Risultati per: Short Acting Opioid

Circulation, Volume 150, Issue Suppl_1, Page A4140779-A4140779, November 12, 2024. Background:Treatment of calcified coronary artery stenosis remains challenging and is associated with worse clinical outcomes. For successful PCI of calcified lesions, it is imperative to achieve sufficient plaque modification before stent implantation.Aims:The aims of the current study were to evaluate coronary microvascular dysfunction and short-term outcomes in heavy calcified coronary lesion underwent PCI with intravascular lithotripsy (IVL) versus rotational atherectomy (RA).Methods:We retrospectively analyzed 91 patients underwent PCI with severely calcified coronary stenosis treated with atherectomy devices. Of these, coronary microvascular function was assessed using temperature-sensor guidewire(PressureWire X, Abott) in 40 patients (IVL: 21, RA: 19) before and after PCI. Procedural success including successful stent delivery with

Circulation, Volume 150, Issue Suppl_1, Page A4146863-A4146863, November 12, 2024. Introduction:The treatment of heart failure (HF) with hydralazine-isosorbide dinitrate (H-ISDN) in African Americans (AA) with New York Heart Association (NYHA) III-IV who remain symptomatic despite optimal medical therapy is a class Ia indication. However, the efficacy of guideline directed medical therapy (GDMT) which combines sodium-glucose cotransporter-2 inhibitors (SGLT2i) and H-ISDN in reducing hospital readmissions has not been well studied.Hypothesis:In self-identified AA adults with advanced heart failure on GDMT including hydralazine-isosorbide dinitrate, the use of a SGLT2i reduces hospitalization for HF.Methods:The patients studied were self-identified AA with advanced HF on GDMT [including any dose of an angiotensin receptor-neprilysin inhibitor (ARNi) or an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin II receptor blocker (ARB), a mineralocorticoid receptor antagonist (MRA), a beta-blocker (BB), H-ISDN, with or without treatment with an SGLT2i]. Data was obtained from the Hospital Corporation of America (HCA) enterprise-wide database from January 2020 to September 2023 using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). The final cohort was divided into two groups: Group 1 consisted of those treated with an ARNi/ACEi/ARB, MRA, a beta blocker, and H-ISDN while Group 2 included those receiving the same combination of medications with the addition of an SGLT2i. Differences in baseline characteristics were analyzed between the two groups. Logistic regression was used to analyze the relationship between the treatment groups and hospital readmission within 90 days.Results:Only 517 AA met inclusion criteria and did not meet exclusion criteria, which included a history of valvular heart disease, hypertrophic or restrictive cardiomyopathy, active myocarditis, history of cardiac arrest, and life-threatening arrhythmias. When controlling for age, gender, diabetes, chronic kidney disease, atrial fibrillation, body mass index, and smoking status, there was no significant difference in the likelihood of 90-day hospital readmission between patients whose GDMT with H-ISDN included an SGLT2i and those whose treatment did not.Conclusions:The results suggest the incorporation of an SGLT2i into GDMT with H-ISDN in AA with advanced HF does not confer additional benefits in the reduction of short-term hospital readmissions for heart failure.

Circulation, Volume 150, Issue Suppl_1, Page A4136554-A4136554, November 12, 2024. Background:In 2023, the AHA published the PREVENT equations for estimating atherosclerotic cardiovascular disease (ASCVD) risk in adults aged 30-79 years.Research Questions:In young adults aged 20-39 years, does PREVENT improve risk prediction for 10- and 30-year ASCVD compared with existing risk assessment tools recommended in the current US guidelines (i.e., Pooled Cohort Equations [PCEs] and Pencina et al. equations)?Aims:To compare the performance of PREVENT vs. PCEs in predicting 10-year ASCVD, and PREVENT vs. Pencina equations in predicting 30-year ASCVD in young adults.Methods:We analyzed data from two complementary sources: (1) pooled data from two large cohorts: Coronary Artery Risk Development in Young Adults (CARDIA) and Framingham Heart Study (FHS; including the Offspring, Third Generation, Omni 1, and Omni 2 cohorts), and (2) electronic health records from Kaiser Permanente Southern California (KPSC). We included adults aged 20-39 years without a history of ASCVD at baseline. The outcome was incident ASCVD (defined as myocardial infarction, fatal coronary heart disease, fatal and nonfatal stroke) at 10 or 30 years. Model discrimination (Harrell’s C) and mean calibration (estimated as the ratio of predicted to observed event rates) were calculated for the overall population and stratified by sex and race/ethnicity.Results:We included 7,606 young adults (mean age 29 years, 53% female, 30% Black) from the pooled cohorts, and 284,667 (mean age 32 years, 61% female, 8% Black, 46% Hispanic) from KPSC. When predicting 10-year risk, PREVENT improved discrimination in both the pooled cohort (ΔHarrell’s C=0.052; 95% CI: 0.014, 0.095) and KPSC (ΔHarrell’s C=0.039; 95% CI: 0.028, 0.049) compared with the PCEs. PREVENT had good calibration (mean calibration ranged from 0.77 to 1.54), whereas the PCEs overestimated 10-year risk (mean calibration ranged from 1.99 to 4.82). When predicting 30-year risk, discrimination was similar for PREVENT and Pencina equations, but both algorithms underestimated 30-year risk with PREVENT showing worse calibration (mean calibration 0.61).Conclusion:PREVENT improved 10-year ASCVD risk prediction in young adults compared to the PCEs but underestimated 30-year risk.

