Background: The use of intraoperative opioids may influence the rate of postoperative complications. This study evaluated the association between intraoperative opioid dose and the risk of 30-day hospital readmission. Methods: We conducted a pre-specified analysis of existing registry data for 153 902 surgical cases performed under general anaesthesia at Massachusetts General Hospital and two affiliated medical centres. We examined the association between total intraoperative opioid dose (categorised in quintiles) and 30-day hospital readmission, controlling for several patient-, anaesthetist-, and case-specific factors. Results: Compared with low intraoperative opioid dosing [quintile 1, median (inter-quartile range): 8 (4-9) mg morphine equivalents], exposure to high-dose opioids during surgery [quintile 5: 32 (27-41) equivalents] is an independent predictor of 30-day readmission [odds ratio (OR) 1.15 (95% confidence interval 1.07-1.24); P<0.001]. Ambulatory surgery patients receiving high opioid doses were found to have the greatest adjusted risk of readmission (OR 1.75; P<0.001) with a clear doseeresponse effect across quintiles (P for trend <0.05), and were more likely to be readmitted early (postoperative days 0-2 vs 3-30; P<0.001). Opioid class modified the association between total opioid dose and readmission, with longer-acting opioids demonstrating a stronger influence (P<0.001). We observed significant practice variability across individual anaesthetists in the utilisation of opioids that could not be explained by patient- and case-specific factors. Conclusions: High intraoperative opioid dose is a modifiable anaesthetic factor that varies in the practice of individual anaesthetists and affects postoperative outcomes. Conservative standards for intraoperative opioid dosing may reduce the risk of postoperative readmission, particularly in ambulatory surgery.

Background We hypothesised that intraoperative non-depolarising neuromuscular blocking agent (NMBA) dose is associated with 30-day hospital readmission. Methods Data from 13,122 adult patients who underwent abdominal surgery under general anaesthesia at a tertiary care hospital were analysed by multivariable regression, to examine the effects of intraoperatively administered NMBA dose on 30-day readmission (primary endpoint), hospital length of stay, and hospital costs. Results Clinicians used cisatracurium (mean dose [SD] 0.19 mg kg-1 [0.12]), rocuronium (0.83 mg kg-1 [0.53]) and vecuronium (0.14 mg kg-1 [0.07]). Intraoperative administration of NMBAs was dose-dependently associated with higher risk of 30-day hospital readmission (adjusted odds ratio 1.89 [95% Confidence Interval (CI) 1.26-2.84] for 5th quintile vs 1st quintile; P for trend: P<0.001), prolonged hospital length of stay (adjusted incidence rate ratio [aIRR] 1.20 [95% CI 1.11-1.29]; P for trend: P<0.001) and increased hospital costs (aIRR 1.18 [95% CI 1.13-1.24]; P for trend: P<0.001). Admission type (same-day vs inpatient surgery) significantly modified the risk (interaction term: aOR 1.31 [95% CI 1.05-1.63], P=0.02), and the adjusted odds of readmission in patients undergoing ambulatory surgical procedures who received high-dose NMBAs vs low-dose NMBAs amounted to 2.61 [95% CI 1.11-6.17], P for trend: P<0.001. Total intraoperative neostigmine dose increased the risk of 30-day readmission (aOR 1.04 [1.0-1.08], P=0.048). Conclusions In a retrospective analysis, high doses of NMBAs given during abdominal surgery was associated with an increased risk of 30-day readmission, particularly in patients undergoing ambulatory surgery.

Noninvasive positive pressure ventilation (NIPPV) has been used in acute heart failure (AHF) for 20 years with no consensus as to its role. Little is known about hospital practice patterns of NIPPV use in AHF, including the timing and setting of therapy, and the relationship between hospital NIPPV

Background: Little is known about cost variation among heart failure (HF) patients across hospitals when controlling for invasive cardiovascular percutaneous and surgical procedures. Methods: We identified all adult HF hospitalizations in 2009-10 Premier, Inc. hospitals with >25 HF hospitalizations. Hospitals were divided into 3 groups by their percent of HF patients receiving invasive percutaneous or surgical procedures: none (0%), moderate (0-10%), and high (>10%) (see figure). The 10% mark was the median across hospitals. For each of the three groups, the median hospitalization cost was calculated for all non-procedural admissions in standard dollar costs (figure). Standard cost assigns each billed item its median cost across all hospitals. The Kruskal-Wallis test was used to assess cost, length of stay, and outcome differences among the 3 groups (p≤0.05). Frequencies of billing categories (e.g. pharmacy, lab, central supply) were calculated and compared across the 3 groups. Results: Median standard dollar costs among non-procedural HF hospitalizations were $5104 (IQR=$3421, $7968), $6108 ($4001, $9934) and $6585 ($4181, $11218) for hospitals with no, moderate and high procedure use, respectively (figure). Respective median lengths of stay were 3, 4, and 4 days, and risk-adjusted mortality was 4.8%, 4.9% and 4.7% (figure). Cost analysis by resource categories showed that the proportion of items billed did not appear to differ by hospital group. Conclusion: The cost of HF hospitalization is higher in more procedure-intense hospitals even among patients who do not receive invasive procedures. Length of stay may contribute to these differences. Despite higher costs, high procedure hospitals do not have materially improved risk-adjusted mortality rates.

Concern about rising cost has focused attention on altering hospital practices to reduce expenses. We examined variation in use of the ICU, a high cost setting, for heart failure (HF) admissions. We identified 188,216 HF discharges from 341 hospitals in the 2009-10 Premier Perspective database. We

Genetic markers identifying women at an increased risk of developing breast cancer exist, yet the majority of inherited risk remains elusive. While numerous BRCA1 coding sequence mutations are associated with breast cancer risk, BRCA1 mutations account for less then 5% of breast cancer risk. Since 3' untranslated region (3'UTR) polymorphisms disrupting microRNA (miRNA) binding can be functional and can act as genetic markers of cancer risk, we tested the hypothesis that such polymorphisms in the 3'UTR of BRCA1 and haplotypes containing these functional polymorphisms may be associated with breast cancer risk. We sequenced the BRCA1 3'UTR from breast cancer patients to identify miRNA disrupting polymorphisms. We further evaluated haplotypes of this region including the identified 3'UTR variants in a large population of controls and breast cancer patients (n = 221) with known breast cancer subtypes and ethnicities. We identified three 3'UTR variants in BRCA1 that are polymorphic in breast cancer populations, and haplotype analysis including these variants revealed that breast cancer patients harbor five rare haplotypes not generally found among controls (9.50% for breast cancer chromosomes, 0.11% for control chromosomes, p = 0.0001). Three of these rare haplotypes contain the rs8176318 BRCA1 3'UTR functional variant. These haplotypes are not biomarkers for BRCA1 coding mutations, as they are found rarely in BRCA1 mutant breast cancer patients (1/129 patients = 0.78%). These rare BRCA1 haplotypes and 3'UTR SNPs may represent new genetic markers of breast cancer risk.

Cardiovascular disease (CVD) is the leading cause of death in Egypt and worldwide, placing great strain on the world’s health systems. High-quality treatment of CVD requires a valid, reliable measurement for ensuring evidence-based care. Clinical outcomes registries have been used to support quality improvement activities in some countries, but there are few examples of their implementation in resource-limited settings. A registry for acute coronary syndrome was piloted in 5 hospitals in Egypt, and observations regarding barriers and enabling factors related to implementation are summarized. Themes that emerged from daily observations include the importance of rapid cycles of change, the need to build a culture of applied research, the importance of modeling a blame-free culture, and key constraints encountered related to human resources and technical infrastructure. This pilot demonstrates that clinical registries may be a cost-effective investment in data infrastructure to support quality improvement in low- and middle-income countries.