Chunyuan Qiu

Background/Objective: The first-year postoperative mortality in elderly hip fracture patients is between 15 and 36%. Current scientific evidence indicates that morbidity and mortality are impacted by time of admission to surgery in hip fracture patients, although anticoagulation (AC) medication status specific optimization is unknown. Our objectives were to identify an ideal preoperative wait time by anticoagulation status in patients before hip fracture repair based on the incidence of postoperative morbidity and mortality. Methods: A total of 35,463 patients age ≥ 65 undergoing hip fracture repair were selected from a United States hip fracture registry (2009–2019). Patients were separated into strata (yes/no) based on whether they received anticoagulation (AC) medications ≤ 100 days prior to surgery. Multivariable logistic regression was adjusted for non-linear surgical wait time trends with prespecified percentiles using cubic splines. Results: A total of 87.1% (N = 30,902) of patients did not have AC preoperatively. Their median wait time was 20.3 h (IQR 13–27 h), and a positive linear trend was observed between surgical wait time and mortality. In patients with pre-operative AC, there was a “U”-shaped trend for all mortality time points although the breakpoint slopes were not significantly different from zero. Conclusions: In the study of more than 30,000 patients, short-term mortality was lowest for non-AC patients, undergoing surgery within the first 6–15 h of admission but remained uniform throughout the first 24 h of admission. These findings can be used to optimize patients prior to hip fracture surgery based on preoperative AC use and can positively affect resource planning and perioperative protocols.

Background: The one-year mortality risk for elderly patients undergoing proximal femur fracture repair surgery is three to four times higher compared to the general population. Other than time to surgery, risk factors for postoperative morbidity and mortality following surgery are poorly understood in the elderly. We sought to identify risk factors associated with morbidity and mortality in geriatric patients by anticoagulation status undergoing hip fracture repair. Methods: Patients aged ≥65 years undergoing surgery for hip fracture repair were included (2009–2019) from a US-based hip fracture registry. Factors associated with 90-day mortality were determined using multivariable logistic regression and stratified by antithrombotic agent medication use prior to surgery. Direct oral anticoagulation (DOAC) medications were the largest group, and all antithrombotic agents were included in the delineation. Results: A total of 35,463 patients were identified, and 87.1% (N = 30,902) were DOAC-naïve. Risk factors for 90-day mortality in DOAC-naïve patients were an American Society of Anesthesiologist’s (ASA) classification ≥3 (odds ratio [OR] = 2.56, 95% confidence interval [CI] = 2.24–2.93), preoperative myocardial infarction (OR = 1.87, 95% CI = 1.33–2.64), male gender (OR = 1.73, 95% CI = 1.59–1.88), congestive heart failure (CHF) (OR = 1.64, 95% CI = 1.50–1.80), psychoses (OR = 1.27, 95% CI = 1.15–1.42), renal failure (OR = 1.29, 95% CI = 1.19–1.40), smoking history (OR = 1.19, 95% CI = 1.09–1.29), chronic pulmonary disease (OR = 1.14, 95% CI = 1.05–1.25), increasing age (OR = 1.07, 95% CI = 1.06–1.07), and decreasing body mass index (BMI) (OR = 1.06, 95% CI = 1.05–1.08). Identified factors for mortality in the DOAC group also included ASA classification ≥3 (OR = 2.15, 95% CI = 1.44–3.20), male gender (OR = 1.68, 95% CI = 1.41–2.01), CHF (OR = 1.45, 95% CI = 1.22–1.73), chronic pulmonary disease (OR = 1.34, 95% CI = 1.12–1.61), decreasing BMI (OR = 1.04, 95% CI = 1.02–1.06), and increasing age (OR = 1.02, 95% CI = 1.01–1.03). Conclusions: Regardless of preoperative DOAC status, ASA classification, gender, CHF, chronic pulmonary disease, lower BMI, and higher age are associated with an increased risk of mortality. Some of these comorbidities can be utilized for risk stratification prior to surgery.

