Search

BACKGROUND Mechanical ventilation with low tidal volumes appears to provide benefit in patients having noncardiac surgery; however, whether it is beneficial in patients having cardiac surgery is unclear. METHODS We retrospectively examined patients having elective cardiac surgery requiring cardiopulmonary bypass through a median sternotomy approach who received mechanical ventilation with a single lumen endotracheal tube from January 2010 to mid-August 2016. Time-weighted average tidal volume (milliliter per kilogram predicted body weight [PBW]) during the duration of surgery excluding cardiopulmonary bypass was analyzed. The association between tidal volumes and postoperative oxygenation (measured by arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen ratio [PaO2/FIO2]), impaired oxygenation (PaO2/FIO2

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Low 25-hydroxyvitamin D is associated with cardiovascular, renal, and infectious risks. Postsurgical patients are susceptible to similar complications, but whether vitamin D deficiency contributes to postoperative complications remains unclear. We tested whether low preoperative vitamin D is associated with cardiovascular events within 30 days after noncardiac surgery. Methods We evaluated a subset of patients enrolled in the biobank substudy of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) study, who were at least 45 yr with at least an overnight hospitalization. Blood was collected preoperatively, and 25-hydroxyvitamin D was measured in stored samples. The primary outcome was the composite of cardiovascular events (death, myocardial injury, nonfatal cardiac arrest, stroke, congestive heart failure) within 30 postoperative days. Secondary outcomes were kidney injury and infectious complications. Results A total of 3,851 participants were eligible for analysis. Preoperative 25-hydroxyvitamin D concentration was 70 ± 30 nmol/l, and 62% of patients were vitamin D deficient. Overall, 26 (0.7%) patients died, 41 (1.1%) had congestive heart failure or nonfatal cardiac arrest, 540 (14%) had myocardial injury, and 15 (0.4%) had strokes. Preoperative vitamin D concentration was not associated with the primary outcome (average relative effect odds ratio [95% CI]: 0.93 [0.85, 1.01] per 10 nmol/l increase in preoperative vitamin D, P = 0.095). However, it was associated with postoperative infection (average relative effect odds ratio [95% CI]: 0.94 [0.90, 0.98] per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.005) and kidney function (estimated mean change in postoperative estimated glomerular filtration rate [95% CI]: 0.29 [0.11, 0.48] ml min-1 1.73 m-2 per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.004). Conclusions Preoperative vitamin D was not associated with a composite of postoperative 30-day cardiac outcomes. However, there was a significant association between vitamin D deficiency and a composite of infectious complications and decreased kidney function. While renal effects were not clinically meaningful, the effect of vitamin D supplementation on infectious complications requires further study.

Objective: The authors assessed the impact of a shared decision-making (SDM) intervention among elderly depressed minority primary care patients not currently receiving treatment. Methods: A total of 202 English and Spanish-speaking primary care participants aged 65 and older who scored positive on the Patient Health Questionnaire-9 (≥10) were randomized at the physician level to receive a brief SDM intervention or usual care (UC). Primary analyses focused on patient adherence to either psychotherapy or antidepressant medication, and reduction in depression severity (Hamilton Depression Rating Scale) over 12 weeks. Results: Patients randomized to physicians in the SDM condition were significantly more likely than patients of physicians randomized to UC to receive a mental health evaluation or initiate some form of treatment (39% versus 21%), and to adhere to psychotherapy visits over 12 weeks. There were no differences between groups in adherence to antidepressant medication or in reduction of depressive symptoms. Conclusion: Among untreated elderly depressed minority patients from an inner-city municipal hospital, a brief SDM intervention was associated with greater initiation and adherence to psychotherapy. However, low treatment adherence rates across both groups and the intervention's lack of impact on clinical outcomes highlight the need to provide focused and accessible mental health services to patients choosing active treatments.

