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Teja B, Bosch NA, Diep C, Pereira TV, Mauricio P, Sklar MC, Sankar A, Wijeysundera HC, Saskin R, Walkey A, Wijeysundera DN, Wunsch H. Complication Rates of Central Venous Catheters: A Systematic Review and Meta-Analysis. JAMA Intern Med 2024; 184:474-482. [PMID: 38436976 DOI: 10.1001/jamainternmed.2023.8232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Importance Central venous catheters (CVCs) are commonly used but are associated with complications. Quantifying complication rates is essential for guiding CVC utilization decisions. Objective To summarize current rates of CVC-associated complications. Data Sources MEDLINE, Embase, CINAHL, and CENTRAL databases were searched for observational studies and randomized clinical trials published between 2015 to 2023. Study Selection This study included English-language observational studies and randomized clinical trials of adult patients that reported complication rates of short-term centrally inserted CVCs and data for 1 or more outcomes of interest. Studies that evaluated long-term intravascular devices, focused on dialysis catheters not typically used for medication administration, or studied catheters placed by radiologists were excluded. Data Extraction and Synthesis Two reviewers independently extracted data and assessed risk of bias. Bayesian random-effects meta-analysis was applied to summarize event rates. Rates of placement complications (events/1000 catheters with 95% credible interval [CrI]) and use complications (events/1000 catheter-days with 95% CrI) were estimated. Main Outcomes and Measures Ten prespecified complications associated with CVC placement (placement failure, arterial puncture, arterial cannulation, pneumothorax, bleeding events requiring action, nerve injury, arteriovenous fistula, cardiac tamponade, arrhythmia, and delay of ≥1 hour in vasopressor administration) and 5 prespecified complications associated with CVC use (malfunction, infection, deep vein thrombosis [DVT], thrombophlebitis, and venous stenosis) were assessed. The composite of 4 serious complications (arterial cannulation, pneumothorax, infection, or DVT) after CVC exposure for 3 days was also assessed. Results Of 11 722 screened studies, 130 were included in the analyses. Seven of 15 prespecified complications were meta-analyzed. Placement failure occurred at 20.4 (95% CrI, 10.9-34.4) events per 1000 catheters placed. Other rates of CVC placement complications (per 1000 catheters) were arterial canulation (2.8; 95% CrI, 0.1-10), arterial puncture (16.2; 95% CrI, 11.5-22), and pneumothorax (4.4; 95% CrI, 2.7-6.5). Rates of CVC use complications (per 1000 catheter-days) were malfunction (5.5; 95% CrI, 0.6-38), infection (4.8; 95% CrI, 3.4-6.6), and DVT (2.7; 95% CrI, 1.0-6.2). It was estimated that 30.2 (95% CrI, 21.8-43.0) in 1000 patients with a CVC for 3 days would develop 1 or more serious complication (arterial cannulation, pneumothorax, infection, or DVT). Use of ultrasonography was associated with lower rates of arterial puncture (risk ratio [RR], 0.20; 95% CrI, 0.09-0.44; 13.5 events vs 68.8 events/1000 catheters) and pneumothorax (RR, 0.25; 95% CrI, 0.08-0.80; 2.4 events vs 9.9 events/1000 catheters). Conclusions and Relevance Approximately 3% of CVC placements were associated with major complications. Use of ultrasonography guidance may reduce specific risks including arterial puncture and pneumothorax.
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Affiliation(s)
- Bijan Teja
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
| | - Nicholas A Bosch
- The Pulmonary Center, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tiago V Pereira
- Clinical Trial Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Paolo Mauricio
- The Pulmonary Center, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
- Department of Emergency Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Michael C Sklar
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
| | - Ashwin Sankar
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Division of Cardiology, Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Refik Saskin
- ICES Central, University of Toronto, Toronto, Ontario, Canada
| | - Allan Walkey
- Division of Health Systems Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
- ICES Central, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Hannah Wunsch
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
- Sunnybrook Research Institute, Toronto, Ontario, Canada
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Diep C, Lee S, Xue Y, Xiao M, Pivetta B, Daza JF, Jung JJ, Wijeysundera DN, Ladha KS. Preoperative depression and outcomes after metabolic and bariatric surgery: A systematic narrative review. Obes Rev 2024:e13743. [PMID: 38572605 DOI: 10.1111/obr.13743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/08/2024] [Accepted: 03/10/2024] [Indexed: 04/05/2024]
Abstract
Preoperative depression is prevalent among patients undergoing metabolic and bariatric surgery (MBS) and is a potentially modifiable risk factor. However, the impact of preoperative depression on MBS outcomes has not been systematically reviewed. A search of MEDLINE, Embase, Cochrane, and PsychINFO (inception to June 2023) was conducted for studies reporting associations between preoperative depression and any clinical or patient-reported outcomes after MBS. Eighteen studies (5 prospective and 13 retrospective) reporting on 5933 participants were included. Most participants underwent gastric bypass or sleeve gastrectomy. Meta-analyses were not conducted due to heterogeneity in reported outcomes; findings were instead synthesized using a narrative and tabular approach. Across 13 studies (n = 3390) the associations between preoperative depression and weight loss outcomes at 6-72 months were mixed overall. This may be related to differences in cohort characteristics, outcome definitions, and instruments used to measure depression. A small number of studies reported that preoperative depression was associated with lower quality of life, worse acute pain, and more perioperative complications after surgery. Most of the included studies were deemed to be at high risk of bias, resulting in low or very low certainty of evidence according to the Risk of Bias In Non-randomized Studies - of Exposure (ROBINS-E) tool. While the impact of preoperative depression on weight loss after MBS remains unclear, there is early evidence that depression has negative consequences on other patient-important outcomes. Adequately powered studies using more sophisticated statistical methods are needed to accurately estimate these associations.
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Affiliation(s)
- Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Sandra Lee
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Yuanxin Xue
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Maggie Xiao
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Bianca Pivetta
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Julian F Daza
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, Canada
| | - James J Jung
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, Canada
- Department of Surgery, St. Michael's Hospital, Toronto, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Anesthesia, St. Michael's Hospital, Toronto, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Anesthesia, St. Michael's Hospital, Toronto, Canada
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Lee S, Xue Y, Petricca J, Kremic L, Xiao MZX, Pivetta B, Ladha KS, Wijeysundera DN, Diep C. The impact of pre-operative depression on pain outcomes after major surgery: a systematic review and meta-analysis. Anaesthesia 2024; 79:423-434. [PMID: 38050423 DOI: 10.1111/anae.16188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/06/2023]
Abstract
Symptoms of depression are common among patients before surgery. Depression may be associated with worse postoperative pain and other pain-related outcomes. This review aimed to characterise the impact of pre-operative depression on postoperative pain outcomes. We conducted a systematic review of observational studies that reported an association between pre-operative depression and pain outcomes after major surgery. Multilevel random effects meta-analyses were conducted to pool standardised mean differences and 95%CI for postoperative pain scores in patients with depression compared with those without depression, at different time intervals. A meta-analysis was performed for studies reporting change in pain scores from the pre-operative period to any time-point after surgery. Sixty studies (n = 501,962) were included in the overall review, of which 18 were eligible for meta-analysis. Pre-operative depression was associated with greater pain scores at < 72 h (standardised mean difference 0.97 (95%CI 0.37-1.56), p = 0.009, I2 = 41%; moderate certainty) and > 6 months (standardised mean difference 0.45 (95%CI 0.23-0.68), p < 0.001, I2 = 78%; low certainty) after surgery, but not at 3-6 months after surgery (standardised mean difference 0.54 (95%CI -0.06-1.15), p = 0.07, I2 = 83%; very low certainty). The change in pain scores from pre-operative baseline to 1-2 years after surgery was similar between patients with and without pre-operative depression (standardised mean difference 0.13 (95%CI -0.06-0.32), p = 0.15, I2 = 54%; very low certainty). Overall, pre-existing depression before surgery was associated with worse pain severity postoperatively. Our findings highlight the importance of incorporating psychological care into current postoperative pain management approaches in patients with depression.
