Brett Doleman

Simple psoas cross-sectional area measurement is a quick and easy method to assess sarcopenia and predicts major surgical complications

AIM Radiologically assessed muscle mass has been suggested as a surrogate marker of functional status and frailty and may predict patients at risk of postoperative complications. We hypothesize that sarcopenia negatively impacts on postoperative recovery and is predictive of complications. METHOD One hundred patients undergoing elective resection for colorectal carcinoma were included in this study. Lean muscle mass was estimated by measuring the cross-sectional area of the psoas muscle at the level of the third lumbar vertebra identified on a preoperative CT scan, normalizing for patient height. Perioperative morbidity was scored according to the Clavien-Dindo classification. All statistical data analyses were carried out using the Statistical Package for the Social Sciences (SPSS) version 20.0. RESULTS Fifteen per cent of patients were identified as sarcopenic. There were no deaths in the study group. Sarcopenia was associated with a significantly increased risk of developing major complications (Grade 3 or greater, OR = 5.41, 95% CI: 1.45-20.15, P = 0.01). Sarcopenia did not predict length of stay, critical care dependency or time to mobilization. CONCLUSION Sarcopenia, as a marker of frailty, is an important risk factor in surgical patients but difficult to estimate using bedside testing. CT scans, performed for preoperative staging, provide an opportunity to quantify lean muscle mass without additional cost or exposure to radiation and eliminate the inconvenience of further investigations.

A systematic review and meta-regression analysis of prophylactic gabapentin for postoperative pain.

We searched MEDLINE, Embase, CINAHL, AMED and CENTRAL databases until December 2014 and included 133 randomised controlled trials of peri‐operative gabapentin vs placebo. Gabapentin reduced mean (95% CI) 24‐h morphine‐equivalent consumption by 8.44 (7.26–9.62) mg, p < 0.001, whereas more specific reductions in morphine equivalents were predicted (R2 = 90%, p < 0.001) by the meta‐regression equation: 3.73 + (−0.378 × control morphine consumption (mg)) + (−0.0023 × gabapentin dose (mg)) + (−1.917 × anaesthetic type), where ‘anaesthetic type’ is ‘1’ for general anaesthesia and ‘0’ for spinal anaesthesia. The type of surgery was not independently associated with gabapentin effect. Gabapentin reduced postoperative pain scores on a 10‐point scale at 1 h, 2 h, 6 h, 12 h and 24 h by a mean (95% CI) of: 1.68 (1.35–2.01); 1.21 (0.88–1.55); 1.28 (0.98–1.57); 1.12 (0.91–1.33); and 0.71 (0.56–0.87), respectively, p < 0.001 for all. The risk ratios (95% CI) for postoperative nausea, vomiting, pruritus and sedation with gabapentin were: 0.78 (0.69–0.87), 0.67 (0.59–0.76), 0.64 (0.51–0.80) and 1.18 (1.09–1.28), respectively, p < 0.001 for all. Gabapentin reduced pre‐operative anxiety and increased patient satisfaction on a 10‐point scale by a mean (95% CI) of 1.52 (0.78–2.26) points and 0.89 (0.22–1.57) points, p < 0.001 and p = 0.01, respectively. All the effects of gabapentin may have been overestimated by statistically significant small study effects.

A systematic review of pre-operative anaemia and blood transfusion in patients with fractured hips.

We systematically reviewed the observational associations of anaemia with outcomes and the effects of interventions to increase haemoglobin concentrations following hip fracture in older people. Anaemia on hospital admission was associated with increased mortality, relative risk 1.64 (95% CI 1.47–1.82), p < 0.0001. After adjustment for co‐morbidities, the association of anaemia with increased mortality remained in four of eight observational studies. There was no association of postoperative transfusion with mortality after adjusting for covariates. Transfusion at 80 g.l−1 vs 100 g.l−1 increased acute myocardial infarction, relative risk 1.67 (95% CI 1.01–2.77), p = 0.05. Transfusion threshold was not associated with differences in other outcomes. There were insufficient high‐quality studies to inform pre‐operative blood transfusion or the use of peri‐operative iron or erythropoietin. Studies for most interventions recruited too few participants to determine effects on infections, mortality or function.

Preventive Acetaminophen Reduces Postoperative Opioid Consumption, Vomiting, and Pain Scores After Surgery: Systematic Review and Meta-Analysis.

