Local Anesthesia for Endovascular Repair of Abdominal Aortic Aneurysm Allows for Accurate Graft Deployment with Durable Results.

BACKGROUND: Local anesthesia (LA) is sparsely used in endovascular aneurysm repair (EVAR) despite short-term benefit, likely secondary to concerns over patient movement preventing accurate endograft deployment. The objective of this study is to examine the association between anesthesia type and endoleak, sac regression, reintervention, and mortality. METHODS: The Vascular Quality Initiative database was queried for all EVAR cases from 2014 to 2022. Patients were included if they underwent percutaneous elective EVAR with anatomical criteria within instructions for use of commercially approved endografts. Multivariable logistic regression with propensity score weighting was used to determine the association between anesthesia type on the risk of any endoleak noted by intraoperative completion angiogram and sac regression. Multivariable survival analysis with propensity score weighting was used to determine the association between anesthesia type and endoleak at 1 year, long-term reintervention, and mortality. RESULTS: Thirteen thousand nine hundred thirty two EVARs met inclusion criteria: 1,075 (8%) LA and 12,857 (92%) general anesthesia (GA). On completion angiogram, LA was associated with fewer rates of any endoleaks overall (16% vs. 24%, P < 0.001). On multivariable analysis with propensity score weighting, LA was associated with similar adjusted odds of any endoleak on intraoperative completion angiogram (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.47-0.68) as well as combined type 1a and type 1b endoleaks (OR 0.72, 95% CI 0.47-1.09). Follow-up computed tomography imaging at 1 year was available for 4,892 patients, 377 (8%) LA and 4,515 (92%) GA. At 1 year, LA was associated with similar rate of freedom from any endoleaks compared to GA (0.66 [95% CI 0.63-0.69] vs. 0.71 [95% CI 0.70-0.72], P = 0.663) and increased rates of sac regression (50% vs. 45%, P = 0.040). On multivariable analysis with propensity score weighting, LA and GA were associated with similar adjusted odds of sac regression (OR 1.22, 95% CI 0.97-1.55). LA and GA had similar rates of endoleak at 1 year (hazard ratio [HR] 0.14, 95% CI 0.63-1.07); however, LA was associated with decreased hazards of combined type 1a and 1b endoleaks at 1 year (HR 0.87, 95% CI 0.80-0.96). LA and GA had similar adjusted long-term reintervention rate (HR 0.77, 95% CI 0.44-1.38) and long-term mortality (HR 1.100, 95% CI 079-1.25). CONCLUSIONS: LA is not associated with increased adjusted rates of any endoleak on completion angiogram or at 1-year follow-up compared to GA. LA is associated with decreased adjusted rates of type 1a and type 1b endoleak at 1 year, but similar rates of sac regression, long-term reintervention, and mortality. Concerns for accurate graft deployment should not preclude use of LA and LA should be increasingly considered when deciding on anesthetic type for standard elective EVAR.

Introducing the Dysphagiameter: a novel patient-reported outcome measure for evaluating dysphagia in oculopharyngeal muscular dystrophy - from conceptual framework to initial development.

Oculopharyngeal muscular dystrophy (OPMD) is a rare late-onset muscle disease associated with progressive dysphagia. As there was no patient-reported outcome measure specific for the assessment of dysphagia in OPMD, the Dysphagiameter was developed. The Food and Drug Administration guidance was followed. In Phase 1, a systematic literature review and an expert consultation were conducted to identify the concepts of interest. It was decided that the instrument should assess difficulty swallowing using pictures of foods of various textures (part A) and impact of dysphagia on activities and participation (part B), as defined by the International Classification of Functioning, Disability and Health. In Phase 2, focus groups (n = 3) and online surveys (n = 55) were conducted to generate the items. Then, the food items for part A were selected and grouped into 17 textures by a panel of registered dietitians. Cognitive interviews were conducted (n = 23) to refine the instrument and assess its clarity and comprehensiveness. The final draft included 82 food items assessing the capacity to swallow foods and drinks (part A) and 10 items assessing the impact of dysphagia on activities and participation (part B). Item reduction and assessment of psychometrics properties, using Rasch analysis, are ongoing as part of Phase 3.

Effect of socioeconomic status on patients undergoing elective abdominal aortic aneurysm repair in a publicly funded health care system.

