Susan Scott

Impact of preoperative change in physical function on postoperative recovery: Argument supporting prehabilitation for colorectal surgery

BACKGROUNDnAbdominal surgery represents a physiologic stress and is associated with a period of recovery during which functional capacity is often diminished. Prehabilitation is a program to increase functional capacity in anticipation of an upcoming stressor. We reported recently the results of a randomized trial comparing 2 prehabilitation programs before colorectal surgery (stationary cycling plus weight training versus a recommendation to increase walking coupled with breathing exercises); however, adherence to the programs was low. The objectives of this study were to estimate: (1) the extent to which physical function could be improved with either prehabilitation program and identify variables associated with response; and (2) the impact of change in preoperative function on postoperative recovery.nnnMETHODSnThis study involved a reanalysis of data arising from a randomized trial. The primary outcome measure was functional walking capacity measured by the Six-Minute Walk Test; secondary outcomes were anxiety, depression, health-related quality of life, and complications (Clavien classification). Multiple linear regression was used to estimate the extent to which key variables predicted change in functional walking capacity over the prehabilitation and follow-up periods.nnnRESULTSnWe included 95 people who completed the prehabilitation phase (median, 38 days; interquartile range, 22-60), and 75 who were also evaluated postoperatively (mean, 9 weeks). During prehabilitation, 33% improved their physical function, 38% stayed within 20 m of their baseline score, and 29% deteriorated. Among those who improved, mental health, vitality, self-perceived health, and peak exercise capacity also increased significantly. Women were less likely to improve; low baseline walking capacity, anxiety, and the belief that fitness aids recovery were associated with improvements during prehabilitation. In the postoperative phase, the patients who had improved during prehabilitation were also more likely to have recovered to their baseline walking capacity than those with no change or deterioration (77% vs 59% and 32%; P = .0007). Patients who deteriorated were at greater risk of complications requiring reoperation and/or intensive care management. Significant predictors of poorer recovery included deterioration during prehabilitation, age >75 years, high anxiety, complications requiring intervention, and timing of follow-up assessment.nnnCONCLUSIONnIn a group of patients undergoing scheduled colorectal surgery, meaningful changes in functional capacity can be achieved over several weeks of prehabilitation. Patients and those who care for them, especially those with poor physical capacity, should consider a prehabilitation regimen to enhance functional exercise capacity before colectomy.

Measuring postoperative recovery: What are clinically meaningful differences?

BACKGROUNDnSurgical innovations are introduced to improve recovery, a complex construct often operationalized by the use of patient-reported outcomes. The minimal clinically important difference (MCID) is the smallest change in an outcome sufficiently important to influence management and is crucial for designing and interpreting comparative effectiveness trials. Our objective was to generate MCID estimates for three postoperative recovery metrics.nnnMETHODSnProspectively collected data on two cohorts of 281 and 130 adult patients undergoing abdominal surgery were analyzed. At each of three visits, patients had completed the 36-Item Short Form Survey from the RAND Medical Outcomes Study (SF-36) and either Community Healthy Activities Model Program for Seniors (CHAMPS) or the 6-minute walk test (6MWT). The MCID was estimated with an anchor-based approach with random effects linear regression models. Patients rating of their own health was used to predict SF-36 domain, CHAMPS, and 6MWT scores. Results are reported as MCID (95% confidence interval).nnnRESULTSnOn the SF-36 domains analyzed, MCIDs were consistently smaller for patients rating their health as excellent or very good (from 8 [6-9] to 15 [12-18]) compared with those for patients rating their health as fair or poor (from 15 [12-19] to 32 [28-36]). For CHAMPS, the MCID was 8 kcal/kg/week (7-9), and for the 6MWT, 14 meters (9-18).nnnCONCLUSIONnPlausible MCIDs and ranges around each estimate are provided. These values should be considered when planning and interpreting abdominal surgery clinical trials where patient-reported outcomes are assessed.

Increased risk of autism spectrum disorders in children born to women with systemic lupus erythematosus: Results from a large population-based cohort

In utero exposure to maternal antibodies and cytokines are potential risk factors for autism spectrum disorders (ASDs). The aim of this study was to determine whether children born to mothers with systemic lupus erythematosus (SLE) have an increased risk of ASD compared to children born to mothers without SLE.