To assess and compare patient-reported long-term health-related quality of life (HRQoL) after combined proximal aortic (arch ± ascending, root) and distal aortic (descending thoracic ± abdominal) replacement using open vs multimodal/endovascular (hybrid) approaches. From 2010 to 2016, 146 adults underwent single- or multi-stage aortic arch plus descending thoracic aorta replacement, 31 open and 115 hybrid. The 2 surgical approach groups had similar preoperative characteristics and extent of surgery. Cross-sectional follow-up revealed 49 deaths (7 open, 42 hybrid). Of the 97 survivors, 72 (74%) responded to the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 survey (18 open, 54 hybrid) a median 6.2 years (15th, 85th percentiles: 3.1, 7.9) after their last aortic surgery. Predictors of HRQoL scores were identified by random forest regression. Overall physical HRQoL T-score was lower than that of population norms (46 vs 50, P0.0001); mental HRQoL T-score was similar (50 vs 50, P0.9). Neither T-score was significantly different according to surgical approach (P ≥ 0.3). Greater number of postoperative complications and history of chronic obstructive pulmonary disease were the most important predictors of lower physical HRQoL, and prior myocardial infarction was the most important predictor of lower mental HRQoL. Although extensive aortic replacement had a small long-term effect on patient-reported physical HRQoL, both physical and mental HRQoL can be preserved in survivors with both surgical approaches. Surgeons should recommend the approach they believe will yield the best long-term survival, but lifelong follow-up is crucial, and patients should understand that they may require multiple operations.

Background Acute type A aortic dissection presents with abrupt onset of pain that requires emergency surgery. However, minimal research exists on posttraumatic stress disorder (PTSD) in survivors. We aimed to quantify the prevalence and describe characteristics of PTSD in patients following dissection. Methods and Results A total of 295 adult survivors of surgical dissection with an email on file were administered a cross‐sectional online survey about their dissection experience; 137 returned questionnaires, and 129 (94%) responded to the 4‐item Primary Care PTSD portion of the survey that was part of a larger lifestyle survey designed to study survivors of aortic dissection and surgery. In addition to the PTSD screening, it inquired about current sexual activity, exercise habits, and employment within the preceding 30 days. At a median of 6.8 years (quartile 1=2.6, quartile 3=8.9 years) after dissection, 23% of patients (30/129) screened positive for PTSD, with 44% (57/129) stating that within the past month they felt constantly on guard or watchful or were easily startled. Of those who screened positive and matched to their electronic medical record (n=27), only 2 (7.4%) had been tested and clinically diagnosed with PTSD. Patients who screened positive for PTSD were more likely to report limited current sexual activity than those who did not (odds ratio, 5.3; 95% CI, 1.9–15 [ P= 0.0006]). Conclusions PTSD is an important mental health consideration in aortic dissection survivors. Physicians should screen these patients for PTSD at follow‐up visits to identify those who test positive and refer them for further testing and treatment, such as trauma‐focused psychotherapy or medication.

Objective Limited data exists on management and outcomes of patients presenting with type A aortic dissection (TAAD) and acute lower extremity ischemia (ALI). The role of limb-related revascularization and optimal treatment strategy remains undefined. The objective of this study was to analyze dissection characteristics, treatment modalities, and outcomes of patients undergoing proximal aortic repair for TAAD with ALI. Methods Consecutive patients who underwent proximal aortic repair for TAAD were identified from a prospectively maintained database. Clinical data, imaging, operative details, and outcomes of patients with TAAD and ALI were retrospectively analyzed. Kaplan-Meier methodology was used to estimate overall and amputation-free survival. Log-rank tests were used to compare overall curves. Predictors of revascularization and in-hospital mortality were determined using multivariable logistic regression analysis. Results From 2010 to 2018, 463 patients with TAAD underwent proximal aortic repair. A total of 81 patients (17%) presented with ALI; 48% (39/81) with isolated ALI, and 52% (42/81) with ALI and renovisceral malperfusion. Thirty percent (24/81) required revascularization in addition to proximal aortic repair. Revascularization strategies involved endovascular (46%; 11/24), open (33%; 8/24), and hybrid (21%; 5/24) interventions. The major amputation rate was 4% (3/81), and in-hospital mortality was 21% (17/81). Amputation-free survival was significantly lower in patients requiring revascularization compared with those who did not (log-rank P = .023). Overall survival did not significantly differ between the two groups (log-rank P = .095). Overall survival was significantly lower in patients with concomitant ALI and renovisceral malperfusion compared with those with isolated ALI (log-rank P = .0017). Distal extent of dissection flap into zone 11 (odds ratio [OR], 5.65; 95% confidence interval [CI], 1.58-20.2; P = .008) and partial/complete thrombosis of any iliac artery (OR, 3.94; 95% CI, 1.23-12.6; P = .021) were associated with increased risk of requiring an additional revascularization procedure. True lumen collapse at level of renovisceral aorta (OR, 8.84; 95% CI, 1.74-44.9; P = .0086) was associated with increased risk of in-hospital mortality. Conclusions ALI resolves after proximal aortic repair of TAAD in most cases. Distal extent of aortic dissection into zone 11 and iliac thrombosis are risk factors for additional peripheral revascularization. True lumen collapse at the renovisceral aorta and TAAD with concomitant ALI and renovisceral malperfusion portends a poor prognosis. A multi-disciplinary team approach to manage these patients who present with ascending aortic dissection and distal malperfusion may improve outcomes in this complex population.

