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Time-To-OR is a critical process measure for trauma performance. However, this measure has not consistently demonstrated improvement in outcome. Using TQIP, we identified facilities by 75th percentile time-to-OR to categorize slow, average, and fast hospitals. Using a GEE model, we calculated odds of mortality for all penetrating abdominal trauma patients, firearm injuries only, and patients with major complication by facility speed. We additionally estimated odds of mortality at the patient level. Odds of mortality for patients at slow facilities was 1.095; 95% CI: 0.746, 1.608; p = 0.64 compared to average. Fast facility OR = 0.941; 95% CI: 0.780, 1.133; p = 0.52. At the patient-level each additional minute of time-to-OR was associated with 1.5% decreased odds of in-hospital mortality (OR 0.985; 95% CI:0.981, 0.989; p < 0.001). For firearm-only patients, facility speed was not associated with odds of in-hospital mortality (p -value = 0.61). Person-level time-to-OR was associated with 1.8% decreased odds of in-hospital mortality (OR 0.982; 95% CI: 0.977, 0.987; p < 0.001) with each additional minute of time-to-OR. Similarly, failure-to-rescue analysis showed no difference in in-hospital mortality at the patient level (p = 0.62) and 0.4% decreased odds of in-hospital mortality with each additional minute of time-to-OR at the patient level (OR 0.996; 95% CI: 0.993, 0.999; p = 0.004). Despite the use of time-to-OR as a metric of trauma performance, there is little evidence for improvement in mortality or complication rate with improved time-to-OR at the facility or patient level. Performance metrics for trauma should be developed that more appropriately approximate patient outcome. [ABSTRACT FROM AUTHOR]

Patients with metabolic syndrome (MetS) are at increased risk of developing cardiovascular disease along with other adverse events after bariatric surgery. The incidence of short-term major adverse cardiovascular events (MACE) in patients with MetS undergoing bariatric surgery is not well characterized. Accredited bariatric surgery centers in the United States and Canada. A total of 760,076 patients aged ≥18 years with body mass index ≥35 kg/m2 who underwent primary bariatric surgery between 2015 and 2018 were included. Patients with both diabetes and hypertension were described as the MetS cohort. Patient characteristics, operative technique, and 30-day outcomes were compared. The primary outcome was incidence of MACE, a composite of myocardial infarction, stroke, and all-cause mortality. Unadjusted and multivariable logistic regression analyses were performed and included an interaction between MetS and hyperlipidemia (HLD). Of the 577,882 patients included, 111,128 (19.2%) exhibited MetS. Patients with MetS more frequently experienced MACE compared with patients without MetS (.3% versus.1%; P <.001). The odds of MACE were greater for patients with MetS versus Non-MetS (odds ratio [OR] 2.87; 95% CI, 2.49–3.32) in the unadjusted analysis. MetS without HLD, MetS with HLD, and Non-MetS with HLD are significantly associated with MACE when compared with those with non-MetS without HLD. Patients with MetS have an increased frequency of cardiac events following bariatric surgery. Future studies should determine if optimization of 1 or more components of MetS or other related co-morbidities reduces the cardiovascular risk for patients. • People with diabetes and hypertension (MetS) account for 19.2% of patients who undergo bariatric surgery. • The rate of short-term major adverse cardiovascular events (MACE) is more common in patients with MetS compared to patients without metabolic syndrome (non-MetS). • The presence of metabolic syndrome and hyperlipidemia (HLD) does not further increase the odds of MACE when compared to metabolic syndrome without HLD. [ABSTRACT FROM AUTHOR]

