Asim Alam

Long-term analgesic use after low-risk surgery: a retrospective cohort study.

BACKGROUND This study evaluated the risk of long-term analgesic use after low-risk surgery in older adults not previously prescribed analgesics. METHODS We conducted a retrospective cohort study using linked, population-based administrative data in Ontario, Canada, from April 1, 1997, through December 31, 2008. We identified Ontario residents 66 years and older who were dispensed an opioid within 7 days of a short-stay surgery (cataract surgery, laparoscopic cholecystectomy, transurethral resection of the prostate, or varicose vein stripping) and assessed the risk of long-term opioid use, defined as a prescription for an opioid within 60 days of the 1-year anniversary of the surgery. In a secondary analysis, we examined the risk of long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs). We used multivariate logistic regression to examine the association between postsurgical use of analgesics and long-term use. RESULTS Among 391,139 opioid-naive patients undergoing short-stay surgery, opioids were newly prescribed to 27,636 patients (7.1%) within 7 days of being discharged from the hospital, and opioids were prescribed to 30,145 patients (7.7%) at 1 year from surgery. An increase in the use of oxycodone was found during this time (from 5.4% within 7 days to 15.9% at 1 year). In our primary analysis, patients receiving an opioid prescription within 7 days of surgery were 44% more likely to become long-term opioid users within 1 year compared with those who received no such prescription (adjusted odds ratio, 1.44; 95% CI, 1.39-1.50). In a secondary analysis, among 383,780 NSAID-naive patients undergoing short-stay surgery, NSAIDs were prescribed to 1169 patients (0.3%) within 7 days of discharge and to 30,080 patients (7.8%) at 1 year from surgery. Patients who began taking NSAIDs within 7 days of surgery were almost 4 times more likely to become long-term NSAID users compared with patients with no such prescription (adjusted odds ratio, 3.74; 95% CI, 3.27-4.28). CONCLUSION Prescription of analgesics immediately after ambulatory surgery occurs frequently in older adults and is associated with long-term use.

The prescription opioid epidemic: an overview for anesthesiologists

PurposeThe objectives for preparing this article were to review the historical context and epidemiology surrounding the North American prescription opioid crisis, to summarize the evidence regarding the benefits and harms of long-term opioid therapy for non-cancer pain, and to outline ways in which anesthesiologists may help ameliorate the problem.SourceWe searched PubMed, Google Scholar, and EMBASE™ for relevant articles using various search terms, including pain, opioid epidemic, history of opioid use, perioperative care, and addiction. Related citations were further explored and searched depending on the specific subtopic of interest.Principal findingsIn the 1980s and early 1990s, opioids were infrequently used for the treatment of chronic pain. Thereafter, however, physicians were gradually inculcated with the message that long-term opioid therapy was a safe and effective treatment option for patients with chronic non-cancer pain. Pharmaceutical companies supported this growing movement and employed aggressive and sometimes misleading marketing strategies for new opioid formulations. As a result, the practice of prescribing opioids flourished in the late 1990s. The surge in prescribing opioids was accompanied by a marked increase in opioid-related morbidity and mortality. This change in practice transpired despite the absence of randomized trials showing clinically significant benefit from the long-term use of opioids. Subsequently, however, a large and growing body of evidence has emerged quantifying the harms associated with long-term opioid therapy. Anesthesiologists widely prescribe opioids for acute and chronic pain; yet, as a group, they may be largely unaware of the current state of this growing epidemic and what role they can play to rectify this problem.ConclusionAnesthesiologists are well positioned to take a leadership role in the management of postoperative discharge opioid therapy in an effort to curb the overutilization of opioids. Furthermore, anesthesiologists who regularly prescribe opioids for chronic pain patients should appreciate the limited evidence base for this practice and communicate the risks of opioid therapy to their patients.RésuméObjectifLes objectifs lors de la préparation de cet article étaient de passer en revue le contexte historique et l’épidémiologie entourant la crise de prescription d’opioïdes nord-américaine, de résumer les données probantes concernant les avantages et les effets nocifs du traitement opioïde à long terme pour les douleurs non cancéreuses, et de proposer différentes pistes aux anesthésiologistes afin qu’ils aident à résoudre le problème.SourceNous avons effectué des recherches dans les bases de données PubMed, Google Scholar et EMBASE™ afin d’en extraire les articles pertinents à l’aide de différents termes de recherche, notamment douleur, épidémie d’opioïdes, histoire de l’utilisation d’opioïdes, soins périopératoires, et accoutumance (soit les termes anglais pain, opioid epidemic, history of opioid use, perioperative care, et addiction, respectivement). Les citations associées ont été recherchées et explorées selon leur thème secondaire spécifique.Constatations principalesAu cours des années 1980 et au début des années 1990, les opioïdes n’étaient que rarement utilisés pour le traitement de la douleur chronique. Par la suite toutefois, il a été progressivement inculqué aux médecins que le traitement opioïde à long terme constituait une option de traitement sécuritaire et efficace pour les patients souffrant de douleur chronique non cancéreuse. Les compagnies pharmaceutiques appuyèrent cet essor et eurent recours à des stratégies commerciales agressives et parfois trompeuses pour promouvoir de nouvelles formulations opioïdes. Ainsi, la pratique de prescrire des opioïdes prospéra à la fin des années 1990. Cette montée des prescriptions d’opioïdes s’accompagna d’une augmentation marquée de la morbidité et de la mortalité liées aux opioïdes. Ce changement de pratique s’étendit malgré l’absence d’études randomisées attestant d’un avantage significatif d’un point de vue clinique quant à l’utilisation à long terme de ces agents. Par la suite toutefois, un corpus grandissant de données probantes émergea, quantifiant les effets nocifs associés à un traitement opioïde à long terme. Les anesthésiologistes prescrivent fréquemment des opioïdes pour le traitement de la douleur aiguë et chronique; pourtant, en tant que collectivité, ils pourraient ne pas être pleinement conscients de l’état actuel de cette crise grandissante et du rôle qu’ils peuvent jouer pour régler ce problème.ConclusionLes anesthésiologistes occupent une position privilégiée pour assumer un rôle de leadership dans la gestion des traitements opioïdes après le congé postopératoire dans un effort pour ralentir la sur-utilisation des opioïdes. De plus, les anesthésiologistes qui prescrivent régulièrement des opioïdes à leurs patients de douleur chronique devraient prendre connaissance des données probantes limitées soutenant cette pratique et expliquer les risques d’un traitement opioïde à leurs patients.

