230 results on '"Houle TT"'
Search Results
2. Reversal of peripheral nerve injury-induced hypersensitivity in the postpartum period: role of spinal oxytocin.
- Author
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Gutierrez S, Liu B, Hayashida K, Houle TT, Eisenach JC, Gutierrez, Silvia, Liu, Baogang, Hayashida, Ken-ichiro, Houle, Timothy T, and Eisenach, James C
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- 2013
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3. Resolution of pain after childbirth.
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Eisenach JC, Pan P, Smiley RM, Lavand'homme P, Landau R, Houle TT, Eisenach, James C, Pan, Peter, Smiley, Richard M, Lavand'homme, Patricia, Landau, Ruth, and Houle, Timothy T
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- 2013
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4. Prognostic value of tissue Doppler-derived E/e' on early morbid events after cardiac surgery.
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Groban L, Sanders DM, Houle TT, Antonio BL, Ntuen EC, Zvara DA, Kon ND, and Kincaid EH
- Abstract
Background: The tissue Doppler-derived surrogate for left ventricular diastolic pressure, E/e', has been used to prognosticate outcome in a variety of cardiovascular conditions. In this study, we determined the relationship of intraoperative E/e' to the use of inotropic support, duration of mechanical ventilation (MV), length of intensive care unit stay (ICU-LOS), and total hospital stay (H-LOS) in patients requiring cardiac surgery. The records of 245 consecutive patients were retrospectively reviewed to obtain 205 patients who had intraoperative transesophageal echocardiography examinations prior to coronary artery bypass grafting and/or valvular surgery. Cox proportional hazards and logistic regression models were used to analyze the relation between intraoperative E/e' or LVEF and early postoperative morbidity (H-LOS, ICU-LOS, and MV) and the probability that a patient would require inotropic support. With adjustments for other predictors (female gender, hypertension, diabetes, history of myocardial infarction, emergency surgery, renal failure, procedure type, and length of aortic cross-clamp time), an elevated E/e' ratio (>=8) was significantly associated with an increased ICU-LOS (49 versus 41 median h, P = 0.037) and need for inotropic support (P = 0.002) while baseline LVEF was associated with inotropic support alone (P < 0.0001). These data suggest that the tissue Doppler-derived index of left ventricular diastolic filling pressure may be a useful indicator for predicting early morbid events after cardiac surgery, and may even provide additional information from that of baseline LVEF. Further, patients with elevated preoperative E/e' may need more careful peri- and postoperative management than those patients with E/e' <8. (Echocardiography 2010;27:131-138) [ABSTRACT FROM AUTHOR] more...
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- 2010
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5. Nosocomial pneumonia risk and stress ulcer prophylaxis: a comparison of pantoprazole vs ranitidine in cardiothoracic surgery patients.
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Miano TA, Reichert MG, Houle TT, Macgregor DA, Kincaid EH, Bowton DL, Miano, Todd A, Reichert, Marc G, Houle, Timothy T, MacGregor, Drew A, Kincaid, Edward H, and Bowton, David L
- Abstract
Background: Stress ulcer prophylaxis (SUP) using ranitidine, a histamine H2 receptor antagonist, has been associated with an increased risk of ventilator-associated pneumonia. The proton pump inhibitor (PPI) pantoprazole is also commonly used for SUP. PPI use has been linked to an increased risk of community-acquired pneumonia. The objective of this study was to determine whether SUP with pantoprazole increases pneumonia risk compared with ranitidine in critically ill patients.Methods: The cardiothoracic surgery database at our institution was used to identify retrospectively all patients who had received SUP with pantoprazole or ranitidine, without crossover between agents. From January 1, 2004, to March 31, 2007, 887 patients were identified, with 53 patients excluded (pantoprazole, 30 patients; ranitidine, 23 patients). Our analysis compared the incidence of nosocomial pneumonia in 377 patients who received pantoprazole with 457 patients who received ranitidine.Results: Nosocomial pneumonia developed in 35 of the 377 patients (9.3%) who received pantoprazole, compared with 7 of the 457 patients (1.5%) who received ranitidine (odds ratio [OR], 6.6; 95% confidence interval [CI], 2.9 to 14.9). Twenty-three covariates were used to estimate the probability of receiving pantoprazole as measured by propensity score (C-index, 0.77). Using this score, pantoprazole and ranitidine patients were stratified according to their probability of receiving pantoprazole. After propensity adjusted, multivariable logistic regression, pantoprazole treatment was found to be an independent risk factor for nosocomial pneumonia (OR, 2.7; 95% CI, 1.1 to 6.7; p = 0.034).Conclusion: The use of pantoprazole for SUP was associated with a higher risk of nosocomial pneumonia compared with ranitidine. This relationship warrants further study in a randomized controlled trial. [ABSTRACT FROM AUTHOR] more...- Published
- 2009
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6. Progressive diastolic dysfunction in the female mRen(2). Lewis rat: influence of salt and ovarian hormones.
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Groban L, Yamaleyeva LM, Westwood BM, Houle TT, Lin M, Kitzman DW, Chappell MC, Groban, Leanne, Yamaleyeva, Liliya M, Westwood, Brian M, Houle, Timothy T, Lin, Marina, Kitzman, Dalane W, and Chappell, Mark C more...
- Abstract
This study determined the contribution of chronic salt loading and early loss of ovarian hormones on diastolic function in the hypertensive female mRen(2). Lewis rat, a monogenetic strain that expresses the mouse renin-2 gene in various tissues. Estrogen-intact mRen2 rats fed a high salt (HS) (8% sodium chloride) diet exhibited early diastolic dysfunction when compared to normal salt-fed (NS) (1% sodium chloride) rats. In contrast, ovariectomized (OVX) rats on either NS or HS diets showed impaired relaxation with evidence of elevated left ventricular filling pressures (E/e') or pseudonormalization. This more advanced stage of diastolic dysfunction was associated with increases in interstitial cardiac fibrosis and high circulating levels of aldosterone, two factors leading to reduced ventricular compliance. These findings may explain the preponderance of diastolic dysfunction and diastolic heart failure in postmenopausal women and provide a potential animal model for evaluating prevention and treatment interventions for this disorder. [ABSTRACT FROM AUTHOR] more...
- Published
- 2008
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7. Pain reproduction during lumbosacral transforaminal epidural steroid injection does not affect outcome.
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Plastaras CT, Heller DS, Sorosky BS, and Houle TT
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Objective: Epidural steroid injections (ESIs) are widely used in clinical practice for the treatment of low back radicular pain. Anecdotally it has been conveyed that the reproduction of a patient's usual pain during ESI was of prognostic value as to which patients would show favorable results from the procedure, however, there is no data available to support this supposition. Design: Retrospective. Setting: Outpatient Spine and Sports Medicine Clinic. Patients: Patients with lumbosacral radicular pain treated with fluoroscopically guided contrast enhanced lumbosacral transforaminal ESI. Outcome Measures: 11-point pain intensity numeric rating scale (PI-NRS). Results: Overall the procedure provided statistically significant pain relief in both groups A (typical radicular pain reproduced) and B (typical radicular pain not reproduced) immediately and significant pain reduction was maintained until the time of the follow-up No reduction in pain was seen in group A vs. B, although in group B there was a strong trend toward having higher pain scores at all times. Conclusion: The reproduction of a patient's typical radicular pain during a fluoroscopically guided contrast enhanced lumbosacral transforaminal ESI does not predict a significant decrease in pain scores immediately after the procedure or at follow up. [ABSTRACT FROM AUTHOR] more...
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- 2006
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8. Multifactorial preoperative predictors for postcesarean section pain and analgesic requirement.