Background: Endoscopic sinus surgery (ESS) offers excellent outcomes for patients with chronic rhinosinusitis (CRS) in the general population. It is unclear whether older patients with significant medical comorbidities experience similar benefits. Objective: The purpose of this study is to evaluate whether increasing medical comorbidity is associated with worse sinonasal quality of life outcomes after ESS in older patients. Methods: This is a retrospective study of CRS patients 55 years or older who underwent elective ESS at an academic institution from July 2017 to June 2019. 22-Item Sino-Nasal Outcomes Test (SNOT-22) scores were gathered at baseline as well as at 3 and 6 months following surgery. Data on demographics, medical comorbidities, preoperative Lund-Mackay (LM) scores, and postoperative complications were extracted from the medical record. The Charlson Comorbidity Index (CCI) was calculated for each patient. Multivariate linear regression was used to evaluate a potential association between CCI and change in SNOT-22 scores at 3 months postoperatively. Results: A total of 205 patients met inclusion criteria with a mean (SD) CCI score of 2 (2.4) and a CCI score range of 0 to 11. The mean (SD) LM score was 8 (5.3). Rates of asthma and nasal polyposis were 28.3% and 36.6%, respectively. The mean (SD) improvement in SNOT-22 scores at 3 and 6 months compared to baseline was 17.9 (19.7) and 20.9 (18.1) points, respectively. After adjusting for covariates, there was no significant association between CCI and change in SNOT-22 scores. Conclusion: Greater medical comorbidity is not associated with worse SNOT-22 outcomes postoperatively, although future studies are needed to determine if comorbidities are associated with higher complication rates. A multidisciplinary approach to perioperative care is critical in maintaining the safety and efficacy of ESS in this patient population. [ABSTRACT FROM AUTHOR]

Readmission after bariatric surgery is multifactorial. Understanding the trends in risk factors for readmission provides opportunity to optimize patients prior to surgery identify disparities in care, and improve outcomes. This study compares trends in bariatric surgery as they relate to risk factors for all-cause readmission. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participating facilities. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was used to analyze 760,076 bariatric cases from 854 centers. Demographics and 30-day unadjusted outcomes were compared between laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (LSG), and Roux-en-Y gastric bypass (RYGB) performed between 2015 and 2018. A multiple logistic regression model determined predictors of readmission. A total of 574,453 bariatric cases met criteria, and all-cause readmission rates decreased from 4.2% in 2015 to 3.5% in 2018 (P <.0001). The percentage of non-Hispanic Black adults who underwent bariatric surgery increased from 16.7% of the total cohort in 2015 to 18.7% in 2018 (P <.0001). The percentage of Hispanic adults increased from 12.1% in 2015 to 13.8% in 2018 (P <.0001). The most common procedure performed was the LSG (71.5%), followed by RYGB (26.9%) and 1.6% LAGB (1.6%) (P <.0001). Men were protected from readmission compared with women (odds ratio [OR]:.87; 95% confidence interval [CI]:.84–.90). Non-Hispanic Black (OR: 1.52; 95% CI: 1.47–1.58)] and Hispanic adults (OR: 1.14; 95% CI: 1.09–1.19) were more likely to be readmitted compared with non-Hispanic White adults. LSG (OR: 1.27; 95% CI: 1.10–1.48) and RYGB (OR: 2.24; 95% CI: 1.93–2.60) were predictive of readmission compared with LAGB. Readmission rates decreased over 4 years. Women, along with non-Hispanic Black and Hispanic adults, were more likely to be readmitted. Future research should focus on gender and racial disparities that impact readmission. • A total of 569,652 patients were readmitted with racial group and procedure predictive of all-cause readmission (Table 3). Non-Hispanic Black [OR 1.52; 95% CI: 1.47-1.58] or Hispanic [OR 1.14; 95% CI: 1.09-1.19] were more likely to be readmitted when compared to non-Hispanic White adults. • LSG [odds ratio (OR) 1.27; 95% confidence interval (CI): 1.10-1.48] and RYGB (OR 2.24; 95% CI: 1.93-2.60) were associated with readmission compared to LAGB. Robotic approach increased from 6.2% in 2015 to 9.8% in 2018 (p<0.0001). LOS > 3 days occurred in 2.9% of laparoscopic procedures vs 3.2% of robotic procedures (P=0.001). The rate of readmission was 3.7% for laparoscopy and 4.3% for robotic surgeries (P<0.0001). • Men comprised < 22% of the total cohort every year. Men, especially Black men, were more likely to present with a BMI ≥ 50kg/m2 compared to women. Interestingly, male gender was protective for readmission (OR 0.87; 95% CI: 0.84-0.90]. It is critical to understand that Black patients, in particular Black men, experience a prolonged LOS more often than White patients. • Further investigation into the intersectionality of race and gender would provide a better understanding of disparities in access and outcomes for bariatric surgery patients. Future studies should review the effects of enhanced recovery protocols across racial groups to better understand readmission after bariatric surgery. [ABSTRACT FROM AUTHOR]