Circulation, Volume 150, Issue Suppl_1, Page A4146149-A4146149, November 12, 2024. Background:The WHO estimates that air pollution causes 7 million premature deaths or about 1 in 8 global deaths. Epidemiological studies indicate that 60-70% of the premature mortality attributed to air pollution are cardiovascular deaths especially in those with pre-existing conditions such as hypertension and heart failure. The underlying pathophysiological mechanisms by which exposures to air pollution worsen cardiovascular disease are unclear.Hypothesis:We hypothesized that the cardiovascular toxicity of particulate air pollution (PM2.5) exposure would be enhanced in the setting of hypertension.Methods:To test this, we combined air pollution exposure with a hypertension model (angiotensin II, 2.5 mg/kg bwt/day: ANGII osmotic pump) where normotensive and hypertensive male wildtype (WT, C57BL/6J) mice were exposed to filtered air or concentrated ambient PM2.5(CAP) for 3 weeks. To understand how combined hypertension and CAP exposure may alter cardiac remodeling, fibrosis and gene transcription (bulk RNAseq) were quantified.Results:Mice with ANGII-infusion developed hypertension (non-invasive tail cuff) that was significantly elevated by CAP exposure. Hypertensive mice also developed cardiac hypertrophy (heart weight/tibia length ratio, mg/mm) independent of exposure [hypertensive: WT+Air, 9.6±0.4; WT+CAP, 10.3±0.4; normotensive groups: WT+Air, 8.3±0.3; WT+CAP, 7.4±0.1). CAP exposure had no effect on differential gene transcription in normotensive mice, yet CAP exposure significantly induced 996 differentially expressed genes (DEG) in hypertensive mice (332 up, 664 down). Gene Ontogeny (GO) analysis found dysregulated gene clusters ( >40 genes) primarily for cardiac and striated muscle development and differentiation. Increased genes included caspase 12 (Casp12) and catechol-O-methyltransferase (Comt)genes that likely reflect enhanced apoptosis and sympathetic input. Downregulated genes included 2 collagen genes (Col5a3andCol6a3) and death inducer-obliterator 1 (Dido1) — reflecting dysregulated cardiac remodeling.Conclusions:Hypertension enhanced the susceptibility of short-term air pollution exposure to worsen cardiovascular effects especially cardiac remodeling. This study reveals potential genetic mechanisms by which air pollution hastens cardiac dysregulation and promotes heart failure – a serious, globally relevant cardiovascular health risk of particulate air pollution.