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Pan PH, Coghill R, Houle TT, Seid MH, Lindel WM, Parker RL, Washburn SA, Harris L, Eisenach JC, Pan, Peter H, Coghill, Robert, Houle, Timothy T, Seid, Melvin H, Lindel, W Michael, Parker, R Lamar, Washburn, Scott A, Harris, Lynne, and Eisenach, James C more...
- Published
- 2006
9. Do not use blocked randomization.
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Berger VW, Nicholson RA, Penzien DB, Lipchik GL, and Houle TT
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- 2006
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10. The Role of Processed Electroencephalogram in Adult Surgical Procedures: A Retrospective Cohort Study.
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Hutto K, van Pelt M, Smith MR, Mueller A, Houle TT, and Lea J
- Subjects
- Humans, Retrospective Studies, Female, Male, Middle Aged, Adult, Cohort Studies, Aged, Anesthesia, General, Monitoring, Intraoperative, Electroencephalography, Nurse Anesthetists
- Abstract
The use of depth of anesthesia monitoring, such as a processed electroencephalogram (pEEG), can decrease the risk of awareness with recall, yet the current standards for monitoring during the administration of anesthesia do not include the use of brain monitoring for anesthetic depth. This retrospective cohort study describes the frequency of use and explores the characteristics of utilization of pEEG monitoring by anesthesia professionals during the administration of general anesthesia in the adult patient population at a large academic medical center. Descriptive associations with pEEG monitoring were confirmed in both univariate and multivariable analyses with multiple patient, anesthetic, and surgical characteristics. After taking anesthesia provider, patient, anesthetic, and surgical characteristics into consideration, 38.0% of the variability in pEEG use was accounted for. Although these data suggest recommended guidelines are being followed, further analyses should examine explicit relationships and differences in pEEG use., Competing Interests: Name: Kaylee Hutto, DNP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author; she is the corresponding author for this article. Disclosures: None. Name: Maria van Pelt, PhD, CRNA, FAAN, FANNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Matthew R. Smith, BA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Ariel Mueller, MA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Timothy T. Houle, PhD Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: Joshua Lea, DNP, MBA, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. The authors did not discuss off-label use within the article. Disclosure statements are available upon request., (Copyright © 2024 by the American Association of Nurse Anesthesiology.) more...
- Published
- 2024
11. Role of anticoagulation therapy in modifying stroke risk associated with new-onset atrial fibrillation after non-cardiac surgery.
- Author
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Azimaraghi O, Rudolph MI, Wongtangman K, Borngaesser F, Doehne M, Ng PY, von Wedel D, Eyth A, Zou F, Tam C, Sauer WJ, Kiyatkin ME, Houle TT, Karaye IM, Zhang L, Schaefer MS, Schaefer ST, Himes CP, Grimm AM, Nafiu OO, Mpody C, Suleiman A, Stiles BM, Di Biase L, Garcia MJ, Bhatt DL, and Eikermann M more...
- Subjects
- Humans, Male, Female, Aged, Middle Aged, Risk Factors, Ischemic Stroke epidemiology, Ischemic Stroke prevention & control, Ischemic Stroke etiology, Adult, Atrial Fibrillation epidemiology, Atrial Fibrillation etiology, Anticoagulants therapeutic use, Anticoagulants adverse effects, Stroke prevention & control, Stroke epidemiology, Stroke etiology, Postoperative Complications prevention & control, Postoperative Complications etiology
- Abstract
The role of antithrombotic therapy in the prevention of ischemic stroke after non-cardiac surgery is unclear. In this study, we tested the hypothesis that the association of new-onset postoperative atrial fibrillation (POAF) on ischemic stroke can be mitigated by postoperative oral anticoagulation therapy. Of 251,837 adult patients (155,111 female (61.6%) and 96,726 male (38.4%)) who underwent non-cardiac surgical procedures at two sites, POAF was detected in 4,538 (1.8%) patients. The occurrence of POAF was associated with increased 1-year ischemic stroke risk (3.6% versus 2.3%; adjusted risk ratio (RRadj) = 1.60 (95% confidence interval (CI): 1.37-1.87), P < 0.001). In patients with POAF, the risk of developing stroke attributable to POAF was 1.81 (95% CI: 1.44-2.28; P < 0.001) without oral anticoagulation, whereas, in patients treated with anticoagulation, no significant association was observed between POAF and stroke (RRadj = 1.04 (95% CI: 0.71-1.51), P = 0.847, P for interaction = 0.013). Furthermore, we derived and validated a computational model for the prediction of POAF after non-cardiac surgery based on demographics, comorbidities and procedural risk. These findings suggest that POAF is predictable and associated with an increased risk of postoperative ischemic stroke in patients who do not receive postoperative anticoagulation., Competing Interests: Competing interests M.E. receives funding from the National Institutes of Health (NIH) (R01AG065554 and R01HL132887) that does not pertain to this manuscript. He holds two patents for acyclic curcubiturils for reversal of drugs of abuse and neuromuscular blocking agents (patent numbers 9956229 and 9469648). He is a member of the associated editorial board for the British Journal of Anaesthesia. D.L.B. discloses the following relationships. Advisory Board: Angiowave, Bayer, Boehringer Ingelheim, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, High Enroll, Janssen, Level Ex, McKinsey, Medscape Cardiology, Merck, MyoKardia, NirvaMed, Novo Nordisk, PhaseBio, PLx Pharma and Stasys; Board of Directors: American Heart Association New York City, Angiowave (stock options), Bristol Myers Squibb (stock), DRS.LINQ (stock options) and High Enroll (stock); Consultant: Broadview Ventures, Hims, SFJ and Youngene; Data Monitoring Committee: Acesion Pharma, Assistance Publique-Hôpitaux de Paris, Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Boston Scientific (chair, PEITHO trial), Cleveland Clinic, Contego Medical (chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo; for the ABILITY-DM trial, funded by Concept Medical; for ALLAY-HF, funded by Alleviant Medical), Novartis, Population Health Research Institute and Rutgers University (for the NIH-funded MINT Trial); Honoraria: American College of Cardiology (ACC) (senior associate editor, Clinical Trials and News; chair, ACC Accreditation Oversight Committee), Arnold and Porter law firm (work related to Sanofi/Bristol Myers Squibb clopidogrel litigation), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee, funded by Boehringer Ingelheim; AEGIS-II executive committee, funded by CSL Behring), Belvoir Publications (editor in chief, Harvard Heart Letter), Canadian Medical and Surgical Knowledge Translation Research Group (clinical trial steering committees), CSL Behring (American Heart Association lecture), Cowen and Company, Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (editor in chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (guest editor and associate editor), K2P (co-chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Oakstone CME (course director, Comprehensive Review of Interventional Cardiology), Piper Sandler, Population Health Research Institute (for the COMPASS operations committee, publications committee and steering committee and USA national co-leader, funded by Bayer), WebMD (CME steering committees) and Wiley (steering committee); Other: Clinical Cardiology (deputy editor); Patent: sotagliflozin (named on a patent for sotagliflozin assigned to Brigham and Women's Hospital, assigned to Lexicon; neither D.L.B. nor Brigham and Women's Hospital receive any income from this patent); Research Funding: Abbott, Acesion Pharma, Afimmune, Aker Biomarine, Alnylam, Amarin, Amgen, AstraZeneca, Bayer, Beren, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Cardax, CellProthera, Cereno Scientific, Chiesi, CinCor, Cleerly, CSL Behring, Eisai, Ethicon, Faraday Pharmaceuticals, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Garmin, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Javelin, Lexicon, Eli Lilly, Medtronic, Merck, Moderna, MyoKardia, NirvaMed, Novartis, Novo Nordisk, Otsuka, Owkin, Pfizer, PhaseBio, PLx Pharma, Recardio, Regeneron, Reid Hoffman Foundation, Roche, Sanofi, Stasys, Synaptic, The Medicines Company, Youngene and 89Bio; Royalties: Elsevier (editor, Braunwald’s Heart Disease); Site Co-Investigator: Abbott, Biotronik, Boston Scientific, CSI, Endotronix, St. Jude Medical (now Abbott), Philips, SpectraWAVE, Svelte and Vascular Solutions; Trustee: ACC; Unfunded Research: FlowCo. M.S.S. received funding for investigator-initiated studies from Merck & Co., which does not pertain to this manuscript. He is an associate editor for BMC Anesthesiology. He received honoraria for lectures from Fisher & Paykel Healthcare and Mindray Medical International Limited. He received an unrestricted philanthropic grant from Jeff and Judy Buzen. All other authors have no support from any organization for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work and no other relationships or activities that could appear to have influenced the submitted work., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.) more...
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- 2024
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12. Startle sign events induced by mechanical manipulation during surgery for neuroma localization: a retrospective cohort study.
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Gorky JM, Karinja SJ, Ranjeva SL, Liu L, Smith MR, Mueller AL, Houle TT, Eberlin KR, and Ruscic KJ
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- Humans, Retrospective Studies, Female, Male, Middle Aged, Cohort Studies, Adult, Reflex, Startle physiology, Aged, Neuroma surgery
- Abstract
Background: Chronic pain from peripheral neuromas is difficult to manage and often requires surgical excision, though intraoperative identification of neuromas can be challenging due to anatomical ambiguity. Mechanical manipulation of the neuroma during surgery can elicit a characteristic "startle sign", which can help guide surgical management. However, it is unknown how anesthetic management affects detection of the startle sign., Methods: We performed a retrospective cohort study of 73 neuroma excision surgeries performed recently at Massachusetts General Hospital. Physiological changes in the anesthetic record were analyzed to identify associations with a startle sign event. Anesthesia type and doses of pharmacological agents were analyzed between startle sign and no-startle sign groups., Results: Of the 64 neuroma resection surgeries included, 13 had a startle sign. Combined intravenous and inhalation anesthesia (CIVIA) was more frequently used in the startle sign group vs. no-startle sign group (54% vs. 8%), while regional blockade with monitored anesthetic care was not associated with the startle sign group (12% vs. 0%), p = 0.001 for anesthesia type. Other factors, such as neuromuscular blocking agents, ketamine infusion, remifentanil infusion, and intravenous morphine equivalents showed no differences between groups., Conclusions: Here, we identified hypothesis-generating descriptive differences in anesthetic management associated with the detection of the neuroma startle sign during neuroma excision surgery, suggesting ways to deliver anesthesia facilitating detection of this phenomenon. Prospective trials are needed to further validate the hypotheses generated., (© 2024. The Author(s).) more...
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- 2024
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13. Cardiac index as a surrogate marker for anxiety in pediatric patients undergoing ambulatory endoscopy: a prospective cohort study.
- Author
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Mai CL, Burns S, August DA, Bhattacharya ST, Mueller A, Houle TT, Anderson TA, and Peck J
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- Humans, Female, Prospective Studies, Male, Child, Adolescent, Child, Preschool, Biomarkers, Anxiety diagnosis, Endoscopy, Heart Rate
- Abstract
Objective. Pediatric patients undergoing medical procedures often grapple with preoperative anxiety, which can impact postoperative outcomes. While healthcare providers subjectively assess anxiety, objective quantification tools remain limited. This study aimed to evaluate two objective measures-cardiac index (CI) and heart rate (HR) in comparison with validated subjective assessments, the modified Yale Preoperative Anxiety Scale (mYPAS) and the numeric rating scale (NRS). Approach. In this prospective, observational cohort study, children ages 5-17 undergoing ambulatory endoscopy under general anesthesia underwent simultaneous measurement of objective and subjective measures at various time points: baseline, intravenous placement, two-minutes post-IV placement, when departing the preoperative bay, and one-minute prior to anesthesia induction. Main Results. Of the 86 enrolled patients, 77 had analyzable CI data and were included in the analysis. The median age was 15 years (interquartile range 13, 16), 55% were female, and most were American Society of Anesthesiologists (ASA) Physical Status 2 (64%), and had previous endoscopies (53%). HR and CI correlated overall ( r = 0.65, 95% CI: 0.62, 0.69; p < 0.001), as did NRS and mYPAS ( r = 0.39, 95% CI: 0.34, 0.44; p < 0.001). The correlation between HR and CI was stronger with NRS ( r = 0.24, 95% CI: 0.19, 0.29; p < 0.001; and r = 0.13, 95% CI: 0.07, 0.19; p < 0.001, respectively) than with mYPAS ( r = 0.06, 95% CI: 0.00, 0.11; p = 0.046; and r = 0.08, 95% CI: 0.02, 0.14; p = 0.006, respectively). The correlation with mYPAS for both HR and CI varied significantly in both direction and magnitude across the different time points. Significance. A modest yet discernable correlation exists between objective measures (HR and CI) and established subjective anxiety assessments., (© 2024 Institute of Physics and Engineering in Medicine. All rights, including for text and data mining, AI training, and similar technologies, are reserved.) more...
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- 2024
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14. Headache activity associated with the 2024 North American eclipse.
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Houle TT, Albanese ML, Gleeson E, Caplis E, and Turner DP
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- Humans, North America, Sunlight, Headache etiology
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- 2024
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15. Hispanic/Latino Ethnicity and Loss of Post-Surgery Independent Living: A Retrospective Cohort Study from a Bronx Hospital Network.
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Witt AS, Rudolph MI, Sterling FD, Azimaraghi O, Wachtendorf LJ, Montilla Medrano E, Joseph V, Akeju O, Wongtangman K, Straker T, Karaye IM, Houle TT, Eikermann M, and Aguirre-Alarcon A
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- Humans, Male, Female, Retrospective Studies, Middle Aged, Aged, New York City, Independent Living, Adult, Risk Factors, Aged, 80 and over, Nursing Homes, Skilled Nursing Facilities, Socioeconomic Factors, Hispanic or Latino, Patient Discharge, Postoperative Complications ethnology
- Abstract
Background: Black race is associated with postoperative adverse discharge to a nursing facility, but the effects of Hispanic/Latino ethnicity are unclear. We explored the Hispanic paradox , described as improved health outcomes among Hispanic/Latino patients on postoperative adverse discharge to nursing facility., Methods: A total of 93,356 adults who underwent surgery and were admitted from home to Montefiore Medical Center in the Bronx, New York, between January 2016 and June 2021 were included. The association between self-identified Hispanic/Latino ethnicity and the primary outcome, postoperative adverse discharge to a nursing home or skilled nursing facility, was investigated. Interaction analysis was used to examine the impact of socioeconomic status, determined by estimated median household income and insurance status, on the primary association. Mixed-effects models were used to evaluate the proportion of variance attributed to the patient's residential area defined by zip code and self-identified ethnicity., Results: Approximately 45.9% (42,832) of patients identified as Hispanic/Latino ethnicity and 9.7% (9074) patients experienced postoperative adverse discharge. Hispanic/Latino ethnicity was associated with lower risk of adverse discharge (relative risk [RR adj ] 0.88; 95% confidence interval [CI], 00.82-0.94; P < .001), indicating a Hispanic Paradox . This effect was modified by the patient's socioeconomic status ( P -for-interaction <.001). Among patients with a high socioeconomic status, the Hispanic paradox was abolished (RR adj 1.10; 95% CI, 11.00-1.20; P = .035). Furthermore, within patients of low socioeconomic status, Hispanic/Latino ethnicity was associated with a higher likelihood of postoperative discharge home with health services compared to non-Hispanic/Latino patients (RR adj 1.06; 95% CI, 11.01-1.12; P = .017)., Conclusions: Hispanic/Latino ethnicity is a protective factor for postoperative adverse discharge, but this association is modified by socioeconomic status. Future studies should focus on postoperative discharge disposition and socioeconomic barriers in patients with Hispanic/Latino ethnicity., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2024 International Anesthesia Research Society.) more...