Objective: High-sensitivity cardiac troponin assays (hs-cTn) aid in diagnosis of myocardial infarction (MI). These assays have lower specificity for non-ST Elevation MI (NSTEMI) in patients with renal disease. Our objective was to determine an optimized cutoff for patients with renal disease.Methods: We conducted an a priori secondary analysis of a prospective FDA study in adults with suspected MI presenting to 29 academic urban EDs between 4/2015 and 4/2016. Blood was drawn 0, 1, 2-3, and 6-9 h after ED arrival. We recorded cTn and estimated glomerular filtrate rate (eGFR) by Chronic Kidney Disease Epidemiology Collaboration equation. The primary endpoint was NSTEMI (Third Universal Definition of MI), adjudicated by physicians blinded to hs-cTn results. We generated an adjusted hscTn rule-in cutoff to increase specificity.Results: 2505 subjects were enrolled; 234 were excluded. Patients were mostly male (55.7%) and white (57.2%), median age was 56 years 472 patients [20.8%] had an eGFR <60 mL/min/1.73 m2. In patients with eGFR <15 mL/min/1.73 m2, a baseline rule-in cutoff of 120 ng/L led to a specificity of 85.0% and Positive Predictive Value (PPV) of 62.5% with 774 patients requiring further observation. Increasing the cutoff to 600 ng/L increased specificity and PPV overall and in every eGFR subgroup (specificity and PPV 93.3% and 78.9%, respectively for eGFR <15 mL/min/1.73m2), while increasing the number (79) of patients requiring observation.Conclusions: An eGFR-adjusted baseline rule-in threshold for the Siemens Atellica hs-cTnI improves specificity with identical sensitivity. Further study in a prospective cohort with higher rates of renal disease is warranted. [ABSTRACT FROM AUTHOR]

Little is known about longitudinal change in physical functioning of older African American/Black and White HIV-infected persons. We examined up to 10 years of data on African American (N = 1,157) and White (N = 400) men with HIV infection and comparable HIV-negative men (n = 1,137 and 530, respectively), age 50–91 years from the Veterans Aging Cohort Study Survey sample. Physical functioning was assessed using the SF-12 (12-Item Short Form Health Survey) physical component summary (PCS) score. Mixed-effects models examined association of demographics, health conditions, health behaviors, and selected interactions with PCS score; HIV biomarkers were evaluated for HIV-infected persons. PCS scores were approximately one standard deviation below that of the general U.S. population of similar age. Across the four HIV/race groups, over time and through ages 65–75 years, PCS scores were maintained; differences were not clinically significant. PCS score was not associated with race or with interactions among age, race, and HIV status. CD4 and viral load counts of African American and White HIV-infected men were similar. Older age, low socioeconomic status, chronic health conditions and depression, lower body mass index, and smoking were associated with poorer PCS score in both groups. Exercising and, counterintuitively, being HIV infected were associated with better PCS score. Among these older African American and White male veterans, neither race nor HIV status was associated with PCS score, which remained relatively stable over time. Chronic disease, depression, and lack of exercise were associated with lower PCS score. To maintain independence in this population, attention should be paid to controlling chronic conditions, and emphasizing good health behaviors. [ABSTRACT FROM AUTHOR]

Introduction: We evaluated the association between neighborhood socioeconomic status (NSES) and sleep quality on cognitive decline in the Health and Retirement Study. Methods: Health and Retirement Study participants (n = 8090), aged 65+ with DNA and multiple biennial cognitive observations (abbreviated Telephone Interview for Cognitive Status), were included. Participants were grouped into quartiles of NSES and sleep quality scores. We adjusted for apolipoprotein E ε4, demographic, and cardiovascular risk factors. Random effects modeling evaluated cognitive change over time. Results: NSES and sleep were significantly associated with cognitive decline, and there was a significant interaction between them (P =.02). Significant differences between high/low NSES and high/low sleep quality (P <.0001) were found. Discussion: Sleep and NSES were associated with cognitive decline; the association between sleep and cognition appeared stronger among those with low NSES. The association between low NSES, poor sleep quality, and cognitive decline was roughly equivalent to the association between apolipoprotein E ε4 and cognitive decline. [ABSTRACT FROM AUTHOR]