BACKGROUND: The association between socioeconomic status (SES) and outcomes after abdominal aortic aneurysm (AAA) repair in publicly funded health care systems is poorly described. The purpose of this study was to determine the effect of SES on postoperative outcomes in patients who underwent AAA repair in Nova Scotia, Canada. METHODS: We performed a retrospective analysis of all elective AAA repairs in Nova Scotia between November 2005 and March 2015 using administrative data sources. We compared postoperative 30-day outcomes and long-term survival across socio-economic quintiles, defined as the Pampalon Material Deprivation Index (MDI) and Social Deprivation Index (SDI). We also compared the relation between baseline characteristics, MDI quintile, SDI quintile and 30-day mortality. We used multivariable logistic regression and survival analysis to calculate adjusted 30-day mortality and long-term survival, respectively. RESULTS: A total of 1913 patients underwent AAA repair during the study period. The overall 30-day mortality rate was 2.6% (50 patients). Thirty-day outcomes including death (p = 0.8), stroke (p = 0.7), myocardial infarction (p = 0.06), length of stay (p = 0.3) and discharge disposition other than home (p = 0.8) were similar across MDI quintiles. Similarly, there was no statistically significant association between SDI quintile and postoperative outcomes. Multivariable analysis showed that age greater than 70 years (odds ratio [OR] 3.06, 95% confidence interval [CI] 1.55-6.06) and open repair (OR 3.22, 95% CI 1.59-6.52) but not MDI quintile (p = NS) or SDI quintile (p = NS) were associated with increased 30-day mortality. There was no effect of MDI or SDI quintile on long-term survival on univariable or multivariable analysis. CONCLUSION: Socioeconomic status does not appear to affect short- or long-term mortality after AAA repair in a publicly funded health care system. Further research is needed to address any existing gaps in screening and referral before repair.

Trends in Incidence of Abdominal Aortic Aneurysm Rupture, Repair, and Mortality in Nova Scotia.

BACKGROUND: The purpose of this study was to examine sex-based trends in incidence of elective abdominal aortic aneurysm (AAA), ruptured AAA, ruptured AAA repair, and AAA-related mortality. METHODS: A retrospective analysis of patients presenting with AAA from 2005 to 2015 was conducted. Rates of elective AAA repair, ruptured AAA, ruptured AAA repair, and mortality were obtained from linking provincial administrative data using medical services insurance billing number. The age-adjusted incidence of elective AAA repair, overall rate of ruptured AAA, ruptured AAA repair, and AAA-related mortality was calculated for each sex based on Canadian census estimates, adjusted to the Canadian standard population. Weighted linear regression was performed to analyze trends in incidence over time. RESULTS: One thousand nine hundred eighty-six elective AAA repairs were identified, of which 1,098 were repaired open and 898 underwent endovascular abdominal aneurysm repair (EVAR). Five hundred and seventy ruptured AAAs were identified, of which 295 (52%) were repaired: 259 open and 36 EVAR. The proportion of ruptured AAA that was repaired did not change over time (P = 0.54). The proportion repairs performed using EVAR increased significantly in both elective (P < 0.001) and rupture repairs (P < 0.001). During the study period, 662 patients died of AAA-associated mortality. The average incidence of elective AAA repair in men was 29.3 (95% confidence interval (CI): 27.8 to 30.8) per 100,000 and decreased over time (P = 0.04), whereas the average incidence in women was 9.2 [8.3 to 10.0] and stable (P = 0.07). The incidence of open elective AAA repair was 10.5 [9.9-11.1] with a decreasing trend over time (P < 0.001) and EVAR was 9.0 (8.5-9.6) with an increasing trend over time (P < 0.001). A decreasing trend of overall ruptured AAA (5.4 [5.0-5.9], P < 0.001), ruptured AAA repair (2.9 [2.5-3.2], P = 0.02), and of AAA-related mortality (6.2 [5.8-6.8], P < 0.001) was found, with consistent trends in both sexes. The incidence of open ruptured AAA repair decreased over time (P = 0.001) whereas the incidence of ruptured EVAR remained stable (P = 0.23). CONCLUSIONS: The incidence of elective AAA repair is decreasing in males but not females, whereas the incidence of rupture has decreased in both sexes. This has translated into reduced incidence of AAA-related mortality. Increased adoption of EVAR for ruptured AAA should continue these trends.

Dying to Get There: Patients Who Reside at Increased Distance from Tertiary Center Experience Increased Mortality Following Abdominal Aortic Aneurysm Rupture.

