. Postmenopausal patients 'never receiving estrogen therapy had a lower rate of ER positive tumors (62%) compared to 'some' users (75%, chi2 = 4.99, p < 0.05). The same relationship was seen for PR ('never' users 44% positive, 'some' users 58% positive, chi2 = 5.19, p < 0.05). We conclude that postmenopausal patients who received 'some' estrogen therapy are more likely to have breast cancers that are estrogen receptor and progesterone receptor positive.

Induction of phase I and phase II drug-metabolizing enzyme mRNA, protein, and activity by BHA, ethoxyquin, and oltipraz

Various natural and synthetic compounds are known to protect against cancer by elevating phase II detoxification enzymes. Generally classified as monofunctional, these inducers are believed to trigger cellular signal(s) that activate gene transcription through an antioxidant or electrophile response element (ARE/EpRE) in responsive genes. In contrast, the phase I enzymes of drug metabolism (cytochrome P450s) are not believed to be induced by monofunctional inducers and P450 genes have not been found to contain functional ARE/EpREs. In this study, rats were treated with the monofunctional inducers tert-butylated hydroxyanisole, ethoxyquin, and oltipraz to study the inducibility of individual glutathione S-transferase isozymes, NADP(H):quinone oxidoreductase, gamma-glutamylcysteine synthetase, UDP-glucuronosyl transferase, and cytochrome P450 enzymes. Hepatic mRNAs were analyzed on Northern blots using gene-specific oligonucleotide probes for GST Ya1, Ya2, Yc1, Yc2, Yb1, Yb2, and Yf, for UGT 1*06, and for P450 1A1, 1A2, 2B1, 2C11, 3A2, and 4A1. NADP(H):quinone oxidoreductase and gamma-glutamylcysteine synthetase mRNAs were detected using cDNA probes. All the phase II detoxification enzymes analyzed, except GST Yf, were induced by the three monofunctional inducers, suggesting that these genes may be regulated by a mechanism involving an ARE/EpRE element in their promoter region. Interestingly, it was found that ethoxyquin was a particularly good inducer for both members of the P450 2B family, 2B1 and 2B2, and both ethoxyquin and oltipraz were also capable of modestly inducing P450 1A2 and 3A2. Oltipraz was found to slightly induce P450 2B2, but not 2B1, at the dose and time analyzed. Induction of mRNA generally correlated well with induction of protein levels determined by Western blot and/or enzyme activity measurements for selected enzymes. The results of this study suggest that many phase II enzymes may contain ARE/EpRE elements in addition to those confirmed to be regulated by a mechanism involving ARE/EpRE elements. In addition, it was found that several P450 enzymes were induced by monofunctional inducers, suggesting a possibility that some phase I enzymes may also be regulated by a mechanism involving ARE/EpRE elements.

The effects of diquat and ciprofibrate on mRNA expression and catalytic activities of hepatic xenobiotic metabolizing and antioxidant enzymes in rat liver

Although the mechanisms responsible for chemically induced oxidative stress are under intense investigation, little is known about the effects of prooxidant chemicals on the expression of drug-metabolizing enzymes. We examined the effects of diquat (0.1 mmol/kg, ip) and ciprofibrate (0.025% w/w, diet), chemicals which induce oxidative stress via different biochemical mechanisms, on the steady-state messenger RNA (mRNA) levels of six cytochrome P450 enzymes, seven glutathione S-transferase (GST) isoenzymes, UDP-glucuronosyl transferase 1-06 (UGT1*06), gamma-glutamylcysteine synthetase (gamma GCS), NADP(H):quinone oxidoreductase (quinone reductase), Cu/Zn superoxide dismutase (SOD), catalase, and 18S ribosomal RNA in the livers of male Sprague-Dawley rats. Effects of chemical treatments on mRNA levels were compared to changes in catalytic activities for selected enzymes. Ciprofibrate treatment selectively decreased CYP1A2 mRNA expression, whereas both chemicals suppressed CYP3A2 mRNA expression. CYP4A1 mRNA expression and lauric acid hydroxylase activities were induced by ciprofibrate treatment, whereas diquat treatment moderately increased CYP4A1 mRNA levels without affecting lauric acid hydroxylase activities. The steady-state mRNA levels encoding constitutively expressed GST isozymes (Ya1, Ya2, Yb1, Yb2, and Yc1) were decreased by diquat exposure, and the mRNA encoding four of the five constitutively expressed GSTs (Ya1, Ya2, Yb1, and Yc1) were also decreased by ciprofibrate treatment. Nonconstitutively expressed or low constitutively expressed genes (CYP1A1, CYP2B1, CYP2B2, GST Yc2, GST Yf, and UGT1*06) were not induced by exposure to the prooxidants. Changes in isozyme-specific catalytic activities were more consistent with the observed changes in mRNA expression for the GSTs than for the P450s. Both treatments had inhibitory effects on hepatic GSH biosynthesis by decreasing gamma GCS large-subunit mRNA expression, gamma GCS catalytic activities, and hepatic GSH concentrations. Cu/Zn SOD and quinone reductase mRNA levels were increased after ciprofibrate exposure, whereas Cu/Zn SOD mRNA expression was decreased in the diquat-treated animals. The results of this study indicate that diquat and ciprofibrate can decrease the expression profile of a number of phase I, phase II, and antioxidant enzymes and inhibit GSH biosynthesis. These effects may involve the pretranslational loss of hepatic mRNAs, possibly due to accelerated production of reactive oxygen species.

