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Perioperative alcohol cessation intervention for postoperative complications

Author/s: 
Egholm, Julie W., Pedersen, Bolette, Møller, Ann M., Adami, Johanna, Juhl, Carsten B., Tønnesen, Hanne

Background: Risky consumption of alcohol is a global problem. More than 3.3 million deaths annually are associated with risky use of alcohol, and global alcohol consumption continues to increase. People who have high alcohol consumption often require planned and emergency surgical procedures.Risky drinking is associated with increased postoperative complications such as infections, cardiopulmonary complications, and bleeding episodes. Alcohol causes disorders of the liver, pancreas, and nervous system. Stopping consumption of alcohol can normalize these organ systems to some degree and may reduce the occurrence of complications after surgery.This review was first published in 2012 and was updated in 2018.

Objectives: To assess the effects of perioperative alcohol cessation interventions on rates of postoperative complications and alcohol consumption.

Search methods: We searched the following databases up until 21 September 2018: Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; MEDLINE; Embase; CINAHL via EBSCOhost; and two trials registers. We scanned the reference lists and citations of included trials and any identified relevant systematic reviews for further references to additional trials. When necessary, we contacted trial authors to ask for additional information.

Selection criteria: We included all randomized controlled trials (RCTs) that evaluated the effects of perioperative alcohol cessation interventions on postoperative complications and alcohol consumption. We included participants with risky consumption of alcohol who were undergoing all types of elective or acute surgical procedures under general or regional anaesthesia or sedation, who were offered a perioperative alcohol cessation intervention or no intervention.We defined 'risky drinking' as alcohol consumption equivalent to more than 3 alcoholic units (AU)/d or 21 AU/week (with 1 AU containing 12 grams of ethanol) with or without symptoms of alcohol abuse or dependency. This corresponds to the amount of alcohol associated with increased postoperative complication rates in most clinical studies.

Data collection and analysis: We used guidance provided in the Cochrane Handbook for Systematic Reviews of Interventions. We presented main outcomes as dichotomous variables in a meta-analysis. When data were available, we conducted subgroup and sensitivity analyses to explore the risk of bias. Primary outcome measures were postoperative complications and in-hospital and 30-day mortality. Secondary outcomes were successful quitting at the end of the programme, postoperative alcohol use, and length of hospital stay. We assessed the quality of evidence using the GRADE approach.

Main results: We included in this updated review one new study (70 participants), resulting in a total of three RCTs (140 participants who drank 3 to 40 AU/d). All three studies were of moderate to good quality. All studies evaluated the effects of intensive alcohol cessation interventions, including pharmacological strategies for alcohol withdrawal symptoms, patient education, and relapse prophylaxis. We identified one ongoing study.Overall, 53 of the 122 participants from three studies who underwent surgery developed any type of postoperative complication that required treatment. Of 61 participants in the intervention groups, 20 had complications, compared with 33 of 61 participants in the control groups (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.40 to 0.96). Results show differences between the three clinical studies regarding outcome measurement and intensity of the interventions. However, all alcohol cessation programmes were intensive and included pharmacological therapy. The overall quality of evidence for this outcome is moderate.In-hospital and 30-day postoperative mortality rates were low in the three studies. Researchers reported one death among 61 participants in the intervention groups, and three deaths among 61 participants in the control groups (RR 0.47, 95% CI 0.07 to 2.96). The quality of evidence for this outcome is low.Investigators describe more successful quitters at the end of the intervention programme than among controls. Forty-one out of 70 participants in the intervention groups successfully quit drinking compared with only five out of 70 participants in the control groups (RR 8.22, 95% CI 1.67 to 40.44). The quality of evidence for this outcome is moderate.All three studies reported postoperative alcohol consumption (grams of alcohol/week) at the end of the programme as median and range values; therefore it was not possible to estimate the mean and the standard deviation (SD). We performed no meta-analysis. All three studies reported length of stay, and none of these studies described a significant difference in length of stay. Data were insufficient for review authors to perform a meta-analysis. No studies reported on the prevalence of participants without risky drinking in the longer term.