Background: Maternal preeclampsia is associated with a risk of autism spectrum disorders (ASD) in offspring. However, it is unknown whether the increased ASD risk associated with preeclampsia is due to preeclampsia onset or clinical management of preeclampsia after onset, as clinical expectant management of preeclampsia allows pregnant women with this complication to remain pregnant for potentially weeks depending on the onset and severity. Identifying the risk associated with preeclampsia onset and exposure provides evidence to support the care of high-risk pregnancies and reduce adverse effects on offspring. Objective: This study aimed to fill the knowledge gap by assessing the ASD risk in children associated with the gestational age of preeclampsia onset and the number of days from preeclampsia onset to delivery. Methods: This retrospective population-based clinical cohort study included 364,588 mother-child pairs of singleton births between 2001 and 2014 in a large integrated health care system in Southern California. Maternal social demographic and pregnancy health data, as well as ASD diagnosis in children by the age of 5 years, were extracted from electronic medical records. Cox regression models were used to assess hazard ratios (HRs) of ASD risk in children associated with gestational age of the first occurrence of preeclampsia and the number of days from first occurrence to delivery. Results: Preeclampsia occurred in 16,205 (4.4%) out of 364,588 pregnancies; among the 16,205 pregnancies, 2727 (16.8%) first occurred at <34 weeks gestation, 4466 (27.6%) first occurred between 34 and 37 weeks, and 9012 (55.6%) first occurred at ≥37 weeks. Median days from preeclampsia onset to delivery were 4 (IQR 2,16) days, 1 (IQR 1,3) day, and 1 (IQR 0,1) day for those first occurring at <34, 34-37, and ≥37 weeks, respectively. Early preeclampsia onset was associated with greater ASD risk (P=.003); HRs were 1.62 (95% CI 1.33-1.98), 1.43 (95% CI 1.20-1.69), and 1.23 (95% CI 1.08-1.41), respectively, for onset at <34, 34-37, and ≥37 weeks, relative to the unexposed group. Within the preeclampsia group, the number of days from preeclampsia onset to delivery was not associated with ASD risk in children; the HR was 0.995 (95% CI 0.986-1.004) after adjusting for gestational age of preeclampsia onset. Conclusions: Preeclampsia during pregnancy was associated with ASD risk in children, and the risk was greater with earlier onset. However, the number of days from first preeclampsia onset to delivery was not associated with ASD risk in children. Our study suggests that ASD risk in children associated with preeclampsia is not increased by expectant management of preeclampsia in standard clinical practice. Our results emphasize the need to identify effective approaches to preventing the onset of preeclampsia, especially during early pregnancy. Further research is needed to confirm if this finding applies across different populations and clinical settings.