Background and Objectives Preventive analgesia has been proposed as a potential strategy to reduce postoperative pain. However, there is currently no review that focuses on acetaminophen for preventive analgesia. Methods We conducted a search of MEDLINE, EMBASE, Cinahl, AMED, and CENTRAL databases identifying randomized controlled trials that compared preventive acetaminophen with postincision acetaminophen. Results Seven studies with 544 participants were included. Overall, the studies showed a reduction in 24-hour opioid consumption (standardized mean difference [SMD] of −0.52; 95% confidence interval [95% CI], −0.98 to −0.06), lower pain scores at 1 hour (MD, −0.50; 95% CI, −0.98 to −0.02) and 2 hours (MD, −0.34; 95% CI, −0.67 to −0.01), and a lower incidence of postoperative vomiting (risk ratio, 0.50; 95% CI, 0.31–0.83) in the preventive acetaminophen group. Current studies are limited by a potential risk of bias. Conclusions To our knowledge, this is the first review to describe a potential preventive effect of acetaminophen. However, well-conducted randomized controlled trials are necessary to substantiate the conclusions of this review.

Systematic review of pre-operative exercise in colorectal cancer patients

AbstractThe aim of this systematic review was to evaluate the evidence for exercise interventions prior to surgery for colorectal cancer resection. The evidence for use of exercise to improve physical fitness and surgical outcomes is as yet unknown. A systematic search was performed of MEDLINE, EMBASE, CINAHL, AMED and BNI databases for studies involving pre-operative exercise in colorectal cancer patients. Eight studies were included in the review. There is evidence that pre-operative exercise improves functional fitness, and to a lesser extent objectively measurable cardio-respiratory fitness prior to colorectal cancer resection. There is no clear evidence at present that this improvement in fitness translates into reduced peri-operative risk or improved post-operative outcomes. Current studies are limited by risk of bias. This review highlights the common difficulty in transferring promising results in a research setting, into significant improvements in the clinical arena. Future research should focus on which type of exercise is most likely to maximise patient adherence and improvements in cardio-respiratory fitness. Ultimately, adequately powered, randomised controlled trials are needed to investigate whether pre-operative exercise improves post-operative morbidity and mortality.

Baseline Morphine Consumption May Explain Between-Study Heterogeneity in Meta-analyses of Adjuvant Analgesics and Improve Precision and Accuracy of Effect Estimates

BACKGROUND: Statistical heterogeneity can increase the uncertainty of results and reduce the quality of evidence derived from systematic reviews. At present, it is uncertain what the major factors are that account for heterogeneity in meta-analyses of analgesic adjuncts. Therefore, the aim of this review was to identify whether various covariates could explain statistical heterogeneity and use this to improve accuracy when reporting the efficacy of analgesics. METHODS: We searched for reviews using MEDLINE, EMBASE, CINAHL, AMED, and the Cochrane Database of Systematic Reviews. First, we identified the existence of considerable statistical heterogeneity (I2 > 75%). Second, we conducted meta-regression analysis for the outcome of 24-hour morphine consumption using baseline risk (control group morphine consumption) and other clinical and methodological covariates. Finally, we constructed a league table of adjuvant analgesics using a novel method of reporting effect estimates assuming a fixed consumption of 50 mg postoperative morphine. RESULTS: We included 344 randomized controlled trials with 28,130 participants. Ninety-one percent of analyses showed considerable statistical heterogeneity. Baseline risk was a significant cause of between-study heterogeneity for acetaminophen, nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors, tramadol, ketamine, &agr;2-agonists, gabapentin, pregabalin, lidocaine, magnesium, and dexamethasone (R2 = 21%–100%; P < .05). There was some evidence that the methodological limitations of the trials explained some of the residual heterogeneity. Type of surgery was not independently associated with analgesic efficacy. Assuming a fixed baseline risk of 50 mg (in order of efficacy), gabapentin, acetaminophen, &agr;2-agonists, nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors, pregabalin, tramadol, magnesium, and lidocaine demonstrated moderate clinically significant reductions (>10 mg). We could not exclude a moderate clinically significant effect with ketamine. Dexamethasone demonstrated a small clinical benefit (>5 mg). CONCLUSIONS: We empirically identified baseline morphine consumption as the major source of heterogeneity in meta-analyses of adjuvant analgesics across all surgical interventions. Controlling for baseline morphine consumption, clinicians can use audit data to estimate the morphine-reducing effect of adding any adjuvant for their local population, regardless which surgery they undergo. Moreover, we have utilized these findings to present a novel method of reporting and an amended method of graphically displaying effect estimates, which both reduces confounding from variable baseline risk in included trials and is able to adjust for other clinical and methodological confounding variables. We recommend use of these methods in clinical practice and future reviews of analgesics for postoperative pain.