Hospital readmission after surgery results in a substantial economic burden, and several recent studies have investigated the impact of race and ethnicity on hospital readmission rates, with the goal to identify hospitals and patients with high readmission risk. This single-institution, retrospective cohort study assesses the impact of race, along with other risk factors, on 30-day readmission rates following spinal surgery. This study is a single-institution retrospective cohort study with accrual from January 1, 2008, to December 31, 2010. Inclusion criteria included adult patients who underwent anterior and/or posterior spinal surgery. The primary aim of this study was to assess the impact of patient race and other risk factors for postoperative hospital readmission within 30 days following spine surgery. A total of 1346 patients (654 male, 692 female) were included in the study. Overall, 159 patients (11.8%) were readmitted in the 30 days following their surgery. Multivariate logistic regression found significant risk factors for 30-day readmission, including Black race (OR: 2.20, C.I. 95% (1.04, 4.64)) and total length of stay greater than 7 days (OR: 4.73, C.I. 95% (1.72, 12.98)). Cervical surgery was associated with decreased odds of readmission (OR: 0.27, C.I. 95% (0.08, 0.91)). Our study demonstrates that race and length of hospital stay influence the incidence of 30-day readmission rates after spinal surgery. Studies such as ours will aid in identifying patients with postoperative readmission risk and help elucidate the underlying factors that may be contributing to disparities in readmission after surgery. [ABSTRACT FROM AUTHOR]

Background: Although primary graft dysfunction (PGD) is a leading cause of mortality and morbidity early post-heart transplant, relatively little is known regarding mechanisms involved in PGD development.Methods and Results: We examined the relationship between cardiac troponin I (cTnI) concentrations in the preservation solution from 43 heart transplant procedures and the development of PGD. Donor hearts were flushed with cold preservation solution (University of Wisconsin [UW] or Custodiol) and stored in the same solution. cTnI concentrations were measured utilizing the i-STAT System and normalized to left ventricular mass. Recipient medical records were reviewed to determine PGD according to the 2014 ISHLT consensus conference. Nineteen patients developed PGD following cardiac transplantation. For both UW and Custodiol, normalized cTnI levels were significantly increased (P = .031 and .034, respectively) for those cases that developed PGD versus no PGD. cTnI levels correlated with duration of ischemic time in the UW group, but not for the Custodiol group. Donor age and donor cTnI (obtained prior to organ procurement) did not correlate with preservation cTnI levels in either UW or Custodiol.Conclusions: Increased preservation solution cTnI is associated with the development of PGD suggesting preservation injury may be a dominant mechanism for the development of PGD. [ABSTRACT FROM AUTHOR]

The article makes use of the data from the National Alzheimer Disease Coordinating Center (NACC) to identify subtypes of cognitively normal adults with various cognition patterns, which may imply later Alzheimer disease (AD) or dementia onset. Findings discussed include the results of the exploratory factor analysis (EFA) performed on the first half of the sample, the latent profile analysis (LPA) done using the CFA factor scores, baseline age and sex, and the predictors of profile membership.

Background: Risk factors and outcomes of bronchial stricture after lung transplantation are not well defined. An association between acute rejection and development of stricture has been suggested in small case series. We evaluated this relationship using a large national registry. Methods: All lung transplantations between April 1994 and December 2008 per the United Network for Organ Sharing (UNOS) database were analyzed. Generalized linear models were used to determine the association between early rejection and development of stricture after adjusting for potential confounders. The association of stricture with postoperative lung function and overall survival was also evaluated. Results: Nine thousand three hundred thirty-five patients were included for analysis. The incidence of stricture was 11.5% (1,077/9,335), with no significant change in incidence during the study period (P = 0.13). Early rejection was associated with a significantly greater incidence of stricture (adjusted odds ratio [AOR], 1.40; 95% confidence interval [CI], 1.22–1.61; p < 0.0001). Male sex, restrictive lung disease, and pretransplantation requirement for hospitalization were also associated with stricture. Those who experienced stricture had a lower postoperative peak percent predicted forced expiratory volume at 1 second (FEV1) (median 74% versus 86% for bilateral transplants only; p < 0.0001), shorter unadjusted survival (median 6.09 versus 6.82 years; p < 0.001) and increased risk of death after adjusting for potential confounders (adjusted hazard ratio 1.13; 95% CI, 1.03–1.23; p = 0.007). Conclusions: Early rejection is associated with an increased incidence of stricture. Recipients with stricture demonstrate worse postoperative lung function and survival. Prospective studies may be warranted to further assess causality and the potential for coordinated rejection and stricture surveillance strategies to improve postoperative outcomes. [Copyright &y& Elsevier]

