Leveraging the Full Continuum of Care to Prevent Opioid Use Disorder

Substance use disorder prevention programs are most effective when matched appropriately to the baseline risk of the population. Individuals who misuse opioids often have unique risk profiles different from those who use other substances such as alcohol or cannabis. However, most substance use prevention programs are geared toward universal audiences, neglecting key inflection points along the continuum of care. The HEAL Prevention Cooperative (HPC) is a unique cohort of research projects that represents a continuum of care, from community-level universal prevention to indicated prevention among older adolescents and young adults who are currently misusing opioids or other substances. This paper describes the theoretical basis for addressing opioid misuse and opioid use disorder across the prevention continuum, using examples from research projects in the HPC.

Superficial temporal artery injury and delayed post-cranioplasty infection

OBJECTIVE

Complications after cranioplasty after decompressive craniectomy (DC) have been reported to be as high as 40%. The superficial temporal artery (STA) is at substantial risk for injury in standard reverse question-mark incisions that are typically used for unilateral DC. The authors hypothesize that STA injury during craniectomy predisposes patients to post-cranioplasty surgical site infection (SSI) and/or wound complication.

METHODS

A retrospective study of all patients at a single institution who underwent cranioplasty after decompressive craniectomy and who underwent imaging of the head (computed tomography angiogram, magnetic resonance imaging with intravenous contrast, or diagnostic cerebral angiography) for any indication between the two procedures was undertaken. The degree of STA injury was classified and univariate statistics were used to compare groups.

RESULTS

Fifty-four patients met inclusion criteria. Thirty-three patients (61%) had evidence of complete or partial STA injury on pre-cranioplasty imaging. Nine patients (16.7%) developed either an SSI or wound complication after cranioplasty and, among these, four (7.4%) experienced delayed (>2 weeks from cranioplasty) complications. Seven of 9 patients required surgical debridement and cranioplasty explant. There was a stepwise but non-significant increase in post-cranioplasty SSI (STA present: 10%, STA partial injury: 17%, STA complete injury: 24%, P=0.53) and delayed post-cranioplasty SSI (STA present: 0%, STA partial injury: 8%, STA complete injury: 14%, P=0.26).

CONCLUSIONS

There is a notable but statistically non-significant trend toward increased rates of SSI in patients with complete or partial STA injury during craniectomy.

Clinical outcomes among distinct groups of patients with severe tricuspid valve regurgitation

Introduction

Severe tricuspid valve regurgitation (TR) is associated with increased 1-year morbidity and mortality. Characterization by valve etiology (primary, secondary, and lead-associated), a classification borrowed from mitral valve disease, has not been universally shown to correlate with outcomes.

Purpose

Among a large, racially diverse cohort with newly identified severe TR, we aimed to 1) characterize outcomes of severe TR by etiology, and 2) assess whether unsupervised phenoclustering or supervised outcome-driven prediction trees were more effective in establishing subgroups of TR with differential clinical risk profiles.

Methods

We retrospectively analyzed outcomes of 5-year all-cause death and a composite of death or heart failure hospitalization (HFH) among adult patients with new severe TR identified by echocardiography between 2007 to 2018 at a large academic tertiary referral center in the United States. Patients were initially categorized by etiology of TR, including primary, secondary, and lead-associated. Second, we separately applied unsupervised hierarchical clustering to identify distinct clusters using demographics, clinical, and echo data at the time of diagnosis. Third, we applied a supervised recursive partitioning algorithm (survival trees) by each outcome to identify distinct TR subgroups. We estimated the cumulative incidence of death and composite death or HFH over 5 years by 1) etiology of TR, 2) distinct clusters, and 3) groups identified by supervised learning (prediction trees).

Results

Among 2,379 consecutive patients with newly identified severe TR, the median age was 70 years, 61% were female, and 40% were Black. Event rates (95% CI) were 30.9 (29.0 to 32.8) events/100 PY for death and 49.0 (45.9 to 52.2) events/100 PY for composite death or HFH over median follow-up of 1.6 years. Event rates were similarly high across TR etiology groups for both death and composite death or HFH (Figure 1). Multiple methods of unsupervised clustering did not yield distinct clusters by patient demographic and imaging characteristics. After applying supervised survival tree modeling, four phenoclusters with distinct clinical prognoses were separately identified for death and composite death or HFH (Figure 2). Variables identified to partition the cohort to discriminate both death and composite death or HFH were age, albumin, blood urea nitrogen, right ventricular contractility, and right ventricular systolic pressure (all p<0.05).

Conclusions

Five-year cumulative incidence of adverse events among patients with newly diagnosed severe TR was 69% for death and 80% for composite death or HFH. TR etiology did not stratify prognosis, while supervised survival tree models identified phenoclusters with distinct clinical risk. The identified subgroups of severe TR with differential outcomes offer insights towards enrichment in clinical trials of TR and risk/benefit analysis in patients undergoing TR therapies.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott

Polysomnography Following Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Introduction

Sleep disturbances are common following traumatic brain injury (TBI) worsening morbidity and other neuropsychiatric symptoms. Post-TBI alterations in sleep architecture require further study.

Objectives

(1) To evaluate polysomnographic measures of sleep architecture in participants with history of TBI compared to controls and as meta-analyses of pooled means. (2) To evaluate effects of timing and severity of TBI on polysomnographic outcomes.