BACKGROUND: Centralization of vascular surgery care for Ruptured Abdominal Aortic Aneurysms (RAAAs) to high-volume tertiary centers may hinder access to timely surgical intervention for patients in remote areas. The objective of this study was to determine the association between distance from vascular care and mortality from RAAAs in the province of Nova Scotia, Canada. METHODS: A retrospective cohort study of all RAAAs in Nova Scotia between 2005 and 2015 was performed through linkage of administrative databases. Patients were divided into groups by estimated travel time from their place of residence to the tertiary center (<1 hr and ≥1 hr) using geographic information software. Baseline and operative characteristics were identified for all patients through available databases and completed through chart review. Mortality at home, during transfer to the vascular center, and overall 30-day mortality were compared between groups using t-test and chi-squared test, as appropriate. Multivariable logistic regression analysis was used to calculate the independent effect of travel time on survival outcomes. RESULTS: A total of 567 patients with RAAA were identified from 2005-2015, of which 250 (44%) resided <1 hr travel time to the tertiary center and 317 (56%) resided ≥1 hr. On multivariable analysis, travel time ≥1 hr from vascular care was an independent predictor of mortality at home (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.07-2.63, P = 0.02), mortality prior to operation (OR 2.64, 95% CI 1.81-3.83, P < 0.001), and overall 30-day mortality (OR 1.61, 95% CI 1.10-2.37, P = 0.02). In patients who received an operation (n = 294), there was no association between increased travel time and mortality (OR 1.02, 95% CI 0.60-1.73, P = 0.94). CONCLUSIONS: Travel time ≥1 hr to the tertiary center is associated with significantly higher mortality from ruptured abdominal aortic aneurysm (AAA). However, there was no difference in overall chance of survival between groups for patients that underwent AAA repair. Therefore, strategies to facilitate early detection, and timely transfer to a vascular surgery center may improve outcomes for patients with RAAA.

Effect of after-hours presentation in ruptured abdominal aortic aneurysm.

OBJECTIVE: Ruptured abdominal aortic aneurysms (RAAAs) are surgical emergencies that require immediate and expert treatment. It has been unclear whether presentation during evenings and weekends, when "on call" teams are primarily responsible for patient care, is associated with worse outcomes. Our objective was to evaluate the outcomes of patients presenting with RAAAs after-hours vs during the workday. METHODS: A retrospective cohort study of all RAAAs in Nova Scotia between 2005 and 2015 was performed through linkage of administrative databases. Patients who had presented to the hospital with RAAAs during the workday (Monday through Friday, 6 am to 6 pm) were compared with those who had presented after-hours (6 pm to 6 am during the week and on weekends). The baseline and operative characteristics were identified for all patients through the available databases and a review of the medical records. Mortality before surgery, 30-day mortality, and operative mortality were compared between groups using multivariable logistic regression, adjusting for factors clinically significant on univariable analysis. RESULTS: A total of 390 patients with RAAAs were identified from 2005 to 2015, of whom 205 (53%) had presented during the workday and 185 (47%) after-hours. The overall chance of survival (OCS) was 45% overall, 49% if admitted to hospital, and 64% if surgery had been performed. During the workday, the OCS was 43% overall, 48% if admitted to hospital, and 67% if surgery had been performed. After-hours, the OCS was 46% overall, 49% if admitted to hospital, and 61% if surgery had been performed. Mortality before surgery was increased for patients who had presented to the hospital during the workday compared with after-hours (36% vs 26%; P = .04). The 30-day mortality (57% vs 54%; P = .62), rates of operative management (63% vs 72%; P = .06), and operative mortality (33% vs 39%; P = .33) were similar between the workday and after-hours groups (57% vs 54%; P = .06). After adjusting for significant clinical variables, the patients who had presented with RAAAs after-hours had had a similar odds of dying before surgery (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.41-1.03), operative management (OR, 1.47; 95% CI, 0.93-2.31), 30-day mortality (OR, 0.98; 95% CI, 0.63-1.51), and operative mortality (OR, 1.33; 95% CI, 0.78-2.26). In the subgroup of patients presenting to a hospital with endovascular capabilities, patients presenting after-hours had had similar odds of 30-day mortality (OR, 1.07; 95% CI, 0.57-2.02), and operative mortality (OR, 1.14; 95% CI, 0.58-2.23). CONCLUSIONS: We found that patients presenting to the hospital with RAAAs after-hours did not have increased adjusted odds of mortality before surgery, operative management, 30-day mortality, or operative mortality.

Sex Differences in Trends in Incidence of Thoracic Aortic Aneurysm Repair and Aortic Dissection: 2005-2015.