Simulation fails to replicate stress in trainees performing a technical procedure in the clinical environment

Abstract Introduction: Simulation-based training (SBT) has become an increasingly important method by which doctors learn. Stress has an impact upon learning, performance, technical, and non-technical skills. However, there are currently no studies that compare stress in the clinical and simulated environment. We aimed to compare objective (heart rate variability, HRV) and subjective (state trait anxiety inventory, STAI) measures of stress theatre with a simulated environment. Methods: HRV recordings were obtained from eight anesthetic trainees performing an uncomplicated rapid sequence induction at pre-determined procedural steps using a wireless Polar RS800CX monitor

The Use of Cannabinoids in Colitis: A Systematic Review and Meta-Analysis

Background Clinical trials investigating the use of cannabinoid drugs for the treatment of intestinal inflammation are anticipated secondary to preclinical literature demonstrating efficacy in reducing inflammation. Methods We systematically reviewed publications on the benefit of drugs targeting the endo-cannabinoid system in intestinal inflammation. We collated studies examining outcomes for meta-analysis from EMBASE, MEDLINE and Pubmed until March 2017. Quality was assessed according to mSTAIR and SRYCLE score. Results From 2008 papers, 51 publications examining the effect of cannabinoid compounds on murine colitis and 2 clinical studies were identified. Twenty-four compounds were assessed across 71 endpoints. Cannabidiol, a phytocannabinoid, was the most investigated drug. Macroscopic colitis severity (disease activity index [DAI]) and myeloperoxidase activity (MPO) were assessed throughout publications and were meta-analyzed using random effects models. Cannabinoids reduced DAI in comparison with the vehicle (standard mean difference [SMD] -1.36; 95% CI, -1.62 to-1.09; I2 = 61%). FAAH inhibitor URB597 had the largest effect size (SMD -4.43; 95% CI, -6.32 to -2.55), followed by the synthetic drug AM1241 (SMD -3.11; 95% CI, -5.01 to -1.22) and the endocannabinoid anandamide (SMD -3.03; 95% CI, -4.89 to -1.17; I2 not assessed). Cannabinoids reduced MPO in rodents compared to the vehicle; SMD -1.26; 95% CI, -1.54 to -0.97; I2 = 48.1%. Cannabigerol had the largest effect size (SMD -6.20; 95% CI, -9.90 to -2.50), followed by the synthetic CB1 agonist ACEA (SMD -3.15; 95% CI, -4.75 to -1.55) and synthetic CB1/2 agonist WIN55,212-2 (SMD -1.74; 95% CI, -2.81 to -0.67; I2 = 57%). We found no evidence of reporting bias. No significant difference was found between the prophylactic and therapeutic use of cannabinoid drugs. Conclusions There is abundant preclinical literature demonstrating the anti-inflammatory effects of cannabinoid drugs in inflammation of the gut. Larger randomised controlled-trials are warranted.

Dialogue vodcasts: a qualitative assessment

to another tweet. Then we analysed the frequencies of other hashtags associated with #ccme13 in order of appearance. The most common hashtag was #MedEd (= medical education), which was found in 451 tweets (14.6% of total tweets), followed by #PaperTiger (= hashtags used during one of the conference symposiums), found in 231 tweets (7.5%), #MedEdPatientsafety (94 tweets, 3.0%), and #WelcomePlenary (93 tweets, 3.0%). The most common non-education hashtag was #top200thingsILoveaboutQuebec, which ranked at 24 in our list of most used hashtags (12 tweets, 0.4%). Next we studied the hashtags used by the largest numbers of the 288 contributors (Tweeters). #MedEd was used by 119 (41.3%) contributors, followed by #PaperTiger (used by 33 contributors [11.5%]) and #sgm2013 (= Spring General Meeting of the Canadian Federation of Medical Students) (used by 30 contributors [10.4%]). The non-education #top200thingsILoveaboutQuebec was tweeted by only 3 contributors (1.0%). What lessons were learned? The analysis of tweets at CCME 2013 showed that Twitter was used to discuss the medical education themes related to the conference more often than for other purposes. This supports the idea that Twitter may be a useful tool for facilitating discussions related to conference topics. Furthermore, evidence of this use of Twitter supports the suggestion that conference organisers should implement new innovations that would facilitate the use of social networking tools in the dissemination of relevant and useful information to a potentially wider audience.

Anaesthetists stress is induced by patient ASA grade and may impair non-technical skills during intubation

The aims of this study were to determine if patient ASA grade was associated with increased stress in anaesthetists with a subsequent effect on non‐technical skills.