The article discusses the occurrence of depression among patients with chronic heart failure. It states that depression is commonly associated with heart failure and it is highly associated with reduced health state of patients. According to the authors, patients with depressive symptoms remitted showed promise in social function, life quality as well as physical function.

Abstract: Introduction: A highly polymorphic T homopolymer was recently found to be associated with late-onset Alzheimer’s disease risk and age of onset. Objective: To explore the effects of the polymorphic polyT tract (rs10524523, referred as ‘523’) on cognitive performance in cognitively healthy elderly individuals. Methods: One hundred eighty-one participants were recruited from local independent-living retirement communities. Informed consent was obtained, and participants completed demographic questionnaires, a conventional paper-and-pencil neuropsychological battery, and the computerized Cambridge Neuropsychological Test Automated Battery (CANTAB). Saliva samples were collected for determination of the TOMM40 ‘523’ (S, L, VL) and the apolipoprotein E (APOE) (ɛ2, 3, 4) genotypes. From the initial sample of 181 individuals, 127 were eligible for the association analysis. Participants were divided into three groups based on ‘523’ genotypes (S/S, S/L-S/VL, and L/L-L/VL-VL/VL). Generalized linear models were used to evaluate the association between the ‘523’ genotypes and neuropsychological test performance. Analyses were adjusted for age, sex, education, depression, and APOE ɛ4 status. A planned subanalysis was undertaken to evaluate the association between ‘523’ genotypes and test performance in a sample restricted to APOE ɛ3 homozygotes. Results: The S homozygotes performed better, although not significantly, than the S/L-S/VL and the VL/L-L/VL-VL/VL genotype groups on measures associated with memory (CANTAB Paired Associates Learning, Verbal Recognition Memory free recall) and executive function (CANTAB measures of Intra-Extra Dimensional Set Shift). Follow-up analysis of APOE ɛ3 homozygotes only showed that the S/S group performed significantly better than the S/VL group on measures of episodic memory (CANTAB Paired Associates Learning and Verbal Recognition Memory free recall), attention (CANTAB Rapid Visual Information Processing latency), and executive function (Digit Symbol Substitution). The S/S group performed marginally better than the VL/VL group on Intra-Extra Dimensional Set Shift. None of the associations remained significant after applying a Bonferroni correction for multiple testing. Conclusions: Results suggest important APOE-independent associations between the TOMM40 ‘523’ polymorphism and specific cognitive domains of memory and executive control that are preferentially affected in early-stage Alzheimer’s disease. [Copyright &y& Elsevier]

