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Background: Older adults commonly experience chronic medical conditions and are at risk of cognitive impairment as a result of age, chronic comorbidity, and medications prescribed to manage multiple chronic conditions. Anticholinergic medications are common treatments for chronic conditions and have been repeatedly associated with poor cognitive outcomes, including delirium and dementia, in epidemiologic studies. However, no study has definitively evaluated the causal relationship between anticholinergics and cognition in a randomized controlled trial design. Utilizing our prior experience in deprescribing anticholinergic medications in various clinical environments, we designed an outpatient deprescribing intervention to prospectively test the potential causal relationship between anticholinergics and cognition in primary care older adults., Methods: This cluster randomized clinical trial will be conducted to evaluate the impact of an anticholinergic deprescribing intervention compared to usual care on outcomes of cognition and safety in primary care older adults. Participants will include those aged 65 years and over, receiving primary care in the greater Indianapolis area, using a strong anticholinergic within the last 2 weeks or with evidence of high-risk exposure in the past year. Those excluded will have a diagnosis of Alzheimer's disease or related dementia, or serious mental illness. The trial plans to enroll 344 participants who will be cluster-randomized at the level of primary care physician to avoid contamination. Participants will complete outcome assessments every 6 months up to 2 years by blinded outcome assessors. The primary outcome of the study is a composite measure of cognition that includes domains assessing executive cognitive function, language, and memory. Secondary outcomes include patient-reported measures of pain intensity, depression, anxiety, sleep disturbance, and health-related quality of life., Discussion: The R2D2 trial will be the largest and longest prospective randomized trial testing the impact of an anticholinergic-specific deprescribing intervention on cognition in primary care older adults. Results could influence deprescribing methodology and provide new insight on the relationship between anticholinergics and cognition., Trial Registration: ClinicalTrials.gov NCT04270474. Registered on February 17, 2020., Competing Interests: Declarations. Ethics approval and consent to participate: All procedures have received and maintained ethical approval from the Institutional Review Board of the Indiana University (IRB# 1811254189; Federal-Wide Assurance Number, FWA00003544). The trial has also been registered at ClinicalTrials.gov (Identifier: NCT04270474). Consent for publication: Not applicable—no identifying images or other personal or clinical details of individual participants are presented here or will be presented in reports of the trial results. The participant information materials and informed consent form are available from the corresponding author on request. Competing interests: Dr. Boustani serves as a Chief Scientific Officer and co-Founder of Blue Agilis; the Chief Health Officer of DigiCare Realized, Inc; and the Chief Health Officer of Mozyne Health, Inc. He has equity interest in Blue Agilis, Inc; DigiCare Realized, Inc; and Mozyne Health, Inc. He sold his equity in Preferred Population Health Management LLC and MyShift, Inc (previously known as RestUp, LLC). He serves as an advisory board member or consultant for Eli Lilly and Co; Eisai, Inc; Merck & Co Inc; Biogen Inc; and Genentech Inc. These conflicts have been reviewed by Indiana University and has been appropriately managed to maintain objectivity. All other authors report no conflicts of interest., (© 2024. The Author(s).)

