Preoperative Screening and Case Cancellation in Cocaine-Abusing Veterans Scheduled for Elective Surgery

Background. Perioperative management of cocaine-abusing patients scheduled for elective surgery varies widely based on individual anecdotes and personal experience. Methods. Chiefs of the anesthesia departments in the Veterans Affairs (VA) health system were surveyed to estimate how often they encounter surgical patients with cocaine use. Respondents were asked about their screening criteria, timing of screening, action resulting from positive screening, and if they have a formal policy for management of these patients. Interest in the development of VA guidelines for the perioperative management of patients with a history of cocaine use was also queried. Results. 172 VA anesthesia departments’ chiefs were surveyed. Response rate was 62%. Over half of the facilities see cocaine-abusing patients at least once a week (52%). Two thirds of respondents canceled or delayed patients with a positive screen regardless of clinical symptoms. Only eleven facilities (10.6%) have a formal policy. The majority of facilities (80%) thought that having formal guidelines for perioperative management of cocaine-abusing patients would be helpful to some extent. Results. 172 VA anesthesia departments’ chiefs were surveyed. Response rate was 62%. Over half of the facilities see cocaine-abusing patients at least once a week (52%). Two thirds of respondents canceled or delayed patients with a positive screen regardless of clinical symptoms. Only eleven facilities (10.6%) have a formal policy. The majority of facilities (80%) thought that having formal guidelines for perioperative management of cocaine-abusing patients would be helpful to some extent. Conclusions. There is a general consensus that formal guidelines would be helpful. Further studies are needed to help formulate evidence-based guidelines for managing patients screening positive for cocaine prior to elective surgery

Pressure-engineered structural and opestical properties of two-dimensional (C4H9NH3)2PbI4 perovskite exfoliated nm-thin flakes

Resolving the structure–property relationships of two-dimensional (2D) organic–inorganic hybrid perovskites is essential for the development of photovoltaic and photoelectronic devices. Here, pressure (0–10 GPa) was applied to 2D hybrid perovskite flakes mechanically exfoliated from butylammonium lead halide single crystals, (C4H9NH3)2PbI4, from which we observed a series of changes of the strong excitonic emissions in the photoluminescence spectra. By correlating with in situ high-pressure X-ray diffraction results, we examine successfully the relationship between structural modifications in the inorganic PbI42– layer and their excitonic properties. During the transition between Pbca (1b) phase and Pbca (1a) phase at around 0.1 GPa, the decrease in ⟨Pb–I–Pb⟩ bond angle and increase in Pb–I bond length lead to an abrupt blue shift of the excitonic bandgap. The presence of the P21/a phase above 1.4 GPa increases the ⟨Pb–I–Pb⟩ bond angle and decreases the Pb–I bond length, leading to a deep red shift of the excitonic bandgap. The total band gap narrowing of ∼350 meV to 2.03 eV at 5.3 GPa before amorphization, facilitates (C4H9NH3)2PbI4 as a much better solar absorber. Moreover, phase transitions inevitably modify the carrier lifetime of (C4H9NH3)2PbI4, where an initial 150 ps at ambient phase is prolongated to 190 ps in the Pbca (1a) phase along with enhanced photoluminescence (PL), originating from pressure-induced strong radiative recombination of trapped excitons.The onset of P21/a phase shortens significantly the carrier lifetime to 53 ps along with a weak PL emission due to pressure-induced severe lattice distortion and amorphization. High-pressure study on (C4H9NH3)2PbI4 nm-thin flakes may provide insights into the mechanisms for synthetically designing novel 2D hybrid perovskite based photoelectronic devices and solar cells.Ministry of Education (MOE)Accepted versionT.T.Y., J.X.Y., and Z.X.S, gratefully acknowledge the Ministry of Education (MOE) for the following grants: AcRF Tier 1 (Reference No: RG103/16); AcRF Tier 2 (MOE2015-T2-1- 148); AcRF Tier 3 (MOE2011-T3-1-005). J.X.Y. is supported by the National Natural Science Foundation of China (Grant No. 11704185) and the Natural Science Foundation of Jiangsu Province, China (Grant No. BK20171021). T.C.S. receives funding from the Ministry of Education Academic Research Fund Tier 1 Grant RG173/16, Tier 2 Grants MOE2015-T2-2- 015 and MOE2016-T2-1-034, and from the Singapore (NRF) through the Singapore−Berkeley Research Initiative for Sustainable Energy (SinBeRISE) CREATE Program and the Competitive Research Program NRF-CRP14-2014-03. S.H.W. is supported by the National Key Basic Research Program of China (2016YFB0700700) and National Natural Science Foundation of China (51672023, 11634003, U1530401). S.J. and J.F. thank Dr. Zhongwu Wang and Dr. Ruipeng Li for their assistance and acknowledge the support from Custom Electronics Inc. and Binghamton University. CHESS was supported by the NSF award DMR-1332208

Dexmedetomidine pharmacodynamics: part I: crossover comparison of the respiratory effects of dexmedetomidine and remifentanil in healthy volunteers,”

Background: Dexmedetomidine, a highly selective ␣ 2 -adrenoceptor agonist used for short-term sedation of mechanically ventilated patients, has minimal effect on ventilation. Methods: This study compared the respiratory effect of dexmedetomidine to that of remifentanil. The authors measured and compared respiratory responses of six healthy male volunteers during (1) a stepwise target-controlled infusion of remifentanil, (2) a stepwise target-controlled infusion of dexmedetomidine, and (3) a pseudonatural sleep session. Results: Compared with baseline, remifentanil infusions resulted in respiratory depression as evidenced by a decrease in respiratory rate and minute ventilation, respiratory acidosis, and apnea episodes resulting in desaturations. Remifentanil disturbed the natural pattern of breathing and flattened the distribution of ventilatory timing (inspiratory time/ventilatory cycle time). The respiratory effects of dexmedetomidine markedly contrasted with those of remifentanil. When compared with baseline, during dexmedetomidine infusions, the respiratory rate significantly increased, and the overall apnea/hypopnea index significantly decreased. The distribution of inspiratory time/ventilatory cycle time showed an increased peak. In addition, dexmedetomidine seemed to mimic some aspect of natural sleep. While the subjects were breathing a 5% CO 2 mixture, hypercapnic arousal phenomena (documented by the Bispectral Index, the electroencephalogram, and sudden increase in the minute ventilation) were observed during dexmedetomidine infusions. Similar phenomena during natural sleep have been reported in the literature

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit