Search

Background: Carotid endarterectomy (CEA) is an effective treatment for the prevention of stroke in patients with carotid artery stenosis. We aimed to clarify the incidence and risk factors for early cognitive dysfunction (eCD) and early cognitive improvement (eCI), defined as change in cognitive performance ≤24 hours after surgery, using a battery of neuropsychometric tests., Methods: In total, 585 patients undergoing CEA were tested with neuropsychometric tests before and after surgery; 155 patients undergoing "simple" spine surgery were the reference group. Patient performance for each test was evaluated by z scores. Cognitive change was defined as eCD (or eCI) if: 1) patients had a z score ≤-2 (or ≥2) in ≥2 cognitive domains or 2) patients had mean z scores across all domains ≤-1.5 (or ≥1.5). Associations between the categorical cognitive outcomes and variables of interest were modeled using the proportional odds model., Results: Of the 585 subjects, 24% had eCD, 6% had eCI, and 70% had "no change." Patients who had eCD were more likely to be statin naïve (odds ratio [OR] 1.23 [1.03-1.48], P = 0.02) or women (OR 1.27 [1.06-1.53], P = 0.02). Those with eCI were less likely to have less formal education (OR 0.95 [0.90-1.00], P = 0.04) and less likely to have diabetes mellitus (OR 0.8 [0.65-0.99], P = 0.04)., Conclusions: Patients having CEA may develop eCD or eCI postoperatively. Medications likely to be associated with less eCD are statins and aspirin, which correlate most strongly in asymptomatic patients. In addition to confirming previous findings, we found that women were more likely than men to develop eCD. More sex-specific studies and analysis are needed to better explore these findings., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Chronic unresolved inflammation plays a causal role in the development of advanced atherosclerosis, but the mechanisms that prevent resolution in atherosclerosis remain unclear. Here, we use targeted mass spectrometry to identify specialized pro-resolving lipid mediators (SPM) in histologically-defined stable and vulnerable regions of human carotid atherosclerotic plaques. The levels of SPMs, particularly resolvin D1 (RvD1), and the ratio of SPMs to pro-inflammatory leukotriene B 4 (LTB 4 ), are significantly decreased in the vulnerable regions. SPMs are also decreased in advanced plaques of fat-fed Ldlr -/- mice. Administration of RvD1 to these mice during plaque progression restores the RvD1:LTB 4 ratio to that of less advanced lesions and promotes plaque stability, including decreased lesional oxidative stress and necrosis, improved lesional efferocytosis, and thicker fibrous caps. These findings provide molecular support for the concept that defective inflammation resolution contributes to the formation of clinically dangerous plaques and offer a mechanistic rationale for SPM therapy to promote plaque stability.

Background: Factors including ASA physical status, blood loss, and case length have been described as correlating with the decision to delay tracheal extubation after specific surgical procedures. In this retrospective study, we investigated whether handoffs by anesthesia attendings were associated with delayed extubation after general anesthesia for a broad range of surgical procedures., Methods: We reviewed the records of 37,824 patients who underwent general anesthesia with an endotracheal tube for surgery (excluding tracheostomy surgery, cardiac surgeries, and liver and lung transplant surgeries) from 2008 to 2013 at Columbia University Medical Center. Our primary outcome was whether the patient was extubated at the end of the surgical case. We hypothesized that attending handoff was a factor that would independently affect the decision of the anesthesiologist to extubate at the end of the surgical case. In addition, we investigated whether the association between handoff and extubation was affected by the timing of the procedure (ending in the daytime versus evening hours) by including an interaction term in the analysis. We adjusted for other variables affecting the decision to delay extubation., Results: Patients (5.4%, n = 2033) were not extubated in the operating room after the completion of their surgery. Cases with an attending handoff appeared to have a greater risk of delayed extubation with an adjusted risk ratio (aRR) of 1.14 (95% confidence interval [CI], 1.03-1.25). Further analysis demonstrated that the attending handoff had a significant effect in daytime cases (aRR, 1.62; 95% CI, 1.29-2.04) but not in evening cases (aRR, 1.07; 95% CI, 0.97-1.19)., Conclusions: Attending handoff was an independent significant factor that increased the risk for the delay of extubation at the end of a surgical case.