Background: The purpose of this study was to examine trends in the incidence of thoracic aortic aneurysm (TAA) repair and aortic dissection. Methods: A retrospective study was conducted of patients from the period 2005-2015 with thoracic aortic disease. Unadjusted mortality was compared in women vs men. Rates of scheduled TAA repair, dissection events, acute type A aortic dissection (TAAD) repair, and aorta-related mortality were obtained from our institution's clinical registry and administrative data sources and used to calculate the age-adjusted incidence for each sex, adjusted to the Canadian standard population. Weighted linear regression was performed to analyze trends over time. Results: A total of 382 scheduled TAA repair operations, 345 dissection events, 85 TAAD repairs, and 182 aorta-related mortalities were identified. Women accounted for 23% of TAA repairs, 39% of dissection events, 22% of TAAD repairs, and 45% of aorta-related mortalities. The incidence of TAA repair was 3.5 per 100,000 person-years (95% confidence interval [CI]: 3.2-3.9), and increased in men (P = 0.02) but not women (P = 0.10) over time. The incidence of aortic dissection was 3.4 per 100,000 (95% CI: 3.1-3.8) and was stable over time (P = 0.43). The average annual age-adjusted incidence of TAAD repair was 0.8 per 100,000 (95% CI: 0.6-1.0) and increased over time (P = 0.001). The overall incidence of aorta-related mortality was 1.8 per 100,000 (95% CI: 1.5-2.0) and decreased over time (P = 0.02). Conclusion: The incidence of TAA repair is increasing in men but not women. Although aorta-related mortality is decreasing overall, disparities exist between the male and female population.

Introduction: L'objectif de cette étude était d'examiner les tendances relatives à l'incidence des réparations d'anévrisme de l'aorte thoracique (AAT) et de dissection aortique. Méthodes: Nous avons mené une étude rétrospective de patients atteints d'une maladie de l'aorte thoracique de la période 2005-2015. Nous avons comparé la mortalité non ajustée entre les femmes et les hommes. Nous avons obtenu les taux de réparations planifiées d'AAT, de dissections, de dissections aortiques de type A (DATA) à la phase aiguë et de mortalité d'origine aortique du registre clinique de notre établissement et des sources de données administratives, et les avons utilisés pour calculer l'incidence ajustée selon l'âge pour chacun des sexes, ajustée à la population canadienne type. Nous avons effectué une régression linéaire pondérée pour analyser les tendances temporelles. Résultats: Nous avons recensé un total de 382 réparations planifiées d'AAT, 345 dissections, 85 réparations de DATA et 182 cas de mortalité d'origine aortique. Les femmes représentaient 23 % des cas de réparation d'AAT, 39 % des cas de dissection, 22 % des cas de réparations de DATA et 45 % des cas de mortalité d'origine aortique. L'incidence des réparations d'AAT était de 3,5 par 100 000 années-personnes (intervalle de confiance [IC] à 95 % : 3,2-3,9) et augmentait chez les hommes (P = 0,02), mais non chez les femmes (P = 0,10) avec le temps. L'incidence des dissections aortiques était de 3,4 par 100 000 (IC à 95 % : 3,1-3,8) et était stable au fil du temps (P = 0,43). L'incidence moyenne annuelle selon l'âge de réparations de DATA était de 0,8 par 100 000 (IC à 95 % : 0,6-1,0) et augmentait avec le temps (P = 0,001). L'incidence globale de mortalité d'origine aortique était de 1,8 par 100 000 (IC à 95 % : 1,5-2,0) et diminuait avec le temps (P = 0,02). Conclusion: L'incidence des réparations d'AAT augmente chez les hommes, mais non chez les femmes. Bien que la mortalité d'origine aortique tende dans l'ensemble à diminuer, il existe des disparités entre la population masculine et la population féminine.

Increased Travel Time to the Tertiary Centre Is Associated With Decreased Long-term Survival Following Ascending Aortic Operations.