Circulation, Volume 150, Issue Suppl_1, Page A4140686-A4140686, November 12, 2024. Background:Comorbid diabetes mellitus (DM) is associated with worse outcomes in patients with chronic limb-threatening ischemia (CLTI). Both lower extremity bypass (LEB) and peripheral vascular interventions (PVI) have demonstrated improved outcomes in peripheral artery disease (PAD). However, comparative effectiveness data for LEB versus PVI in patients with CLTI and DM is limited.Objective:This study aimed to evaluate and compare 30-day and 90-day (1) all-cause mortality, and (2) major amputation rates among patients with CLTI and comorbid DM undergoing LEB versus PVI.Methods:Patients undergoing LEB and PVI were identified from the Vascular Quality Initiative registry, linked with Medicare claims outcomes data. Propensity scores were generated using 12 variables, and a 1:1 matching method was employed. The 30-day and 90-day mortality risks for LEB versus PVI were evaluated using Kaplan-Meier survival analysis and Cox proportional hazards models, incorporating interaction terms for DM. For amputation outcomes, cumulative incidence functions and Fine-Gray competing risks models were employed, with interaction terms for DM included.Results:Among 4,210 patients undergoing LEB or PVI (2,105 in each group), the mean age was 70.9 ± 10.9 years, with 69.3% being male and 76.4% white. DM was present in 62.3% (2,662 patients). In patients with DM, 30-day all-cause mortality rates were comparable between the LEB and PVI groups (2.1% vs. 2.6%; log-rank p-value=0.844). However, LEB was associated with significantly lower 90-day all-cause mortality rates compared to PVI (5.1% vs. 7.6%; log-rank p-value=0.013). Additionally, LEB was associated with a lower risk of 30-day major amputation rates compared to PVI (2.7% vs. 4.2%; p=0.049), though no significant difference was observed in 90-day major amputation rates (9.4% vs. 10.9%; p=0.196).Conclusion:Among patients with CLTI and comorbid DM, LEB was associated with a lower risk of 30-day major amputation rates and 90-day all-cause mortality compared to PVI. These findings provide contemporary insights into the management of CLTI in diabetic patients, supporting informed shared decision-making for those often considered high-risk for surgical intervention.

Circulation, Volume 150, Issue Suppl_1, Page A4147962-A4147962, November 12, 2024. Introduction:Heart transplants (HT) and left ventricular assist devices (LVADs) are treatment options for advanced heart failure refractory to standard therapy. Historically, LVADs have been used as either destination therapy or a bridge to transplant. However, recent changes to the organ allocation system have deprioritized patients on LVADs as transplant recipients, leading to divisive views on the role of an LVAD. We sought to describe outcomes with each modality, highlighting each option’s strengths and clinical utility.Aim:To assess costs related to index hospitalization, 30-day (30DRC) and 90-day (90DRC) readmission categories for both subgroups.Method:We analyzed the National Readmission Database (NRD) from January 1, 2018, to December 31, 2021, identifying patients with HT and LVAD via ICD-10-CM codes. We selected this recent time frame to limit the influence of older LVAD technology and heart allocation schemes. We excluded patients

Circulation, Volume 150, Issue Suppl_1, Page A4141813-A4141813, November 12, 2024. Introduction:In 2021, the American Society of Nephrology Task Force recommended using the new CKD-EPI 2021 formula to estimate the glomerular filtration rate (eGFR) and to classify CKD. Evidence to compare the efficacy of this new formula with the current utilized formula, including MDRD and CKD-EPI 2009, in predicting the short-term outcomes of Asian patients with acute heart failure (AHF) is lacking.Hypothesis:The eGFR calculated by the CKD-EPI 2021 formula predicts short-term outcomes of patients with AHF more accurately than those calculated by the MDRD and CKD-EPI 2009 formulas.Methods:We conducted a pilot retrospective cohort study from January 1, 2023, to December 31, 2023, at Can Tho Central General Hospital in Can Tho, Vietnam. Our study included patients aged ≥18 who were admitted with AHF, NT-pro BNP levels exceeding 300 pg/mL, and creatinine result within 24 hours of admission. eGFR was calculated using 3 different formulas such as CKD-EPI 2021, CKD-EPI 2009, and MDRD. The short-term outcome was determined by 3-months post-discharge all causes mortality.Results:The final cohort comprised 146 patients, with a mean age of 65.6 ± 14.2 years and male proportion of 46%. Significant correlations were observed among the three formulas, with the strongest correlation observed between the CKD-EPI 2021 and 2009 formulas. In predicting short-term outcomes, the CKD-EPI 2021 and CKD-EPI 2009 formulas demonstrated superior performance compared to the MDRD formula, with respective area under the curve values of 0.634, 0.635, and 0.607. After multivariable analysis, from 90mL/min/1.73m2, every 10 ml/min/1.73 m2decrease in eGFR calculated by CKD-EPI 2021, CKD-EPI 2009, and MDRD was associated with a 32% (95% CI: 9-49), 26% (95% CI: 4-47), and 30% (95% CI: 8-47) increase in the odds of all-cause mortality among patients with AHF. Only CKD-EPI 2021 formula showed significant predictive prognostic value (log-rank test, p=0.049) (Figure).Conclusion:The CKD-EPI 2021 formula showed superior prognostic efficacy for short-term outcomes in Asian patients with acute heart failure (AHF) compared to current formulas. Further research involving larger patient cohorts and longer-term outcomes is warranted.