Authors' conclusions: This systematic review assessed the efficacy of perioperative alcohol cessation interventions for postoperative complications and alcohol consumption. All three studies showed a significant reduction in the number of participants who quit drinking alcohol during the intervention period. Intensive alcohol cessation interventions offered for four to eight weeks to participants undergoing all types of surgical procedures to achieve complete alcohol cessation before surgery probably reduced the number of postoperative complications. Data were insufficient for review authors to assess their effects on postoperative mortality. No studies reported an effect on length of stay, and no studies addressed the prevalence of risky drinking in the longer term.Included studies were few and reported small sample sizes; therefore one should be careful about drawing firm conclusions based on these study results. All three studies were conducted in Denmark, and most participants were men. The included participants may represent a selective group, as they could have been more motivated and/or more interested in participating in clinical research or otherwise different, and effects may have been overestimated for both intervention and control groups in these studies. Trial results indicate that these studies are difficult to perform, that strong research competencies are necessary for future studies, and that further evaluation of perioperative alcohol cessation interventions in high-quality randomized controlled trials is needed. Once published and assessed, the one 'ongoing' study identified may alter the conclusions of this review.

Conflict of interest statement

Hanne Tønnesen has authored all three of the studies included in this review (Egholm 2017; Tønnesen 1999a; Tønnesen 2002).

Julie Weber Melchior Egholm, Johanna Adami, and Bolette Pedersen have authored one of the included studies (Egholm 2017).

Hanne Tønnesen is also the primary investigator for the ongoing study (NCT02188446).

Therefore, to avoid any potential bias, Carsten B Juhl extracted data and checked the interpretation against study reports and any available study registration details or protocols as an independent review author.

The Unrecognized Prevalence of Primary Aldosteronism

Author/s: 
Brown, JM, Siddiqui, M, Calhoun, DA, Carey, RM, Hopkins, PN, Williams, GH, Vaidya, A

Background:

Primary aldosteronism is a nonsuppressible renin-independent aldosterone production that causes hypertension and cardiovascular disease.

 

Objective:

To characterize the prevalence of nonsuppressible renin-independent aldosterone production, as well as biochemically overt primary aldosteronism, in relation to blood pressure.

 

Design:

Cross-sectional study.

 

Setting:

4 U.S. academic medical centers.

 

Participants:

Participants with normotension (n = 289), stage 1 hypertension (n = 115), stage 2 hypertension (n = 203), and resistant hypertension (n = 408).

 

Measurements:

Participants completed an oral sodium suppression test, regardless of aldosterone or renin levels, as a confirmatory diagnostic for primary aldosteronism and to quantify the magnitude of renin-independent aldosterone production. Urinary aldosterone was measured in participants in high sodium balance with suppressed renin activity. Biochemically overt primary aldosteronism was diagnosed when urinary aldosterone levels were higher than 12 µg/24 h.

 

Results:

Every blood pressure category had a continuum of renin-independent aldosterone production, where greater severity of production was associated with higher blood pressure, kaliuresis, and lower serum potassium levels. Mean adjusted levels of urinary aldosterone were 6.5 µg/24 h (95% CI, 5.2 to 7.7 µg/24 h) in normotension, 7.3 µg/24 h (CI, 5.6 to 8.9 µg/24 h) in stage 1 hypertension, 9.5 µg/24 h (CI, 8.2 to 10.8 µg/24 h) in stage 2 hypertension, and 14.6 µg/24 h (CI, 12.9 to 16.2 µg/24 h) in resistant hypertension; corresponding adjusted prevalence estimates for biochemically overt primary aldosteronism were 11.3% (CI, 5.9% to 16.8%), 15.7% (CI, 8.6% to 22.9%), 21.6% (CI, 16.1% to 27.0%), and 22.0% (CI, 17.2% to 26.8%). The aldosterone–renin ratio had poor sensitivity and negative predictive value for detecting biochemically overt primary aldosteronism.

 

Limitation:

Prevalence estimates rely on arbitrary and conventional thresholds, and the study population may not represent nationwide demographics.

 

Conclusion:

The prevalence of primary aldosteronism is high and largely unrecognized. Beyond this categorical definition of primary aldosteronism, there is a prevalent continuum of renin-independent aldosterone production that parallels the severity of hypertension. These findings redefine the primary aldosteronism syndrome and implicate it in the pathogenesis of “essential” hypertension.

 

Primary Funding Source:

National Institutes of Health.

Keywords 
primary aldosteronism hypertension cardiovascular disease

Prevalence of Cannabis Withdrawal Symptoms Among People With Regular or Dependent Use of Cannabinoids: A Systematic Review and Meta-analysis

Author/s: 
Bahji, A., Stephenson, C., Tyo, R., Hawken, E.R., Seitz, D.P.