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- 2024
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16. Development and validation of a score for prediction of postoperative respiratory complications in infants and children (SPORC-C).
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Luedeke CM, Rudolph MI, Pulverenti TS, Azimaraghi O, Grimm AM, Jackson WM, Jaconia GD, Stucke AG, Nafiu OO, Karaye IM, Nichols JH, Chao JY, Houle TT, and Eikermann M
- Abstract
Background: In infants and children, postoperative respiratory complications are leading causes of perioperative morbidity, mortality, and increased healthcare utilisation. We aimed to develop a novel score for prediction of postoperative respiratory complications in paediatric patients (SPORC for children)., Methods: We analysed data from paediatric patients (≤12 yr) undergoing surgery in New York and Boston, USA for score development and external validation. The primary outcome was postoperative respiratory complications within 30 days after surgery, defined as respiratory infection, respiratory failure, aspiration pneumonitis, pneumothorax, pleural effusion, bronchospasm, laryngospasm, and reintubation. Data from Children's Hospital at Montefiore were used to create the score by stepwise backwards elimination using multivariate logistic regression. External validation was conducted using a separate cohort of children who underwent surgery at Massachusetts General Hospital for Children., Results: The study included data from children undergoing 32,187 surgical procedures, where 768 (2.4%) children experienced postoperative respiratory complications. The final score consisted of 11 predictors, and showed discriminatory ability in development, internal, and external validation cohorts with areas under the receiver operating characteristic curve of 0.85 (95% confidence interval: 0.83-0.87), 0.84 (0.80-0.87), and 0.83 (0.80-0.86), respectively., Conclusion: SPORC is a novel validated score for predicting the likelihood of postoperative respiratory complications in children that can be used to predict postoperative respiratory complications in infants and children., (Copyright © 2024 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.) more...
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- 2024
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17. A Multiresolution Approach with Method-Informed Statistical Analysis for Quantifying Lymphatic Pumping Dynamics.
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Razavi MS, Ruscic KJ, Korn EG, Marquez M, Houle TT, Singhal D, Munn LL, and Padera TP
- Abstract
Despite significant strides in lymphatic system imaging, the timely diagnosis of lymphatic disorders remains elusive. One main cause for this is the absence of standardized, quantitative methods for real-time analysis of lymphatic contractility. Here, we address this unmet need by combining near-infrared lymphangiography imaging with an innovative analytical workflow. We combined data acquisition, signal processing, and statistical analysis to integrate traditional peak and-valley with advanced wavelet time-frequency analyses. Decision theory was used to evaluate the primary drivers of attributable variance in lymphangiography measurements to generate a strategy for optimizing the number of repeat measurements needed per subject to increase measurement reliability. This approach not only offers detailed insights into lymphatic pumping behaviors across species, sex and age, but also significantly boosts the reliability of these measurements by incorporating multiple regions of interest and evaluating the lymphatic system under various gravitational loads. By addressing the critical need for improved imaging and quantification methods, our study offers a new standard approach for the imaging and analysis of lymphatic function that can improve our understanding, diagnosis, and treatment of lymphatic diseases. The results highlight the importance of comprehensive data acquisition strategies to fully capture the dynamic behavior of the lymphatic system. more...
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- 2024
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18. Pain medication beliefs in individuals with headache.
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Turner DP, Bertsch J, Caplis E, and Houle TT
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- Humans, Female, Male, Adult, Middle Aged, Cross-Sectional Studies, Medication Adherence, Headache, Surveys and Questionnaires, Health Knowledge, Attitudes, Practice, Young Adult, Aged, Analgesics
- Abstract
Objective: To evaluate pain medication beliefs in a community sample of individuals with headache., Background: Previous studies of medication adherence for individuals with headache have identified a high rate of prescription nonfulfillment, frequent medication discontinuation, and widely varying levels of medication-related satisfaction. Still, there is a limited understanding of how these individuals view their medications and their relationships with health-care providers. Insight into these perceptions could prove useful in explaining medication adherence behaviors., Methods: In this secondary analysis of a cross-sectional study, data from N = 215 adults with headache were analyzed. Participants completed the Pain Medication Attitudes Questionnaire (PMAQ), Center for Epidemiologic Studies Depression Scale (CES-D), State-Trait Anxiety Inventory Form Y-2, Weekly Stress Inventory Short Form, and Migraine Disability Scale. These participants also provided a list of their current pain medications., Results: Using the PMAQ, participants could be characterized as having medication beliefs that were "trusting and unconcerned" (n = 83/215 [38.6%]), "skeptical and somewhat worried" (n = 99/215 [46.0%]), or "skeptical and concerned" (n = 33/215 [15.3%]). Individuals with skeptical and concerned beliefs expressed elevated concerns (z > 1.15) about side effects, scrutiny, perceived need, tolerance, withdrawal, and addiction. Individuals who were trusting and unconcerned expressed low levels (z < -0.40) of these beliefs. Increasing levels of mistrust and medication concerns were correlated with higher depression scores on the CES-D, with values ranging from r = 0.23 to r = 0.38., Conclusions: Subgroups of pain medication beliefs were identified, including two groups of patients with at least some concerns about their medical providers. Beliefs ranged from a lack of concern about using pain medications to worries about scrutiny and harm. It is unclear if poor experiences with pain medications cause these beliefs or if they prevent individuals from effectively utilizing medications. Additionally, more negative beliefs about pain medications were associated with more depressive symptoms., (© 2024 American Headache Society.) more...
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- 2024
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19. High-Dose Inhaled Nitric Oxide in Acute Hypoxemic Respiratory Failure Due to COVID-19: A Multicenter Phase II Trial.
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Di Fenza R, Shetty NS, Gianni S, Parcha V, Giammatteo V, Safaee Fakhr B, Tornberg D, Wall O, Harbut P, Lai PS, Li JZ, Paganoni S, Cenci S, Mueller AL, Houle TT, Akeju O, Bittner EA, Bose S, Scott LK, Carroll RW, Ichinose F, Hedenstierna M, Arora P, and Berra L more...
