Rhonda Bryce

The association between obesity and outcomes in critically ill patients

BACKGROUND Obesity rates are increasing worldwide, particularly in North America. The impact of obesity on the outcome of critically ill patients is unclear. METHODS A prospective observational cohort study of consecutive patients admitted to a tertiary critical care unit in Canada between January 10, 2008 and March 31, 2009 was conducted. Exclusion criteria were age <18 years, admission <24 h, planned cardiac surgery, pregnancy, significant ascites, unclosed surgical abdomen and brain death on admission. Height, weight and abdominal circumference were measured at the time of intensive care unit (ICU) admission. Coprimary end points were ICU mortality and a composite of ICU mortality, reintubation, ventilator-associated pneumonia, line sepsis and ICU readmission. Subjects were stratified as obese or nonobese, using two separate metrics: body mass index (BMI) ≥ 30 kg/m(2) and a novel measurement of 75th percentile for waist-to-height ratio (WHR). RESULTS Among 449 subjects with a BMI ≥ 18.5 kg/m(2), both BMI and WHR were available for comparative analysis in 348 (77.5%). Neither measure of obesity was associated with the primary end points. BMI ≥ 3 0 kg/m(2) was associated with a lower odds of six-month mortality than the BMI <30 kg/m(2) group (adjusted OR 0.59 [95% CI 0.36 to 0.97]; P=0.04) but longer intubation times (adjusted RR 1.56 [95% CI 1.17 to 2.07]; P=0.003) and longer ICU length of stay (adjusted RR 1.67 [95% CI 1.21 to 2.31]; P=0.002). Conversely, measurement of 75th percentile for WHR was associated only with decreased ICU readmission (OR 0.23 [95% CI 0.07 to 0.79]; P=0.02). CONCLUSIONS Obesity was not necessarily associated with worse outcomes in critically ill patients.

Exploring Diversity in Socioeconomic Inequalities in Health Among Rural Dwelling Canadians

PURPOSE To describe the patterning of socioeconomic inequalities in health among rural dwelling women and men in a Canadian province, exploring diversity in associations by measure of socioeconomic position, health outcome, and demographic characteristics. METHODS Baseline data from the Saskatchewan Rural Health Study was used, an ongoing prospective cohort study examining the health of rural people in Saskatchewan, Canada. Of the 11,004 eligible addresses, responses to mailed questionnaires were obtained from 4,624 (42%) households, representing 8,261 women and men. Multiple logistic regression was the primary method of analysis; generalized estimating equations were utilized to account for household clustering. Associations between 5 health outcomes (self-rated health, chronic obstructive lung disease, diabetes, heart attack, high blood pressure) and 4 indicators of socioeconomic position (income, education, financial strain, occupational skill level) were assessed, with age and gender as potential effect modifiers. FINDINGS With the exception of occupational skill level, socioeconomic position (SEP) indicators were strongly and inversely related to most health outcomes, often in a graded manner. Associations between SEP and several health outcomes were weaker for older than younger participants (heart attack, high blood pressure, lung disease) and stronger among women compared to men (high blood pressure, lung disease). CONCLUSIONS The patterning of SEP-health associations observed in this rural Canadian sample suggests the need for health promotion strategies and policy initiatives to be broadly targeted at individuals and families occupying a wide range of socioeconomic circumstances.

Does intravenous lidocaine infusion during video-assisted thoracoscopic surgery reduce postoperative analgesia? A randomized controlled study.