IMPORTANCE: 

Cannabis withdrawal syndrome (CWS)-a diagnostic indicator of cannabis use disorder-commonly occurs on cessation of heavy and prolonged cannabis use. To date, the prevalence of CWS syndrome has not been well described, nor have the factors potentially associated with CWS.

OBJECTIVES: 

To estimate the prevalence of CWS among individuals with regular or dependent use of cannabinoids and identify factors associated with CWS.

DATA SOURCES: 

A search of literature from database inception to June 19, 2019, was performed using MEDLINE, Embase, PsycINFO, Web of Science, the Cumulative Index to Nursing and Allied Health Literature, ProQuest, Allied and Complementary Medicine, and Psychiatry online, supplemented by manual searches of reference lists of included articles.

STUDY SELECTION: 

Articles were included if they (1) were published in English, (2) reported on individuals with regular use of cannabinoids or cannabis use disorder as a primary study group, (3) reported on the prevalence of CWS or CWS symptoms using a validated instrument, (4) reported the prevalence of CWS, and (5) used an observational study design (eg, cohort or cross-sectional).

DATA EXTRACTION AND SYNTHESIS: 

All abstracts, full-text articles, and other sources were reviewed, with data extracted in duplicate. Cannabis withdrawal syndrome prevalence was estimated using a random-effects meta-analysis model, alongside stratification and meta-regression to characterize heterogeneity.

MAIN OUTCOMES AND MEASURES: 

Cannabis withdrawal syndrome prevalence was reported as a percentage with 95% CIs.

RESULTS: 

Of 3848 unique abstracts, 86 were selected for full-text review, and 47 studies, representing 23 518 participants, met all inclusion criteria. Of 23 518 participants included in the analysis, 16 839 were white (72%) and 14 387 were men (69%); median (SD) age was 29.9 (9.0) years. The overall pooled prevalence of CWS was 47% (6469 of 23 518) (95% CI, 41%-52%), with significant heterogeneity between estimates (I2 = 99.2%). When stratified by source, the prevalence of CWS was 17% (95% CI, 13%-21%) in population-based samples, 54% in outpatient samples (95% CI, 48%-59%), and 87% in inpatient samples (95% CI, 79%-94%), which were significantly different (P < .001). Concurrent cannabis (β = 0.005, P < .001), tobacco (β = 0.002, P = .02), and other substance use disorders (β = 0.003, P = .05) were associated with a higher CWS prevalence, as was daily cannabis use (β = 0.004, P < .001).

CONCLUSIONS AND RELEVANCE: 

These findings suggest that cannabis withdrawal syndrome appears to be prevalent among regularusers of cannabis. Clinicians should be aware of the prevalence of CWS in order to counsel patients and support individuals who are reducing their use of cannabis.

Keywords 
cannabis cannabis use withdrawl predictors

Tinnitus

Author/s: 
Piccirillo, JF, Rodebaugh, TL, Lenze, EJ

Tinnitus is an auditory perception in the absence of an auditory stimulus. It may be associated with acoustic trauma (eg, exposure to loud noise), chronic hearing loss, emotional stressors, or spontaneous occurrence. The psychopathological reaction to the perceived auditory stimulus is an enormous source of distress and disability for many patients with tinnitus. National health surveys estimate that nearly 10 in 100 adults experience some form of tinnitus. Among workers exposed to occupational noise, the prevalence of tinnitus is 15 per 100. Of these, tinnitus is burdensome and chronic for roughly 20 million and extreme and debilitating tinnitus for 2 million US residents. Many patients with tinnitus report that the auditory perception impairs sleep, concentration, and cognitive function required for day-to-day functioning. Among the nearly 4.5 million US military veterans receiving service-connected compensation, 42% receive compensation for tinnitus, which makes it the most prevalent service-connected disability. The number of veterans who receive compensation due to tinnitus is nearly 60% greater than the number of veterans who receive compensation for hearing loss, which is the condition with the second most disability claims.

Keywords 
tinnitus hearing loss noise

Screening for Alcohol Use and Brief Counseling of Adults — 13 States and the District of Columbia, 2017

Author/s: 
McKnight-Eily, LR, Okoro, CA, Turay, K, Acero, C, Hungerford, D

What is already known about this topic?

Binge drinking increases the risk for adverse health conditions and death. Alcohol screening and brief intervention (SBI), recommended by the U.S. Preventive Services Task Force (USPSTF) for all adults in primary care, is effective in reducing binge drinking.

What is added by this report?

In 2017, 81% of survey respondents were asked by their health care provider about alcohol consumption and 38% about binge drinking at a checkup in the past 2 years. Among those asked about alcohol use and who reported current binge drinking, 80% received no advice to reduce their drinking.