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Affiliation(s)
- S Lee
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Y Xue
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - J Petricca
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - L Kremic
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - M Z X Xiao
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - B Pivetta
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - K S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, Canada
| | - D N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, Canada
| | - C Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
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Gandotra S, Daza JF, Diep C, Mitani AA, Ladha KS, Wijeysundera DN. Psychological Distress After Inpatient Noncardiac Surgery: A Secondary Analysis of the Measurement of Exercise Tolerance Before Surgery Prospective Cohort Study. Ann Surg 2024; 279:450-455. [PMID: 37477019 DOI: 10.1097/sla.0000000000006031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVE To describe the incidence and natural progression of psychological distress after major surgery. BACKGROUND The recovery process after surgery imposes physical and mental burdens that put patients at risk of psychological distress. Understanding the natural course of psychological distress after surgery is critical to supporting the timely and tailored management of high-risk individuals. METHODS We conducted a secondary analysis of the "Measurement of Exercise Tolerance before Surgery" multicentre cohort study (Canada, Australia, New Zealand, and the UK). Measurement of Exercise Tolerance before Surgery recruited adult participants (≥40 years) undergoing elective inpatient noncardiac surgery and followed them for 1 year. The primary outcome was the severity of psychological distress measured using the anxiety-depression item of EQ-5D-3L. We used cumulative link mixed models to characterize the time trajectory of psychological distress among relevant patient subgroups. We also explored potential predictors of severe and/or worsened psychological distress at 1 year using multivariable logistic regression models. RESULTS Of 1546 participants, moderate-to-severe psychological distress was reported by 32.6% of participants before surgery, 27.3% at 30 days after surgery, and 26.2% at 1 year after surgery. Psychological distress appeared to improve over time among females [odds ratio (OR): 0.80, 95% CI: 0.65-0.95] and patients undergoing orthopedic procedures (OR: 0.73, 95% CI: 0.55-0.91), but not among males (OR: 0.87, 95% CI: 0.87-1.07) or patients undergoing nonorthopedic procedures (OR: 0.95, 95% CI: 0.87-1.04). Among the average middle-aged adult, there were no time-related changes (OR: 0.94, 97% CI: 0.75-1.13), whereas the young-old (OR: 0.89, 95% CI: 0.79-0.99) and middle-old (OR: 0.87, 95% CI: 0.73-1.01) had small improvements. Predictors of severe and/or worsened psychological distress at 1 year were younger age, poor self-reported functional capacity, smoking history, and undergoing open surgery. CONCLUSIONS One-third of adults experience moderate to severe psychological distress before major elective noncardiac surgery. This distress tends to persist or worsen over time among select patient subgroups.
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Affiliation(s)
- Sakshi Gandotra
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
| | - Julian F Daza
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Aya A Mitani
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Generoso E, Diep C, Hua C, Rader E, Ran R, Lee NJ, Rivera-Lara L. Assessing risk factors associated with breakthrough early post-traumatic seizures in patients receiving phenytoin prophylaxis. Front Neurol 2024; 14:1329042. [PMID: 38239322 PMCID: PMC10795534 DOI: 10.3389/fneur.2023.1329042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/14/2023] [Indexed: 01/22/2024] Open
Abstract
Objective Post-traumatic seizure (PTS) is a well-known complication of traumatic brain injury (TBI). The objective of this study was to identify risk factors associated with breakthrough early PTS in TBI patients receiving phenytoin prophylaxis. Methods This was a single-centered retrospective study including adult patients admitted to the intensive care unit (ICU), had a TBI, and started on phenytoin for seizure prophylaxis within 24 h of admission. The primary outcome was the incidence and factors associated with early PTS, defined as a confirmed seizure on a continuous electroencephalogram within 7 days of TBI. Secondary outcomes included the association between early post-traumatic seizures and ICU length of stay, hospital length of stay, and in-hospital mortality. Results A total of 105 patients were included in the final analysis. Patients with early PTS were older (65 vs. 48 years old, p = 0.01), had a higher Marshall score (5 vs. 2, p = 0.01), were more likely to have a Marshall score > 2 (73 vs. 37%, p = 0.01), and had more neurosurgeries for hematoma evacuation (57 vs. 19%, p = 0.01). In patients with early PTS, 57% had a level at the time of seizure, and of those, 87.5% had a therapeutic level (>10 mcg/mL). Patients with early PTS had a longer ICU length of stay (14.7 vs. 5.9 days, p = 0.04) and a greater proportion of hospital mortality (21 vs. 2%, p = 0.02). Conclusion Patients with higher age, Marshall score, and neurosurgical procedures for hematoma evacuation had higher incidences of breakthrough early PTS despite the use of phenytoin prophylaxis. The majority of patients with early PTS had therapeutic phenytoin levels at the time of seizure when a level was available; however, approximately half (43%) did not have a level.
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Affiliation(s)
- Eugene Generoso
- Department of Pharmacy, Stanford Health Care, Palo Alto, CA, United States
| | - Calvin Diep
- Department of Pharmacy, Stanford Health Care, Palo Alto, CA, United States
| | - Carolyn Hua
- Department of Pharmacy, Stanford Health Care, Palo Alto, CA, United States
| | - Elizabeth Rader
- Department of Pharmacy, Stanford Health Care, Palo Alto, CA, United States
| | - Ran Ran
- Department of Emergency and Critical Care Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Nathanael J. Lee
- Department of Neurology, Stanford Health Care, Palo Alto, CA, United States
| | - Lucia Rivera-Lara
- Department of Neurology, Stanford Health Care, Palo Alto, CA, United States
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Daza JF, Wijeysundera HC, Diep C, Ladha KS, Cuthbertson BH, Wijeysundera DN. Healthcare Costs of New Functional Impairment in the Year after Noncardiac Surgery. Anesthesiology 2023; 139:902-904. [PMID: 37874043 DOI: 10.1097/aln.0000000000004674] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
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Diep C, Ladha KS. Reply to: 'Co-use of opioids with cannabis - evaluating risks and benefits'. Reg Anesth Pain Med 2023; 48:626-627. [PMID: 37263745 DOI: 10.1136/rapm-2023-104626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 06/03/2023]
Affiliation(s)
- Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
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Goel A, Rai Y, Sivadas S, Diep C, Clarke H, Shanthanna H, Ladha KS. Use of Psychedelics for Pain: A Scoping Review. Anesthesiology 2023; 139:523-536. [PMID: 37698433 DOI: 10.1097/aln.0000000000004673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
Chronic pain is a public health concern that affects approximately 1.5 billion people globally. Conventional therapeutic agents including opioid and non-opioid analgesics have been associated with adverse side effects, issues with addiction, and ineffective analgesia. Novel agents repurposed to treat pain via different mechanisms are needed to fill the therapeutic gap in chronic pain management. Psychedelics such as lysergic acid diethylamide and psilocybin (the active ingredient in psychedelic mushrooms) are thought to alter pain perception through direct serotonin receptor agonism, anti-inflammatory effects, and synaptic remodeling. This scoping review was conducted to identify human studies in which psychedelic agents were used for the treatment of pain. Twenty-one articles that assessed the effects of psychedelics in treating various pain states were included. The present scarcity of clinical trials and small sample sizes limit their application for clinical use. Overall, psychedelics appear to show promise for analgesia in patients with certain headache disorders and cancer pain diagnoses. Future studies must aim to examine the combined effects of psychotherapy and psychedelics on chronic pain.
