Total joint arthroplasty (TJA) patients often receive allogeneic blood transfusion. In this study we sought to create and validate a clinical prediction rule for transfusion in TJA using data that are easily available when scheduling the procedure. Logistic regression modeling was applied to retrospective data from all TJA procedures performed in Edmonton, Alberta in 2000 (n = 1875). The area under the receiver operating curve for the resulting model in the training and validation data sets was 0.80 and 0.76 respectively. By assigning a simple score based on six independent predictors (age, gender, weight, hemoglobin, ASA operative risk classification and whether revision surgery was planned), it was possible to classify a given subject's risk of receiving allogeneic transfusion. We conclude that accurate prediction of transfusion risk in TJA is possible using a rule based on simple preoperative clinical and laboratory data. Such prediction could allow transfusion prevention strategies to be applied selectively to those at greatest risk.
PurposeDespite increasing use, proton therapy (PT) remains a relatively limited resource. The purpose of this study was to assess clinical and demographic differences in PT use for prostate cancer compared to intensity modulated radiation therapy (IMRT) at a single institution.Methods and materialsAll patients with low- and intermediate-risk prostate cancer (N = 633) who underwent definitive radiation therapy between 2010 and 2015 were divided into PT (n = 508) and IMRT (n = 125) comparison groups and compared using χ2 and independent sample t tests. Univariable and multivariable logistic regression analyses were conducted to assess the associations between PT use and demographic, clinical, and treatment characteristics.ResultsThe PT and IMRT cohorts varied by age, race, poverty, distance, treatment year, and treating physician. Patients who underwent IMRT were more likely to be older (mean age, 66 vs. 68 years), black (51% vs. 75%), and living in poverty or close to the facility (mean distance between residence and facility, 90 vs. 21 miles; P < .05). Prostate-specific antigen, prostate volume, and International Index of Erectile Function were significantly higher in the IMRT cohort (P < .05), but insurance type, risk group, tumor stage, Gleason score, and patient-reported urinary and bowel scores did not differ significantly (P > .05). Patients who underwent PT were more likely to receive hypofractionated therapy and less likely to receive androgen deprivation therapy (P < .01). On multivariable analysis, black (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.15-0.57) and other race (OR, 0.42; 95% CI, 0.20-0.90); distance (OR, 1.14; 95% CI, 1.06-1.24); treatment years 2011 (OR, 4.87; 95% CI, 2.23-10.6), 2012 (OR, 8.27; 95% CI, 3.43-19.9), and 2014 (OR, 4.44; 95% CI, 1.94-10.2) relative to 2010; and a single treating physician (OR, 0.38; 95% CI, 0.18-0.81) relative to the reference physician with the highest rate of use were associated with PT use, whereas clinical factors such as prostate-specific antigen, prostate volume, International Index of Erectile Function, and androgen deprivation therapy were not.ConclusionSociodemographic disparities exist in PT use for prostate cancer at an urban academic institution. Further investigation of potential barriers to access is warranted to ensure equitable distribution across all demographic groups.
Objectives The aim of this study was to investigate the analgesic efficacy of methadone vs buprenorphine within the QUAD protocol for anaesthesia in cats undergoing ovariohysterectomy. Methods One hundred and twenty cats were recruited to an assessor-blinded, randomised clinical trial. Cats received either methadone (5 mg/m) or buprenorphine (180 µg/m) combined with ketamine, midazolam and medetomidine intramuscularly. Anaesthesia was maintained with isoflurane in oxygen. Atipamezole was administered at extubation. Pain was assessed using the feline Composite Measure Pain Scale (CMPS-F), a dynamic interactive visual analogue scale (DIVAS) and mechanical nociceptive threshold (MNT). Sedation, pain, heart rate and respiratory rate were measured prior to QUAD administration, before intubation, and 2, 4, 6 and 8 h post-QUAD administration. If indicated by the CMPS-F, rescue analgesia was provided with 0.5 mg/kg of methadone administered intramuscularly. Meloxicam was administered after the last assessment. Differences in pain scores between groups were compared using a two-way repeated-measures ANOVA and requirement for rescue analgesia was compared using a χ test. Results Cats administered methadone had lower CMPS-F scores over time ( P = 0.04). Eighteen of 60 cats required rescue analgesia in the methadone group vs 29/60 in the buprenorphine group ( P = 0.028). All cats that received rescue analgesia required it within 6 h post-QUAD administration. There were no differences between groups in MNT or pain measured using the DIVAS. Conclusions and relevance Methadone produced clinically superior postoperative analgesia for the first 8 h after neutering than buprenorphine when used within the QUAD protocol.
Practice points• The perioperative phase of surgery is characterized by many transitions in care.• Appropriate treatment of hyperglycemia and hypoglycemia during the perioperative phase of surgery could improve the likelihood of successfully transitioning a patient within a desired glucose target range to the inpatient healthcare team.• Lack of attention to perioperative glucose monitoring could result in a missed severe hypoglycemic or hyperglycemic event.• Careful monitoring of glucose levels should occur at all phases of perioperative care to monitor for extremes in glucose levels.• Institutions should examine how their diabetes patients are being managed throughout the perioperative period, identify aspects of care in need of improvement, and develop local standards of care.• Implementing standards of care for patients with diabetes undergoing elective surgery can improve key quality measures during the perioperative period. SUMMARY Aim: Assess impact of perioperative care guidelines for patients with diabetes mellitus undergoing elective surgical procedures. Methods: Perioperative guidelines were developed, with key measures compared with a historical cohort. Results: The postguidelines implementation cohort (n = 303) had 326 surgeries compared with 254 in the historical cohort (n = 241). Hemoglobin A 1c was measured in 80 versus 47% historically (p < 0.01); preoperative glucose monitoring was 95 versus 88% (p < 0.01); intraoperative glucose monitoring was 67 versus 29% (p < 0.01); and postanesthesia care unit data were unchanged (p = 0.11). Insulin use increased throughout perioperative care (p ≤ 0.04). Mean preoperative glucose was 130 versus 141 mg/dl (p < 0.01); and, for postanesthesia care, 152 versus 162 mg/dl (p = 0.01). Conclusion: Standards of care improve perioperative glucose monitoring, insulin use and possibly glucose control. Preoperative, intraoperative, and postoperative hyperglycemia are all associated with poorer patient outcomes [1-18]. Limited data indicate that lower preoperative hemoglobin A 1c (HbA 1c ) is associated with fewer infectious complications in surgical patients [1,2]. One study demonstrated For reprint orders, please contact: reprints@futuremedicine.com
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