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Background: Depression is the largest source of global medical disability, highlighting the importance of translating and validating depression screening instruments to improve our understanding of differences in the prevalence of depression in divergent cultures around the world. The aim of this study was to translate and evaluate a widely used depression screening and diagnostic instrument, the Patient Health Questionnaire-9 (PHQ-9), for use with Tibetan populations. A secondary aim was to use the Tibetan-PHQ-9 (T-PHQ-9) to estimate the prevalence of depression symptoms in a population of Tibetan-speaking Buddhist monastic scholars engaging in a 6-year science curriculum in India, the Emory Tibet Science Initiative (ETSI).Methods: Three-hundred-eighty-four monastics (363 monks, 21 nuns) completed the T-PHQ-9. We computed measures of internal consistency and conducted factor analysis to evaluate scale performance. Following this, we evaluated the prevalence of depressive symptoms among the monastic population. We also conducted cognitive interviews with six monastics to explore their thought processes when completing the instrument and when thinking about depression symptoms.Results: The T-PHQ-9 had acceptable reliability and demonstrated a single-factor structure. While having low energy was the most commonly endorsed symptom, monastics did not have overall higher endorsement rates of other somatic symptoms when compared with endorsement rates of emotional symptoms. Over 10% of the monastics scored in the moderately severe to severe range and met criteria for major depressive disorder using standard diagnostic criteria cut-offs. First year monks had the highest mean score, and there was not a significant difference between monks and nuns. Cognitive interviews revealed some variation in the cognitive processes used to complete the instrument, particularly with symptoms related to energy and concentration.Conclusion: These preliminary findings indicate that the Tibetan PHQ-9 is a reliable instrument for assessing depressive symptoms, as evidenced by its ability to inform how symptoms are experienced, interpreted, and communicated among Buddhist monastics. Results from the cognitive interviews may be important for further refining the instrument.

Background Depression is the largest contributing factor to global disability, and the translation and validation of depression screening instruments is vital toward understanding the prevalence of depression symptoms around the world. The aim of this study was to translate a widely used depression screening instrument, the Patient Health Questionnaire (PHQ), for use with Tibetan populations, and to explore the prevalence of depression symptoms in a population of Tibetan-speaking Buddhist monastic science scholars. Methods A total of 384 monastics (363 monks, 21 nuns) completed the Tibetan PHQ-9. We computed measures of internal consistency and conducted factor analysis to evaluate scale performance, and describe the prevalence of depression symptoms among the monastic population and subgroups. Results The Tibetan PHQ-9 had acceptable reliability and demonstrated a single-factor structure. While having low energy was the most commonly endorsed symptom, monastics did not have overall higher rates of other somatic symptoms. Over 10% of the monastics scored in the moderately severe to severe range, using standard diagnostic criteria cut-offs. First year monks had the highest mean score, and there was not a significant difference between monks and nuns. Conclusion These preliminary findings indicate that the Tibetan PHQ-9 is a reliable instrument for exploring and assessing depression symptoms and that it will be useful toward examining how symptoms are experience, interpreted, and communicated among Buddhist monastics.

Background:Clostridioides difficile infection (CDI) following colorectal surgery can lead to significant adverse outcomes. Although previous studies have identified risk factors for CDI, their relative importance for predicting complications remains unclear. Objective: We sought to use machine-learning algorithms to accurately determine which perioperative risk factors are most predictive of adverse outcomes after CDI. Methods: The National Surgical Quality Improvement Project (NSQIP) database was used to identify all patients who developed CDI after a colorectal operation in 2016 (N = 14,392). We excluded patients without CDI and patients Results: There were 841 patients in our cohort (median age 66 years (IQR, 55–75.8), 482 (57%) were women, and the mean American Society of Anesthesiologists [ASA] class score was 2.9 (SD, ±0.7). Of all colorectal surgeries, 172 (20.5%) were emergent. Overall mortality was 3.8% (n=32), and 371 patients (44.1%) experienced at least 1 postoperative complication, of which infectious complications (eg, septic shock, sepsis, wound infection, urinary tract infection) were most common (n=255, 30.3%). The RTOR rate was 10.3% (n = 87), the non–home discharge rate was 23.8% (n = 200), and the readmission rate was 30.9% (n = 260). The input variables most predictive of any adverse outcome were hematocrit (VIP, 24.9%), ASA class (VIP, 24.4%), creatinine (VIP, 17.4%), and prealbumin (VIP, 11.6%). The probability of any adverse outcome was 90.6% in the setting of hematocrit ≤27%, ASA class ≥3, creatinine ≥1.6 mg/dL, and prealbumin ≤3.1 mg/dL. All machine-learning models had an AUROC ≥0.99. Conclusions: Although nonpatient factors can contribute to unfavorable outcomes in patients with CDI following colorectal surgery, we identified 4 patient-specific variables that account for almost 80% of any adverse outcomes. Although further prospective study is needed, individuals with these preoperative risk factors could consider delaying their elective colorectal operations until they are medically optimized.Funding: NoneDisclosures: None