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Affiliation(s)
- Akash Goel
- Department of Anesthesiology, St. Michael's Hospital, Toronto, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Yeshith Rai
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Shayan Sivadas
- Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada; Department of Anesthesiology and Pain Medicine, Toronto General Hospital, Toronto, Canada
| | - Harsha Shanthanna
- Departments of Anesthesia, Surgery and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Karim S Ladha
- Department of Anesthesiology, St. Michael's Hospital, Toronto, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
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Ladha KS, Wijeysundera DN, Wunsch H, Clarke H, Diep C, Jivraj NK, Martins D, Chung H, Bath K, Gomes T. The Association Between Opioid Prescribing and Opioid-Related Mortality Within Neighborhoods in Ontario, Canada: A Case-Control Study. J Stud Alcohol Drugs 2023; 84:389-397. [PMID: 36971756 DOI: 10.15288/jsad.22-00170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVE Recent Canadian data show that the prescribing of opioids has declined while the number of opioid deaths continues to rise. This study aimed to assess the relationship between neighborhood-level opioid prescription rates and opioid-related mortality among individuals without an opioid prescription. METHOD This was a nested case-control study using data in Ontario from 2013 to 2019. Neighborhood-level data were analyzed by using dissemination areas that consist of 400-700 people. Cases were defined as individuals who had an opioid-related death without an opioid prescription filled in the year prior. Cases and controls were matched using a disease risk score. After matching, there were 2,401 cases and 8,813 controls. The primary exposure was the total volume of opioids dispensed within the individual's dissemination area in the 90 days before the index date. Conditional logistic regression was used to examine the association between opioid prescriptions and the risk of overdose. RESULTS There was no significant association between the total volume of opioid prescriptions dispensed in a dissemination area and opioid-related mortality. In subgroup analyses stratifying the cohort into prescription and nonprescription opioid-related mortality, the number of prescriptions dispensed was positively associated with prescription opioid-related mortality. There was also a significant inverse association between the increased total volume of opioids dispensed and nonprescription opioid mortality. CONCLUSIONS Our results suggest that prescription opioids dispensed within a neighborhood can have both potential benefits and harms. The opioid epidemic requires a nuanced approach that ensures appropriate pain care for patients while also creating a safer environment for opioid use through harm-reduction strategies.
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Affiliation(s)
- Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Hannah Wunsch
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Naheed K Jivraj
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Diana Martins
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - Karanpreet Bath
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
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McParland AL, Bhatia A, Matelski J, Tian C, Diep C, Clarke H, Kapustin D, Triveda A, Brull R, Singh M. Evaluating the impact of cannabinoids on sleep health and pain in patients with chronic neuropathic pain: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med 2023; 48:180-190. [PMID: 36598058 DOI: 10.1136/rapm-2021-103431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 10/25/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Chronic neuropathic pain is often debilitating and can have a significant impact on sleep health and quality of life. There is limited information on the impact of cannabinoids on sleep health when treating neuropathic pain. OBJECTIVE The objectives of this systematic review and meta-analysis were to determine the effect of cannabinoids on sleep quality, pain intensity, and patient impression of treatment efficacy in patients with neuropathic pain. EVIDENCE REVIEW Nine available medical literature databases were searched for randomized controlled trials comparing synthetic and natural cannabinoids to placebo in patients with neuropathic pain syndromes. Data on validated tools for sleep quality, pain intensity, patients' global impression of change (PGIC), and incidence of adverse effects of cannabinoids were extracted and synthesized. FINDINGS Of the 3491 studies screened, eight randomized controlled trials satisfied the inclusion criteria for this review. Analyses were performed using R -4.1.2. using the metafor package and are interpreted using alpha=0.05 as the threshold for statistical significance. Validated measures for sleep health were not used in most studies. Meta-analysis of data from six studies showed that cannabinoids were associated with a significant improvement in sleep quality (standardized mean difference (SMD): 0.40; 95% CI: 0.19 to -0.61, 95% prediction interval (PI): -0.12 to 0.88, p-value=0.002, I2=55.26, τ2=0.05, Q-statistic=16.72, GRADE: moderate certainty). Meta-analysis of data from eight studies showed a significant reduction in daily pain scores in the cannabinoid (CB) group (SMD: -0.55, 95% CI:-0.69 to -0.19, 95% PI: -1.51 to 0.39, p=0.003, I2=82.49, τ2=0.20, Q-statistic=47.69, GRADE: moderate certainty). However, sleep health and analgesic benefits were associated with a higher likelihood of experiencing daytime somnolence, nausea, and dizziness. CONCLUSIONS Cannabinoids have a role in treating chronic neuropathic pain as evidenced by significant improvements in sleep quality, pain intensity, and PGIC. More research is needed to comprehensively evaluate the impact of cannabinoids on sleep health and analgesic efficacy. PROSPERO REGISTRATION NUMBER CRD42017074255.
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Affiliation(s)
- Aidan Leonard McParland
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Anuj Bhatia
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Chenchen Tian
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - Calvin Diep
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - Hance Clarke
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Kapustin
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Aditya Triveda
- School of Graduate Studies, McMaster University, Hamilton, Ontario, Canada
| | - Richard Brull
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - Mandeep Singh
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, Ontario, Canada
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11
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Hornstein G, Diep C, Masson JB, Potvin J, Gobeil JF, Noiseux N, Forcillo J. The Use of Three-Dimensional Printing in Cardiac Structural Disease: A Review. Innovations (Phila) 2023; 18:132-143. [PMID: 36988286 DOI: 10.1177/15569845231161287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
OBJECTIVE Three-dimensional printing (3DP), or additive fabrication, is a process in which a physical 3D model is created using a multitude of 2-dimensional images. This process has been applied to numerous surgical subspecialties with growing interest for the use of 3DP in adult structural heart disease. This scoping review evaluates the use of 3DP in transcatheter and surgical aortic and mitral valve interventions as well as left atrial appendage occlusion in terms of its practical and clinical application. METHODS Articles were identified through PubMed and Embase using MeSH search terms as well as independent searches. A total of 645 articles were screened, and 37 were retained for qualitative analysis. RESULTS Operative planning was coded in 100% of articles, complication prevention in 43%, medical education in 5.4%, patient education in 0%, and simulation in 5.4%. CONCLUSIONS The main uses of 3DP in acquired structural heart disease are centered around operative planning and complication prevention, with moderate use regarding surgical simulation and infrequent use regarding medical and/or patient education. Although patient anatomy varies greatly, deploying 3DP as a large-scale tool remains a possibility. The more 3D models are made, the more can be learned about demographic subsets of patient populations. Due to the lack of standard operating procedures for the creation of 3DP models, the cost-effectiveness of these models is hard to determine and likely center specific. More research into this facet could inform centers that wish to implement this tool.
