Background-Homeless people represent an extremely disadvantaged group in North America. Among older homeless men, cardiovascular disease (CVD) is the leading cause of death. The objective of this study was to examine cardiovascular risk factors in a representative sample of homeless adults and identify opportunities for improved risk factor modification. Methods and Results-Homeless persons were randomly selected at shelters for single adults in Toronto. Response rate was 79%. Participants (nϭ202) underwent interviews, physical measurements, and blood sampling. The mean age of participants was 42 years, and 89% were men. The prevalence of smoking among homeless subjects (78%; 95% confidence interval [CI], 72% to 84%) was significantly higher than in the general population (standardized morbidity ratio [SMR], 254; 95% CI, 216 to 297). Hypertension, high cholesterol, and diabetes were not more prevalent than in the general population but were often poorly controlled. Homeless men were significantly less likely to be overweight or obese than men in the general population (SMR, 79; 95% CI, 63 to 98). Cocaine use in the last year was reported by 29% of subjects (95% CI, 23% to 36%). CVD was reported by 15% of subjects, fewer than one third of whom reported taking aspirin or cholesterol-lowering medication. According to multiple-risk-factor equations, the median estimated 10-year absolute risk of myocardial infarction or coronary death among homeless men aged 30 to 74 years was 5% (interquartile range, 3% to 9%). Conclusions-Cardiovascular

Until recently, the belief that adequate pain management was not achievable while patients remained on buprenorphine was the impetus for the perioperative discontinuation of buprenorphine. We aimed to use an expert consensus Delphibased survey technique to 1) specify the need for perioperative guidelines in this context and 2) offer a set of recommendations for the perioperative management of these patients. The major recommendation of this practice advisory is to continue buprenorphine therapy in the perioperative period. It is rarely appropriate to reduce the buprenorphine dose irrespective of indication or formulation. If analgesia is inadequate after optimisation of adjunct analgesic therapies, we recommend initiating a full mu agonist while continuing buprenorphine at some dose. The panel believes that before operation, physicians must distinguish between buprenorphine use for chronic pain (weaning/conversion from longterm high-dose opioids) and opioid use disorder (OUD) as the primary indication for buprenorphine therapy. Patients should ideally be discharged on buprenorphine, although not necessarily at their preoperative dose. Depending on analgesic requirements, they may be discharged on a full mu agonist. Overall, long-term buprenorphine treatment retention and harm reduction must be considered during the perioperative period when OUD is a primary diagnosis. The authors recognise that inter-patient variability will require some individualisation of clinical practice advisories. Clinical practice advisories are largely based on lower classes of evidence (level 4, level 5). Further research is required in order to implement meaningful changes in practitioner behaviour for this patient group.

No abstract

Purpose Technical proficiency in anesthesia has historically been determined subjectively. The purpose of this study was to establish the construct validity for the Imperial College Surgical Assessment Device (ICSAD), a measure of hand motion efficiency, as an objective assessment tool for technical skill performance, by examining its ability to distinguish between operators of different levels of experience performing a labour epidural. Concurrent validity for the ICSAD was investigated by comparison to a validated task specific checklist (CL) and global rating scale (GRS). Methods A single blinded, prospective, controlled study design compared three groups of subjects: novice residents (\30 epidurals), experienced residents ([100 epidurals), and staff anesthesiologists ([500 epidurals). Performance was measured using the ICSAD (number of movements, path length, time) and scores from a CL and GRS graded by examiners blinded to the level of training. Data were analyzed by multivariate analysis of variance (MANOVA). Results Twenty-nine subjects were recruited. Novice residents had longer path lengths compared to experienced residents (P = 0.031) and staff anesthesiologists (P = 0.0004), made more movements (P = 0.012) and took more time than staff (P = 0.009). Novice residents scored significantly worse on the GRS compared to experienced residents (P = 0.029) and staff (P = 0.01) and had significantly lower CL scores compared to staff (P = 0.003). Conclusions Construct and concurrent validity for the ICSAD was established for a regional anesthesia technique by demonstrating that it can distinguish between operators of different levels of experience and by comparing it to the current standards of technical skill assessment. RésuméObjectif La compe´tence technique en anesthe´sie est traditionnellement e´value´e de façon subjective. L'objectif de cette e´tude e´tait d'e´tablir la validite´de la me´thode soustendant le dispositif d'e´valuation chirurgicale de l'Imperial College (ICSAD -Imperial College Surgical Assessment Device), une mesure de l'efficacite´des mouvements de la main, en tant qu'outil d'e´valuation objectif de la performance des compe´tences techniques. Pour ce faire, nous avons examine´la capacite´du dispositif a`faire la distinction entre les ope´rateurs de diffe´rents niveaux d'expe´rience re´alisant une pe´ridurale pour le travail Résultats Vingt-neuf sujets ont e´te´recrute´s. Les re´sidents novices avaient des parcours plus longs comparativement aux re´sidents expe´rimente´s (P = 0,031) et aux anesthe´si-ologistes traitants (P = 0,0004), faisaient plus de mouvements (P = 0,012) et ont pris plus de temps que les anesthe´siologistes traitants (P = 0,009). Les re´sidents novices ont eu des scores conside´rablement moins bons sur l'e´chelle GRS comparativement aux re´sidents expe´rimente´s (P = 0,029) et aux anesthe´siologistes traitants (P = 0,01) et des scores sur la LC conside´rablement plus bas par rapport aux anesthe´siologistes traitants (P = 0,003). Conclusion La validite´de la me´tho...