Objective We conducted a 12-week double-blind study of stabilization pharmacotherapy in patients with remitted psychotic depression (PD). Methods Seventy-one persons aged 18 years or older who had achieved remission of PD when randomized to either olanzapine plus sertraline or olanzapine plus placebo were continued on the double-blind treatment associated with remission. Symptoms of depression and psychosis, and weight, were measured once every 4 weeks. Cholesterol, triglycerides, and glucose were measured at stabilization phase baseline and Week 12/termination. Results The effect of treatment did not significantly change with time for depression, weight, or metabolic measures in the stabilization phase. Eight of the 71 participants (11.3%; 95% CI: 5.8, 20.7) experienced a relapse of major depression, psychosis, or both. Treatment groups did not differ in the frequency of relapse. In the entire study group, the adjusted estimate for change in weight was an increase of 1.66 kg (95% CI: 0.83, 2.48) and the adjusted estimate for change in total cholesterol was a decrease of 14.8 mg/dL (95% CI: 3.5, 26.1) during the 12-week stabilization phase; the remaining metabolic measures did not significantly change. Conclusion Continuation of acute treatment was associated with stability of remission.

Background Laparoscopic surgical approaches enhance recovery, reduce postoperative pain, and shorten hospital length-of-stay. Nevertheless, increased intra-abdominal pressure is associated with decreased renal blood flow, renal hypoxia and acute kidney injury. When combined with Trendelenburg positioning, renal function may further deteriorate. We tested the primary hypothesis that the combination of laparoscopic surgical approach and Trendelenburg position is associated with larger reductions in estimated Glomerular Filtration Rate (eGFR) within the initial 48 postoperative hours compared to open surgery without Trendelenburg positioning. Secondarily, we tested, if laparoscopic procedures are associated with greater incidence of postoperative acute kidney injury. Methods Adults who had laparoscopic colorectal surgery in Trendelenburg position at the Cleveland Clinic Main Campus from 2009 to 2016 were propensity-matched to patients who had comparable open procedures. Patients with pre-existing renal impairment were excluded. Results Among 7,357 eligible patients, 1,846 laparoscopic cases with Trendelenburg were matched to 1,846 open cases. No association was found between laparoscopic approach and postoperative eGFR. A significant protective effect of the laparoscopic procedure on the odds of having AKI was found. Patients who had laparoscopic surgeries were an estimated 0.70 (95% CI 0.55, 0.90, pHolm-adj = 0.006) times as likely to have AKI as open surgical patients. Conclusion Despite compelling potential mechanisms, laparoscopic approach with Trendelenburg position in adult colorectal surgeries did not worsen postoperative eGFR, and actually reduced postoperative acute kidney injury. Given the other advantages of laparoscopic surgery, the approach should not be avoided for concerns about renal injury.

Background Childhood and adolescent obesity increased in recent decades, and caregivers face an increasing number of obese pediatric surgical patients. Some clinical and pharmacogenetic data suggest that obese patients have altered pain sensitivity and analgesic requirements. Objective To test the primary hypothesis that increased BMI in pediatric patients is associated with increased pain during the initial 48 postoperative hours. Secondarily, we tested whether BMI is associated with increased opioid consumption during the same period. Design Retrospective single-center cohort study. Setting Pediatric surgical wards in a tertiary medical center. Patients A total of 808 opioid naive patients aged 8 to 18 years having elective non-cardiac surgery with hospital stay of at least 48 h in the Cleveland Clinic between 2010 and 2015. Interventions None. Measurements Using U.S. Centers for Disease Control definitions for childhood weight classifications, we retrospectively evaluated the association between body mass index (BMI) percentile and time-weighted average pain scores and opioid consumption. We used multivariable linear regression to test for an association with postoperative pain scores, and multivariable gamma regression to test for an association with postoperative opioid consumption (in mg morphine equivalents Kg−1). Results BMI was not associated with postoperative pain after general, orthopedic, or neuro-spinal surgeries. Pain increased by 0.07 [98.75% CI: (0.01, 0.13), Padj Conclusion We found no clinically important increase in pain scores or opioid consumption in association with higher BMI in patients 8 to 18 years of age recovering from elective non-cardiac surgery.