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Affiliation(s)
- Gabrielle Hornstein
- Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), QC, Canada
| | - Calvin Diep
- Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), QC, Canada
| | - Jean-Bernard Masson
- Department of Cardiology, Centre Hospitalier de l'Université de Montréal (CHUM), QC, Canada
| | - Jeannot Potvin
- Department of Cardiology, Centre Hospitalier de l'Université de Montréal (CHUM), QC, Canada
| | - Jean-François Gobeil
- Department of Cardiology, Centre Hospitalier de l'Université de Montréal (CHUM), QC, Canada
| | - Nicolas Noiseux
- Department of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), QC, Canada
| | - Jessica Forcillo
- Department of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), QC, Canada
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12
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Lu B, Wong M, Ha D, Bounthavong M, Banaei N, Deresinski S, Diep C. Piperacillin/tazobactam versus cefepime or carbapenems for cefoxitin-non-susceptible Enterobacter cloacae, Klebsiella aerogenes, Citrobacter freundii, Serratia marcescens and Morganella morganii bacteraemia in immunocompromised patients. J Antimicrob Chemother 2023; 78:1009-1014. [PMID: 36879495 PMCID: PMC10068414 DOI: 10.1093/jac/dkad037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/24/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND The role of piperacillin/tazobactam for treatment of serious infections due to AmpC-producing organisms remains debatable, particularly in immunocompromised patients. METHODS This was a retrospective cohort study in immunocompromised patients that investigated the effect of definitive treatment with either piperacillin/tazobactam versus cefepime or carbapenems for bacteraemia caused by cefoxitin-non-susceptible Enterobacterales. The primary endpoint was a composite of clinical and microbiological failure. A logistic regression model was constructed to assess the impact of definitive treatment choice on the primary endpoint. RESULTS A total of 81 immunocompromised patients with blood cultures positive for cefoxitin-non-susceptible Enterobacterales were included for analysis. There was more microbiological failure in the piperacillin/tazobactam arm compared with the cefepime/carbapenem arm (11.4% versus 0.0%, P = 0.019). Definitive treatment with cefepime or a carbapenem was associated with a decreased odds of clinical or microbiological failure (OR 0.303, 95% CI 0.093-0.991, P = 0.048) when controlling for baseline characteristics. CONCLUSIONS In immunocompromised patients with bacteraemia due to cefoxitin-non-susceptible Enterobacterales, definitive treatment with piperacillin/tazobactam was associated with an increased risk of microbiological failure and higher odds of clinical or microbiological failure compared with cefepime or carbapenems.
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Affiliation(s)
- Brian Lu
- Department of Pharmacy, Stanford Health Care, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Miranda Wong
- Department of Pharmacy, Stanford Health Care, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - David Ha
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, Stanford, CA, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Mark Bounthavong
- Division of Clinical Pharmacy, UCSD Skaggs School of Pharmacy & Pharmaceutical Sciences, La Jolla, CA, USA
| | - Niaz Banaei
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Division of Clinical Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Stanley Deresinski
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, Stanford, CA, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Calvin Diep
- Department of Pharmacy, Stanford Health Care, 300 Pasteur Drive, Stanford, CA 94305, USA
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13
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Diep C, Goel A, Wijeysundera DN, Clarke H, Ladha KS. Co-use of cannabis and prescription opioids in adults in the USA: a population-based, cross-sectional analysis of the NHANES from 2009 to 2018. Reg Anesth Pain Med 2022; 48:rapm-2022-103933. [PMID: 36543390 DOI: 10.1136/rapm-2022-103933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/03/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Cannabis and cannabinoids continue to gain popularity as adjuncts or alternatives to opioids in pain management, with evolving evidence of effectiveness. The relationship between cannabis and opioid use has previously been investigated in smaller cohorts or ecological samples, but not yet in a nationally representative sample. METHODS A cross-sectional analysis of adults in the USA was undertaken using National Health and Nutrition Examination Survey (NHANES) data from 2009 to 2018. The primary exposure was self-reported use of at least one opioid-containing prescription medication in the 30 days prior to survey administration. The outcome of interest was self-reported cannabis use in the same period. Multivariable logistic regression was used to adjust for sociodemographic and health-related covariates, and NHANES survey sample weights were included in modeling. Prescription opioid users were then subclassified as short-term users (<90 days) or chronic users (≥90 days) in secondary analysis. RESULTS A total 10,928 survey respondents were included in analyses, representing 110 million adults in the USA aged 18-59. In this weighted cohort, 5.6%±0.4% reported a recent opioid prescription. Among prescription opioid users, 18.4%±3.1% reported recent cannabis use, not significantly different from 17.7%±0.7% among non-users (OR 1.05, 95% CI 0.81 to 1.36, p=0.714). After adjustment for covariates, opioid users were significantly less likely to have recently used cannabis (adjusted OR, aOR 0.70, 95% CI 0.51 to 0.97, p=0.032). When opioid users were subclassified by duration of prescription, there was no detectable difference in recent cannabis use between chronic opioid users and short-term opioid users (aOR 1.11, 95% CI 0.70 to 1.78, p=0.649). CONCLUSION Recent prescription opioid use was associated with decreased odds of cannabis use in this cross-sectional analysis of a nationally representative cohort. These findings suggest that use of cannabis or prescription opioids may not independently promote use of the other.
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Affiliation(s)
- Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Akash Goel
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Medicine, University Health Network, Toronto, Ontario, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
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14
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Lu B, Wong M, Diep C, Ha DR, Bounthavong M, Banaei N, Deresinski S. 1863. Treatment and Outcomes of Cefoxitin-Non-Susceptible Serratia marcescens, Klebsiella aerogenes, Citrobacter freundii, Enterobacter cloacae, and Morganella morganii Bacteremia with Piperacillin/Tazobactam Versus Cefepime or Carbapenem in Immunocompromised Patients. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
A recent guidance suggested “caution if prescribing piperacillin-tazobactam for serious infections caused by organisms at high risk of significant AmpC production” and that the preferred antibiotic choice should be either cefepime or a carbapenem, despite an admitted lack of definitive evidence. Examination of this question in immunocompromised patients may provide such evidence.
Methods
This was a retrospective, single-center study conducted from January 2016 to December 2021. We included immunocompromised patients aged 18 years or older who had a laboratory confirmed blood culture positive for Enterobacterales showing non-susceptibility to cefoxitin and were definitively treated with piperacillin-tazobactam, cefepime, or a carbapenem. The primary endpoint was a composite of clinical or microbiological failure, which was comprised of in-hospital 30-day mortality, white blood count >12 x 109/L or temperature >38°C on days 5-7, microbiological failure on days 3-5, or microbiological recurrence/relapse on days 5-30.
Results
We identified 81 patients who were included for analysis. Baseline characteristics between arms were similar between groups except for more frequent severe neutropenia (p=0.010) and higher Pitt bacteremia scores (p=0.042) in the cefepime/carbapenem group. Within the piperacillin/tazobactam arm, 17 of 35 (48.6%) had clinical or microbiological failure, compared to 17 of 46 (37.0%) patients in the carbapenem/cefepime arm (p=0.294). Microbiological failure occurred in 4 of 35 (11.4%) patients treated with piperacillin/tazobactam compared to 0 of 46 (0%) patients treated with a carbapenem/cefepime (p=0.019). In multivariate analysis, patients treated with a carbapenem/cefepime had a 69% lower odds of clinical or microbiological failure compared to those treated with piperacillin/tazobactam (OR = 0.31; 95% confidence interval, 0.10-0.98).