What are the implications for public health practice?

Implementation of alcohol SBI as recommended by USPSTF, coupled with population-level evidence-based interventions, can reduce binge drinking among U.S. adults.

Keywords 
alcohol use screening and brief intervention alcohol SBI binge drinking

Pharmacotherapy for the Treatment of Cannabis Use Disorder: A Systematic Review

Author/s: 
Kondo, K.K., Morasco, B.J., Nugent S.M., O'Neil, ME, Ayers, C.K., Freeman, M., Kansagara, D.

BACKGROUND:

Cannabis use disorder (CUD) is a growing concern, and evidence-based data are needed to inform treatment options.

PURPOSE:

To review the benefits and risks of pharmacotherapies for the treatment of CUD.

DATA SOURCES:

MEDLINE, PsycINFO, Cochrane Database of Systematic Reviews, and clinical trial registries from inception through September 2019.

STUDY SELECTION:

Pharmacotherapy trials of adults or adolescents with CUD that targeted cannabis abstinence or reduction, treatment retention, withdrawal symptoms, and other outcomes.

DATA EXTRACTION:

Data were abstracted by 1 investigator and confirmed by a second. Study quality was dually assessed, and strength of evidence (SOE) was determined by consensus according to standard criteria.

DATA SYNTHESIS:

Across 26 trials, the evidence was largely insufficient. Low-strength evidence was found that selective serotonin reuptake inhibitors (SSRIs) do not reduce cannabis use or improve treatment retention. Low- to moderate-strength evidence was found that buspirone does not improve outcomes and that cannabinoids do not increase abstinence rates (moderate SOE), reduce cannabis use (low SOE), or increase treatment retention (low SOE). Across all drug studies, no consistent evidence of increased harm was found.

LIMITATIONS:

Few methodologically rigorous trials have been done. Existing trials are hampered by small sample sizes, high attrition rates, and heterogeneity of concurrent interventions and outcomes assessment.

CONCLUSION:

Although data on pharmacologic interventions for CUD are scarce, evidence exists that several drug classes, including cannabinoids and SSRIs, are ineffective. Because of increasing access to and use of cannabis in the general population, along with a high prevalence of CUD among current cannabis users, an urgent need exists for more research to identify effective pharmacologic treatments.

PRIMARY FUNDING SOURCE:

U.S. Department of Veterans Affairs. (PROSPERO: CRD42018108064).

Outcomes Associated With Oral Anticoagulants Plus Antiplatelets in Patients With Newly Diagnosed Atrial Fibrillation

Author/s: 
Fox, KAA, Velentgas, P, Camm, AJ, Bassand, JP, Fitzmaurice, DA, Gersh, BJ, Goldhaber, SZ, Goto, S, Haas, S, Misselwitz, F, Pieper, KS, Turpie, AGG, Verhegut, FWA, Dabrowski, E, Luo, K, Gibbs, L, Kakkar, AK, GARFIELD-AF Investigators

IMPORTANCE:

Patients with nonvalvular atrial fibrillation at risk of stroke should receive oral anticoagulants (OAC). However, approximately 1 in 8 patients in the Global Anticoagulant Registry in the Field (GARFIELD-AF) registry are treated with antiplatelet (AP) drugs in addition to OAC, with or without documented vascular disease or other indications for AP therapy.

OBJECTIVE:

To investigate baseline characteristics and outcomes of patients who were prescribed OAC plus AP therapy vs OAC alone.

DESIGN, SETTING, AND PARTICIPANTS:

Prospective cohort study of the GARFIELD-AF registry, an international, multicenter, observational study of adults aged 18 years and older with recently diagnosed nonvalvular atrial fibrillation and at least 1 risk factor for stroke enrolled between March 2010 and August 2016. Data were extracted for analysis in October 2017 and analyzed from April 2018 to June 2019.

EXPOSURE:

Participants received either OAC plus AP or OAC alone.

MAIN OUTCOMES AND MEASURES:

Clinical outcomes were measured over 3 and 12 months. Outcomes were adjusted for 40 covariates, including baseline conditions and medications.