Prophylactic Use of Tranexamic Acid for Postpartum Bleeding Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Despite multimodal approaches to treatment, postpartum hemorrhage (PPH) is a life-threatening condition whose incidence continues to rise. In developing areas, such as sub-Saharan Africa, PPH is the leading cause of maternal mortality. Tranexamic acid (TXA) is a possible prophylactic treatment for the prevention of PPH. We performed a systematic review and meta-analysis of randomized trials comparing prophylactic TXA vs placebo or no treatment in term parturients to quantify the effects of prophylactic TXA administration on peripartum bleeding outcomes. The meta-analysis was performed using a random-effects model. The outcomes assessed were (i) incidence of PPH, (ii) mean blood loss (in milliliters) within 24hours, (iii) incidence of red blood cell transfusion within 24hours, (iv) use of additional uterotonics, (v) minor side effects (ie, nausea, vomiting, headache, etc), (vi) major venous thromboembolism, (vii) length of hospital stay, and (viii) mortality. Eighteen trials (3846 subjects) were included in the quantitative analysis, with 1935 patients receiving TXA. The studies were of poor to moderate quality. Prophylactic TXA administration was associated with a decreased incidence of PPH after delivery (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.17-0.59; P = .0006), a reduction in mean blood loss by 149.1mL (95% CI, 112.9-185.2; P < .00001), and a reduction in red blood cell transfusions (OR, 0.28; 95% CI, 0.15-0.49; P < .00001) while also being associated with a reduction in the use of additional uterotonics (OR, 0.45; 95% CI, 0.30-0.66; P < .00001). Minor side effects were more common in those who received TXA (OR, 2.51; 95% CI, 1.69-3.74; P < .00001). There appeared to be no increased risk of venous thromboembolism and no difference in length of hospital stay associated with TXA use. Although prophylactic TXA administration may be associated with improved peripartum bleeding, existing evidence is insufficient for any definitive recommendations secondary to the poor to moderate quality of the literature. A large well-designed, methodologically sound, randomized controlled trial is needed to better delineate the true effect size and address potential safety concerns.