It is important to characterize in-hospital mortality after cardiac surgery and understand the relationships between postoperative length of intensive care unit stay, postoperative length of hospital stay, and the likelihood of in-hospital mortality.We retrospectively identified all cardiac surgery cases that resulted in in-hospital mortality over an 8-year period at a single center. For these subjects we collected demographic data, preoperative comorbidities, and postoperative complications. We performed stepwise multivariate linear regression to determine which postoperative complications were associated with mortality timing. We also analyzed the relationships between postoperative length of intensive care unit stay, postoperative length of hospital stay, and in-hospital mortality in all patients (including survivors) who had cardiac surgery during the same time period. Finally, we calculated the daily incremental observed mortality rate for patients in the hospital up to postoperative day 50.Six hundred twenty-one in-hospital mortalities occurred among 18,348 patients during the study period (3.4%). Four postoperative complications were associated with mortality timing. Cardiac arrest had a negative association with the number of days until mortality, while deep sternal wound infection, stroke, and pneumonia had a positive association (all p0.05). Postoperative complications explained 15% of the variability in mortality timing (R2 model=0.15). The odds ratio for in-hospital mortality was 1.033 for each postoperative day in the hospital and 1.071 for each postoperative day in the intensive care unit (both p0.05).Most in-hospital mortality occurs during the first week after cardiac surgery with few mortalities occurring after a protracted hospital course. Postoperative complications have a limited ability to explain the variability in mortality timing. Increased length of postoperative intensive care unit stay and hospital stay after cardiac surgery are associated with an increased likelihood of in-hospital mortality.

Objective To evaluate the use of urine dopamine and catecholamine concentrations as diagnostic aids in a patient with neuroleptic malignant syndrome (NMS) in the emergency department setting. Case summary A 61-year-old female on multiple medications, including several antipsychotics, rapidly deteriorated, with fever, lead-pipe rigidity, and decreased level of consciousness. The patient died 20 days after initial presentation to an emergency department. The Naranjo probability scale indicated probable causality for NMS due to quetiapine, haloperidol, and risperidone in this patient, whereas the Naranjo scale assigned only possible causality for serotonin syndrome developing with serotonergic agents. Laboratory investigations of blood and urine revealed elevations in dopamine, metanephrines, and epinephrines, as well as trazodone and risperidone. Serotonin metabolites were not elevated. Discussion NMS is a rare and potentially severe adverse effect associated with the use of antipsychotic medications. It is mainly characterized by hyperthermia, altered mental state, hemodynamic dysregulation, elevated serum creatine kinase, and rigors. It has been associated with multisystem organ failure potentially leading to rhabdomyolysis, acute respiratory distress syndrome, and disseminated intravascular coagulation. The prevalence of this syndrome is associated with the use of neuroleptics. Serotonin syndrome is another adverse drug reaction leading to NMS associated with elevated serotonin. It occurs when multiple serotonergic medications are ingested and is associated with rapid onset of altered mental status, myoclonus, and autonomic instability. Differentiating between NMS and serotonin syndrome can be challenging because of their similar clinical presentation. This case highlights the importance of a diagnostic aid being available to help distinguish between the 2 syndromes. Conclusions We propose that laboratory findings that include dopamine and serotonin metabolites can be used as adjuncts to clinical and prescription histories in the diagnosis of NMS. The use of urinary catecholamine as a diagnostic aid in NMS needs further evaluation.

A 76-yr-old man underwent carinal resection for squamous cell carcinoma through the right posterolateral thoracotomy approach. Ventilation was maintained by the use of two high-frequency jet ventilators, each attached to a separate catheter during the time of resection and reconstruction of the tracheal carina. These catheters were introduced through the endotracheal tube and positioned into the left and right main bronchi at the beginning of the tracheal resection. Then, conventional ventilation was replaced by high-frequency jet ventilation (HFJV) with different ventilatory variables for each lung. During two-lung jet ventilation there was good oxygenation, normocapnia and no cardiovascular complications. The principle advantage of using two separate high-frequency ventilators is that it allows for maximum ventilatory efficiency with lungs of different compliance.

Intensive care unit (ICU) physician staffing models for cardiac surgery patients vary widely and correlate poorly with outcomes. Clinical outcomes associated with 24-hour, in-house intensivists working in a dedicated post-cardiac surgical unit has not been previously investigated. We sought to examine the safety and efficacy of such a model.A retrospective, propensity-matched, cohort study of all patients undergoing a cardiac surgical procedure at a single tertiary center was performed. The control cohort (n = 1,467) consisted of patients admitted to the traditional, mixed surgical intensive care unit (SICU) from January 2005 to January 2007. The intervention cohort (n = 1,089) consisted of patients admitted to a newly created "hybrid" cardiac surgery ICU (CICU) from January 2007 to January 2008, which was staffed by 24-hour in-house consultant intensivists and a daytime, fast track cardiac anesthesiologist. The primary outcomes were blood product utilization, requirement for ventilation, and ICU recidivism.The proportion of patients in the CICU cohort who received transfused red blood cells was decreased compared with the SICU cohort (30.2% versus 42.3%, p0.001). Similar reductions in platelets and fresh frozen plasma were also observed. The CICU patients were less likely to arrive to the ICU intubated (43.7% versus 66.5%, p0.001). There were no differences in postoperative complications. Overall hospital length of stay was reduced in the CICU cohort by a median of 1 day (6 days [interquartile range, 5 to 8] versus 7 days [5 to 9], p0.001). Significant reductions in mortality and ICU recidivism were not observed.The current Manitoba CICU model of 24-hour intensive care physician/cardiac anesthesiologist staffing in postoperative cardiac surgery care is associated with reduced transfusion of blood components, decreased requirement for mechanical ventilation, and shorter hospital length of stay.