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- Adult, Humans, Nitric Oxide therapeutic use, Single-Blind Method, Respiration, Artificial, Administration, Inhalation, COVID-19 complications, Respiratory Insufficiency drug therapy, Respiratory Insufficiency etiology
- Abstract
Rationale: The effects of high-dose inhaled nitric oxide on hypoxemia in coronavirus disease (COVID-19) acute respiratory failure are unknown. Objectives: The primary outcome was the change in arterial oxygenation (Pa
O /Fi2 O ) at 48 hours. The secondary outcomes included: time to reach a Pa2 O /Fi2 O .300mmHg for at least 24 hours, the proportion of participants with a Pa2 O /Fi2 O .300mmHg at 28 days, and survival at 28 and at 90 days. Methods: Mechanically ventilated adults with COVID-19 pneumonia were enrolled in a phase II, multicenter, single-blind, randomized controlled parallel-arm trial. Participants in the intervention arm received inhaled nitric oxide at 80 ppm for 48 hours, compared with the control group receiving usual care (without placebo). Measurements and Main Results: A total of 193 participants were included in the modified intention-to-treat analysis. The mean change in Pa2 O /Fi2 O ratio at 48 hours was 28.3mmHg in the intervention group and 21.4mmHg in the control group (mean difference, 39.1mmHg; 95% credible interval [CrI], 18.1 to 60.3). The mean time to reach a Pa2 O /Fi2 O .300mmHg in the interventional group was 8.7 days, compared with 8.4 days for the control group (mean difference, 0.44; 95% CrI, 23.63 to 4.53). At 28 days, the proportion of participants attaining a Pa2 O /Fi2 O .300mmHg was 27.7% in the inhaled nitric oxide group and 17.2% in the control subjects (risk ratio, 2.03; 95% CrI, 1.11 to 3.86). Duration of ventilation and mortality at 28 and 90 days did not differ. No serious adverse events were reported. Conclusions: The use of high-dose inhaled nitric oxide resulted in an improvement of Pa2 O /Fi2 O at 48 hours compared with usual care in adults with acute hypoxemic respiratory failure due to COVID-19. more...2 - Published
- 2023
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20. Age-Dependent Electroencephalogram Features in Infants Under Spinal Anesthesia Appear to Mirror Physiologic Sleep in the Developing Brain: A Prospective Observational Study.
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Santa Cruz Mercado LA, Lee JM, Liu R, Deng H, Johnson JJ, Chen AL, He M, Chung ER, Bharadwaj KM, Houle TT, Purdon PL, and Liu CA
- Subjects
- Humans, Infant, Sleep physiology, Electroencephalography, Brain physiology, Gestational Age, Anesthesia, Spinal
- Abstract
Background: Infants under spinal anesthesia appear to be sedated despite the absence of systemic sedative medications. In this prospective observational study, we investigated the electroencephalogram (EEG) of infants under spinal anesthesia and hypothesized that we would observe EEG features similar to those seen during sleep., Methods: We computed the EEG power spectra and spectrograms of 34 infants undergoing infraumbilical surgeries under spinal anesthesia (median age 11.5 weeks postmenstrual age, range 38-65 weeks postmenstrual age). Spectrograms were visually scored for episodes of EEG discontinuity or spindle activity. We characterized the relationship between EEG discontinuity or spindles and gestational age, postmenstrual age, or chronological age using logistic regression analyses., Results: The predominant EEG patterns observed in infants under spinal anesthesia were slow oscillations, spindles, and EEG discontinuities. The presence of spindles, observed starting at about 49 weeks postmenstrual age, was best described by postmenstrual age ( P =.002) and was more likely with increasing postmenstrual age. The presence of EEG discontinuities, best described by gestational age ( P = .015), was more likely with decreasing gestational age. These age-related changes in the presence of spindles and EEG discontinuities in infants under spinal anesthesia generally corresponded to developmental changes in the sleep EEG., Conclusions: This work illustrates 2 separate key age-dependent transitions in EEG dynamics during infant spinal anesthesia that may reflect the maturation of underlying brain circuits: (1) diminishing discontinuities with increasing gestational age and (2) the appearance of spindles with increasing postmenstrual age. The similarity of these age-dependent transitions under spinal anesthesia with transitions in the developing brain during physiological sleep supports a sleep-related mechanism for the apparent sedation observed during infant spinal anesthesia., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2023 International Anesthesia Research Society.) more...
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- 2023
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21. Trends in gender, race, and ethnic diversity among prospective physical medicine and rehabilitation physicians.
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Dixon G, McGeary D, Silver JK, Washington M, Houle TT, Stampas A, Schappell J, Smith S, and Verduzco-Gutierrez M
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- Humans, Female, United States, Ethnicity, Minority Groups, Prospective Studies, Internship and Residency, Physicians, Physical and Rehabilitation Medicine
- Abstract
Background: As the proportion of women and individuals who are underrepresented in medicine slowly rises, disparities persist in numerous arenas and specialties. In physical medicine and rehabilitation (PM&R), there is a continued need to focus on diversity among trainees. This study aims to evaluate diversity among PM&R applicants and residents over the past 6 years., Objective: To describe the demographic trends in PM&R over the last 6 years and compare those findings with trends in other specialties., Design: Surveillance., Setting: Analyses of national databases from self-reported questionnaires., Participants: The study consists of 126,833 medical school matriculants, 374,185 resident applicants, and 326,134 resident trainees over the last 6 years., Main Outcome Measures: Self-reported demographic data from the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education were analyzed for medical school matriculants, PM&R applicants, and current residents for the cycles of 2014-2015 to 2019-2020. The data were then comparatively reviewed between PM&R and other medical specialties., Results: In the 6 cycles evaluated, women accounted for 36%-39% of PM&R residents, but 47%-48% in non-PM&R specialties. Women applicants to the PM&R specialty averaged 34.4% over the 6 years analyzed, which was the fourth lowest of the 11 specialties examined. Black or African American and Hispanic, Latino, or of Spanish Origin populations each accounted for only 6% of PM&R residents. PM&R demonstrated a noticeably higher proportion of White (62.1% vs. 60.3%) and an observably lower proportion of Black or African American (6.0% vs. 7.1%) and Hispanic, Latino, or of Spanish Origin (6.3% vs. 7.9%) residents compared with non-PM&R specialties., Conclusion: There is underrepresentation of women and multiple racial and ethnic minority groups in the field of PM&R from applicants to trainees demonstrating a need to improve recruitment efforts., (© 2023 American Academy of Physical Medicine and Rehabilitation.) more...
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- 2023
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22. The impact of residency training level on early postoperative desaturation: A retrospective multicenter cohort study.
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Beier J, Ahrens E, Rufino M, Patel J, Azimaraghi O, Kumar V, Houle TT, Schaefer MS, Eikermann M, and Wongtangman K
- Subjects
- Adult, Humans, Cohort Studies, Retrospective Studies, Anesthesia, General, Hospitals, University, Postoperative Complications epidemiology, Postoperative Complications etiology, Internship and Residency
- Abstract
Objective: We studied the primary hypothesis that the training level of anesthesiology residents (first clinical anesthesia year, CA1 vs CA2/3 residents) is associated with early postoperative desaturation (oxygen saturation < 90%). We also analyzed the change in the rate (trajectory) of desaturation during the resident's development from CA1 to CA2/3 resident, and its effects on postoperative respiratory complications., Design: Retrospective hospital registry study., Setting: Two university-affiliated hospitals networks (MA and NY, USA)., Patients: 140,818 adults undergoing non-cardiac surgery under general anesthesia and extubation in the operating room by residents (n = 378) between 2005 and 2021., Measurements: Multivariate logistic and quantile regression were used in the analyses. The secondary outcome was major respiratory complication within 7 days after surgery., Main Results: In 6.5% and 1.6% of cases, early postoperative desaturation to < 90% and 80% occurred. Compared to CA2/3 residents, CA1 residents had higher odds of experiencing early postoperative desaturation to < 90% and 80% (adjusted odds ratio [ORadj], 1.07; 95%CI 1.03-1.12; p = 0.002, and ORadj 1.10; 95%CI 1.01-1.20; p = 0.037, respectively). The change in postoperative desaturation rate during the transition from CA1 to CA2/3 status varied substantially from ORadj 0.80 (decreased risk) to 1.33 (increased risk). Major respiratory complication did not differ between experience levels (p = 0.52). However, a strong decline in improvement regarding the rate of postoperative desaturation during the transition from CA1 to CA2/3, was paralleled by an increased odds of major respiratory complication for CA2/3 residents (ORadj 1.20; 95%CI 1.02-1.42; p = 0.026, p-for-interaction = 0.056)., Conclusion: Patients treated by CA1 residents have an increased risk of postoperative desaturation. Some residents show an improvement and others a decline in postoperative desaturation rate. Our secondary analysis suggests that there should be more focus on those residents who had a declining performance in postoperative desaturation despite becoming more experienced., Competing Interests: Declaration of Competing Interest Matthias Eikermann and Maximilian S. Schaefer received a grant from Merck not related to this study. Maximilian S. Schaefer is an associate editor for BMC Anesthesiology. He received honoraria for presentations from Fisher & Paykel Healthcare and Mindray Medical International Limited, as well as funds from philanthropic donors Jeffrey and Judith Buzen. All other authors have no conflicts of interest to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.) more...