Objective: Thoracoabdominal aortic aneurysms (TAAAs) occur most commonly in elderly individuals, who are often suboptimal candidates for open repair because of significant comorbidities. The availability of a hybrid option, including open visceral debranching with endovascular aneurysm exclusion, may have advantages in these patients who are at high-risk for conventional repair. This report details the evolution of our technique and results with complete visceral debranching and endovascular aneurysm exclusion for TAAA repair in high-risk patients. Methods: Between March 2005 and June 2011, 47 patients (51% women) underwent extra-anatomic debranching of all visceral vessels, followed by aneurysm exclusion by endovascular means at a single institution. A median of four visceral vessels were bypassed. The debranching procedure was initially performed through a partial right medial visceral rotation approach, leaving the left kidney posterior in the first 22 patients, and in the last 25 by a direct anterior approach to the visceral vessels. The debranching and endovascular portions of the procedure were performed in a single operation in the initial 33 patients and as a staged procedure during a single hospital stay in the most recent 14. Results: Median patient age was 71.0 ± 9.8 years. All had significant comorbidity and were considered suboptimal candidates for conventional repair: 55% had undergone previous aortic surgery, 40% were American Society of Anesthesiologists (ASA) class 4, and baseline serum creatinine was 1.5 ± 1.3 mg/dL. The 30-day/in-hospital rates of death, stroke, and permanent paraparesis/plegia were 8.5%, 0%, and 4.3%, respectively, but 0% in the most recent 14 patients undergoing staged repair. These patients had significantly shorter combined operative times (314 vs 373 minutes), decreased intraoperative red blood cell transfusions (350 vs 1400 mL), and were more likely to be extubated in the operating room (50% vs 12%) compared with patients undergoing simultaneous repair. Over a median follow-up of 19.3 ± 18.5 months, visceral graft patency was 97%; all occluded limbs were to renal vessels and clinically silent. There have been no type I or III endoleaks or reinterventions. Kaplan-Meier overall survival is 70.7% at 2 years and 57.9% at 5 years. Conclusions: Hybrid TAAA repair through complete visceral debranching and endovascular aneurysm exclusion is a good option for elderly high-risk patients less suited to conventional repair in centers with the requisite surgical expertise with visceral revascularization. A staged approach to debranching and endovascular aneurysm exclusion during a single hospitalization appears to yield optimal results. [Copyright &y& Elsevier]

Background: Mental stress-induced myocardial ischemia (MSIMI) is common in patients with clinically stable coronary heart disease (CHD) and is associated with poor outcomes. Depression is a risk factor of MSIMI. The REMIT trial investigates whether selective serotonin reuptake inhibitor (SSRI) treatment can improve MSIMI. The rationale and outline of the study are described.Method: In this single-center randomized clinical trial, adult patients with clinically stable CHD are recruited for baseline mental and exercise stress testing assessed by echocardiography. In addition, psychometric questionnaires are administered, and blood samples are collected for platelet activity analysis. Patients who demonstrate MSIMI, defined by new abnormal wall motion, ejection fraction reduction ≥8%, and/or development of ischemic ST change in electrocardiogram during mental stress testing, are randomized at a 1:1 ratio to escitalopram or placebo for 6 weeks. Approximately 120 patients with MSIMI are enrolled in the trial. The stress testing, platelet activity assessment, and psychometric questionnaires are repeated at the end of the 6-week intervention. The hypothesis of the study is that SSRI treatment improves MSIMI via mood regulation and modification of platelet activity.Conclusion: The REMIT study examines the effect of SSRI on MSIMI in vulnerable patients with CHD and probes some potential underlying mechanisms. [ABSTRACT FROM AUTHOR]

Background: Mental stress–induced myocardial ischemia (MSIMI) is common in patients with clinically stable coronary heart disease (CHD) and is associated with poor outcomes. Depression is a risk factor of MSIMI. The REMIT trial investigates whether selective serotonin reuptake inhibitor (SSRI) treatment can improve MSIMI. The rationale and outline of the study are described. Method: In this single-center randomized clinical trial, adult patients with clinically stable CHD are recruited for baseline mental and exercise stress testing assessed by echocardiography. In addition, psychometric questionnaires are administered, and blood samples are collected for platelet activity analysis. Patients who demonstrate MSIMI, defined by new abnormal wall motion, ejection fraction reduction ≥8%, and/or development of ischemic ST change in electrocardiogram during mental stress testing, are randomized at a 1:1 ratio to escitalopram or placebo for 6 weeks. Approximately 120 patients with MSIMI are enrolled in the trial. The stress testing, platelet activity assessment, and psychometric questionnaires are repeated at the end of the 6-week intervention. The hypothesis of the study is that SSRI treatment improves MSIMI via mood regulation and modification of platelet activity. Conclusion: The REMIT study examines the effect of SSRI on MSIMI in vulnerable patients with CHD and probes some potential underlying mechanisms. [Copyright &y& Elsevier]