Circulation, Volume 150, Issue Suppl_1, Page A4146866-A4146866, November 12, 2024. Introduction:Accumulating evidence suggests that cardiovascular disease (CVD) risk is associated with climatic variables and the impact of these factors is likely to be increasing with changes in the global climate. Nevertheless, the underlying physiological mechanisms remain unclear, and it remains unknown whether urban greenspaces could contribute to climatic resilience by mitigating these mechanisms. Moreover, to-date most studies assessing CVD risk consider only ambient temperature, which may not fully capture physiologically relevant thermal conditions. Accordingly, using varied measures of heat, our objective was to assess how short-term heat exposure is related to arterial stiffness, and whether these associations are modified by area greenness.Methods:Adult participants, aged 25-70 years, were recruited from a neighborhood in Louisville, KY during the summer months of 2018 and 2019. Arterial Stiffness was measured by augmentation index (AIX) via pulse wave analysis in 714 participants. We assessed 7 heat metrics, including ambient temperature, dew point temperature, net effective temperature, Heat Index, and Universal Thermal Climate Index (UTCI), calculated as the 24h mean on the day of participants’ visit. Greenness surrounding participants’ homes was assessed by tree canopy within a 500m buffer. Linear regression was used to estimate associations between heat metrics and arterial stiffness, adjusting for socio-demographic and behavioral factors. Subgroup analysis was performed by tertiles of greenness.Results:Participants were predominantly female (61%) and White (77%), with an average age of 49.5 years. The median daily temperature during study visits was 24.4°C (range=12.2 to 28.9°C) and the median daily UTCI was 26.1°C (IQR=5.4°C). The strongest association between heat metrics and AIX was observed for UTCI (2.0% per IQR; 95% CI:0.4, 3.6), followed by net effective temperature (1.8% per IQR; 95% CI: 0.1, 3.6), while dew point temperature had the weakest association (0.6% per IQR; 95% CI: -0.8, 2.0). Stratifying our analysis by tertiles of tree canopy, we observed significant associations between heat metrics and AIX in low canopy areas, with a dose response decrease in associations among medium and high canopy areas.Conclusion:Increased arterial stiffness could be an important contributor to excessive CVD risk associated with physiologically relevant measures of heat exposure, which could be mitigated by surrounding greenspaces.

Introduction
Buprenorphine is a highly effective treatment for opioid use disorder (OUD). However, provider observations and preliminary research suggest that the current standard maintenance dose may be insufficient for suppressing withdrawal and preventing cravings among people who use or have used fentanyl. Buprenorphine dosing guidelines were based on studies among people who use heroin and have not been formally re-evaluated since fentanyl became predominant in the unregulated drug supply. We aim to compare the effectiveness of a high (24 mg) vs standard (16 mg) maintenance daily dose of buprenorphine for improving retention in treatment, decreasing the use of non-prescribed opioids, preventing cravings and reducing opioid overdose risk in patients.

Methods and analysis
Adults who are initiating or continuing buprenorphine for moderate to severe OUD and have a recent history of fentanyl use (n=250) will be recruited at four outpatient substance use treatment clinics in Rhode Island. Patients continuing buprenorphine must be on doses of 16 mg or less and have ongoing fentanyl use to be eligible. Participants will be randomly assigned 1:1 to receive either a high (24 mg) or standard (16 mg) maintenance daily dose, each with usual care, and followed for 12 months to evaluate outcomes. Providers will determine the buprenorphine initiation strategy, with the requirement that participants reach the study maintenance dose within 7 days of randomisation. Providers may adjust the maintenance dose, if clinically needed, for participant safety. The primary study outcome is retention in buprenorphine treatment at 6 months postrandomisation, measured using clinical and statewide administrative data. Other outcomes include non-prescribed opioid use and opioid cravings (secondary), as well as non-fatal or fatal opioid overdose (exploratory).

Ethics and dissemination
This protocol was approved by the Brown Institutional Review Board (STUDY00000075). Results will be presented at conferences and published in peer-reviewed journals.

Trial registration number
NCT06316830.

New England Journal of Medicine, Ahead of Print.

This Viewpoint discusses the spread of medetomidine in the US illicit opioid market and the need for monitoring and a public health response.

Introduction
As the US continues to battle the opioid epidemic, recovery residences remain valuable services for people in recovery. While there is a growing body of literature describing positive outcomes experienced by people who live in recovery residences, little is known about the experience of people who live in these residences while taking medications for an opioid use disorder (MOUD) as part of their recovery. Thus, this study has three aims: (1) expand the availability of recovery residences that meet the National Alliance for Recovery Residences standards in Texas and serve individuals taking medications for an opioid use disorder as part of their recovery; (2) evaluate recovery residences for people taking MOUD as part of their recovery; and (3) compare the cost-effectiveness of recovery residences to treatment-as-usual.