Importance: Maternal labor epidural analgesia (LEA) and oxytocin use for labor and delivery have been reported to be associated with child autism spectrum disorders (ASD). However, it remains unclear whether these 2 common medications used during labor and delivery have synergistic associations with ASD risk in children.Objective: To assess the independent associations of LEA and oxytocin during labor and delivery with ASD, as well as outcome modification associated with the concurrent use of both interventions.Design, Setting, and Participants: Data for this cohort study included 205 994 singleton births with vaginal deliveries in a single integrated health care system in Southern California from calendar years 2008 to 2017. Children were followed up to December 31, 2021. Data on use of LEA and oxytocin, covariates, and ASD outcome in children were obtained from electronic medical records. Cox proportional hazards regression was used to estimate the hazard ratios (HRs) adjusting for covariates.Exposures: Labor epidural analgesia and/or oxytocin use during labor and delivery.Main Outcomes and Measures: A child’s clinical diagnosis of ASD during follow-up and at age of diagnosis.Results: Among the cohort, 153 880 children (74.7%) were exposed to maternal LEA and 117 808 children (57.2%) were exposed to oxytocin during labor and delivery. The population of children was approximately half boys and half girls. The median (IQR) age of the mothers was 30.8 (26.8-34.5) years for those not exposed to LEA, 30.0 (25.9-33.8) years for those exposed to LEA, 30.4 (26.5-34.1) years for those unexposed to oxytocin, and 30.0 (25.9-33.9) years for those exposed to oxytocin during labor and delivery. A total of 5146 children (2.5%) had ASD diagnosed during follow-up. Oxytocin exposure was higher among LEA-exposed (67.7%) than -unexposed (26.1%) children. The ASD risk associated with LEA was independent of oxytocin exposure (HR, 1.28; 95% CI, 1.18-1.38); however, the ASD risk associated with oxytocin was not significant after adjusting for LEA exposure (HR, 1.05; 95% CI, 0.99-1.12). A significant interaction of LEA and oxytocin on child ASD risk was found (P = .02 for interaction). Compared with no exposure, HRs were 1.20 (95% CI, 1.09-1.32) for LEA alone, 1.30 (95% CI, 1.20-1.42) for both LEA and oxytocin, and 0.90 (95% CI, 0.78-1.04) for oxytocin alone.Conclusions and Relevance: The findings of this cohort study suggest an association between maternal LEA and ASD risk in children, and the risk appeared to be further increased if oxytocin was also administered. Oxytocin exposure without LEA exposure was not associated with ASD risk in children. These findings must be interpreted with caution. Further studies are needed to replicate or refute the study results and examine biological plausibility.

Microaggression is widespread in the health care industry and occurs in every health care delivery setting. It comes in many forms, from subtle to obvious, unconscious to conscious, and verbal to behavioral. Women and minority groups (eg, race/ethnicity, age, gender, sexual orientation) are often marginalized during medical training and subsequent clinical practice. These contribute to the development of psychologically unsafe working environments and widespread physician burnout. Physicians experiencing burnout who work in unsafe psychological environments impact the safety and quality of patient care. In turn, these conditions impose high costs on the health care system and organizations. Microaggressions and psychological unsafe work environments are intricately related and mutually enhanced. Therefore, addressing both simultaneously is a good business practice and a responsibility for any health care organization. Additionally, addressing them can reduce physician burnout, decrease physician turnover, and improve the quality of patient care. To counter microaggression and psychological unsafe, it takes conviction, initiative, and sustainable efforts from individuals, bystanders, organizations, and government agencies.

Perioperative care delivery is a patient-centered, multidisciplinary process. It relies heavily on synchronized teamwork from a well-coordinated team. Perioperative physicians-surgeons and anesthesiologists-face enormous challenges in surgical care delivery due to changing work environments, post-COVID consequences, shift work disorder, value conflict, escalating demands, regulatory complexity, and financial uncertainties. Physician burnout in this working environment has become increasingly prevalent. It is not only harmful to physicians' health and well-being, but it also affects the quality and safety of patient care. Additionally, the economic costs associated with physician burnout are untenable due to the high turnover rate, high recruitment expenses, and potential early permanent exit from medical practice. In this deteriorating environment of unbalanced physician supply/demand, recognizing, managing, and preventing physician burnout may help preserve the system's most valuable asset and contribute to higher quality and safety of patient care. Leaders in government agencies, health care systems, and organizations must work together to re-engineer the health care system for better physicians and patient care.