To the Editor, Recent meta-analyses show that lidocaine infusions during open abdominal surgery reduce opioid consumption, postoperative ileus, and hospital length of stay; however, results in other surgeries have been conflicting. We conducted a single-centre double-blind randomized controlled trial to investigate whether intravenous lidocaine for video-assisted thoracoscopic surgery (VATS) would lower postoperative opioid requirements. Secondary outcomes included pain scores and side effects such as nausea, vomiting, pruritis, constipation, and symptoms of lidocaine toxicity, including lightheadedness, tinnitus, oral numbness, arrhythmias, altered mental status, or seizures. This trial is registered at ClinicalTrials.gov NCT01277835. After approval from the Biomedical Research Ethics Board at the University of Saskatchewan on February 3, 2010, informed consent was obtained from adults aged 18-75 yr, American Society of Anesthesiologists physical status I-III, and scheduled for VATS from April 2010 to February 2013. Computer randomization allocated patients into two groups according to a 1:1 ratio. The lidocaine treatment group received a 1.5 mg kg bolus of intravenous lidocaine on induction, followed by an infusion of 3 mg min for patients weighing[70 kg or 2 mg min for patients weighing\ 70 kg. The placebo group received a normal saline bolus and an infusion to simulate the study drug. Anesthetic induction was standardized. Postanesthesia care unit (PACU) nurses administered morphine to keep the patients’ numerical rating scale\ 4. All surgical team members (anesthesiologist, surgeon, and nurses) were blinded to the treatment groups. Forty-eight patients were enrolled in the study. Complete data were available for 36 patients (19 lidocaine group; 17 control group) in this per-protocol analysis. Reasons for attrition of 12 patients included: surgical procedure converted to an open procedure (seven patients), failure to connect the lidocaine infusion (one), no data collected on the ward (one), and personal reasons (three). Demographic characteristics were similar between groups (Table). The Table also includes a summary of all study results with a comparison between groups for up to 48 hr postoperatively. We found no statistically significant difference in intraoperative fentanyl use or morphine use in recovery. Postoperative morphine requirements and pain scores were low in both groups and not significantly different at any time. There was no difference in occurrence of side effects, most of which were opioid related: nausea, constipation, urinary retention, and pruritis. One patient in the control group experienced respiratory depression not requiring invasive ventilation. In the PACU, one patient experienced blurry vision and lightheadedness and another experienced hypotension, both in the control group. There were no symptoms of lidocaine toxicity. This trial suggests that an infusion of intravenous lidocaine during VATS procedures does not reduce opioid consumption in the operating room or postoperatively and does not reduce postoperative pain scores. This may be due in part to the relatively low consumption of morphine noted among our patients. Postoperative morphine consumption among VATS M. Slovack, MD (&) B. Taylor, MD D. Ong, MD Department of Anesthesiology, Royal University Hospital, Saskatoon, SK, Canada e-mail: mark.slovack@usask.ca

Trajectories of pain severity in juvenile idiopathic arthritis: results from the Research in Arthritis in Canadian Children Emphasizing Outcomes cohort

Abstract We studied children enrolled within 90 days of juvenile idiopathic arthritis diagnosis in the Research in Arthritis in Canadian Children Emphasizing Outcomes (ReACCh-Out) prospective inception cohort to identify longitudinal trajectories of pain severity and features that may predict pain trajectory at diagnosis. A total of 1062 participants were followed a median of 24.3 months (interquartile range = 16.0-37.1 months). Latent trajectory analysis of pain severity, measured in a 100-mm visual analogue scale, identified 5 distinct trajectories: (1) mild-decreasing pain (56.2% of the cohort); (2) moderate-decreasing pain (28.6%); (3) chronically moderate pain (7.4%); (4) minimal pain (4.0%); and (5) mild-increasing pain (3.7%). Mean disability and quality of life scores roughly paralleled the pain severity trajectories. At baseline, children with chronically moderate pain, compared to those with moderate-decreasing pain, were older (mean 10.0 vs 8.5 years, P = 0.01) and had higher active joint counts (mean 10.0 vs 7.2 joints, P = 0.06). Children with mild-increasing pain had lower joint counts than children with mild-decreasing pain (2.3 vs 5.2 joints, P < 0.001). Although most children with juvenile idiopathic arthritis in this cohort had mild or moderate initial levels of pain that decreased quickly, about 1 in 10 children had concerning pain trajectories (chronically moderate pain and mild-increasing pain). Systematic periodic assessment of pain severity in the months after diagnosis may help identify these concerning pain trajectories early and lay out appropriate pain management plans. Focused research into the factors leading to these concerning trajectories may help prevent them.

