Gregory William Roberts

Background: Spinal surgery is associated with substantial post-operative analgesia needs. Opioid-sparing therapy with non-steroidal anti-inflammatories (NSAIDs) and atypical opioids (tramadol, tapentadol) offer an option before the use of conventional opioids. We assessed the uptake of NSAID and atypical opioid use and their association with conventional opioid prescribing. Methods: Those undergoing spinal surgery at a tertiary hospital were retrospectively assessed for NSAID and atypical opioid use in the 24 hours before discharge. The relationship with the discharge prescribing of analgesia was analysed. Results: Of 147 eligible subjects, only 28% of NSAID-eligible and 51% of atypical opioid-eligible subjects received these in the 24 hours before discharge. Multiple linear regressions indicate that atypical opioid use was independently associated with both decreased conventional opioid use in the 24 hours before discharge (p = 0.0089) and decreased conventional opioid prescribing at discharge (p = 0.0054), whereas NSAID use was not. There was poor correlation between conventional opioid use in the 24 hours before discharge and the amount prescribed at discharge (r2 = 0.066, p = 0.0020). Of the 40 who did not require conventional opioid analgesia in the 24 hours before discharge, 19 were prescribed opioids at discharge. Conversely, of the 41 patients who required > 20 mg oxycodone in the 24 hours before discharge, 19 received no conventional opioid at discharge. Conclusion: Inpatient atypical opioid use was associated with decreased conventional opioid use in the 24 hours before discharge and at discharge. Choice and quantity of discharge prescribing was inconsistent with inpatient use in the 24 hours before discharge. NSAIDs and atypical opioids were largely underused. There is significant scope for improved prescribing of post-operative opioid-sparing analgesia in those undergoing spinal surgery. Keywords: postoperative pain · analgesia · opioids · NSAID

Background: The glycemic ratio (GR), defined as the ratio of mean intensive care unit (ICU) blood glucose (BG) to estimated preadmission BG (EPBG), may provide superior prognostic insight compared with the single admission snapshot represented by the stress hyperglycemia ratio (SHR, the ratio of ICU admission BG to EPAG). Methods: This retrospective study included 4148 patients treated in a university-affiliated medical-surgical ICU from 2019 to 2023 who had >4 ICU BG measurements and a glycated hemoglobin (HbA1c) measured at admission. We compared SHR and GR prognostic ability for mortality, analyzed across prespecified GR and SHR bands, and calculated observed:expected mortality ratios (OEMRs). Results: We observed a more sharply defined J-shaped relationship between GR and mortality compared with that generated by SHR. Mortality in the reference band of 0.8 to P = .0087), and for the strata ≥1.4, mortality was 25.6% vs 20.5% ( P = .0376). Compared with the reference band, GR < 0.8 and GR > 1.0 had higher OEMR ( P < .0001 for each), but the OEMR for SHR 1.0 compared with the reference band was not significantly different. Conclusions: Glycemic ratio was superior to SHR as a predictor of mortality. This study demonstrates that a mean ICU BG level representing 80% to 100% of the patient’s EPBG was associated with the lowest mortality rate in a heterogeneous cohort of critically ill patients. These results may inform current BG management strategies and should be considered when designing future interventional trials in the critically ill.

Background: Interventional studies investigating blood glucose (BG) management in intensive care units (ICU) have been inconclusive. New insights are needed. We assessed the ability of a new metric, the Glycemic Ratio (GR), to determine the relationship of ICU glucose control relative to preadmission glycemia and mortality. Methods: Retrospective cohort investigation (n = 4790) in an adult medical-surgical ICU included patients with minimum four BGs, hemoglobin (Hgb), and hemoglobin A1c (HbA1c). The GR is the quotient of mean ICU BGs (mBG) and estimated preadmission BG, derived from HbA1c. Results: Mortality displayed a J-shaped curve with GR (nadir GR 0.9), independent of background glycemia, consistent for HbA1c 6.5%, and Hgb >10 g/dL vs 6.5%, and dependent on preadmission glycemia. In adjusted analysis, GR remained associated with mortality (odds ratio = 2.61, 95% confidence interval = 1.48-4.62, P = .0012), but mBG did not (1.004, 1.000-1.009, .059). A single value on admission was not independently associated with mortality. Conclusions: The GR provided new insight into malglycemia that was not apparent using mBG, or an admission value. Mortality was associated with acute change from preadmission glycemia (GR). Further assessment of the impact of GR deviations from the nadir in mortality at GR 0.80 to 0.99, as both relative hypo- and hyperglycemia, and as duration of exposure and intensity, may further define the multifaceted nature of malglycemia.