RESULTS:

A total of 24 436 patients (13 438 [55.0%] male; median [interquartile range] age, 71 [64-78] years) were analyzed. Among eligible patients, those receiving OAC plus AP therapy had a greater prevalence of cardiovascular indications for AP, including acute coronary syndromes (22.0% vs 4.3%), coronary artery disease (39.1% vs 9.8%), and carotid occlusive disease (4.8% vs 2.0%). Over 1 year, patients treated with OAC plus AP had significantly higher incidence rates of stroke (adjusted hazard ratio [aHR], 1.49; 95% CI, 1.01-2.20) and any bleeding event (aHR, 1.41; 95% CI, 1.17-1.70) than those treated with OAC alone. These patients did not show evidence of reduced all-cause mortality (aHR, 1.22; 95% CI, 0.98-1.51). Risk of acute coronary syndrome was not reduced in patients taking OAC plus AP compared with OAC alone (aHR, 1.16; 95% CI, 0.70-1.94). Patients treated with OAC plus AP also had higher rates of all clinical outcomes than those treated with OAC alone over the short term (3 months).

CONCLUSIONS AND RELEVANCE:

This study challenges the practice of coprescribing OAC plus AP unless there is a clear indication for adding AP to OAC therapy in newly diagnosed atrial fibrillation.

Keywords 
anticoagulants atrial fibrillation stroke antiplatelet

Twenty-Four-Hour Movement Guidelines and Body Weight in Youth

Author/s: 
Zhu, X, Healy, S, Haegele, JA, Patterson, F

Objective

To examine the prevalence of youth meeting the 24-hour healthy movement guidelines (ie, ≥60 minutes of moderate-to-vigorous physical activity, ≤2 hours of screen time, age-appropriate sleep duration), and which combination of meeting these guidelines was most associated with bodyweight status, in a nationally representative US sample.

Study design

Cross-sectional data from the 2016-2017 National Survey of Children's Health were used. A multinomial regression model of body weight status was generated (underweight, overweight, obese vs healthy weight) and then stratified by sex. Analyses were adjusted for potential confounders.

Results

The sample (n = 30 478) was 50.4% female, 52.4% white, and the mean age was 13.85 ± 2.28 years; 15% percent were obese and 15.2% were overweight. Overall, 9.4% met all 3 of the 24-hour healthy movement guidelines, 43.6% met 2, 37.9% met 1, and 9.1% met none. Meeting zero guidelines (vs 3) was associated with the greatest likelihood of overweight (aOR, 1.85; 95% CI, 1.31-2.61), and obesity (aOR, 4.25; 95% CI, 2.87-6.31). Females (aOR, 4.97; 95% CI, 2.59-9.53) had higher odds of obesity than males (aOR, 3.99; 95% CI, 2.49-6.40) when zero (vs 3) guidelines were met. Meeting the moderate-to-vigorous physical activity guideline, either alone or in combination with screen time or sleep duration (vs all 3), was associated with the lowest odds for overweight and obesity in the full sample.

Conclusion

Meeting all movement guidelines was associated with the lowest risk for obesity, particularly in females. Meeting the moderate-to-vigorous physical activity guideline may be a priority to prevent overweight and obesity in youth.

Keywords 
24-hour healthy movement screen time sleep physical activity children adolescent

The Potential Emergence of Disease-Modifying Treatments for Alzheimer Disease: The Role of Primary Care in Managing the Patient Journey

Author/s: 
Lam, J., Hlávka, J., Mattke, S.

Despite recent setbacks, disease-modifying treatments (DMTs) for Alzheimer disease (AD) might become available within a few years. These DMTs are likely to be used in the early stages of AD to avoid the progression to manifest dementia, which implies that a large reservoir of prevalent cases would need to be evaluated when DMTs first become available. Primary care providers (PCPs) would play a vital role in managing the patient flow to specialty care. We review the literature on diagnostic tests that could be used by PCPs and estimate the impact of different testing approaches on demand for specialty care.While many tests have been evaluated, only the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) perform acceptably for detection of early-stage cognitive decline with sensitivities and specificities of 55% to 82% and 72% to 84%, respectively, for the MMSE; and 77% to 96% and 73% to 95%, respectively, for the MoCA. However, neither test is sufficiently specific for the AD pathology and would result in 4 to 5 false positives for each true positive. Blood-based tests for AD biomarkers may soon become available for clinical use. A plasma amyloid-β (Aβ) test has been shown to have a sensitivity of up to 97% and specificity of up to 81%. Adding this test to the MMSE or MoCA could reduce false positives by approximately 80%.These findings suggest a combination of brief cognitive tests and blood-based biomarker tests will allow PCPs to identify patients with potential early stage AD efficiently and triage them for further evaluation.

Keywords 
Alzheimer Disease
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