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- 2023
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23. Association Between Postoperative Delirium and Long-Term Subjective Cognitive Decline in Older Patients Undergoing Cardiac Surgery: A Secondary Analysis of the Minimizing Intensive Care Unit Neurological Dysfunction with Dexmedetomidine-Induced Sleep Trial.
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Namirembe GE, Baker S, Albanese M, Mueller A, Qu JZ, Mekonnen J, Wiredu K, Westover MB, Houle TT, and Akeju O
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- Humans, Aged, Intensive Care Units, Sleep, Postoperative Complications diagnosis, Postoperative Complications epidemiology, Postoperative Complications prevention & control, Emergence Delirium, Dexmedetomidine adverse effects, Delirium chemically induced, Delirium diagnosis, Delirium epidemiology, Cardiac Surgical Procedures adverse effects, Cognitive Dysfunction chemically induced, Cognitive Dysfunction diagnosis, Cognitive Dysfunction epidemiology
- Abstract
Objectives: This study aimed to evaluate whether a measure of subjective cognitive decline (SCD), the Patient-Reported Outcomes Measurement Information System (PROMIS) Applied Cognition-Abilities questionnaire, was associated with postoperative delirium. It was hypothesized that delirium during the surgical hospitalization would be associated with a decrease in subjective cognition up to 6 months after cardiac surgery., Design: This was a secondary analysis of data from the Minimizing Intensive Care Unit Neurological Dysfunction with Dexmedetomidine-induced Sleep randomized, placebo-controlled, parallel-arm superiority trial., Setting: Data from patients recruited between March 2017 and February 2022 at a tertiary medical center in Boston, Massachusetts were analyzed in February 2023., Participants: Data from 337 patients aged 60 years or older who underwent cardiac surgery with cardiopulmonary bypass were included., Interventions: Patients were assessed preoperatively and postoperatively at 30, 90, and 180 days using the subjective PROMIS Applied Cognition-Abilities and telephonic Montreal Cognitive Assessment., Measurement and Main Results: Postoperative delirium occurred within 3 days in 39 participants (11.6%). After adjusting for baseline function, participants who developed postoperative delirium self-reported worse cognitive function (mean difference [MD] -2.64 [95% CI -5.25, -0.04]; p = 0.047) up to 180 days after surgery, as compared with nondelirious patients. This finding was consistent with those obtained from objective t-MoCA assessments (MD -0.77 [95% CI -1.49, -0.04]; p = 0.04)., Conclusions: In this cohort of older patients undergoing cardiac surgery, in-hospital delirium was associated with SCD up to 180 days after surgery. This finding suggested that measures of SCD may enable population-level insights into the burden of cognitive decline associated with postoperative delirium., Competing Interests: Declaration of Competing Interest A.M. reports receiving funding from Roche Diagnostics and the University of Chicago for statistical consulting projects related to biomarkers in preeclampsia. T.T.H. reports receiving personal fees from Anesthesiology and Headache. O.A. is listed as an inventor on brain monitoring patents assigned to Massachusetts General Hospital. No other disclosures were reported., (Copyright © 2023 Elsevier Inc. All rights reserved.) more...
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- 2023
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24. Preliminary results from a randomized, controlled, cross-over trial of intrathecal oxytocin for neuropathic pain.
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Eisenach JC, Curry RS, and Houle TT
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- Humans, Cross-Over Studies, Hyperalgesia drug therapy, Pain Measurement, Double-Blind Method, Oxytocin therapeutic use, Neuralgia drug therapy
- Abstract
Objective: Compare intrathecal oxytocin, 100 µg to placebo on ongoing neuropathic pain and mechanical hyperalgesia and allodynia., Study Design: Randomized, controlled, double-blind cross-over., Setting: Clinical research unit., Subjects: Individuals aged 18 to 70 years with neuropathic pain for at least 6 months., Methods: Individuals received intrathecal injections of oxytocin and saline, separated by at least 7 days, and ongoing pain in neuropathic area (VAS [visual analog scale]) and areas of hypersensitivity to von Frey filament and cotton wisp brushing were measured for 4 hours. Primary outcome was VAS pain in the first 4 hours after injection, analyzed by linear mixed effects model. Secondary outcomes were verbal pain intensity scores at daily intervals for 7 days and areas of hypersensitivity and elicited pain for 4 hours after injections., Results: The study was stopped early after completion of 5 of 40 subjects planned due to slow recruitment and funding limitations. Pain intensity prior to injection was 4.75 ± 0.99 and modeled pain intensity decreased more after oxytocin than placebo to 1.61 ± 0.87 and 2.49 ± 0.87, respectively (P = .003). Daily pain scores were lower in the week following injection of oxytocin than saline (2.53 ± 0.89 vs 3.66 ± 0.89; P = .001). Allodynic area decreased by 11%, but hyperalgesic area increased by 18% after oxytocin compared to placebo. There were no study drug related adverse effects., Conclusion: Although limited by the small number of subjects studied, oxytocin reduced pain more than placebo in all subjects. Further study of spinal oxytocin in this population is warranted., Trial Registration: This study was registered at ClinicalTrials.gov on 03/27/2014 (NCT02100956). The first subject was studied on 06/25/2014., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.) more...
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- 2023
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25. Association of Intraoperative Opioid Administration With Postoperative Pain and Opioid Use.