Increased Risk of Autism Spectrum Disorders in Children Born to Women with Systemic Lupus Erythematosus: Results from the OSLER Cohort

In utero exposure to maternal antibodies and cytokines are potential risk factors for autism spectrum disorders (ASDs). The aim of this study was to determine whether children born to mothers with systemic lupus erythematosus (SLE) have an increased risk of ASD compared to children born to mothers without SLE.

Increased Congenital Heart Defects in Children Born to Women With Systemic Lupus Erythematosus Results From the Offspring of Systemic Lupus Erythematosus Mothers Registry Study

Background— In a large population-based study, we aimed to determine whether children born to women with systemic lupus erythematosus (SLE) have an increased risk of congenital heart defects (CHDs) in comparison with children born to women without SLE. Methods and Results— The Offspring of SLE Mothers Registry (OSLER) includes all women who had ≥1 hospitalization for delivery after SLE diagnosis, identified through Quebec’s healthcare databases (1989–2009), and a randomly selected control group of women, matched ≥4:1 for age and year of delivery. We identified children born live to SLE mothers and their matched controls, and ascertained CHD based on ≥1 hospitalization or physician visit with relevant diagnostic codes, within the first 12 months of life. We performed multivariable logistic regression analyses, using the generalized estimating equation method, to adjust for relevant covariates. Five hundred nine women with SLE had 719 children, whereas 5824 matched controls had 8493 children. In comparison with controls, children born to women with SLE experienced more CHD (5.2% [95% confidence interval (CI), 3.7–7.1] versus 1.9% [95% CI, 1.6–2.2], difference 3.3% [95% CI, 1.9–5.2]). In multivariable analyses, children born to women with SLE had a substantially increased risk of CHD (odds ratio, 2.62; 95% CI, 1.77–3.88) in comparison with controls. In addition, in comparison with controls, offspring of SLE mothers had a substantially increased risk of having a CHD repair procedure (odds ratio, 5.82; 95% CI, 1.77–19.09). Conclusions— In comparison with children from the general population, children born to women with SLE have an increased risk of CHD, and an increased risk of having a CHD repair procedure, as well.

Patterns of care at end of life for people with primary intracranial tumors: lessons learned

To determine the variability in processes of care in the last 6 months of life experienced by patients dying of primary intracranial tumors and potential predictors of place of death, axa0death-backwards cohort was assembled using historical data and 1,623 decedents were identified. 90xa0% of people had ≥1 admission to an acute care hospital and 23xa0% spent ≥3xa0months of their last 6xa0months of life in acute care. 44xa0% had ≥1 ER visits and 30xa0% were admitted ≥1 times to ICU. Only 18xa0% had a home visit by a physician. 10xa0% died at home but 49xa0% died in hospital, while 40xa0% died in a palliative care facility. Age, comorbidities, and being diagnosed with grade 4 astrocytoma were associated with greater burden of care. Level of care burden and age were associated with higher odds of dying in a treatment intensive place of death, being diagnosed with grade 4 astrocytoma had opposite effect. Despite valuable research efforts to improve the treatment of primary intracranial tumors that focus on biology, refinements to surgery, radiation, and chemotherapy, there is also room to improve aspects of care at the end of life situation. An integrative approach for this patients’ population, from diagnosis to death, could potentially reduce the care burden in the final period on the health care system, patient’s family and improve access to a better place of death.

Increased male-to-female ratio among children born to women with systemic lupus erythematosus: comment on the article by Lockshin et al.