Detection of acute avascular necrosis of the femoral head in dogs: dynamic contrast-enhanced MR imaging vs spin-echo and STIR sequences

OBJECTIVE

Spin-echo MR imaging has been shown to be highly sensitive in the detection of avascular necrosis. Very early avascular necrosis can, however, appear normal on MR images. We compared dynamic contrast-enhanced MR imaging with conventional spin-echo and short Tl inversion-recovery (STIR) sequences for detecting acute osteonecrosis in an animal model.

MATERIALS AND METHODS

Avascular necrosis was induced unilaterally in the femoral heads of five dogs that were imaged with a 1.5-T system within 3 hr of devascularization. After standard T1-weighted, T2-weighted, and STIR images, gradient-recalled echo images, 28/5 (TR/TE) with a 45 degrees flip angle, were obtained at 6-sec intervals for 90 sec synchronous with the IV administration of 0.2 mmol of gadoteridol per kilogram of body weight at a rate of 2 ml/sec via an automated injector. Two animals were reimaged after 7 days.

RESULTS

Spin-echo and STIR images did not show any acute changes in the ischemic femoral heads. In contrast, significant differences were present in the enhancement profiles of the marrow spaces in the normal and ischemic femoral heads (p = .005). Normal marrow was characterized by rapid enhancement, with an average signal intensity increase of 83% peaking at 36 sec; no measurable enhancement was seen in the marrow of the ischemic femoral head. Spin-echo images, obtained 7 days after devascularization (n = 2), showed changes characteristic of avascular necrosis. Dynamic contrast-enhanced MR images showed persistent lack of enhancement in the avascular marrow of the ischemic femoral head. A junctional zone, characterized by rapid contrast enhancement in excess of 120% without early washout, was identified at the interface between normal and avascular marrow.

CONCLUSION

In this experimental model, dynamic contrast-enhanced MR imaging proved significantly more sensitive than conventional spin-echo and STIR imaging in the detection of acute avascular necrosis.

An unusual presentation of splenic rupture

A case is described of rupture of the spleen with a hemoperitoneum which was forced through two abdominal wall hernias to produce potentially misleading ecchymosis of the upper midline and the thigh. The diagnostic significance of the entire clinical presentation is discussed.

Evaluating benign breast disease

Benign breast diseases are present in some form in nearly all women. A basic understanding of breast anatomy and physiology, underlying pathology and methods available for evaluating breast problems provides the ability to assess the client's breast complaint. Four common breast problems--fibrocystic disease, fibroadenoma, mammary duct ectasia, and intraductal papilloma--are described along with guidelines for assessment and referral or follow-up. Current breast-imaging options are discussed in terms of their usefulness and limitations. The value of consumer education regarding benign breast problems cannot be overstated. The National Cancer Institute offers free consumer information explaining benign breast diseases and evaluation techniques.

Elimination of mechanical failure of the Hickman right atrial catheter

The double lumen Hickman right atrial catheter (Evermed Co., Palo Alto, Calif.) is usually inserted through an open venous cutdown into the internal jugular or cephalic vein. It is difficult to mechanically secure. Tight ligatures around the vein opening and catheter occlude the lumen of the Silastic rubber catheter while loose ligatures allow slippage. Migration of the tip into the vena cava or innominate vein causes fibrin sleeve formation and occlusion. Because of problems during the initial use of this catheter, we modified a subsequent series by placing a Silastic rubber bead on the catheter. The catheter is carefully trimmed so that the tip will lie in the right atrium and the bead is placed into the vein proximal to the securing ligature. Comparison of the two series of primarily leukemic patients revealed complete elimination of mechanical problems in patients with beaded catheters (0/18), and significant mechanical failure in unbeaded catheters (7/23). These data indicate that adequate fixation of the Hickman catheter at the level of the venotomy and placement of the tip in the right atrium eliminates mechanical failure and markedly improves catheter function.