SummaryObjective South Asians have higher rates of type 2 diabetes and cardiovascular disease compared to most other racial/ethnic groups. Increased hepatic de novo lipogenesis (DNL) in response to dietary sugar may accelerate the development of these chronic diseases in this population. Study design Hepatic DNL in response to a calorically sweetened beverage was measured in an outpatient setting in 15 South Asians and 15 Caucasians with similar and normal body mass indexes, waist circumferences, glucose tolerance and lipid profiles. Blood was sampled before and hourly for 4 h after the ingestion of a single beverage made with glucose (1·5 g/kg) and fructose (1·5 g/kg). The main outcome, DNL, was measured as the increase in %palmitate (16:0) in very low-density lipoprotein (VLDL) triglyceride (TG) over 4 h. Results After the sugar dose, the increase in %16:0 in VLDL TG was significantly greater in South Asians vs Caucasians (P = 0·01). VLDL and total TG also increased to a significantly greater extent in South Asians (P = 0·04 and

ObjectiveResearch on the impact of natural disasters on the mental health of older adults finds both vulnerabilities and resilience. We report on the rates of clinically significant depression among older adults (aged ≥60 years) living in areas affected by Hurricane Sandy in 2012 and the factors associated with mental health need.MethodsThe Sandy Mobilization, Assessment, Referral and Treatment for Mental Health (SMART-MH) program integrates community outreach and needs assessments to identify older adults with mental health and aging service needs. Older adults with significant anxiety or depressive symptoms were offered short-term psychotherapy. Social service referrals were made directly to community agencies. All SMART-MH activities were offered in Spanish, Russian, Mandarin/Cantonese, and English.ResultsAcross the full sample, 14% of participants screened positive for depression. Hurricane Sandy stressors predicted increased odds of depression, including storm injury, post-storm crime, and the total count of stressors. Outcomes varied significantly by age group, such that all Sandy-related variables remained significant for younger-old adults (aged 60–74 years), whereas only the loss of access to medical care was significant for older-old adults (aged ≥75 years).ConclusionsStorm-affected communities show higher rates of depressive symptoms than seen in the general population, with storm stressors affecting mental health needs differentially by age group. (Disaster Med Public Health Preparedness. 2017;11:97–109)

Objective Personalized Intervention for Depressed Patients with COPD (PID-C), a treatment mobilizing patients to participate in their care, was found more effective than usual care. To further improve its efficacy, we developed a Problem Solving-Adherence (PSA) intervention integrating problem solving into adherence enhancement procedures. We tested the hypothesis that PSA is more effective than PID-C in reducing depressive symptoms. Exploratory analyses sought to identify patients with distinct depressive symptom trajectories and compare their clinical profiles. Design Randomized controlled trial. Setting Acute inpatient rehabilitation and community. Participants A total of 101 diagnosed with chronic obstructive pulmonary disease (COPD) and major depression after screening 633 consecutive admissions for acute inpatient rehabilitation. Intervention Fourteen sessions of PID-C versus PSA over 26 weeks. Measurements 24-item Hamilton Depression Rating Scale. Results PSA was not more efficacious than PID-C in reducing depressive symptoms. Exploratory latent class growth modeling identified two distinct depressive symptoms trajectories. Unlike patients with unfavorable course (28%) who remained symptomatic, patients with favorable course (72%) had a decline of symptoms during the hospitalization followed by a milder decline after discharge. Patients with unfavorable course were younger and had greater scores in disability, anxiety, neuroticism, and dyspnea related limitation in activities and lower self-efficacy scores. Conclusions Both interventions led to sustained improvement depressive symptoms. PID-C matches the skills of clinicians employed by community rehabilitation programs and can be integrated in the care of depressed COPD patients. Patients with severe disability, anxiety, neuroticism, and low self-efficacy are at risk for poor outcomes and in need of close follow-up and targeted interventions.