Conclusion
In immunocompromised patients with bacteremia due to cefoxitin-non-susceptible Serratia marcescens, Klebsiella aerogenes, Citrobacter freundii, Enterobacter cloacae, or Morganella morganii, definitive treatment with piperacillin/tazobactam was associated with a higher likelihood of microbiological failure compared with treatment with a carbapenem or cefepime.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
- Brian Lu
- Stanford Health Care , Stanford, California
| | - Miranda Wong
- Lucile Packard Children's Hospital Stanford , Stanford, California
| | | | - David R Ha
- Stanford Health Care , Stanford, California
| | - Mark Bounthavong
- Skaggs School of Pharmacy & Pharmaceutical Sciences , San Diego, California
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15
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Picarelli H, Yamaki VN, Solla DJF, Neville IS, Santos AGD, Freitas BSAGD, Diep C, Paiva WS, Teixeira MJ, Figueiredo EG. The preoperative neutrophil-to-lymphocyte ratio predictive value for survival in patients with brain metastasis. Arq Neuropsiquiatr 2022; 80:922-928. [PMID: 36261127 PMCID: PMC9770070 DOI: 10.1055/s-0042-1755324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The neutrophil-to-lymphocyte (NLR), monocyte-to-lymphocyte (MLR), platelet-to-lymphocyte ratio (PLR), and red blood cell distribution width (RDW) have been previously studied as predictors of survival in different malignancies. OBJECTIVE The aim of this study was to evaluate the predictive value of these hematologic inflammatory biomarkers for patients with brain metastases (BM). METHODS We reviewed a consecutive cohort of patients at Instituto do Cancer do Estado de São Paulo (ICESP-FMUSP) from 2011 to 2016 with ≥ 1 BM treated primarily by surgical resection. The primary outcome was 1-year survival. We optimized the NLR, MLR, PLR, and RDW cutoff values, preserving robustness and avoiding overestimation of effect size. RESULTS A total of 200 patients (mean age 56.1 years; 55.0% female) met inclusion criteria. Gross-total resection was achieved in 89.0%. The median (quartiles) preoperative and postoperative KPS scores were 60 (50-80) and 80 (60-90), respectively. Preoperative NLR was significantly associated with survival (HR 2.66, 95% CI: 1.17-6.01, p = 0.019). A NLR cutoff value of 3.83 displayed the most significant survival curve split. CONCLUSIONS Preoperative NLR is an independent predictor of survival in newly diagnosed BM. We propose a cutoff value of 3.83 for preoperative NLR testing may be clinically useful as predictor of poor survival in this population. The wide accessibility of the NLR favors its inclusion in clinical decision-making processes for BM management.
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Affiliation(s)
- Helder Picarelli
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Divisão de Neurocirurgia, São Paulo SP, Brazil.,Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto do Câncer de São Paulo, São Paulo SP, Brazil.
| | - Vitor Nagai Yamaki
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Divisão de Neurocirurgia, São Paulo SP, Brazil.
| | - Davi Jorge Fontoura Solla
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Divisão de Neurocirurgia, São Paulo SP, Brazil.
| | - Iuri Santana Neville
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Divisão de Neurocirurgia, São Paulo SP, Brazil.,Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto do Câncer de São Paulo, São Paulo SP, Brazil.
| | - Alexandra Gomes dos Santos
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Divisão de Neurocirurgia, São Paulo SP, Brazil.,Address for correspondence Alexandra Gomes dos Santos
| | | | - Calvin Diep
- University of Toronto Medical School, Department of Anesthesiology and Pain Medicine, Toronto, Ontario, Canada.
| | - Wellingson Silva Paiva
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Divisão de Neurocirurgia, São Paulo SP, Brazil.
| | - Manoel Jacobsen Teixeira
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Divisão de Neurocirurgia, São Paulo SP, Brazil.
| | - Eberval Gadelha Figueiredo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Divisão de Neurocirurgia, São Paulo SP, Brazil.
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16
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Drozdz SJ, Goel A, McGarr MW, Katz J, Ritvo P, Mattina GF, Bhat V, Diep C, Ladha KS. Ketamine Assisted Psychotherapy: A Systematic Narrative Review of the Literature. J Pain Res 2022; 15:1691-1706. [PMID: 35734507 PMCID: PMC9207256 DOI: 10.2147/jpr.s360733] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/20/2022] [Indexed: 11/23/2022] Open
Abstract
Currently, ketamine is used in treating multiple pain, mental health, and substance abuse disorders due to rapid-acting analgesic and antidepressant effects. Its limited short-term durability has motivated research into the potential synergistic actions between ketamine and psychotherapy to sustain benefits. This systematic review on ketamine-assisted psychotherapy (KAP) summarizes existing evidence regarding present-day practices. Through rigorous review, seventeen articles that included 603 participants were identified. From available KAP publications, it is apparent that combined treatments can, in specific circumstances, initiate and prolong clinically significant reductions in pain, anxiety, and depressive symptoms, while encouraging rapport and treatment engagement, and promoting abstinence in patients addicted to other substances. Despite much variance in how KAP is applied (route of ketamine administration, ketamine dosage/frequency, psychotherapy modality, overall treatment length), these findings suggest psychotherapy, provided before, during, and following ketamine sessions, can maximize and prolong benefits. Additional large-scale randomized control trials are warranted to understand better the mutually influential relationships between psychotherapy and ketamine in optimizing responsiveness and sustaining long-term benefits in patients with chronic pain. Such investigations will assist in developing standardized practices and maintenance programs.
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Affiliation(s)
- Sandra J Drozdz
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
| | - Akash Goel
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada.,Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Matthew W McGarr
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Joel Katz
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Psychology, York University, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada.,School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Paul Ritvo
- Department of Psychology, York University, Toronto, ON, Canada.,School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | | | - Venkat Bhat
- Interventional Psychiatry Program, St. Michael's Hospital, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Karim S Ladha
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
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17
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Diep C, Bhat V, Wijeysundera DN, Clarke HA, Ladha KS. The Association between Recent Cannabis Use and Suicidal Ideation in Adults: A Population-based Analysis of the NHANES from 2005 to 2018. Can J Psychiatry 2022; 67:259-267. [PMID: 33641436 PMCID: PMC9014669 DOI: 10.1177/0706743721996112] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE With the increasing prevalence of cannabis use, there is a growing concern about its association with depression and suicidality. The aim of this study was to examine the relationship between recent cannabis use and suicidal ideation using a nationally representative data set. METHODS A cross-sectional analysis of adults was undertaken using National Health and Nutrition Examination Survey data from 2005 to 2018. Participants were dichotomized by whether or not they had used cannabis in the past 30 days. The primary outcome was suicidal ideation, and secondary outcomes were depression and having recently seen a mental health professional. Multiple logistic regression was used to adjust for potential confounders, and survey sample weights were considered in the model. RESULTS Compared to those with no recent use (n = 18,599), recent users (n = 3,127) were more likely to have experienced suicidal ideation in the past 2 weeks (adjusted odds ratio [aOR] 1.54, 95% CI, 1.19 to 2.00, P = 0.001), be depressed (aOR 1.53, 95% CI, 1.29 to 1.82, P < 0.001), and to have seen a mental health professional in the past 12 months (aOR 1.28, 95% CI, 1.04 to 1.59, P = 0.023). CONCLUSIONS Cannabis use in the past 30 days was associated with suicidal thinking and depression in adults. This relationship is likely multifactorial but highlights the need for specific guidelines and policies for the prescription of medical cannabis for psychiatric therapy. Future research should continue to characterize the health effects of cannabis use in the general population.
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Affiliation(s)
- Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Ontario, Canada
| | - Venkat Bhat
- Department of Psychiatry, University of Toronto, Ontario, Canada.,Department of Psychiatry, St. Michael's Hospital, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Faculty of Medicine, Institute of Medical Science, University of Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario, Canada.,Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Hance A Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Ontario, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, Ontario, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario, Canada.,Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
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18
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Vachhani K, Wijeysundera DN, Mistry N, Clarke H, Diep C, Ladha KS. The relationship between cannabis use and legalization frameworks: A cross-sectional analysis using a nationally representative survey. Prev Med 2022; 156:106978. [PMID: 35131207 DOI: 10.1016/j.ypmed.2022.106978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 01/16/2022] [Accepted: 01/29/2022] [Indexed: 10/19/2022]
Abstract
State policies related to cannabis have rapidly evolved but the impact of current legislative frameworks on usage is not well characterized. This study explored cannabis use patterns under different legalization statuses in the United States. The dataset included individuals from the Behavioral Risk Factor Surveillance System survey in 2017 and 2018. Respondents were categorized into limited medical use, full medical use, or full legalization groups based on their state's cannabis policies. The primary outcome was cannabis use in the past 30 days. Among users, we characterized frequency, method, and reason for use. Logistic regression models were estimated to assess associations between legal status and these outcome measures. The study sample included 168,299 respondents. The unweighted proportion of respondents reporting cannabis use were: 4.96% in states with limited medical use, 6.50% in states with full medical use, and 12.33% in states with full legalization. Adjusted odds of use were greater for the full medical use group (1.13, 95%CI:1.02-1.25) and the full legalization group (2.53, 95%CI:2.28-2.82) compared to the limited medical use group. Users were more likely to use non-smoking methods in the full legalization group compared to the limited medical use group (1.77, 95%CI:1.41-2.22). A greater proportion of users in the full legalization group reported medical usage than in the other two groups. Policymakers should consider these findings in order to allow for use while safeguarding public health.