BACKGROUND: The association between travel time from tertiary care centre and outcomes after ascending thoracic aortic surgery is unknown. We determined the effect of travel time from the tertiary care centre on outcomes in ascending aortic repair in Nova Scotia. METHODS: A retrospective analysis of patients undergoing elective and emergent ascending thoracic aortic operations from 2005 to 2015 was carried out. Patient's residential geographic coordinates were used to calculate travel time to the tertiary care centre, and patients who resided < 1 hour vs ≥ 1 hour were compared. Multivariable logistic regression was performed to determine the effect of travel time on in-hospital outcomes. Cox-proportional hazard modelling and Kaplan-Meier survival estimates were created to determine the effect on long-term survival. RESULTS: A total of 476 patients underwent ascending thoracic aortic surgery from 2005 to 2015. Patients who resided < 1 hour from the tertiary care centre vs patients who resided ≥ 1 hour had similar rates of in-hospital mortality (4.4% vs 6.1%, P = 0.42), in-hospital composite complications (66.7% vs 67.7%, P = 0.80), hospital length of stay (median 9 days; interquartile range [7-16] vs 10 [7-17], P = 0.41), and discharge disposition other than home (9.7% vs 11.7%, P = 0.55). Compared with patients who resided < 1 hour from the tertiary centre, patients who resided ≥ 1 hour were at higher risk for long-term mortality (hazard ratio, 2.19; 95% confidence interval, 1.13-4.28; P = 0.02). CONCLUSIONS: Patients who reside remotely from the tertiary centre experience equivalent in-hospital outcomes but decreased long-term survival following ascending aortic operations. These findings may guide resource expansion for postoperative follow-up.

Atrial functional versus ventricular functional mitral regurgitation: Prognostic implications.

BACKGROUND: Atrial functional mitral regurgitation (FMR) occurs because of left atrial dilatation or atrial fibrillation in heart failure with preserved left ventricular (LV) function, contrary to ventricular FMR, which occurs because of LV dysfunction. Despite pathophysiological differences, current guidelines do not discriminate between these 2 entities. METHODS: From January 2002 to March 2019, all adult patients with ≥3+ mitral regurgitation who underwent mitral valve repair or replacement were identified. Postoperative outcomes and midterm time-to-event rates (survival and reoperation) were compared. RESULTS: Overall, 94 atrial FMR (mean age, 67.6 years) and 84 ventricular FMR (mean age, 64 years) patients met inclusion criteria. Differences in baseline cardiac morphology and function of the atrial FMR and ventricular FMR patients were as follows: concomitant atrial fibrillation (37.2% vs 14.3%), heart failure (42.6% vs 63.1%), LV ejection fraction (60% vs 37%), at least moderate LV dilation (4.8% vs 40.6%), and moderate/severe right heart dysfunction (15.2% vs 5.1%), respectively. Operative mortality was 0% in the atrial FMR versus 1.2% in the ventricular FMR cohort. Actuarial estimates of survival and freedom from reoperation at 5 and 10 years was significantly higher in the atrial FMR cohort versus the ventricular FMR cohort. Ventricular FMR also remained a significant predictor of midterm mortality in our risk-adjusted analysis (adjusted hazard ratio for ventricular FMR, 1.8; 95% confidence interval, 1.001-3.26). CONCLUSIONS: There are important differences in baseline characteristics in terms of cardiac morphology and function among atrial FMR and ventricular FMR patients, which appear to affect in-hospital and midterm outcomes. Because of these discrepancies, early discrimination between these 2 etiologies of FMR might facilitate more tailored approaches to management.

Cross-cultural adaptation of the SWAL-QOL and the Sydney Swallow Questionnaire (SSQ) into French-Canadian and preliminary assessment for their use in an oculopharyngeal muscular dystrophy (OPMD) population.

PURPOSE: Patient-reported outcomes (PRO) assessing dysphagia are an essential component of clinical trials to consider how patients feel and function in response to treatments. The selected PRO needs to be translated in several languages using a systematic process ensuring its validity and equivalence for use in multicenter clinical trials. The main objectives were to translate the SWAL-QOL and the Sydney Swallow Questionnaire (SSQ) into French Canadian (SWAL-QOL-FC and SSQ-FC) and to assess their appropriateness for patients with oculopharyngeal muscular dystrophy (OPMD). METHODS: A forward- and back-translation process was followed including independent mother-tongue translators followed by committee review. Known-groups validity was assessed by comparing scores of OPMD French-Canadian participants (n = 21) known to differ in dysphagia severity according to the 80-ml drinking test score. A Mann-Whitney test was used to compare the mean scores. Cognitive interviews were conducted later on to ensure a posteriori cultural equivalence among French-Canadian participants (n = 28). RESULTS: Evidences of adequate known-groups validity was shown for the SSQ-FC. Only two domains out of 10 of the SWAL-QOL-FC (burden and eating duration) showed adequate known-groups validity. In addition, the difference in the mean composite score was not significant. Several conceptual equivalence issues were found in both questionnaires as a result of the cognitive interviews. CONCLUSION: This study provided evidence that the SSQ-FC presents better validity than the SWAL-QOL-FC in a small sample size of OPMD participants. The findings of the cognitive interviews suggest the need to develop an OPMD-specific questionnaire to capture better the whole spectrum of disease severity.