Platelet Utilization: A Canadian Blood Services Research and Development Symposium

Considerable progress has been made in recent years in understanding platelet biology and in strengthening the clinical evidence base around platelet transfusion thresholds and appropriate platelet dosing. Platelet alloimmunization rates have also declined. Nevertheless, controversies and uncertainties remain that are relevant to how these products can best be used for the benefit of platelet transfusion recipients. Platelets are unique among the blood products directly derived from whole blood or apheresis donations in requiring storage, with shaking, at ambient temperature. Storage is accordingly constrained between the need to limit the growth of any microbes in the product and the need to minimize losses in platelet function associated with storage. Proteomic and genomic approaches are being applied to the platelet storage lesion. Platelet inventory management is made challenging by these constraints. Although bacterial screening has enhanced the safety of platelet transfusions, pathogen reduction technology may offer further benefits. Continuing clinical investigations are warranted to understand the value of transfusing platelets prophylactically or only in response to bleeding in different patient groups and how best to manage the most grievously injured trauma patients. Patients refractory to platelet transfusions also require expert clinical management. The engineering of platelet substitute products is an active area of research, but considerable hurdles remain before any clinical uses may be contemplated. Roles for platelets in biological areas distinct from hemostasis are also emerging. Platelet utilization is variably affected by all of the above factors, by demographic changes, by new medications, and by new patient care approaches.

The characteristics of psychiatrists disciplined by professional colleges in Canada.

Background The identification of health care professionals who are incompetent, impaired, exploitative or have criminal intent is important for public safety. It is unclear whether psychiatrists are more likely to commit medical misconduct offences than non-psychiatrists, and if the nature of these offences is different. Aim The aim of this study was to compare the characteristics of psychiatrists disciplined in Canada and the nature of their offences and disciplinary sentences for the ten years from 2000 through 2009 to other physicians disciplined during that timeframe. Methods Utilizing a retrospective cohort design, we constructed a database of all physicians disciplined by provincial licensing authorities in Canada for the ten years from 2000 through 2009. Demographic variables and information on type of misconduct violation and penalty imposed were also collected for each physician disciplined. We compared psychiatrists to non-psychiatrists for the various outcomes. Results There were 82 (14%) psychiatrists of 606 physicians disciplined in Canada in the ten years from 2000 through 2009, double the national proportion of psychiatrists. Of those disciplined psychiatrists, 8 (9.6%) were women compared to 29% in the national cohort. A total of 5 (6%) psychiatrists committed at least two separate offenses, accounting for approximately 11% of the total violations. A higher proportion of psychiatrists were disciplined for sexual misconduct (OR 3.62 [95% Confidence Interval [CI] 2.45–5.34]), fraudulent behavior (OR 2.32 [95% CI 1.20–4.40]) and unprofessional conduct (OR 3.1 [95% CI 1.95–4.95]). As a result, psychiatrists had between 1.85–4.35 greater risk of having disciplinary penalties in almost all categories in comparison to other physicians. Conclusion Psychiatrists differ from non-psychiatrist physicians in the prevalence and nature of medical misconduct. Efforts to decrease medical misconduct by psychiatrists need to be conducted and systematically evaluated.

The Characteristics of International Medical Graduates Who Have Been Disciplined by Professional Regulatory Colleges in Canada: A Retrospective Cohort Study.

Purpose This study evaluated the proportion and characteristics of international medical graduates (IMGs) who have been disciplined by professional regulatory colleges in Canada in comparison with disciplined North American medical graduates (NAMGs). Method The authors compiled a database of the nature of professional misconduct and penalties incurred by disciplined physicians from January 2000 to May 2015 using public records. They compared discipline data for IMGs versus those for NAMGs, and calculated risk ratios (RRs) and 95% confidence intervals (CIs) for select outcomes. Results There were 794 physicians disciplined; 922 disciplinary cases during the 15-year study period. IMGs composed an average of 23.4% (standard deviation = 1.1%) of the total physician population and represented one-third of disciplined physicians and discipline cases. The overall disciplinary rate for all Canadian physicians was 8.52 cases per 10,000 physician years (95% CI [7.77, 9.31]). This rate per group was higher for IMGs than for NAMGs (12.91 [95% CI (11.50, 14.43)] vs. 8.16 [95% CI (7.53, 8.82)] cases per 10,000 physician years, P < .01, and RR 1.58 (95% CI [1.38, 1.82]). IMGs were disciplined at significantly higher rates than NAMGs if they were trained in South Africa (RR 1.73 [95% CI (1.14, 2.51), P < .01), Egypt (RR 3.59 [95% CI (2.18, 5.52)], P < .01), or India (RR 1.66 [95% CI (1.01, 2.55)], P = .03). Conclusions IMGs are disciplined at a higher rate than NAMGs. Future initiatives should be focused to delineate the exact cause of this observation.

Characteristics of Internal Medicine Physicians Disciplined by Professional Colleges in Canada.