Background: Early cognitive dysfunction (eCD) is a subtle form of neurological injury observed in ∼25% of carotid endarterectomy (CEA) patients. Statin use is associated with a lower incidence of eCD in asymptomatic patients having CEA., Objective: To determine whether eCD status is associated with worse long-term survival in patients taking and not taking statins., Methods: This is a post hoc analysis of a prospective observational study of 585 CEA patients. Patients were evaluated with a battery of neuropsychometric tests before and after surgery. Survival was compared for patients with and without eCD stratifying by statin use. At enrollment, 366 patients were on statins and 219 were not. Survival was assessed by using Kaplan-Meier methods and multivariable Cox proportional hazards models., Results: Age ≥75 years (P = .003), diabetes mellitus (P < .001), cardiac disease (P = .02), and statin use (P = .014) are significantly associated with survival univariately (P < .05) by use of the log-rank test. By Cox proportional hazards model, eCD status and survival adjusting for univariate factors within statin and nonstatin use groups suggested a significant effect by association of eCD on survival within patients not taking statin (hazard ratio, 1.61; 95% confidence interval, 1.09-2.40; P = .018), and no significant effect of eCD on survival within patients taking statin (hazard ratio, 0.98; 95% confidence interval, 0.59-1.66; P = .95)., Conclusion: eCD is associated with shorter survival in patients not taking statins. This finding validates eCD as an important neurological outcome and suggests that eCD is a surrogate measure for overall health, comorbidity, and vulnerability to neurological insult., Abbreviations: aHR, adjusted hazards ratiosCEA, carotid endarterectomyCI, confidence intervalDM, diabetes mellituseCD, early cognitive dysfunctionNDI, National Death IndexNLR, neutrophil/lymphocyte ratioSD, standard deviationSEM, standard error of the mean.

Object: Neurocognitive performance is used to assess multiple cognitive domains, including motor coordination, before and after carotid endarterectomy (CEA). Although gross motor strength is impaired with ischemia of large cortical areas or of the internal capsule, the authors hypothesize that patients undergoing CEA demonstrate significant motor deficits of hand coordination contralateral to the operative side, which is more clearly manifest in the nondominant hand than in the dominant hand with ischemia of smaller cortical areas., Methods: The neurocognitive performance of 374 patients was evaluated with a battery of neuropsychometric tests. Both asymptomatic and symptomatic patients undergoing CEA were included. The authors evaluated the patients' dominant and nondominant hand performance on the Grooved Pegboard test, a test of hand coordination, to demonstrate their functional laterality. Neurocognitive dysfunction was evaluated as the difference in performance before and after CEA according to group-rate and event-rate analyses. The z scores were generated for all tests using a reference group of patients who were having simple spine surgery. Dominant and nondominant motor coordination functions were evaluated as raw scores and as calculated z scores., Results: According to event-rate analysis, significantly more patients undergoing CEA of the opposite carotid artery demonstrated nondominant than dominant hand deficits of coordination (41.2% vs 26.4%, respectively, p = 0.02). Similarly, according to group-rate analysis, in patients undergoing CEA of the opposite carotid artery, raw difference scores from the Grooved Pegboard test reflected greater nondominant than dominant hand deficits of coordination (21.0 ± 54.4 vs 9.7 ± 37.0, respectively, p = 0.02)., Conclusions: Patients undergoing CEA of the opposite carotid artery are more likely to demonstrate nondominant than dominant hand deficits of coordination because of greater dexterity in the dominant hand before surgery.

Introduction: Transient bradycardia during the stimulation phase of electroconvulsive therapy (ECT) is a well-known clinical observation. The optimal dose of atropine needed to prevent bradycardia has not been determined. This study was designed to investigate the effect of low doses of atropine on heart rate during ECT., Methods: Patients who received at least 2 different doses of atropine over their series of right unilateral ECT were included in the analysis. The anesthetic consisted of 0, 0.2, 0.3, or 0.4 mg of atropine, methohexital, and succinylcholine. Heart rate was measured by the RR interval, the time between sequential R waves on the electrocardiogram. Analysis was performed using logistic multivariate regression and repeated-measures multivariate analysis of variance., Results: One hundred eighteen ECT sessions were identified from 19 patients. Patients were grouped into 4 groups by atropine dose (0, 0.2, 0.3, or 0.4 mg) with 9, 33, 13, and 63 ECT sessions identified for each dose, respectively. Patients who received atropine had significantly less bradycardia after electrical stimulus and a faster heart rate through the seizure than patients who did not receive atropine. There was no significant difference in heart rate between patients receiving 0.2, 0.3, and 0.4 mg of atropine at any time point. There was no significant difference in heart rate at time points after the seizure conclusion in any group of patients., Conclusion: Low-dose atropine results in significantly less bradycardia after electrical stimulus. There was no significant difference in heart rate across low doses of atropine.