Abstract: Objective: The objective of this article was to determine whether, in drug intervention trials, growth mixture modeling (GMM) is able to identify drug-responsive trajectory classes that are not evident in traditional growth modeling approaches. Methods: We reanalyzed acute phase (biweekly data up to 7 occasions) and longitudinal (12 months) data on the 469 patients in the SADHART-CHF study of the safety and efficacy of sertraline for depression in patients with heart failure. GMM was used to identify the trajectory classes present in the treatment and placebo groups, based on Hamilton Depression Rating Scale scores. Results: Two distinct trajectory classes were identified in the treatment group: (1) chronic depressives (12%), who remained depressed through the treatment phase; and (2) responders (88%), who had scores indicating nondepression at the conclusion of the acute phase. At baseline, chronic depressives were distinguished by higher Hamilton Depression Rating Scale scores, the presence of implantable cardioverter defibrillators, and a history of anxiety. During follow-up, they were more likely to have unstable angina. Only responders remitted (70%). Three distinct trajectories were identified in the placebo group: (1) moderating depressives (19%), (2) temporary improvers (13%), and (3) responders (68%). At baseline, the classes differed in mean Hamilton Depression Rating Scale scores, responders'' scores falling between the other 2 classes, and the proportion with renal disease. Only remission differed at follow-up: responders (76%), moderating depressives (21%), and temporary improvers (3%). Where the traditional analytic approach found improvement from moderate to mild depression but no significant treatment effect, GMM found response in 20% more people in the treatment group than in the placebo group. Conclusions: Unlike conventionally used, standard analytic approaches, which focus on intervention impact at study end or change from baseline to study end, GMM enables maximum use of repeated data to identify unique trajectories of latent classes that are responsive to the intervention. ClinicalTrials.gov identifier: NCT00078286. [Copyright &y& Elsevier]

Background: Sertraline, a selective serotonin-reuptake inhibitor, has demonstrated substantial mood improvement in patients with post myocardial infarction or with unstable angina. The impact of sertraline on the prognosis and depression of patients with chronic heart failure (HF) and comorbid major depressive disorder (MDD) is unknown.Method: This is a prospective, randomized, double-blind, placebo-controlled study designed to assess the safety and efficacy of sertraline in the treatment of MDD in patients with HF. The study is designed also to examine the effects of treating depression on cardiac events and morbidity/mortality in patients with HF. Approximately 500 men and women who are >or=45 years of age with current MDD and chronic systolic HF, characterized by left ventricular ejection fraction or=II, comprise the study population. Eligible participants are randomized to either sertraline or placebo for a 12-week acute treatment phase. All patients, regardless of acute treatment phase completion, are followed routinely until the last subject completes 6-month follow-up. Quality of life and certain physiologic parameters, as well as pro-inflammatory and HF biomarkers, that may reflect the impact of sertraline in this particular population are measured at baseline and at the end of the acute treatment phase.Conclusion: Because of the high prevalence of depression and its significant adverse impact on prognosis of patients with ischemic heart disease (IHD) and HF, the Safety and Efficacy of Sertraline for Depression in Patients with Chronic Heart Failure (SADHART-CHF) trial aims to assess the effects of sertraline on response of depression as well as on the cardiac prognosis of patients with HF. [ABSTRACT FROM AUTHOR]

Spouses are often the first providers of informal care when their partners develop dementia. We used The National Longitudinal Caregiver Study (NLCS, 4 annual surveys, 1999 to 2002) and identified 3 distinct longitudinal patterns (trajectory classes) of total daily caregiving time provided by the wife to her husband using Generalized growth mixture models (GGMM). About 56.4% of the sample (N=828) was found to have an increase in the trajectory of total daily caregiving time (mean 252 min/d at baseline, rising to 471 min/d at time 4). Four hundred forty-four (30.3%) caregivers had a trajectory described by a moderate increase in caregiving time (an increase from a mean of 464 min/d at baseline to 533 at wave 4), whereas 195 (13.3%) had a sharply declining trajectory (a decline from a mean of 719 min/d at baseline to 421 at wave 4). There was no significant difference in the duration (time since onset) of caregiving at baseline for these 3 trajectories. GGMM are well suited for the identification of distinct trajectory classes. Here they show that there are large differences in caregiving time provided to persons with dementia, who seem to be quite similar. [ABSTRACT FROM AUTHOR]