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Affiliation(s)
- Kathak Vachhani
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Nikhil Mistry
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Hance Clarke
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Karim S Ladha
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada.
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Schwenk ES, Gupta RK, Diep C. Recent cannabis use and nightly sleep duration in adults: an infographic. Reg Anesth Pain Med 2021; 47:105. [PMID: 34873025 DOI: 10.1136/rapm-2021-103294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/06/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Eric S Schwenk
- Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rajnish K Gupta
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
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Diep C, Tian C, Vachhani K, Won C, Wijeysundera DN, Clarke H, Singh M, Ladha KS. Recent cannabis use and nightly sleep duration in adults: a population analysis of the NHANES from 2005 to 2018. Reg Anesth Pain Med 2021; 47:100-104. [PMID: 34873024 DOI: 10.1136/rapm-2021-103161] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/22/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND While popularly consumed for its perceived benefits as a sleeping aid, the impact of cannabis on sleep-wake regulation in clinical studies is inconclusive. The purpose of this study was to determine the relationship between cannabis use and nightly sleep duration in a nationally representative dataset. METHODS A cross-sectional analysis of adults was undertaken using the National Health and Nutrition Examination Survey data from 2005 to 2018. Respondents were dichotomized as recent users or non-users if they had used or not used cannabis in the past 30 days, respectively. The primary outcome was nightly sleep duration, categorized as short (<6 hours), optimal (6-9 hours), and long (>9 hours). Multinomial logistic regression was used to adjust for sociodemographic and health-related covariates, and survey sample weights were used in modeling. RESULTS From a sample representing approximately 146 million adults in the USA, 14.5% reported recent cannabis use. In an adjusted analysis, recent users were more likely than non-users to report both short sleep (OR 1.34, 95% CI 1.12 to 1.59, p<0.001) and long sleep (OR 1.56, 95% CI 1.25 to 1.96, p<0.001). Heavy users (≥20 of the past 30 days) were even more likely to be at the extremes of nightly sleep duration. DISCUSSION Recent cannabis use was associated with the extremes of nightly sleep duration in a nationally representative sample of adults, with suggestions of a dose-response relationship. Our findings highlight the need to further characterize the sleep health of regular cannabis users in the population.
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Affiliation(s)
- Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Chenchen Tian
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kathak Vachhani
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Christine Won
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
| | - Mandeep Singh
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada .,Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
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21
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Diep C, Meng L, Pourali S, Hitchcock MM, Alegria W, Swayngim R, Ran R, Banaei N, Deresinski S, Holubar M. Effect of rapid methicillin-resistant Staphylococcus aureus nasal polymerase chain reaction screening on vancomycin use in the intensive care unit. Am J Health Syst Pharm 2021; 78:2236-2244. [PMID: 34297040 PMCID: PMC8661079 DOI: 10.1093/ajhp/zxab296] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE To determine the impact of a pharmacist-driven methicillin-resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) screen on vancomycin duration in critically ill patients with suspected pneumonia. METHODS This was a retrospective, quasi-experimental study at a 613-bed academic medical center with 67 intensive care beds. Adult patients admitted to the intensive care unit (ICU) between 2017 and 2019 for 24 hours or longer and empirically started on intravenous vancomycin for pneumonia were included. The primary intervention was the implementation of a MRSA nasal PCR screen protocol. The primary outcome was duration of empiric vancomycin therapy. Secondary outcomes included the rate of acute kidney injury (AKI), the number of vancomycin levels obtained, the rate of resumption of vancomycin for treatment of pneumonia, ICU length of stay, hospital length of stay, the rate of ICU readmission, and the rate of in-hospital mortality. RESULTS A total of 418 patients were included in the final analysis. The median vancomycin duration was 2.59 days in the preprotocol group and 1.44 days in the postprotocol group, a reduction of approximately 1.00 day (P < 0.01). There were significantly fewer vancomycin levels measured in the postprotocol group than in the preprotocol group. Secondary outcomes were similar between the 2 groups, except that there was lower AKI and fewer vancomycin levels obtained in the postprotocol group (despite implementation of area under the curve-based vancomycin dosing) as compared to the preprotocol group. CONCLUSION The implementation of a pharmacist-driven MRSA nasal PCR screen was associated with a decrease in vancomycin duration and the number of vancomycin levels obtained in critically ill patients with suspected pneumonia.
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Affiliation(s)
- Calvin Diep
- Department of Pharmacy, Stanford Healthcare, Palo Alto, CA, USA
| | - Lina Meng
- Department of Pharmacy, Stanford Healthcare, Palo Alto, CA, USA
| | - Samaneh Pourali
- Department of Pharmacy, Stanford Healthcare, Palo Alto, CA, USA
| | - Matthew M Hitchcock
- Department of Infectious Diseases, Central Virginia VA Health Care System, Richmond, VA, USA
| | - William Alegria
- Department of Pharmacy, Stanford Healthcare, Palo Alto, CA, USA
| | - Rebecca Swayngim
- Department of Pharmacy, Denver Health Medical Center, Denver, CO, USA
| | - Ran Ran
- Department of Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Niaz Banaei
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.,Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, Clinical Microbiology Laboratory, Stanford Healthcare, Palo Alto, CA, USA
| | - Stan Deresinski
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Marisa Holubar
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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22
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Diep C, Tian C, Won C, Ladha K, Singh M. 236 The association between recent cannabis use and nightly sleep duration in adults in the USA from 2005-2018. Sleep 2021. [DOI: 10.1093/sleep/zsab072.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Shifts in medicolegal attitudes towards cannabis, coupled with widespread legalization, have led to North America having the highest prevalence of cannabis use worldwide. Amongst other known physiologic effects, regular cannabis use can cause changes to sleep duration and quality. The purpose of this study was to examine the relationship between recent cannabis use and sleep duration using a nationally representative data set.
Methods
A cross-sectional analysis of adults was undertaken using the National Health and Nutrition Examination Survey (NHANES) data from 2005–2018. Respondents were dichotomized by whether or not they had used cannabis in the past 30 days. The primary outcome was inadequate nightly sleep duration, defined as self-reported sleep duration less than 6 hours per night. Secondary outcomes were related to self-reported issues with sleep. Multiple logistic regression was used to adjust for potential confounders and survey sample weights were considered in the model.
Results
Compared to those with no recent cannabis use (n=18,631), recent users (n=3,135) were more likely to report less than 6 hours of sleep per night (aOR 1.33 95% 1.13–1.57, p<0.001). Recent users were also more likely to report difficulty falling asleep, staying asleep, or sleeping too much in the past two weeks (aOR 1.21, 95% CI: 1.09–1.35, p<0.001), and having ever mentioned these issues to a physician (aOR 1.21, 95% CI: 1.07–1.37, p=0.003). Respondents using cannabis at least 20 of the past 30 days were characterized as heavy users, and were even more likely than moderate users to report insufficient sleep. These results did not significantly differ between years of survey administration.
Conclusion
Recent cannabis use was associated with inadequate nightly sleep duration in adults and demonstrates a dose-dependent relationship. Although this relationship is complex and our findings cannot suggest directionality, they highlight the need to further characterize the sleep health of regular cannabis users in the general population. This is especially prudent as cannabinoids are becoming widely accepted for recreational use and increasingly prescribed as medical therapy.