Long-term laryngotracheal complications following cardiac surgery.

BACKGROUND AND AIM OF THE STUDY: Long-term laryngotracheal complications have not been described in adult patients undergoing cardiac surgery. The purpose of this study was to determine the incidence of and risk factors for laryngotracheal complications following cardiac surgery. METHODS: A retrospective chart review of patients at high risk for laryngotracheal complications following cardiac surgery between 2006 and 2016 was performed. High-risk patients were reviewed to determine the presence of laryngotracheal complications including laryngotracheal stenosis, keyhole deformity, or vocal cord immobility. Logistic regression was used to identify predictors of long-term laryngotracheal complications. RESULTS: Of 11,417 patients who underwent cardiac surgery, 1099 were identified as at high risk. Of these, 24 (2.2%) developed laryngotracheal complications following their surgery and intensive care unit (ICU) stay. Laryngotracheal stenosis and keyhole deformity were present in 13 (1.2%) and 6 (0.5%) patients, respectively. Logistic regression demonstrated older age (age ≥ 70 odds ratio [OR] 0.31, 95% confidence interval [CI] 0.12-0.83) was protective, while readmission to ICU for ventilation (OR 3.11, 95% CI 1.17-8.25) and receiving a tracheostomy (OR 7.83, 95% CI 2.22-27.6) were associated with laryngotracheal complications. CONCLUSIONS: The incidence of long-term laryngotracheal complications following cardiac surgery was 2.2%. Readmission to ICU for ventilation and having a tracheostomy performed were associated with laryngotracheal complications.

Nutritional Risk in Oculopharyngeal Muscular Dystrophy: Beyond Dysphagia.

Purpose: To document the nutritional risk in adults with oculopharyngeal muscular dystrophy (OPMD) and its association with oropharyngeal dysphagia.Methods: In this cross-sectional study, 33 adults with molecular confirmation of OPMD between 50 and 75 years old were recruited from the registry of a university-affiliated neuromuscular clinic. Nutritional risk was assessed with the French version of Seniors in the Community: Risk Evaluation for Eating and Nutrition II (SCREEN II), whereas the severity of dysphagia was assessed using the French-Canadian version of the Sydney Swallow Questionnaire. Anthropometric measurements were performed with standardized procedures.Results: SCREEN II scores showed high nutritional risk for 81.8% of OPMD participants with 6 factors contributing to nutritional risk in at least 50% of the sample. Pearson's correlational analysis showed a significant moderate relationship between dysphagia and nutritional risk (r = -0.470; P = 0.006).Conclusion: To our knowledge, this study is the first to investigate the nutritional risk of adults with OPMD. Our results indicate that individuals with OPMD may be at high nutritional risk mostly associated with swallowing difficulty, in the absence of a low body mass index. The present study highlights the need for dietary counseling in OPMD.

Is IDDSI an Evidence-Based Framework? A Relevant Question for the Frail Older Population.

To delay impacts of aging, optimal nutritional status is essential. Several factors can reduce food intake, such as isolation, income, and cognitive/physical decline. Additionally, chewing and swallowing difficulties, or dysphagia, often disrupt the ability to consume life-long favorite dishes. Food and liquids could require modification of texture or consistency to ensure a comfortable or safe swallow. The food industry, foodservices facilities, and caregivers need quality control benchmarks to provide adequate nourishment and meet these new feeding challenges. The International Dysphagia Diet Standardisation Initiative (IDDSI) is proposing the IDDSI framework and testing methods to describe food used in nutritional care plans to circumvent dysphagia and improve communication among caregivers. This systematic review assesses the validity and reliability of the IDDSI testing methods using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN). Two publications presented content validity whereas 19 publications looked at construct validity or reliability for the IDDSI testing methods. One study was conducted in older adults presenting dysphagia. This review concludes that there is insufficient evidence to recommend the IDDSI testing methods. Further research, conducted with robust methodological design and reporting, is needed to develop and assess nutritious adapted food for frail older populations.

Prediction of temporary epicardial pacing wire use in cardiac surgery.