AbstractPhysician misconduct is of serious concern to patient safety and quality of care. Currently, there are limited data on disciplinary proceedings involving internal medicine (IM) physicians.The aim of this study was to investigate the number and nature of disciplinary cases among IM physicians compared with those of other disciplined physicians.Our retrospective study reviewed information from all provincial Colleges of Physicians and Surgeons (CPS) and compiled a database of all disciplined physicians from 2000 to 2013 in Canada. Disciplinary rate differences (RDs) were calculated for IM physicians and compared with other physicians.From 2000 to 2013, overall disciplinary rates were low (9.6 cases per 10,000 physician years). There were 899 disciplinary cases, 49 of which involved 45 different IM physicians. IM physicians comprised 10.8% of all disciplined physicians and were disciplined at a lower rate than non-IM physicians, incurring 5.18 fewer cases per 10,000 physician years than other physicians (95% confidence interval [CI] 3.62–6.73; P < 0.001). They were significantly less likely to be disciplined for: unprofessional conduct (RD 1.16; CI 0.45–1.87; P = 0.001); unlicensed activity (RD 0.78; CI 0.37–1.19; P < 0.001); standard of care issues (RD 1.37; CI 0.49–2.26; P = 0.002); sexual misconduct (RD 1.65; CI 0.90–2.40; P < 0.001); miscellaneous (RD 0.80; CI 0.11–1.50; P = 0.020); mental illness (RD 0.06; CI 0.01–0.12; P = 0.025); inappropriate prescribing (RD 0.74; CI 0.15–1.33; P = 0.010); and criminal conviction (RD 0.33; CI 0.00–0.65; P = 0.048). No significant differences were found with respect to unclear violations, fraudulent behavior/prevarication, or offenses involving drugs/alcohol (all RDs less than 0.32). IM physicians were also less likely to incur the following penalties: voluntary license surrender (RD 0.53; CI 0.37–0.69; P < 0.001); suspension (RD 2.39; CI 1.26–3.51; P < 0.001); retraining/assessment (RD 1.58; CI 0.77–2.39; P < 0.001); restriction (RD 1.60; CI 0.74–2.46; P < 0.001); other (RD 0.52; CI 0.07–0.97; P = 0.030); formal reprimand (RD 2.78; CI 1.77–3.79; P < 0.001); or fine (RD 3.28; CI 1.89–4.67; P < 0.001). No significant differences were found with respect to revocation or mandated counseling/rehabilitation (all RDs less than 0.46).Generally, disciplinary rates among physicians were low. Compared with other physicians, IM physicians have significantly lower disciplinary rates overall and are less likely to incur the majority of disciplinary offenses and penalties.

Massive haemorrhage protocol: what's the best protocol?

Massive transfusion protocols became common practice between 2006 and 2010. The terminology of ‘massive transfusion protocol’ was improved to ‘massive haemorrhage protocol (MHP)’ with the astute recognition that at the start of such a protocol, it is unclear which patients will meet the definition of massive transfusion (10 U/24 h). Despite the majority of the literature being reported from the trauma population, hospitals have generally adopted a single MHP for all patients. It remains unclear whether the same protocol can be used for all patients. MHPs assist with the prevention and management of the acute coagulopathy of trauma/shock (ACOTS). The goals of a MHP are to improve haemostasis, communication and patient outcomes. The protocol must be specific for an individual hospital, depending on factors such as prehospital transport times, distance from laboratory to trauma and operating rooms, patient populations served and types of tests available. The key components of a MHP are the 6Ts: triggering of the protocol, laboratory testing, tranexamic acid, temperature maintenance, transfusion support and termination of the protocol when haemostasis is achieved. The evidence and importance of each of these steps will be discussed in detail. It is also critical that a quality assurance programme supports the MHP. Poor compliance with the institutional MHP is associated with inferior survival. Each MHP activation should be followed by a formal debrief by the team. Audits should be performed to determine compliance and to inform annual update of the MHP. Formal training and/or simulation should be a core part of the policy.

Perioperative transfusion-related acute lung injury: the Canadian Blood Services experience.