Support (if any):
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Affiliation(s)
- Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto
| | | | - Christine Won
- Department of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine
| | - Karim Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto
| | - Mandeep Singh
- Department of Anesthesiology and Pain Medicine, University of Toronto
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Meng L, Pourali S, Hitchcock MM, Ha DR, Mui E, Alegria W, Fox E, Diep C, Swayngim R, Chang A, Banaei N, Deresinski S, Holubar M. Discontinuation Patterns and Cost Avoidance of a Pharmacist-Driven Methicillin-Resistant Staphylococcus aureus Nasal Polymerase Chain Reaction Testing Protocol for De-escalation of Empiric Vancomycin for Suspected Pneumonia. Open Forum Infect Dis 2021; 8:ofab099. [PMID: 34386545 PMCID: PMC8355456 DOI: 10.1093/ofid/ofab099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/02/2021] [Indexed: 12/28/2022] Open
Abstract
A pharmacist-driven methicillin-resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR)-based testing protocol with a 70% acceptance rate for vancomycin discontinuation within 24 hours of negative results significantly reduced unnecessary vancomycin use with an estimated cost avoidance of $40 per vancomycin course. We found high concordance (141 of 147, 96%) of culture-based versus PCR-based MRSA nasal screening.
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Affiliation(s)
- L Meng
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, Stanford, California, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | - S Pourali
- Department of Pharmacy, Stanford Health Care, Stanford, California, USA
| | - M M Hitchcock
- Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - D R Ha
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, Stanford, California, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | - E Mui
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, Stanford, California, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | - W Alegria
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, Stanford, California, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | - E Fox
- Department of Pharmacy, Stanford Health Care, Stanford, California, USA
| | - C Diep
- Department of Pharmacy, Stanford Health Care, Stanford, California, USA
| | - R Swayngim
- Department of Pharmacy, Stanford Health Care, Stanford, California, USA
| | - A Chang
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, Stanford, California, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - N Banaei
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - S Deresinski
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, Stanford, California, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - M Holubar
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, Stanford, California, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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Meng L, Pourali S, Hitchcock MM, Ha DR, Mui E, Alegria W, Diep C, Banaei N, Chang A, Deresinski S, Holubar M. 1489. Safety and Performance of a Pharmacist-Driven Nasal MRSA PCR Protocol for De-escalation of Empiric Vancomycin for Suspected Pneumonia at an Academic Medical Center. Open Forum Infect Dis 2020. [PMCID: PMC7777533 DOI: 10.1093/ofid/ofaa439.1670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Limited published data supports the de-escalation of empiric anti-methicillin resistant Staphylococcus aureus (MRSA) antibiotics for suspected pneumonia upon negative nasal MRSA screening. Besides limited sample sizes, special populations, such as those who are immunocompromised and/or critically ill, have been underrepresented in these reports. We describe real-world efficacy and safety of a pharmacist-driven nasal MRSA PCR testing protocol implemented at Stanford Health Care in May 2018 across a diverse patient population. Methods This was an observational cohort study of adult patients who received vancomycin for empiric pneumonia before (PRE) vs after (POST) implementation of a pharmacist-driven nasal MRSA PCR testing protocol (between 05/01/2017 - 08/31/2017 (PRE) and 5/7/2018 - 12/31/2019 (POST). The primary outcome measure was duration of vancomycin administration. Secondary outcomes included time to vancomycin discontinuation, frequency of restarting vancomycin for empiric pneumonia within 7 days, acute kidney injury (defined as “risk” by RIFLE criteria), and MRSA respiratory cultures. Statistical methods are described in Figure A. Figure A. Statistical methods ![]()
Results Total of 610 patients were included in this study with 116 in the PRE group and 494 in the POST group. Over 40% were critically ill and approximately 37% were immunocompromised in both groups (Table 1). For the primary outcome, median vancomycin duration was significantly shorter in the POST group (1.29 days; 95% CI 1.13-1.45) vs. PRE group (1.98 days; 95% CI 1.49-2.46) (p < 0.0005), a 34.8% reduction (Figure 1). Median vancomycin duration was lower in patients with a negative vs positive nasal MRSA PCR (1.20 days [95% CI 1.08-1.33] vs 2.53 days [95% CI 1.77-3.29], p < 0.0005), a 52.6% reduction (Figure 2). MRSA was recovered in respiratory cultures in 1.7% vs 1.4% in the PRE vs POST groups. One (0.002%) patient had a negative nasal MRSA PCR but culture-confirmed MRSA pneumonia and recovered after completing a treatment course. Secondary safety outcomes were similar between groups (Table 2). Tables 1 and 2: Baseline Characteristics and Secondary Outcomes ![]()
Figure 1. Primary Outcome: Kaplan–Meier Estimates of Cumulative Active Vancomycin Therapy Before and After Implementation of Nasal MRSA PCR protocol ![]()
Figure 2. Secondary Outcome: Figure 2. Kaplan–Meier Estimates of Cumulative Active Vancomycin Therapy in Patients with Negative vs Positive Nasal MRSA PCR ![]()
Conclusion Pharmacist-driven nasal MRSA PCR testing is effective and safe in early de-escalation of empiric vancomycin used for pneumonia treatment in a diverse population including critically ill and immunocompromised patients. Disclosures All Authors: No reported disclosures
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Affiliation(s)
- Lina Meng
- Stanford Hospital and Clinics, CUPERTINO, California
| | | | | | - David R Ha
- Stanford Antimicrobial Safety and Sustainability Program, Stanford, California
| | - Emily Mui
- Stanford Health Care, STANFORD, California
| | | | | | - Niaz Banaei
- Stanford University School of Medicine, STANFORD, California
| | - Amy Chang
- Stanford University, Stanford, California
| | | | - Marisa Holubar
- Stanford University School of Medicine, STANFORD, California
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25
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Diep C, Wong D, Wijeysundera DN, Katz J, Clarke HA, Ladha KS. The association between patient-reported pain scores and physical activity in the postoperative period: A prospective observational study. J Clin Anesth 2020; 66:109916. [PMID: 32485540 DOI: 10.1016/j.jclinane.2020.109916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/08/2020] [Accepted: 05/23/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Calvin Diep
- Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada
| | - Dorothy Wong
- Department of Anesthesiology, Toronto General Hospital, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, 123 Edward Street, Toronto, Ontario M5G 1E2, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College Street, Toronto, Ontario M5T 3M6, Canada; Department of Anesthesia, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, Ontario M5B 1T8, Canada
| | - Joel Katz
- Department of Anesthesiology, Toronto General Hospital, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, 123 Edward Street, Toronto, Ontario M5G 1E2, Canada; Department of Psychology, York University, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada
| | - Hance A Clarke
- Department of Anesthesiology, Toronto General Hospital, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, 123 Edward Street, Toronto, Ontario M5G 1E2, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, 123 Edward Street, Toronto, Ontario M5G 1E2, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College Street, Toronto, Ontario M5T 3M6, Canada; Department of Anesthesia, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, Ontario M5B 1T8, Canada.