BACKGROUND: Placement of temporary epicardial pacing wires (TEPW) at the end of open heart surgery cases is routine but can be associated with complications. Identification of patients who are high risk for requiring pacing would be beneficial on guiding selective TEPW placement. The purpose of this study was to identify predictors of temporary pacing immediately post cardiac surgery. METHODS: A retrospective analysis of patients undergoing cardiac surgery from 2005 to 2016 at the Maritime Heart Center was conducted. Analysis was performed of patients who require pacing on arrival to the cardiovascular intensive care unit (CVICU) compared with those who were not paced. Multivariable logistic regression was used to determine each variable's risk adjusted likelihood of pacing for the entire cohort. Subgroup analysis was performed in the isolated procedures. RESULTS: A total of 11 752 patient underwent surgery from the year 2005 to 2016. Two thousand and fifty-one (17.5%) required pacing on arrival to CVICU. Older age, female sex, preoperative renal failure, lower ejection fraction (EF), preoperative arrhythmia, preoperative use of calcium channel blockers, and longer cross-clamp times were risk factors for pacing. In the isolated coronary artery bypass grafting and aortic valve replacement groups, findings were similar to the overall cohort. Only age, obesity, and chronic obstructive pulmonary disease were risk factors for pacing in the isolated mitral valve (MV) repair group and only preoperative arrhythmia in the isolated MV replacement group. CONCLUSION: We have identified risk factors for TEPW use following cardiac surgery and in isolated procedure subgroups. These risk factors may help guide selective TEPW placement.

Variability in opioid prescribing practices among cardiac surgeons and trainees.

BACKGROUND AND AIM: The opioid epidemic has become a major public health crisis in recent years. Discharge opioid prescription following cardiac surgery has been associated with opioid use disorder; however, ideal practices remain unclear. Our aim was to examine current practices in discharge opioid prescription among cardiac surgeons and trainees. METHODS: A survey instrument with open- and closed-ended questions, developed through a 3-round Delphi method, was circulated to cardiac surgeons and trainees via the Canadian Society of Cardiac Surgeons. Survey questions focused on routine prescription practices including type, dosage and duration. Respondents were also asked about their perceptions of current education and guidelines surrounding opioid medication. RESULTS: Eighty-one percent of respondents reported prescribing opioids at discharge following routine sternotomy-based procedures, however, there remained significant variability in the type and dose of medication prescribed. The median (interquartile range) number of pills prescribed was 30 (20-30) with a median total dose of 135 (113-200) Morphine Milligram Equivalents. Informal teaching was the most commonly reported primary influence on prescribing habits and a lack of formal education regarding opioid prescription was associated with a higher number of pills prescribed. A majority of respondents (91%) felt that there would be value in establishing practice guidelines for opioid prescription following cardiac surgery. CONCLUSIONS: Significant variability exists with respect to routine opioid prescription at discharge following cardiac surgery. Education has come predominantly from informal sources and there is a desire for guidelines. Standardization in this area may have a role in combatting the opioid epidemic.

Incidence of tamponade following temporary epicardial pacing wire removal.

BACKGROUND AND AIM OF STUDY: Placement of temporary epicardial pacing wires (TEPW) is common practice in cardiac surgery. Removal of TEPW in the postoperative period can lead to serious bleeding necessitating surgical intervention and conferring high morbidity. The purpose of this study is to determine the incidence of TEPW removal complications. METHODS: A retrospective review of all major cardiac operations at our institution from 2005 to 2016 was conducted. Patients were identified using the Maritime Heart Center Database. We reviewed preoperative, intra-operative, and postoperative characteristics of patients who returned to the operating room more than or equal to 3 days after their index operation to identify those who had bleeding and/or tamponade as a consequence of TEPW removal and any subsequent morbidity. RESULTS: A total of 11 754 patients underwent cardiac surgery at our institution between 2005 and 2016. Of these patients, 88 (0.75%) went back to the operating theater for bleeding and/or tamponade more than or equal to 3 days from their initial index operation. Of these, 11 (0.09%) were secondary to TEPW removal where two (0.017%) suffered irreversible anoxic brain injury. All 11 patients were on antiplatelet therapy with the addition of either deep venous thrombosis (DVT) prophylaxis or therapeutic anticoagulation, which is the standard of care at our institution. CONCLUSIONS: Bleeding complications following TEPW removal are rare but have significant consequences including increased hospital length of stay, resource utilization, and morbidity. Standardized practice to address antiplatelet, DVT prophylaxis, and anticoagulation before removal may help further reduce the incidence of serious bleeding events.

Transcatheter vs surgical aortic valve replacement in patients with interstitial lung disease.