Initial Experience Using a Telerobotic Ultrasound System for Adult Abdominal Sonography

Purpose The study sought to assess the feasibility of performing adult abdominal examinations using a telerobotic ultrasound system in which radiologists or sonographers can control fine movements of a transducer and all ultrasound settings from a remote location. Methods Eighteen patients prospectively underwent a conventional sonography examination (using EPIQ 5 [Philips] or LOGIQ E9 [GE Healthcare]) followed by a telerobotic sonography examination (using the MELODY System [AdEchoTech] and SonixTablet [BK Ultrasound]) according to a standardized abdominal imaging protocol. For telerobotic examinations, patients were scanned remotely by a sonographer 2.75 km away. Conventional examinations were read independently from telerobotic examinations. Image quality and acceptability to patients and sonographers was assessed. Results Ninety-two percent of organs visualized on conventional examinations were sufficiently visualized on telerobotic examinations. Five pathological findings were identified on both telerobotic and conventional examinations, 3 findings were identified using only conventional sonography, and 2 findings were identified using only telerobotic sonography. A paired sample t test showed no significant difference between the 2 modalities in measurements of the liver, spleen, and diameter of the proximal aorta; however, telerobotic assessments overestimated distal aorta and common bile duct diameters and underestimated kidney lengths (P values < .05). All patients responded that they would be willing to have another telerobotic examination. Conclusions A telerobotic ultrasound system is feasible for performing abdominal ultrasound examinations at a distant location with minimal training and setup requirements and a moderate learning curve. Telerobotic sonography (robotic telesonography) may open up the possibility of remote ultrasound clinics for communities that lack skilled sonographers and radiologists, thereby improving access to care.

Positive-pressure ventilation during transport: a randomized crossover study of self-inflating and flow-inflating resuscitators in a simulation model.

Positive‐pressure ventilation during transport of intubated patients is generally delivered via a hand‐pressurized device. Of these devices, self‐inflating resuscitators (SIR) and flow‐inflating resuscitators (FIR) constitute the two major types used. Selection of a particular device for transport, however, remains largely an institutional practice.

Incidence and Economic Impact of Incidental Findings on 18F-FDG PET/CT Imaging

Purpose The study sought to determine the incidence of incidental findings on whole-body positron emission tomography with computed tomography (PET/CT) imaging and the average costs of investigations to follow-up or further characterize incidental findings. Methods Imaging reports of 215 patients who underwent whole-body PET/CT imaging were retrospectively reviewed. Our provincial picture archiving and communication system was queried and patient charts were reviewed to identify all investigations performed to follow-up incidental findings within 1 year of the initial PET/CT study. Costs of follow-up imaging studies (professional and technical components) and other diagnostic tests and procedures were determined in Canadian dollars (CAD) and U.S. dollars (USD) using the 2015 Ontario Health Insurance Plan Schedule of Benefits and Fees and 2016 U.S. Medicare Physician Fee Schedule, respectively. Results At least 1 incidental finding was reported in 161 reports (74.9%). The mean number of incidental findings ranged from 0.64 in patients <45 years of age to 2.2 in patients 75 years of age and older. Seventy-five recommendations for additional investigations were made for 64 (30%) patients undergoing PET/CT imaging, and 14 of those were carried out specifically to follow-up incidental findings. Averaged across all 215 patients, the total cost of investigations recommended to follow-up incidental findings was CAD

Satisfaction and Quality of Life Related to Chemotherapy With an Arm Port: A Pilot Study

105.51 (USD

The Utility of the Elbow Sign in the Diagnosis of OSA

127.56) per PET/CT study if all recommendations were acted on, and CAD

Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evaluation in a simulated setting

22.77 (USD