Aim: Stress‐induced hyperglycaemia (SIH) is the acute increase from preadmission glycaemia and is associated with poor outcomes. Early recognition of SIH and subsequent blood glucose (BG) management improves outcomes, but the degree of SIH provoked by distinct diagnostic categories remains unknown. Quantification of SIH is now possible using the stress hyperglycaemia ratio (SHR), which measures the proportional change from preadmission glycaemia, based on haemoglobin A_1c (HbA_1c).Methods: We identified eligible patients for eight medical (n = 892) and eight surgical (n = 347) categories. Maximum BG from the first 24 h of admission for medical, or postoperatively for surgical patients was used to calculate SHR.Results: Analysis of variance indicated differing SHR and BG within both the medical (p < 0.0001 for both) and surgical cohort (p < 0.0001 for both). Diagnostic categories were associated with signature levels of SHR that varied between groups. Medically, SHR was greatest for ST‐elevation myocardial infarction (1.22 ± 0.33) and sepsis (1.37 ± 0.43). Surgically, SHR was greatest for colectomy (1.62 ± 0.48) and cardiac surgeries (coronary artery graft 1.56 ± 0.43, aortic valve replacement 1.71 ± 0.33, and mitral valve replacement 1.75 ± 0.34).SHR values remained independent of HbA_1c, with no difference for those with HbA_1c above or below 6.5% (p > 0.11 for each). BG however was highly dependent on HbA_1c, invariably elevated in those with HbA_1c ≥ 6.5% (p < 0.001 for each), and unreliably reflected SIH.Conclusion: The acute stress response associated with various medical and surgical categories is associated with signature levels of SIH. Those with higher expected SHR are more likely to benefit from early SIH management, especially major surgery, which induced SIH typically 40% greater than medical cohorts. SHR equally recognised the acute change in BG from baseline across the full HbA_1c spectrum while BG did not and poorly reflected SIH.

Long-term treatment with warfarin is recommended for patients with atrial fibrillation at risk

We assessed hospitalisations for gastrointestinal bleeding directly related to primary prevention aspirin in lower risk patients for a 6-month period in three South Australian hospitals. Those with related underlying pathology or concurrent causative medication were excluded. Identified patients (n = 22) carried little co-morbidity, 41% received prior proton-pump inhibitors and 68% were aged >70 years. Mean hospital admission cost was $6769 (95% confidence interval $5198–$8340), with projected state and national annual costs of $0.57 and $8.12 million respectively. In light of recent guideline changes, clinicians need to vigorously assess the need for primary prevention aspirin.

Background: The aim of this study is to compare metrics specific for stress‐induced hyperglycemia (SIH) with glucose for predicting ischemic stroke outcome.Methods: This observational retrospective study (n = 300) included patients acutely hospitalized for ischemic stroke over a 3.8‐year period. We assessed the association between acute ischemic stroke outcome with the stress hyperglycemia ratio (SHR, relative increase in glycemia) and glycemic gap (GG, absolute increase in glycemia) using admission values and 5‐day maximum values, along with incidence of poor outcome above recognized clinical thresholds of glucose 10 mmol/L, SHR 1.14, and GG 2.5 mmol/L.Results: At admission, only SHR was associated with outcome after adjustment for clinical covariates (odds ratio [OR] = 2.88; 95% CI: 1.05‐7.91; P = .041), while glucose or GG were not. Admission SHR ≥ 1.14 was also an indicator of poor outcome (39.1% vs 23.4%, P = .016), but not glucose ≥10 mmol/L or GG ≥ 2.5 mmol/L. All 5‐day maximum glucose metrics were associated with outcome, as was any SHR ≥ 1.14 (40.9% vs 20.1%, P < .001) or GG ≥ 2.5 mmol/L (42.9% vs 23.4%, P = .011), but not glucose ≥10 mmol/L. Increased comorbidity was strongly associated with worse outcome (P < .001) in all models.Conclusions: SHR provided the best prognostic insight at admission to assess the relationship between SIH and ischemic stroke outcome. Absolute glucose levels failed to account for natural interpatient variation in background glycemia and provided little prognostic insight. To assess the impact of SIH, future interventional studies need to be designed using designated markers of SIH such as SHR in preference to absolute glucose.