BACKGROUND: Patients with underlying interstitial lung disease (ILD) who undergo cardiac surgery are at high risk of postoperative pulmonary complications. It remains unclear if transcatheter aortic valve replacement (TAVR) offers any benefit over surgical aortic valve replacement (SAVR) in ILD patients with severe aortic stenosis. METHODS: All adult patients with a diagnosis of ILD who underwent either a TAVR or isolated SAVR between January 2002 and December 2017 were retrospectively reviewed. Operative mortality, 30-day readmissions, and adjusted 1-year survival were compared between the two cohorts. RESULTS: The overall cohort included 52 TAVR and 74 SAVR patients. While TAVR patients were significantly older (77.2 vs 72.9 years) with higher Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) scores compared with SAVR patients (6.29 vs 4.49; all P < .02), operative mortality was similar (5.8% vs 4.1%; P = .45). Rates of postoperative stroke, permanent pacemaker implantation, reintubation, and 30-day readmissions did not differ between the two groups (all P > .46). However, TAVR was associated with significantly shorter hospital and intensive care unit (ICU) length of stay, shorter ventilation times, and less requirement for ICU admission (all P < .05). Thirty-day readmissions and adjusted 1-year survival were also similar between the two groups (hazard ratio for TAVR vs SAVR = 1.34; 95% CI: 0.7-2.6). CONCLUSIONS: Among ILD patients with symptomatic aortic stenosis, TAVR was associated with comparable operative and risk-adjusted 1-year survival to SAVR. TAVR patients also had shorter ventilator times, ICU and hospital stay despite being at higher risk. Together, our findings suggest that TAVR may be a better option in this unique cohort.

Patient-reported disease burden in oculopharyngeal muscular dystrophy.

INTRODUCTION: There is currently little evidence regarding oculopharyngeal muscular dystrophy (OPMD) disease burden reported by patients. In this study we aim to elicit direct patient input regarding OPMD disease burden. METHODS: We conducted semistructured interviews with 25 participants with genetically confirmed OPMD and a wide range of disease duration (15 ± 8 years). Using the Framework Technique, themes and categories were then extracted. RESULTS: Analyses revealed 7 themes (physical impact, mental impact, social impact, perception of progression, treatment perceptions, coping strategies, and access to disease information), encompassing 27 categories of OPMD disease burden. The most frequent categories were related to dysphagia, coping strategies for dysphagia, and impaired mobility. DISCUSSION: This study demonstrates the importance of considering, when providing clinical care, the broad range of coping strategies patients use to deal with OPMD symptoms, especially dysphagia, to properly assess limitations and monitor real disease progression.

Long-Term Effects of a Multimodal Physiotherapy Program on the Severity of Somatosensory Tinnitus and Identification of Clinical Indicators Predicting Favorable Outcomes of the Program.

BACKGROUND: Tinnitus, the perception of sound in the absence of external auditory stimuli, is commonly associated with problems of the auditory system. Head and neck disorders can also be involved in tinnitus emergence. In such cases, the term somatosensory tinnitus is used. Physiotherapy treatments have been identified as a promising avenue in the treatment of somatosensory tinnitus. PURPOSE: The aim of the study was to explore the effect of a physiotherapy program on the intensity and severity of somatosensory tinnitus and to identify the clinical characteristics of the patients who respond well to this treatment. RESEARCH DESIGN: Quasi-experimental pre-post single-group design. STUDY SAMPLE: Thirty-one adults with presumed somatosensory tinnitus. INTERVENTION: All participants received on average ten physiotherapy treatments over six weeks. Treatments included cervical and thoracic mobilizations, as well as muscular strengthening, stretching, postural instruction, and cervical stabilization. DATA COLLECTION AND ANALYSIS: Outcomes were measured at baseline, at the end of the physiotherapy program, and three months later. The primary outcomes were the Tinnitus Handicap Inventory and visual analog scales for loudness and annoyance caused by tinnitus. After the last evaluation, participants were divided into two groups: improved and unimproved participants. Participants were considered improved if they (1) showed significant improvement in at least two of the three primary outcome measures and (2) indicated subjective improvement. Thereafter, the baseline characteristics that correctly identify participants susceptible to improve significantly following treatment were determined (Cohen's effect size d > 0.8). RESULTS: A significant improvement in tinnitus intensity was observed at the end of the program. Of the 31 participants, 14 experienced persistent improvement in the intensity of their tinnitus and were classified as improved. Baseline characteristics strongly associated with tinnitus improvement were no increase in tinnitus when exposed to noise (d = -1.57), no family history of tinnitus (d = -1.16), somatosensory modulation in response to the contraction used to resist pressure applied to the forehead (d = 1.20), and recent onset of tinnitus (d = 1.03). CONCLUSIONS: This exploratory study showed that a multimodal physiotherapy program is effective in decreasing the severity of tinnitus, principally in individuals presenting with somatosensory tinnitus in combination with specific clinical characteristics.