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Santa Cruz Mercado LA, Liu R, Bharadwaj KM, Johnson JJ, Gutierrez R, Das P, Balanza G, Deng H, Pandit A, Stone TAD, Macdonald T, Horgan C, Tou SLJ, Houle TT, Bittner EA, and Purdon PL
- Subjects
- Adult, Humans, Female, Middle Aged, Male, Hydromorphone therapeutic use, Retrospective Studies, Pain, Postoperative drug therapy, Fentanyl therapeutic use, Analgesics, Opioid, Opioid-Related Disorders
- Abstract
Importance: Opioids administered to treat postsurgical pain are a major contributor to the opioid crisis, leading to chronic use in a considerable proportion of patients. Initiatives promoting opioid-free or opioid-sparing modalities of perioperative pain management have led to reduced opioid administration in the operating room, but this reduction could have unforeseen detrimental effects in terms of postoperative pain outcomes, as the relationship between intraoperative opioid usage and later opioid requirements is not well understood., Objective: To characterize the association between intraoperative opioid usage and postoperative pain and opioid requirements., Design, Setting, and Participants: This retrospective cohort study evaluated electronic health record data from a quaternary care academic medical center (Massachusetts General Hospital) for adult patients who underwent noncardiac surgery with general anesthesia from April 2016 to March 2020. Patients who underwent cesarean surgery, received regional anesthesia, received opioids other than fentanyl or hydromorphone, were admitted to the intensive care unit, or who died intraoperatively were excluded. Statistical models were fitted on the propensity weighted data set to characterize the effect of intraoperative opioid exposures on primary and secondary outcomes. Data were analyzed from December 2021 to October 2022., Exposures: Intraoperative fentanyl and intraoperative hydromorphone average effect site concentration estimated using pharmacokinetic/pharmacodynamic models., Main Outcomes and Measures: The primary study outcomes were the maximal pain score during the postanesthesia care unit (PACU) stay and the cumulative opioid dose, quantified in morphine milligram equivalents (MME), administered during the PACU stay. Medium- and long-term outcomes associated with pain and opioid dependence were also evaluated., Results: The study cohort included a total of 61 249 individuals undergoing surgery (mean [SD] age, 55.44 [17.08] years; 32 778 [53.5%] female). Increased intraoperative fentanyl and intraoperative hydromorphone were both associated with reduced maximum pain scores in the PACU. Both exposures were also associated with a reduced probability and reduced total dosage of opioid administration in the PACU. In particular, increased fentanyl administration was associated with lower frequency of uncontrolled pain; a decrease in new chronic pain diagnoses reported at 3 months; fewer opioid prescriptions at 30, 90, and 180 days; and decreased new persistent opioid use, without significant increases in adverse effects., Conclusions and Relevance: Contrary to prevailing trends, reduced opioid administration during surgery may have the unintended outcome of increasing postoperative pain and opioid consumption. Conversely, improvements in long-term outcomes might be achieved by optimizing opioid administration during surgery. more...
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- 2023
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26. Association Between Intraoperative Dexamethasone and Postoperative Mortality in Patients Undergoing Oncologic Surgery: A Multicentric Cohort Study.
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Blank M, Katsiampoura A, Wachtendorf LJ, Linhardt FC, Tartler TM, Raub D, Azimaraghi O, Chen G, Houle TT, Ferrone C, Eikermann M, and Schaefer MS
- Subjects
- Adult, Humans, Dexamethasone therapeutic use, Dexamethasone adverse effects, Postoperative Nausea and Vomiting, Surgical Wound Infection epidemiology, Surgical Wound Infection prevention & control, Cohort Studies, Antiemetics adverse effects, Hyperglycemia chemically induced, Hyperglycemia drug therapy
- Abstract
Objective: We examined the effects of dexamethasone on postoperative mortality, recurrence-free survival, and side effects in patients undergoing oncologic operations., Background: Dexamethasone prevents nausea and vomiting after anesthesia and may affect cancer proliferation., Methods: A total of 30,561 adult patients undergoing solid cancer resection between 2005 and 2020 were included. Multivariable logistic regression was applied to investigate the effect of dexamethasone on 1-year mortality and recurrence-free survival. Effect modification by the cancer's potential for immunogenicity, defined as a recommendation for checkpoint inhibitor therapy based on the National Comprehensive Cancer Network guidelines, was investigated through interaction term analysis. Key safety endpoints were dexamethasone-associated risk of hyperglycemia >180 mg/dL within 24 hours and surgical site infections within 30 days after surgery., Results: Dexamethasone was administered to 38.2% (11,666/30,561) of patients (6.5±2.3 mg). Overall, 3.2% (n=980/30,561) died and 15.4% (n=4718/30,561) experienced cancer recurrence within 1 year of the operation. Dexamethasone was associated with a -0.6% (95% confidence interval: -1.1, -0.2, P =0.007) 1-year mortality risk reduction [adjusted odds ratio (OR adj ): 0.79 (0.67, 0.94), P =0.009; hazard ratio=0.82 (0.69, 0.96), P =0.016] and higher odds of recurrence-free survival [OR adj : 1.28 (1.18, 1.39), P <0.001]. This effect was only present in patients with solid cancers who were defined as not to respond to checkpoint inhibitor therapy [OR adj : 0.70 (0.57, 0.87), P =0.001 vs OR adj : 1.13 (0.85, 1.50), P =0.40]. A high (>0.09 mg/kg) dose of dexamethasone increased the risk of postoperative hyperglycemia [OR adj : 1.55 (1.32, 1.82), P <0.001], but not for surgical site infections [OR adj : 0.84 (0.42, 1.71), P =0.63]., Conclusions: Dexamethasone is associated with decreased 1-year mortality and cancer recurrence in patients undergoing surgical resection of cancers that are not candidates for immune modulators. Dexamethasone increased the risk of postoperative hyperglycemia, however, no increase in surgical site infections was identified., Competing Interests: M.E. has received grants for investigator-initiated trials not related to this manuscript from Merck & Co. and serves as a consultant on the advisory board of Merck & Co. He is an Associate Editor of the British Journal of Anaesthesia . M.S. has received grants for investigator-initiated studies not related to this manuscript from Merck & Co. and is an Associate Editor of BMC Anesthesiology . T.T.H. reports grants from the National Institute of Neurological Disorders and Stroke (PI), grants from the National Institute of General Medical Sciences, personal fees from Headache, personal fees from Anesthesiology, and personal fees from Cephalalgia outside the submitted work; no other relationships or activities that could appear to have influenced the submitted work. The remaining authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.) more...
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- 2023
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27. Information theory and headache triggers.
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Turner DP, Caplis E, Bertsch J, and Houle TT
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- Humans, Cross-Sectional Studies, Surveys and Questionnaires, Precipitating Factors, Information Theory, Headache etiology, Headache diagnosis
- Abstract
Objectives: This secondary analysis evaluated the information content exhibited by various measurement strategies of commonly perceived causes, or "triggers," of headache attacks., Background: When evaluating triggers of primary headache attacks, the variation observed in trigger candidates must be measured to compare against the covariation in headache activity. Given the numerous strategies that could be used to measure and record headache trigger variables, it is useful to consider the information contained in these measurements., Methods: Using previously collected data from cohort and cross-sectional studies, online data sources, and simulations, the Shannon information entropy exhibited by many common triggers was evaluated by analyzing available time-series or theoretical distributions of headache triggers. The degree of information, reported in bits, was compared across trigger variables, measurement strategies, and settings., Results: A wide range of information content was observed across headache triggers. Due to lack of variation, there was little information, near 0.00 bits, in triggers like red wine and air conditioning. Most headache triggers exhibited more information when measured using an ordinal scale of presence/degree (e.g., absent, mild, moderate, severe) versus a present/absent binary coding. For example, the trigger "joy" exhibited 0.03 bits when assessed using binary coding but 1.81 bits when coded using an ordinal scale. More information was observed with the use of count data (0.86 to 1.75 bits), Likert rating scales (1.50 to 2.76 bits), validated questionnaires (3.57 to 6.04 bits), weather variables (0.10 to 8.00 bits), and ambulatory monitoring devices (9.19 to 12.61 bits)., Conclusions: Although commonly used, all binary-coded measurements contain ≤1.00 bit of information. Low levels of information in trigger variables make associations with headache activity more difficult to detect. Assessments that balance information-rich measurements with reasonable participant burden using efficient formats (e.g., Likert scales) are recommended to enhance the evaluation of the association with headache activity., (© 2023 American Headache Society.) more...
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- 2023
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28. Sound and light levels in intensive care units in a large urban hospital in the United States.
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Leone MJ, Dashti HS, Coughlin B, Tesh RA, Quadri SA, Bucklin AA, Adra N, Krishnamurthy PV, Ye EM, Hemmige A, Rajan S, Panneerselvam E, Higgins J, Ayub MA, Ganglberger W, Paixao L, Houle TT, Thompson BT, Johnson-Akeju O, Saxena R, Kimchi E, Cash SS, Thomas RJ, and Westover MB more...