Nonadherence to antidepressant medication is common and leads to poor outcomes. Early nonadherence is especially problematic.To test the effectiveness of a psychosocial intervention to improve early adherence among older patients whose primary care physician newly initiated an antidepressant for depression.The Treatment Initiation and Participation Program (TIP) was offered in a 2-site randomized clinical effectiveness study between January 2011 and December 2014 at primary care practices in New York, New York, and Ann Arbor, Michigan. Analyses began in February 2016. All participants were middle-aged and older adults (aged ≥55 years) who received newly initiated depression treatment by their primary care physician and recruited within 10 days of their prescription. Analyses were intention-to-treat.Participants were randomly assigned to the intervention (TIP) or treatment as usual. Participants in the TIP group identified and addressed barriers to adherence, including stigma, misconceptions, and fears about treatment, before developing a personalized adherence strategy. The Treatment Initiation and Participation Program was delivered in three 30-minute contacts scheduled during a 6-week period just after the antidepressant was prescribed.The primary outcome was self-reported adherence on the Brief Medication Questionnaire, with adequate early adherence defined as taking 80% or more of the prescribed doses at 6 and 12 weeks. The secondary outcome was depression severity.In total, 231 middle-aged and older adults (167 women [72.3%] and 64 men [27.7%]) without significant cognitive impairment were randomly assigned to the TIP intervention (n = 115) or treatment as usual (n = 116). Participants had a mean (SD) age of 67.3 (8.4) years. Participants in the TIP group were 5 times more likely to be adherent at 6 weeks (odds ratio, 5.54; 95% CI, 2.57 to 11.96; χ21 = 19.05; P .001) and 3 times more likely to be adherent at both 6 and 12 weeks (odds ratio, 3.27; 95% CI, 1.73 to 6.17; χ21 = 13.34; P .001). Participants in the TIP group showed a significant earlier reduction (24.9%) in depressive symptoms (95% CI, 13.9 to 35.9; t337 = 4.46; adjusted P .001). In both groups, participants who were 80% adherent at weeks 6 and 12 had a 15% greater improvement in depressive symptoms from baseline over the course of treatment (95% CI, -0.2 to -30; t369 = 1.93; P = .051).The Treatment Initiation and Participation Program is an effective intervention to improve early adherence to pharmacotherapy. Improved adherence can promote improvement in depression.clinicaltrials.gov Identifier: NCT01301859.

Studies demonstrate that use of prostate-specific antigen screening decreased significantly following the US Preventive Services Task Force (USPSTF) recommendation against prostate-specific antigen screening in 2012.To determine downstream effects on practice patterns in prostate cancer diagnosis and treatment following the 2012 USPSTF recommendation.Procedural volumes of certifying and recertifying urologists from 2009 through 2016 were evaluated for variation in prostate biopsy and radical prostatectomy (RP) volume. Trends were confirmed using the New York Statewide Planning and Research Cooperative System and Nationwide Inpatient Sample. The study included a representative sample of urologists across practice settings and nationally representative sample of all RP discharges. We obtained operative case logs from the American Board of Urology and identified urologists performing at least 1 prostate biopsy (n = 5173) or RP (n = 3748), respectively.The 2012 USPSTF recommendation against routine population-wide prostate-specific antigen screening.Change in median biopsy and RP volume per urologist and national procedural volume.Following the USPSTF recommendation, median biopsy volume per urologist decreased from 29 to 21 (interquartile range [IQR}, 12-34; P .001). After adjusting for physician and practice characteristics, biopsy volume decreased by 28.7% following 2012 (parameter estimate, -0.25; SE, 0.03; P .001). Similarly, following the USPSTF recommendation, median RP volume per urologist decreased from 7 (IQR, 3-15) to 6 (IQR, 2-12) (P .001), and in adjusted analyses, RP volume decreased 16.2% (parameter estimate, -0.15; SE, 0.05; P = .003).Following the 2012 USPSTF recommendation, prostate biopsy and RP volumes decreased significantly. A panoramic vantage point is needed to evaluate the long-term consequences of the 2012 USPSTF recommendation.