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Diep C, Goel A, Ladha KS. Mass identification of potential service sector donors of personal protective equipment from an online directory during the COVID-19 pandemic. Can J Public Health 2020; 111:404-405. [PMID: 32462461 PMCID: PMC7252415 DOI: 10.17269/s41997-020-00334-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/03/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Calvin Diep
- Faculty of Medicine, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada.
| | - Akash Goel
- Department of Anesthesiology and Pain Medicine, University of Toronto, 123 Edward St, Toronto, ON, M5G 1E2, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, 123 Edward St, Toronto, ON, M5G 1E2, Canada
- Department of Anesthesia, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada
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Korneta O, Diep C, Luppov V, Zhao Z. Breakthrough instruments and products Janis Research Company, LLC Cryogen free sub-Kelvin ARPES system. Rev Sci Instrum 2020; 91:059501. [PMID: 32486701 DOI: 10.1063/5.0007690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/18/2020] [Indexed: 06/11/2023]
Abstract
The Janis Research cryogen-free sub-K continuous flow cryostat for angle-resolved photoemission spectroscopy is a convenient multi-functional tool, suitable for a wide range of research applications. In this article, the design and operating principles of the cryostat are described.
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Affiliation(s)
- O Korneta
- Janis Research Company, LLC, 225 Wildwood Avenue, Woburn, Massachusetts 01801-2025, USA
| | - C Diep
- Janis Research Company, LLC, 225 Wildwood Avenue, Woburn, Massachusetts 01801-2025, USA
| | - V Luppov
- Janis Research Company, LLC, 225 Wildwood Avenue, Woburn, Massachusetts 01801-2025, USA
| | - Z Zhao
- Janis Research Company, LLC, 225 Wildwood Avenue, Woburn, Massachusetts 01801-2025, USA
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McMahon W, Ftouni S, Collet J, Diep C, Rajaratnam S, Maruff P, Drummond S, Anderson C. Task-dependent effects of the wake maintenance zone on cognition and alertness, with and without sleep loss. Sleep Med 2019. [DOI: 10.1016/j.sleep.2019.11.698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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29
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Warden BA, Diep C, Ran R, Thomas M, Cigarroa JE. The effect of heparin infusion intensity on outcomes for bridging hospitalized patients with atrial fibrillation. Clin Cardiol 2019; 42:995-1002. [PMID: 31483512 PMCID: PMC6788575 DOI: 10.1002/clc.23256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 08/05/2019] [Accepted: 08/26/2019] [Indexed: 12/18/2022] Open
Abstract
Background Perioperative bridging in atrial fibrillation (AF) is associated with low thromboembolic rates but high bleeding rates. Recent guidance cautions the practice of bridging except in high risk patients. However, the practice of bridging varies widely and little data exist regarding appropriate anticoagulation intensity when using intravenous unfractionated heparin (UFH). Hypothesis To determine if high intensity UFH infusion regimens are associated with increased bleeding rates compared to low intensity regimens for bridging patients with AF. Methods We conducted a single center retrospective cohort study of admitted patients with non‐valvular AF receiving UFH for ≥24 hours. UFH intensities were chosen at the providers' discretion. The primary endpoint was the rate of bleeding defined by the International Society on Thrombosis and Hemostasis during UFH infusion or within 24 hours of discontinuation. The secondary endpoint was a composite of cardiovascular events, arterial thromboembolism, venous thromboembolism, myocardial infarctions and death during UFH infusion. Results A total of 497 patients were included in this analysis. Warfarin was used in 82.1% and direct acting oral anticoagulants in 14.1% of patients. The rate of any bleed was higher among high intensity compared to low intensity UFH regimens (10.5% vs 4.9%, odds ratio = 2.29, 95% confidence interval = 1.07‐4.90). Major bleeding was significantly higher among high intensity compared to low intensity UFH regimens. There was no difference in composite thrombotic events or death. Conclusions Low intensity UFH infusions, targeting lower anticoagulation targets, were associated with decreased bleeding rates without a signal of increased thromboembolic events in hospitalized AF patients.
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Affiliation(s)
- Bruce A Warden
- Department of Pharmacy Services, Oregon Health & Science University, Portland, Oregon
| | - Calvin Diep
- Department of Pharmacy, Stanford Medical Center, Stanford, California
| | - Ran Ran
- Department of Critical Care Medicine, Oregon Health & Science University, Portland, Oregon
| | - Matthew Thomas
- Department of Pharmacotherapy, Washington State University College of Pharmacy and Pharmaceutical Sciences, Spokane, Washington
| | - Joaquin E Cigarroa
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
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Diep C, Ftouni S, Drummond S, Anderson C. 0813 ENHANCING SLOW WAVE ACTIVITY VIA AN AUTOMATED PHASE LOCKED ACOUSTIC STIMULATION. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Shih AW, Jamula E, Diep C, Lin Y, Armali C, Heddle NM, Traore A, Doherty J, Shah N, Hillis CM. Audit of provincial IVIG Request Forms and efficacy documentation in four Ontario tertiary care centres. Transfus Med 2017; 27:122-131. [PMID: 28144996 DOI: 10.1111/tme.12391] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/29/2016] [Accepted: 12/30/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Retrospective audit of IVIG Request Forms in four Ontario tertiary care centres: to determine the case mix of new IVIG requests, to authenticate information provided, and to determine documentation of clinical efficacy. AIMS To understand contributors to increases in IVIG utilisation and to determine whether IVIG is being used and monitored appropriately. INTRODUCTION Intravenous immunoglobulin (IVIG) use in Canada is high compared with other developed countries. We performed a retrospective audit of new IVIG Request Forms across four tertiary care centres in Ontario, one with an active surveillance programme, to determine the case mix, authenticate information provided and assess documentation of efficacy. METHODS Consecutive adult patients with a first-time IVIG request in 2014 were included. The ordering physician specialty, form completeness, documentation of diagnostic criteria for the medical condition and indication for IVIG use and documentation of efficacy were assessed by form and chart review. RESULTS Of 178 patients, the most common indications for IVIG were immune thrombocytopenia (24.2%) and secondary immune deficiency (20.2%). The most frequent prescribers were haematologists (37.6%) and neurologists (10.7%). Other conditions not listed on the form represented 24.2% of cases, with most not indicated in current guidelines. A total of 32.6% of cases overall lacked verification of diagnostic criteria and 51.7% lacked verification for IVIG utilisation criteria, with the number of cases meeting criteria based on documentation being higher at the active surveillance site (P = 0.005). A total of 19.1% of cases had a discrepancy between the indication written on the form and the documented clinical diagnosis. A total of 18.7% of clinic notes following IVIG had no mention of efficacy. CONCLUSION Our audit demonstrates a lack of compliance with IVIG Request Form requirements, a lack of documentation of diagnostic criteria and efficacy, and suggests inappropriate use of IVIG. Current implementation of the form may not be sufficient as a strategy for improving appropriate IVIG use.
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Affiliation(s)
- A W Shih
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - E Jamula
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - C Diep
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Y Lin
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - C Armali
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - N M Heddle
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada.,Centre for Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - A Traore
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - J Doherty
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - N Shah
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - C M Hillis
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada.,Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Jacquot L, Berthaud L, Sghaïr A, Diep C, Brand G. The Influence of “Tastiness” and “Healthiness” Labels in Cheese Flavor Perception. CHEMOSENS PERCEPT 2013. [DOI: 10.1007/s12078-013-9146-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Between 1977 and 1979 an age stratified sample of people 65 years and over living in the community and in institutions in Gisborne, New Zealand was assessed medically and socially. This sample was followed and reviewed in 1982. At follow up 308 subjects were seen, 227 had died, and 24 had left the area. Factors predicting mortality were assessed. Using a log rank test, factors predicting mortality included age, impaired mental function, functional disability, urinary incontinence, prescribed drugs, pulse pressure, erythrocyte sedimentation rate (ESR), systolic pressure, cardiovascular drugs, and falls. However, a number of these factors increased in prevalence with age. Using a Cox's regression analysis for factors predicting mortality after controlling for age, the following were found to be significant predictors: impaired mental function; functional disability; urinary incontinence; prescribed drugs, ESR and falls. A proportional hazards general linear model showed that the major predictors of mortality in old age were markers of established disease.
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