BACKGROUND Maternal preeclampsia is associated with a risk of autism spectrum disorders (ASD) in offspring. However, it is unknown whether the increased ASD risk associated with preeclampsia is due to preeclampsia onset or clinical management of preeclampsia after onset, as clinical expectant management of preeclampsia allows pregnant women with this complication to remain pregnant for potentially weeks depending on the onset and severity. Identifying the risk associated with preeclampsia onset and exposure provides evidence to support the care of high-risk pregnancies and reduce adverse effects on offspring. OBJECTIVE This study aimed to fill the knowledge gap by assessing the ASD risk in children associated with the gestational age of preeclampsia onset and the number of days from preeclampsia onset to delivery. METHODS This retrospective population-based clinical cohort study included 364,588 mother-child pairs of singleton births between 2001 and 2014 in a large integrated health care system in Southern California. Maternal social demographic and pregnancy health data, as well as ASD diagnosis in children by the age of 5 years, were extracted from electronic medical records. Cox regression models were used to assess hazard ratios (HRs) of ASD risk in children associated with gestational age of the first occurrence of preeclampsia and the number of days from first occurrence to delivery. RESULTS Preeclampsia occurred in 16,205 (4.4%) out of 364,588 pregnancies; among the 16,205 pregnancies, 2727 (16.8%) first occurred at <34 weeks gestation, 4466 (27.6%) first occurred between 34 and 37 weeks, and 9012 (55.6%) first occurred at ≥37 weeks. Median days from preeclampsia onset to delivery were 4 (IQR 2,16) days, 1 (IQR 1,3) day, and 1 (IQR 0,1) day for those first occurring at <34, 34-37, and ≥37 weeks, respectively. Early preeclampsia onset was associated with greater ASD risk (P=.003); HRs were 1.62 (95% CI 1.33-1.98), 1.43 (95% CI 1.20-1.69), and 1.23 (95% CI 1.08-1.41), respectively, for onset at <34, 34-37, and ≥37 weeks, relative to the unexposed group. Within the preeclampsia group, the number of days from preeclampsia onset to delivery was not associated with ASD risk in children; the HR was 0.995 (95% CI 0.986-1.004) after adjusting for gestational age of preeclampsia onset. CONCLUSIONS Preeclampsia during pregnancy was associated with ASD risk in children, and the risk was greater with earlier onset. However, the number of days from first preeclampsia onset to delivery was not associated with ASD risk in children. Our study suggests that ASD risk in children associated with preeclampsia is not increased by expectant management of preeclampsia in standard clinical practice. Our results emphasize the need to identify effective approaches to preventing the onset of preeclampsia, especially during early pregnancy. Further research is needed to confirm if this finding applies across different populations and clinical settings.

We present a case of a 60-year-old male who has undergone Achilles’ tendon repair with amnion augmentation on the right side. Before the surgery, liposomal bupivacaine was requested by the patient, and this was used to block the popliteal and adductor canal nerves for intraoperative anesthetic and postoperative pain control. The patient understood the benefits and risks of the regional nerve block with this medication and its off-label use. After the surgery, the patient underwent an irregular course of anesthetic, including delayed motor weakness, and became non-weight-bearing temporarily. The motor block was inconsistent and non-linear. Initially, the motor block completely resolved with a return to the sensation after three days. Then, on day four, a complete motor block developed, which resolved gradually over the next four days. After 10 days, the patient had full resolution of symptoms. He denies any pain since the surgery.

In Reply We appreciate the valuable perspectives and the thoughtful scrutiny that has been stimulated by our study, including those brought forward by Kern-Gold

Labor epidural analgesia (LEA) is the most commonly administered neuraxial anesthesia for labor pain.¹ In the United States, more than 70% of women receive some form of a neuraxial procedure during labor. Although the effectiveness of neuraxial anesthesia for labor pain management and the safety of neuraxial anesthesia for the fetus and newborns during the perinatal period have been well documented, the long-term effects of neuraxial anesthesia on the offspring are largely unknown.^2-4 Limited toxicology and animal studies have shown that standard clinical doses of local anesthetics (LAs) can produce neurotoxic effects and alter normal behavioral development in rhesus monkeys.⁵ Recent observational studies with humans found that general anesthesia for cesarean deliveries was associated with an approximately 50% increased risk for children to develop autism spectrum disorders (ASDs) compared with vaginal deliveries.^6,7 A recent meta-analysis comprising 61 studies with 20 million deliveries concluded that birth by cesarean delivery was significantly associated with the risk of ASD.⁸ However, these studies did not address the potential risk associated with the common use of neuraxial anesthesia for routine vaginal delivery. Given that LEA is currently the criterion standard for labor pain management for routine vaginal delivery, it is critical to assess whether maternal LEA exposure has any long-term association with outcomes in offspring.