Background: Depression is prevalent in patients with heart failure (HF) and is associated with short-term poor prognosis. However, the long-term effect of depression and the use of self-administered depression evaluation on HF prognosis remained unknown. The study sought to assess the association of depressive symptoms and long-term mortality of patients with HF and to explore the prognostic predictability of the Beck Depression Inventory (BDI) scale for patients with HF. Methods: Hospitalized patients with HF between March 1997 and June 2003 were recruited. All participants were given the self-administered BDI scale for depression assessment during the index admission. They were then followed for 6 months for the collection of vital status, and annually thereafter. Results: Total study population comprises 1006 patients. The mean BDI score was 8.3 ± 7.1. The average days of follow-up were 971 ± 730 and the vital status was obtained from all participants. During this period, 42.6% of the participants died. Depression (defined by BDI score ≥10) was significantly and independently associated with reduced survival (adjusted hazard ratio 1.36, 95% CI 1.09-1.70, P < .001). Patients whose BDI scores were 5 to 9, 10 to 18, and ≥19 were 21%, 53%, and 83% more likely to die, respectively, than patients whose BDI score was <5 (P < .001). Conclusions: Self-rated depression by BDI is independently linked with higher long-term mortality in patients with HF. Significant dose effect of depressive symptoms on higher mortality is noted. [Copyright &y& Elsevier]

Background: Constipation, a common and sometimes severe problem in the elderly, is often treated with laxatives.Objective: The purpose of this study was to determine the prevalence of laxative use and identify determinants of such use among representative black and white community-dwelling elderly persons.Methods: This was a cross-sectional survey of 4136 participants at baseline (1986–1987) in the Duke University Established Populations for Epidemiologic Studies of the Elderly. Data on demographic characteristics, health status, health service use, and use of prescription and over-the-counter drugs were collected in participants'' homes. Use of the following types of laxatives was examined: bulking, hyperosmotic, lubricant, stimulant, stool softener, saline, and miscellaneous agents.Results: It was found that 10.2% of participants used ≥1 laxative. Stimulants and bulking agents were the most commonly used classes. Only 11.6% of laxative users reported concurrent consumption of ≥2 laxatives. Multivariate logistic regression analyses indicated that laxative use was more likely in women (adjusted OR, 1.78; 95% CI, 1.34–2.37), those with >4 physicians visits in the previous year (adjusted OR, 1.72; 95% CI, 1.16–2.53), those unable to walk a half mile (adjusted OR, 1.44; 95% CI, 1.11–1.87), and those using ≥4 over-the-counter nonlaxative medications (adjusted OR, 2.09; 95% CI, 1.15–3.81). A nonsignificant association was seen between laxative use and the use of anticholinergic agents (adjusted OR, 1.38; 95% CI, 1.00–1.89).Conclusions: Laxative use is common among community-dwelling elderly persons and is related to specific factors concerning sociodemographics, health status, and access to health care. Studies are needed that examine the impact of laxative use on bowel function and quality of life in the elderly. [Copyright &y& Elsevier]

Background/Purpose Children with inherited metabolic diseases (IMDs) undergoing umbilical cord blood transplantation (UCBT) who are at risk for post-transplant failure to thrive may benefit from pretransplant gastrostomy tube (GT) placement. Here we sought to determine predictors of posttransplant failure to thrive. Methods A retrospective analysis was performed for IMD patients who underwent UCBT at a single center from 2001 to 2011. Patients who received GTs were compared with controls. Multivariable logistic regression was used to determine significant predictors for GT placement. Recursive partitioning was performed to determine appropriate cut-offs for significant continuous variables. Results Two hundred and seventeen patients met inclusion criteria of which twenty-three were excluded due to death within one hundred days of transplant. Forty (20.6%) of the remaining patients underwent a surgical GT placement. Multivariable logistic regression demonstrated that weight percentile at time of transplant was significantly associated with GT placement (Adjusted odds ratio (AOR): 0.87 per 10th percentile, p = 0.022). Recursive partitioning demonstrated that the 40th weight percentile at time of transplant was an optimal cut-off for predicting GT placement. Conclusions Patients preparing for umbilical cord transplantation who are below the 40th percentile for weight may benefit from pre-emptive GT placement prior to transplant. [ABSTRACT FROM AUTHOR]