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Harsha Shanthanna,1 Alparslan Turan,2 Jessica Vincent,3 Remie Saab,2 Yaron Shargall,4 Turlough O’Hare,1 Kimberly Davis,5 Sylvanus Fonguh,3 Kumar Balasubramaniam,3 James Paul,1 Ian Gilron,6 Henrik Kehlet,7 Daniel I Sessler,2 Mohit Bhandari,8 Lehana Thabane,9 PJ Devereaux9 1Department of Anesthesia, McMaster University, Hamilton, ON, Canada; 2Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; 3Population Health Research Institute, Hamilton, ON, Canada; 4Department of Surgery, St Joseph’s Healthcare Hamilton, Hamilton, ON, Canada; 5Acute Pain Service, St. Joseph Healthcare Hamilton, Hamilton, ON, Canada; 6Departments of Anesthesiology and Perioperative Medicine, Biomedical and Molecular Sciences, Centre for Neuroscience Studies and School of Policy Studies, Queen’s University, Kingston, ON, Canada; 7Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark; 8Department of Surgery, McMaster University, Hamilton, ON, Canada; 9Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, CanadaCorrespondence: Harsha ShanthannaDepartment of Anesthesia, McMaster University, 1280 Main St. W., Hamilton, Ontario L8S 4K1, CanadaTel +1 905-525-9140 ext. 21737Fax +1 905-523-1224Email shanthh@mcmaster.caPurpose: We conducted a feasibility 2× 2 factorial trial comparing N-methyl-D-aspartate (NMDA) antagonists (intravenous ketamine and oral memantine) versus placebo and intravenous steroids versus placebo, in patients having elective video-assisted thoracic surgery lobectomies, at St. Joseph’s Hamilton, Canada, and Cleveland Clinic, Cleveland, USA. Our feasibility objectives were: 1) recruitment rate/week; 2) recruitment of ≥ 90% of eligible patients; and 3) > 90% follow-up. Secondary objectives were incidence and intensity of persistent post-surgical pain (PPSP) and other clinical and safety outcomes.Methods: Using computerized randomization, patients were allocated to one of four groups: NMDA active with steroid placebo; NMDA placebo with steroid active; both NMDA and steroid active; both NMDA and steroid placebo. Patients, health providers, and data analysts were blinded to allocation. Patients were followed for 3 months after randomization.Results: The trial was initiated in May 2017 at Hamilton and, after subsequent regulatory and ethics approval, in April 2018 at Cleveland. The trial had to be stopped after only 1 month of recruitment in Cleveland because the packaged study medications (memantine) expired and we were unable to procure the dosage required. Among 41 eligible patients, 27 (66%) were randomized. The recruitment rate/week was 0.63, 95% confidence interval (CI): 0.47– 0.79 in Hamilton; and 1, 95% CI: 0.83– 1.17 in Cleveland. Follow-up was complete for all 24 patients (100%) in Hamilton, and 3 of 4 patients in Cleveland. In total, only 4 patients (15%), and 2 patients (7%) had persistent pain at rest and with movement, respectively. There were no significant differences between groups for other outcomes.Conclusion: The trial had to be stopped prematurely due to non-availability of study medications. Trial feasibility objectives of recruiting 90% of eligible patients and recruiting at least one patient/week per site were not met. Consideration for protocol changes will be necessary for the full trial.Trial Registration: NCT02950233.Keywords: persisting pain, chronic pain, prevention, NMDA antagonists, steroids, ketamine

Importance: Blood collection for laboratory testing in intensive care unit (ICU) patients is a modifiable contributor to anemia and red blood cell (RBC) transfusion. Most blood withdrawn is not required for analysis and is discarded., Objective: To determine whether transitioning from standard-volume to small-volume vacuum tubes for blood collection in ICUs reduces RBC transfusion without compromising laboratory testing procedures., Design, Setting, and Participants: Stepped-wedge cluster randomized trial in 25 adult medical-surgical ICUs in Canada (February 5, 2019 to January 21, 2021)., Interventions: ICUs were randomized to transition from standard-volume (n = 10 940) to small-volume tubes (n = 10 261) for laboratory testing., Main Outcomes and Measures: The primary outcome was RBC transfusion (units per patient per ICU stay). Secondary outcomes were patients receiving at least 1 RBC transfusion, hemoglobin decrease during ICU stay (adjusted for RBC transfusion), specimens with insufficient volume for testing, length of stay in the ICU and hospital, and mortality in the ICU and hospital. The primary analysis included patients admitted for 48 hours or more, excluding those admitted during a 5.5-month COVID-19-related trial hiatus., Results: In the primary analysis of 21 201 patients (mean age, 63.5 years; 39.9% female), which excluded 6210 patients admitted during the early COVID-19 pandemic, there was no significant difference in RBC units per patient per ICU stay (relative risk [RR], 0.91 [95% CI, 0.79 to 1.05]; P = .19; absolute reduction of 7.24 RBC units/100 patients per ICU stay [95% CI, -3.28 to 19.44]). In a prespecified secondary analysis (n = 27 411 patients), RBC units per patient per ICU stay decreased after transition from standard-volume to small-volume tubes (RR, 0.88 [95% CI, 0.77 to 1.00]; P = .04; absolute reduction of 9.84 RBC units/100 patients per ICU stay [95% CI, 0.24 to 20.76]). Median decrease in transfusion-adjusted hemoglobin was not statistically different in the primary population (mean difference, 0.10 g/dL [95% CI, -0.04 to 0.23]) and lower in the secondary population (mean difference, 0.17 g/dL [95% CI, 0.05 to 0.29]). Specimens with insufficient quantity for analysis were rare (≤0.03%) before and after transition., Conclusions and Relevance: Use of small-volume blood collection tubes in the ICU may decrease RBC transfusions without affecting laboratory analysis., Trial Registration: ClinicalTrials.gov Identifier: NCT03578419.

Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce heart failure (HF) in a broad range of populations, but they have not been studied specifically in patients with atrial fibrillation (AF). We aimed to examine the association between SGLT2i eligibility and cardiovascular events in patients with AF to evaluate the potential utility of SGLT2is for AF management., Methods: We pooled data from 2 randomized controlled trials (RCTs) of patients with AF (RE-LY and ACTIVE-W). Among patients assigned to anticoagulation arms, those meeting the enrollment criteria from at least 1 of the phase 3 SGLT2i RCTs were classified as "SGLT2i eligible" and the remainder as "SGLT2i ineligible." The primary outcome was the composite of HF hospitalization or cardiovascular death., Results: A total of 21,484 patients with AF (mean age: 71.2 ± 8.8, 36.1% women, median CHA 2 DS 2 -VASc Score = 3) were included. The proportion of patients with AF eligible for SGLT2i was 41.2%. SGLT2i-eligible patients had higher rates of cardiovascular death or hospitalization for HF (5.8 vs 3.2 per 100 person-years, P log-rank < 0.001), cardiovascular death (3.9 vs 1.5 per 100 person-years, P log-rank < 0.001), and hospitalization for HF (2.5 vs 1.9 per 100 person-years, P log-rank < 0.001). The age- and sex-adjusted model showed that SGLT2i-eligible patients were at a higher risk of cardiovascular death and hospitalization for HF (hazard ratio [HR], 1.97; 95% confidence interval [CI], 1.79-2.17; P < 0.001), cardiovascular death (HR, 2.75; 95% CI, 2.41-3.13; P < 0.001), and hospitalization for HF (HR, 1.41; 95% CI, 1.23-1.62; P < 0.001) than ineligible patients., Conclusions: Most patients with AF do not currently have indications for SGLT2is but still have substantial risk of cardiovascular events. Future randomized trials should evaluate the efficacy of SGLT2is in patients with AF., (Copyright © 2022 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial showed that rivaroxaban plus aspirin reduced major adverse cardiovascular events (MACE) in patients with chronic coronary artery disease (CAD) and/or peripheral artery disease (PAD). We explored whether CHA 2 DS 2 -VASc or CHADS 2 scores, well-validated tools for assessing risk of thromboembolic events in atrial fibrillation, can identify vascular patients at highest risk of recurrent events who may derive greatest benefits of treatment. Methods Predictive accuracies of the CHA 2 DS 2 -VASc and CHADS 2 scores for MACE, were assessed in this analysis of the COMPASS trial. Kaplan-Meier estimates of cumulative risk were used to compare the effects of rivaroxaban plus aspirin (n = 9152) with aspirin alone (n = 9126) according to risk scores. Results High CHA 2 DS 2 -VASc (6-9) or CHADS 2 (3-6) scores were associated with over three times greater absolute risk of MACE compared with CHA 2 DS 2 -VASc score of 1-2 or CHADS 2 score of 0. The effects of rivaroxaban plus aspirin compared with aspirin alone were consistent across CHA 2 DS 2 -VASc and CHADS 2 score categories for MACE, bleeding and net clinical benefit, with greatest reduction in MACE observed in patients treated for 30 months with highest CHADS 2 score (3-6) (hazard ratio = 0.67, 95% CI: 0.53-0.86, p = 0.0012, 25 events per 1000 patients prevented). Conclusion The CHA 2 DS 2 -VASc and CHADS 2 scores can be used in patients with chronic CAD and/or PAD to identify patients who are at highest risk of MACE. Those identified at highest risk by CHADS 2 scores had greatest benefit from dual pathway inhibition with rivaroxaban plus aspirin. Clinical Trial Registration: NCT01776424., (Copyright © 2021. Published by Elsevier B.V.)

Background: Healthcare-associated infections (HCAI) are still a major problem especially in most intensive care units (ICU). Incompliance by clinical staff with hand hygiene (HH) increases rates of preventable infections. We report the outcome of the Belgian national hand hygiene campaign from 2005 to 2015 with focus on intensive care units., Methods: Using the World Health organisation (WHO) standardised observation roster, trained infection control teams measured adherence to HH guidelines by direct observation. HH opportunities were counted and the actual episodes of HH were scored as no HH, HH with water and soap, or HH with alcohol-based hand rub. Measurements were repeatedly done before and after a one month awareness campaign every second year. Compliance was stratified by indication and by type of healthcare worker, and computed as a percentage of the number of HH episodes with water and soap or with alcohol-based hand rub, divided by the number of opportunities., Results: A total of 108,050 hand hygiene opportunities were observed in ICU during this period. HH compliance increased significantly from 49.6 % before campaign in 2005 to 72.0 % before campaign in 2015. Over the same time frame, post campaign compliance increased from 67.0 to 80.2 %. The number of opportunities observed substantially increased when automated feedback was installed., Conclusions: In Belgian intensive care units, hand hygiene compliance is getting improved overtime, though consecutive campaigns with immediate feedback are required to achieve and sustain a high compliance rate.