Objectives: This study aims to evaluate the efficacy of Apnex, Inspire, and ImThera hypoglossal nerve stimulation (HGNS) devices in changing the severity of obstructive sleep apnea (OSA)., Method: ology: A systematic search was conducted across the databases to collect baseline and postoperative outcome measures. Articles were then filtered and data from post-filtration was extracted. The efficacy of each device was assessed individually, and the reported outcomes were analyzed at short-term (≤1 year) and long-term (>1 year) intervals., Results: A total of 30 papers were included; 26 were single-arm studies encompassing 549 middle-aged overweight patients. Four RCTs included 273 participants. Results show that HGNS is an effective and safe treatment option. The Inspire device significantly improved, reducing the apnea-hypopnea index (AHI) by -20.14 events/h in the short term and -15.91 events/h in the long term. It also decreased the oxygen desaturation index (ODI) by -14.16 events/h (short term) and -12.95 events/h (long term). Patient-reported outcomes showed decreased Epworth Sleepiness Scale (ESS) scores by -5.02 (short term) and -4.90 (long term) and improved Functional Outcomes of Sleep Questionnaire (FOSQ) scores by 3.58 (short term) and 3.28 (long term). The Apnex and the ImThera devices featured similar improvements but to a lesser extent., Conclusion: Hypoglossal nerve stimulation is a safe and effective treatment for patients with OSA, exhibiting high adherence and satisfaction rates. However, it is important to note the potential for refining selection criteria to include a wider spectrum of patients with OSA., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Older adults commonly experience chronic medical conditions and are at risk of cognitive impairment as a result of age, chronic comorbidity, and medications prescribed to manage multiple chronic conditions. Anticholinergic medications are common treatments for chronic conditions, and have been repeatedly associated with poor cognitive outcomes, including delirium and dementia, in epidemiologic studies. However, no study has definitively evaluated the causal relationship between anticholinergics and cognition in a randomized controlled trial design. Utilizing our prior experience in deprescribing anticholinergic medications in various clinical environments, we designed an outpatient deprescribing intervention to prospectively test the potential causal relationship between anticholinergics and cognition in primary care older adults., Methods: This cluster randomized clinical trial will be conducted to evaluate the impact of an anticholinergic deprescribing intervention compared to usual care on outcomes of cognition and safety in primary care older adults. Participants will include those aged 65 years and over, receiving primary care in the greater Indianapolis area, using a strong anticholinergic within the last two weeks or with evidence of high-risk exposure in the past year. Those excluded will have a diagnosis of Alzheimer's disease or related dementia, or serious mental illness. The trial plans to enroll 344 participants who will be cluster-randomized at the level of primary care physician to avoid contamination. Participants will complete outcome assessments every six months up to 2 years by blinded outcome assessors. The primary outcome of the study is a composite measure of cognition that includes domains assessing executive cognitive function, language, and memory. Secondary outcomes include patient-reported measures of pain intensity, depression, anxiety, sleep disturbance, and health-related quality of life., Discussion: The R2D2 trial will be the largest and longest prospective randomized trial testing the impact of an anticholinergic-specific deprescribing intervention on cognition in primary care older adults. Results could influence deprescribing methodology and provide new insight on the relationship between anticholinergics and cognition., Competing Interests: Competing Interests All other authors report no conflicts of interest.

The best aortic prostheses have been debated for decades. The introduction of stentless aortic bioprostheses was aimed at improving hemodynamics and potentially the durability of aortic bioprostheses. Despite the good short- and long-term outcomes after implantation of stentless aortic bioprostheses, their use remains limited owing to the technically demanding implantation techniques. Nevertheless, stentless aortic bioprostheses might be of special benefit in certain indications, where they could be a valuable addition to the surgical armamentarium.

Background  Obesity is a limiting factor for the use of bilateral internal mammary arteries (BIMAs). Therefore, we assessed the safety of their use in different degrees of obesity. Patients and Methods  We studied two groups of patients with obesity using propensity matching. The first group received single internal mammary artery and saphenous vein grafts (SIMA group, 526 patients) and the second group received bilateral internal mammary arteries (BIMA group, 526 patients). Patients were classified further according to their body mass index (BMI) into overweight (BMI = 25-29.9 kg/m 2 ), obese (BMI = 30-34.9 kg/m 2 ), and severely obese (BMI ≥ 35 kg/m 2 ). Results  Preoperative data were similar regarding age (62.78 ± 9.96 vs. 62.98 ± 9.66 years; p  = 0.734), female sex (17.5 vs. 18.6%; p  = 0.631), diabetes mellitus (26.3 vs. 27.2%; p  = 0.74), EuroSCORE (3.21 ± 2.23 vs. 3.18 ± 2.41; p  = 0.968), and COPD (16 vs. 16%; p  = 1). No significant differences were noticed between the two groups regarding the number of peripheral anastomoses (3.09 ± 0.84 vs. 3.12 ± 0.83; p  = 0.633), myocardial infarction (1.7 vs. 1.7%; p  = 1), reexploration (1.3 vs. 2.1%; p  = 0.34), deep sternal wound infection (DSWI) (2.1 vs. 2.9%; p  = 0.43), and 30-day mortality (0.8 vs. 1.1%; p  = 0.53). Multivariate analysis identified BMI and intensive care unit stay as independent predictors for DSWI. However, postoperative blood loss (694.56 ± 631.84 vs. 811.67 ± 688.73 mL; p  < 0.001) and the incidence of pneumothorax (1 vs. 2.7%; p  = 0.037) were higher in BIMA group. Conclusion  Patients with obesity can benefit from BIMA grafting. However, postoperative blood loss and the incidence of pneumothorax can be higher using this technique., Competing Interests: Conflict of Interest: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)