PURPOSE Transfusion-related acute lung injury (TRALI) is a devastating transfusion-associated adverse event. There is a paucity of data on the incidence and characteristics of TRALI cases that occur perioperatively. We classified suspected perioperative TRALI cases reported to Canadian Blood Services between 2001 and 2012, and compared them to non-perioperative cases to elucidate factors that may be associated with an increased risk of developing TRALI in the perioperative setting. METHODS All suspected TRALI cases reported to Canadian Blood Services (CBS) since 2001 were reviewed by two experts or, from 2006 to 2012, the CBS TRALI Medical Review Group (TMRG). These cases were classified based on the Canadian Consensus Conference (CCC) definitions and detailed in a database. Two additional reviewers further categorized them as occurring within 72 h from the onset of surgery (perioperative) or not in that period (non-perioperative). Various demographic and characteristic variables of each case were collected and compared between groups. RESULTS Between 2001 and 2012, a total of 469 suspected TRALI cases were reported to Canadian Blood Services; 303 were determined to be within the TRALI diagnosis spectrum. Of those, 112 (38%) were identified as occurring during the perioperative period. Patients who underwent cardiac surgery requiring cardiopulmonary bypass (25.0%), general surgery (18.0%) and orthopedics patients (12.5%) represented the three largest surgical groups. Perioperative TRALI cases comprised more men (53.6% vs. 41.4%, p=0.04) than non-perioperative patients. Perioperative TRALI patients more often required supplemental O2 (14.3% vs. 3.1%, p=0.0003), mechanical ventilation (18.8% vs. 3.1%), or were in the ICU (14.3% vs. 3.7%, p=0.0043) prior to the onset of TRALI compared to non-perioperative TRALI patients. The surgical patients were transfused on average more components than non-perioperative patients (6.0 [SD=8.3] vs. 3.6 [5.2] products per patient, p=0.0002). Perioperative TRALI patients were transfused more plasma (152 vs. 105, p=0.013) and cryoprecipitate (51 vs. 23, p<0.01) than non-perioperative TRALI patients. There was no difference between donor antibody test results between the groups. CONCLUSION CBS data has provided insight into the nature of TRALI cases that occur perioperatively; this group represents a large proportion of TRALI cases.

The off-label utilization of prothrombin complex concentrate with cryoprecipitate as an alternative to plasma transfusion in bleeding patients with acute right ventricular failure

To the Editor, The coagulopathic patient with right ventricular failure presents a conundrum to the perioperative clinician. Because these patients are preload dependent, hemorrhage may rapidly result in cardiogenic shock and end-organ ischemia. Acute coagulation factor replacement to correct factor deficiencies and reverse bleeding entails the transfusion of a large volume of plasma (10-15 mL kg), which will increase most coagulation factors by 20-30% so as to approach the 30-40% target levels considered adequate for hemostasis. In turn, however, such large transfusion volumes can potentially decrease left ventricular preload and cardiac output through ventricular interdependence. Furthermore, when the surgical setting is cardiothoracic, volume overload may promote catastrophic wound or graft dehiscence. When confronted with such complex coagulopathic patients, we have administered the combination of prothrombin complex concentrates (PCCs) with cryoprecipitate as a lower-volume alternative to plasma transfusion. The combination of 1,000 units of a four-factor prothrombin complex and 10 units of cryoprecipitate provides most coagulation factors in doses comparable with four units of plasma, but at less than 15% of the volume (Table). We acknowledge that neither Factor V nor Factor XI is present in significant quantities in either PCCs or cryoprecipitate but propose that these shortfalls are unlikely to be clinically meaningful. The platelet transfusions that many hemorrhaging patients require (particularly in the setting of the acquired thrombasthenia of cardiopulmonary bypass circuits) likely provide an alternative source of Factor V, as 20% of circulating Factor V is contained within platelet alpha granules. While Factor XI concentrates are available, they are not currently licensed in Canada and are therefore difficult to obtain. Furthermore, the significance of not replenishing Factor XI in a patient with global coagulopathy is unclear. In patients with congenital Factor XI deficiency, for example, there is a poor correlation between factor levels and bleeding tendency, possibly reflecting the ability of tissue-factor(TF)/Factor VII to activate Factor IX, Factor XI’s natural substrate. As one of the hemostatic mechanisms of Factor XI is the induction of thrombin activatable fibrinolysis inhibitor, the co-administration of antifibrinolytic medications, such as tranexamic acid (considered a standard of care in patients undergoing cardiopulmonary bypass surgery), may also provide some compensation for relative Factor XI deficiency in hemorrhaging patients. Given the above, with the long circulating half-life of Factor XI at 50 hr and its thrombogenicity when plasma levels exceed 70%, we do not endorse specific replacement in this setting. Our anecdotal experience regarding the hemostatic efficacy of PCCs when combined with cryoprecipitate suggests that the combination may be a useful alternative to plasma in patients with global coagulopathy who are unable to tolerate plasma transfusions, particularly if they are already being managed concurrently with platelet transfusions and A. Alam, MD (&) C. Cserti-Gazdewich, MD J. Pendergrast, MD Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, ON, Canada e-mail: asim.alam@sunnybrook.ca