Methods and analysis
In collaboration with community partners, we opened 15 recovery residences in the State of Texas to house people taking MOUD as part of their recovery. We are collecting quantitative and qualitative data to evaluate outcomes at the intrapersonal, interpersonal, organisational and community levels. At the intrapersonal level, we are assessing changes in behavioural and psychosocial constructs using a longitudinal survey, objectively measuring current substance use with a point-of-interview breathalyser and urinalysis, and examining changes in healthcare utilisation using data obtained from a healthcare information exchange. We are collecting interpersonal data using in-depth individual interviews with residents and staff. We are collecting organisational data using field observation and a cost-effectiveness study, and we are collecting community data using neighbourhood mapping.

Ethics and dissemination
The UTHealth institutional review board approved all protocols. We will disseminate study findings via conference presentations, peer-reviewed publications and brief community reports.

This systematic review and meta-analysis examines evidence from 39 studies on hypersensitivity to cold pain among patients with opioid use disorder and its association with indices of opioid tolerance, withdrawal, and abstinence.

New England Journal of Medicine, Volume 391, Issue 17, Page 1644-1647, October 31, 2024.

Introduction
The rise of opioid-free anaesthesia (OFA) aims to reduce postoperative pain while reducing opioid-related side effects during surgery. However, the various adjuvant agents used in OFA complicate the evaluation of their effectiveness and risks. Recent reviews question the clinical benefits of OFA, highlighting the need for thorough evaluation. This protocol describes a network meta-analysis to compare the effectiveness of OFA with opioid-based anaesthesia and will identify key components for optimal postoperative outcomes.

Methods and analysis
We will perform a systematic search of literature published in English without time restriction in Embase, The Cochrane Library, MEDLINE (via PubMed) and CINAHL, along with Google Scholar for grey literature. The final search will be performed on 1 October 2024. We will include randomised controlled trials with adult patients undergoing surgery with general anaesthesia, excluding preclinical, observational, regional anaesthesia-only and prolonged anaesthesia outside the operating room studies. The primary outcome is postsurgical pain scores, with secondary outcomes including quality of recovery, opioid consumption, adverse effects and long-term events. We will assess bias using the Cochrane risk of bias 2 tool and conduct Bayesian network meta-analyses for pooled estimates. We will report effect estimates as ORs and standardised mean differences with 95% credible intervals and assess certainty using GRADE methodology.

Ethics and dissemination
Ethics approval is not required for this systematic review. Results will be published in a peer-reviewed journal and presented at national and international anaesthesia and pain management conferences.

PROSPERO registration number
CRD42024505853.

Introduction
Increased globalisation and technological advancements have led to the emergence of distributed teams in various sectors, including healthcare. However, our understanding of how leadership, communication and collaboration influence distributed healthcare teams remains limited.

Objectives
This study aimed to map knowledge on leadership, communication and collaboration in short-term distributed teams across various fields to gain insights that could benefit healthcare.

Design
Scoping review.

Data source
A database search of PubMed, CINAHL, Scopus and PsycINFO was conducted in May 2021 and updated in February 2023 and May 2024.

Eligibility criteria
Articles were eligible if they involved leadership, communication or collaboration in distributed short-term teams supported by synchronised audio-visual communication technology. Two researchers independently screened titles, abstracts and full texts for inclusion.

Data extraction and synthesis
Extracted data on leadership, communication and collaboration were synthesised narratively and reported in terms of patterns, advances, gaps, evidence for practice and research recommendations.

Results
Among 6591 articles, 55 met the eligibility criteria, spanning military, engineering, business, industrial and healthcare contexts. The research focus has shifted over time from adverse effects to solutions for overcoming challenges in distributed teams. Inclusive leadership is vital for engaging all team members. ‘Team opacity’, the absence of non-verbal cues and reduced awareness of team members’ actions, can occur in distributed teams relying on technology. Clear communication is crucial for avoiding misunderstandings and fostering collaboration and adaptability. Developing shared mental models and trust is more challenging, leading to uncertainty and reduced information sharing. There is a lack of studies examining how to apply this knowledge to health professionals’ education.

Conclusion
Our findings highlight the importance of implementing strategies in healthcare to enhance inclusive leadership and improve communication in distributed healthcare settings. More empirical research is needed to understand the intricacy of distributed healthcare settings and identify effective ways to train distributed healthcare teams.