To the Editor: New experimental evidence suggests that a subset of antiDNA antibodies cross-reacting with the N-methyl-D-aspartate (NMDA) receptor can bind brainstem neuronal receptors, induce apoptosis, and result in a marked preferential loss of female fetuses in murine models of systemic lupus erythematosus (SLE) (1). Observational studies assessing the sex of offspring born to women with SLE are scant and limited by their sample size (2). In a recent study of 281 liveborn children of mothers with SLE, Lockshin et al did not observe an increased male-to-female ratio in offspring of antiphospholipid antibody–negative mothers with SLE compared with the general population (2). Thus, in a large population-based study, we aimed to determine the sex ratio of children born to women with SLE compared with children born to women without SLE. We identified all women with at least 1 hospitalization for a delivery (either for a stillbirth or a live birth) after SLE diagnosis, using Quebec’s physician billing and hospitalization databases (from January 1, 1989 to December 31, 2009). These administrative databases capture all fee-for-service outpatient and hospital medical visits in a universal health care system within the province of Quebec, Canada (population 7.5 million). Women were defined as having SLE if they had either been hospitalized at least once with an SLE diagnosis recorded prior to or at the time of delivery, or if they had at least 2 physician visits with a diagnosis of SLE, occurring 2 months to 2 years apart, up to the time of delivery. This way of defining cases of SLE has been previously shown to have high specificity (99.9%) (3). We randomly selected a general population control group, composed of women matched at least 4:1 for age and year of delivery, who had not been diagnosed as having SLE prior to or at the time of delivery. Quebec’s administrative databases contain valid data on the sex of newborns (4), which we used to calculate the male-to-female ratios for all births occurring in SLE patients and in non-SLE subjects. We performed multivariate logistic regression analysis, with the offspring’s sex as the dependent variable, adjusting for the potential effect of preeclampsia (previously shown to increase the male-to-female ratio in the general population [5]) and race/ethnicity. As administrative databases do not provide data on antibody profiles (i.e., anti-DNA antibodies) and as anti–NMDA receptor antibodies are not commercially available, we could not assess the independent effect of autoantibodies on the sex of the offspring. Among this population, 512 women with SLE had 729 births after diagnosis, while 5,836 matched control women had 8,541 births. In unadjusted estimates, the male-to-female ratio was higher among children born to women with SLE (odds ratio [OR] 1.26, 95% confidence interval [95% CI] 1.09–1.46) versus controls (OR 1.06, 95% CI 1.02–1.11), resulting in an unadjusted OR of 1.18 (95% CI 1.01–1.38). In multivariate analysis with adjustment for the effect of preeclampsia and race/ethnicity, women with SLE had substantially increased odds of having male offspring versus women without SLE (OR 1.18, 95% CI 1.01–1.38). In conclusion, in this large population-based sample, we found a substantial increase in the male-to-female ratio among children born to women with SLE compared with controls. These results should prompt further research on male predominance in children born to women with SLE. Dr. Vinet’s work was supported by a Canadian Institutes for Health Research Fellowship. Dr. Bernatsky’s work was supported by a Career award from the Fonds de Recherche en Santé du Québec and by a Junior Investigator award from the Canadian Institutes for Health Research. Dr. Clarke’s work was supported by a Career award from the Fonds de Recherche en Santé du Québec.

Brief Report: Causes of Stillbirths in Women With Systemic Lupus Erythematosus.

There are few precise or recent estimates of the risk or causes of stillbirths in women with systemic lupus erythematosus (SLE). Thus, we undertook the present study to examine causes of stillbirths in mothers with SLE versus those without SLE.

The Association Between Home Palliative Care Services and Quality of End-of-Life Care Indicators in the Province of Québec

CONTEXTnIn Canada, governments have increased spending on home care to promote better end-of-life care. In the province of Québec, Canada, home palliative care (PC) services (HPCS) are provided by Public Local Community-Based Health Care Service providers (Centres Locaux de Services Communautaires [CLSC]) with universal coverage. Accordingly, there should be no regional variations of these services and their effect on quality of end-of-life PC (QEoLPC) indicators.nnnOBJECTIVESnTo test if all the CLSCs provided the same level of HPCS to cancer patients in the province of Québec, Canada, and the association between level of HPCS and QEoLPC indicators.nnnMETHODSnCharacteristics of 52,316 decedents with cancer were extracted from administrative databases between 2003 and 2006. Two gender-specific adjusted performance of CLSCs in delivering HPCS models were created using gender-specific hierarchical regression adjusted for patient and CLSC neighborhood characteristics. Using the same approach, the strength of the association between the adjusted performance of CLSCs in delivering HPCS and the QEoLPC indicators was estimated.nnnRESULTSnOverall, 27,255 (52.1%) decedents had at least one HPCS. Significant variations in the adjusted performance of CLSC in delivering HPCS were found. Higher performance led to a lower proportion of men having more than one emergency room visit during the last month of life (risk ratio [RR] 0.924; 95% CI 0.867-0.985), and for women, a higher proportion dying at home (RR 2.255; 95% CI 1.703-2.984) and spending less time in hospital (RR 0.765; 95% CI 0.692-0.845).nnnCONCLUSIONnProvision of HPCS remained limited in Québec, but when present, they were associated with improved QEoLPC indicators.

Causes of stillbirths in women with systemic lupus erythematosus

There are few precise or recent estimates of the risk or causes of stillbirths in women with systemic lupus erythematosus (SLE). Thus, we undertook the present study to examine causes of stillbirths in mothers with SLE versus those without SLE.