Methods

PRISMA compliant systematic review was conducted of MEDLINE, PsycINFO, EMBASE and Scopus. Inclusion criteria: 1) reporting polysomnography in the context of TBI and 2) operationalizing TBI using clear/formalized criteria. Data were pooled in random-effects meta-analyses with outcomes expressed as mean differences (MD).

Results

In participants with TBI, sleep was comprised of 19.39% REM sleep, 8.13% N1, 51.18% N2, and 17.53% N3, as determined by meta-analyses of single means. Total sleep time was reduced in chronic (>6 months) TBI compared to acute-intermediate TBI (<6 months) (p=0.01). Compared to controls, participants with TBI differed with increased N1 sleep (MD=0.64%; 95%CI=0.02,1.25; p=0.04), reduced sleep efficiency (MD=-1.65%; 95%CI=-3.18,-0.12; p=0.03), and reduced sleep latency on the multiple sleep latency test (MD=-5.90mins; 95%CI=-10.09,-1.72; p<0.01). On sub-group analyses, participants with mild TBI differed from controls with reduced total sleep time (MD=-29.22mins, 95%CI=-54.16,-4.27; p=0.02). Similarly, participants with acute-intermediate TBI exhibited increased sleep latency compared to controls (MD=8.96mins; 95%CI=4.07,13.85; p<0.01) and differed significantly from participants with chronic TBI (X2(1,N=608)=6.54; p=0.01).

Conclusions

Sleep architecture is altered following TBI with potential implications regarding functional outcomes and recovery. These alterations appear to differ based on severity of injury and time since injury.

Disclosure

No significant relationships.

Comparing Outcomes of COVID-19 vs NonCOVID-19 Lung Transplant Recipients on ECMO as a Bridge to Transplant

Purpose

Methods

Results

Conclusion

The association between platelet dysfunction and adverse outcomes in cardiac surgical patients

Haemostatic activation during cardiopulmonary bypass is associated with prothrombotic complications. Although it is not possible to detect and quantify haemostatic activation directly, platelet dysfunction, as measured with point-of-care-assays, may be a useful surrogate. In this study, we assessed the association between cardiopulmonary bypass-associated platelet dysfunction and adverse outcomes in 3010 cardiac surgical patients. Platelet dysfunction, as measured near the end of the rewarming phase of cardiopulmonary bypass, was calculated as the proportion of non-functional platelets after activation with collagen. Logistic regression and multivariable analyses were applied to assess the relationship between platelet dysfunction and a composite of in-hospital death; myocardial infarction; stroke; deep vein thrombosis or pulmonary embolism; and acute kidney injury (greater than a two-fold increase in creatinine). The outcome occurred in 251 (8%) of 3010 patients. The median (IQR [range]) percentage platelet dysfunction was less for those without the outcome as compared with those with the outcome; 14% (8-28% [1-99%]) vs. 19% (11-45% [2-98%]), p < 0.001. After risk adjustment, platelet dysfunction was independently associated with the composite outcome (p < 0.001), such that for each 1% increase in platelet dysfunction there was an approximately 1% increase in the composite outcome (OR 1.012; 95%CI 1.006-1.018). This exploratory study suggests that cardiopulmonary bypass-associated platelet dysfunction has prognostic value and may be a useful clinical measure of haemostatic activation in cardiac surgery.

Pre-operative anaemia, intra-operative hepcidin concentration and acute kidney injury after cardiac surgery: a retrospective observational study

Acute kidney after cardiac surgery is more common in anaemic patients, whereas haemolysis during cardiopulmonary bypass may lead to iron-induced renal injury. Hepcidin promotes iron sequestration by macrophages: hepcidin concentration is reduced by anaemia and increased by inflammation. We analysed the associations in 525 patients between pre-operative anaemia (haemoglobin < 130 g.l^-1 in men and < 120 g.l^-1 in women), intra-operative hepcidin concentration and acute kidney injury (dialysis or > 26.4 μmol.l^-1 or > 50% creatinine increase during the first two days after cardiac surgery. Rates of pre-operative anaemia and postoperative kidney injury were 109/525 (21%) and 36/525 (7%), respectively. The median (IQR [range]) intra-operative hepcidin concentration was 20 (10-33 [0-125]) μg.l^-1 and was lower in anaemic patients than those who were not: 15 (4-28 [0-125]) μg.l^-1 vs. 21 (12-33 [0-125]) μg.l^-1 , respectively, p = 0.002. Four variables were independently associated with postoperative kidney injury, for which the beta-coefficients (SE) were: minutes on cardiopulmonary bypass, 0.016 (0.004), p < 0.001; intra-operative hepcidin concentration, 0.032 (0.008), p < 0.001; pre-operative anaemia, 1.97 (0.56), p < 0.001; and Cleveland clinic risk score, 0.88 (0.35), p = 0.005. Contrary to generally increased rates of kidney injury in patients with higher hepcidin concentrations, rates of kidney injury in anaemic patients were lower in patients with higher hepcidin concentrations, beta-coefficient (SE) -0.037 (0.01), p = 0.007. In cardiac surgical patients the rate of postoperative acute kidney injury predicted by the Cleveland risk score might be adjusted for pre-operative anaemia and intra-operative cardiopulmonary bypass time and hepcidin concentration. Pre-operative correction of anaemia, reduction in intra-operative bypass time and modification of iron homeostasis and hepcidin concentration might reduce acute kidney injury.