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- Adult, Aged, Female, Humans, Male, Middle Aged, Hospitals, Urban, Noise, Sleep, United States, Circadian Rhythm, Intensive Care Units
- Abstract
Intensive care units (ICUs) may disrupt sleep. Quantitative ICU studies of concurrent and continuous sound and light levels and timings remain sparse in part due to the lack of ICU equipment that monitors sound and light. Here, we describe sound and light levels across three adult ICUs in a large urban United States tertiary care hospital using a novel sensor. The novel sound and light sensor is composed of a Gravity Sound Level Meter for sound level measurements and an Adafruit TSL2561 digital luminosity sensor for light levels. Sound and light levels were continuously monitored in the room of 136 patients (mean age = 67.0 (8.7) years, 44.9% female) enrolled in the Investigation of Sleep in the Intensive Care Unit study (ICU-SLEEP; Clinicaltrials.gov: #NCT03355053), at the Massachusetts General Hospital. The hours of available sound and light data ranged from 24.0 to 72.2 hours. Average sound and light levels oscillated throughout the day and night. On average, the loudest hour was 17:00 and the quietest hour was 02:00. Average light levels were brightest at 09:00 and dimmest at 04:00. For all participants, average nightly sound levels exceeded the WHO guideline of < 35 decibels. Similarly, mean nightly light levels varied across participants (minimum: 1.00 lux, maximum: 577.05 lux). Sound and light events were more frequent between 08:00 and 20:00 than between 20:00 and 08:00 and were largely similar on weekdays and weekend days. Peaks in distinct alarm frequencies (Alarm 1) occurred at 01:00, 06:00, and at 20:00. Alarms at other frequencies (Alarm 2) were relatively consistent throughout the day and night, with a small peak at 20:00. In conclusion, we present a sound and light data collection method and results from a cohort of critically ill patients, demonstrating excess sound and light levels across multiple ICUs in a large tertiary care hospital in the United States. ClinicalTrials.gov, #NCT03355053. Registered 28 November 2017, https://clinicaltrials.gov/ct2/show/NCT03355053. more...
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- 2023
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29. Learning headache triggers through experience: A laboratory study.
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Turner DP and Houle TT
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- Adult, Humans, Cross-Sectional Studies, Precipitating Factors, Headache etiology, Research Design
- Abstract
Objective: To examine how individuals may learn headache trigger beliefs through sequential symbolic pairings of trigger candidates and headache attacks., Background: Learning from experience may be a major source of information about headache triggers. Little is known about learning-based influences on the establishment of trigger beliefs., Methods: This cross-sectional, observational study included N = 300 adults with headache who participated in a laboratory computer task. First, participants rated the chances (0%-100%) that encountering specific triggers would lead to experiencing a headache. Then, 30 sequential images with the presence or absence of a common headache trigger were presented alongside images representing the presence or absence of a headache attack. The primary outcome measure was the cumulative association strength rating (0 = no relationship to 10 = perfect relationship) between the trigger and headache using all previous trials., Results: A total of N = 296 individuals completed 30 trials for each of three triggers, yielding 26,640 total trials for analysis. The median [25th, 75th] association strength ratings for each of the randomly presented headache triggers were 2.2 [0, 3] for the Color Green, 2.7 [0, 5] for Nuts, and 3.9 [0, 8] for Weather Changes. There was a strong association between the "true" cumulative association strength and corresponding ratings. A 1-point increase on the phi scale (i.e., no relationship to perfect relationship) was associated with a 1.20 (95% CI: 0.81 to 1.49, p < 0.0001) point increase in association strength rating. A participant's prior belief about the potency of a trigger affected their perceived rating of the accumulating evidence, accounting for 17% of the total variation., Conclusion: In this laboratory task, individuals appeared to learn trigger-headache associations through repeated exposures to accumulating symbolic evidence. Prior beliefs about the triggers appeared to influence ratings of the strength of relationships between triggers and headache attacks., (© 2023 American Headache Society.) more...
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- 2023
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30. Race/Ethnicity and Duration of Anesthesia for Pediatric Patients in the US: a Retrospective Cohort Study.
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Rosenbloom JM, Deng H, Mueller AL, Alegria M, and Houle TT
- Subjects
- Child, Humans, Black or African American, Ethnicity, Hispanic or Latino, Retrospective Studies, White, Asian, American Indian or Alaska Native, Time Factors, Anesthesia statistics & numerical data
- Abstract
Background: Previous literature has demonstrated adverse patient outcomes associated with racial/ethnic disparities in health services. Because patients/parents and providers care about the duration of anesthesia, this study focuses on this outcome., Objectives: To determine the association between race/ethnicity and duration under anesthesia., Research Design: In this retrospective cohort study of data from the Multicenter Perioperative Outcomes Group, White non-Latino was the reference and was compared with Black non-Latino children, Latino, Asian, Native American, Other, and "Unknown" race children., Subjects: Children aged 3 to 17 years., Outcomes: Induction duration (primary outcome), procedure-end duration, and total duration under anesthesia (secondary outcomes)., Results: Of 37,596 eligible cases, 9,610 cases with complete data were analyzed. The sample consisted of 6,894 White non-Latino patients, 1,021 Black non-Latino patients, 50 Latino patients, 287 Asian patients, 26 Native American patients, 57 "Other" race patients, and 1,275 patients of "Unknown" race. The mean induction time was 11.9 min (SD 5.6 min). In adjusted analysis, Black non-Latino patients had 5% longer induction and procedure-end durations than White non-Latino children (exponentiated beta coefficient [Exp (β)] 1.05, 95% CI: 1.02-1.08, p < 0.01 and Exp (β) 1.08, 95% CI 1.04-1.13, p < 0.01 respectively)., Conclusions: White non-Latino children had shorter induction and procedure-end durations than Black children. The differences in induction and procedure-end time were small but may be meaningful on a population-health level., (© 2022. W. Montague Cobb-NMA Health Institute.) more...
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- 2023
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31. The association between gut microbiota and postoperative delirium in patients.
- Author
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Zhang Y, Baldyga K, Dong Y, Song W, Villanueva M, Deng H, Mueller A, Houle TT, Marcantonio ER, and Xie Z
- Subjects
- Humans, Female, Aged, Male, RNA, Ribosomal, 16S, Bacteroidetes, Emergence Delirium, Gastrointestinal Microbiome
- Abstract
Postoperative delirium is a common postoperative complication in older patients, and its pathogenesis and biomarkers remain largely undetermined. The gut microbiota has been shown to regulate brain function, and therefore, it is vital to explore the association between gut microbiota and postoperative delirium. Of 220 patients (65 years old or older) who had a knee replacement, hip replacement, or laminectomy under general or spinal anesthesia, 86 participants were included in the data analysis. The incidence (primary outcome) and severity of postoperative delirium were assessed for two days. Fecal swabs were collected from participants immediately after surgery. The 16S rRNA gene sequencing was used to assess gut microbiota. Principal component analyses along with a literature review were used to identify plausible gut microbiota, and three gut bacteria were further studied for their associations with postoperative delirium. Of the 86 participants [age 71.0 (69.0-76.0, 25-75% percentile of quartile), 53% female], 10 (12%) developed postoperative delirium. Postoperative gut bacteria Parabacteroides distasonis was associated with postoperative delirium after adjusting for age and sex (Odds Ratio [OR] 2.13, 95% Confidence Interval (CI): 1.09-4.17, P = 0.026). The association between delirium and both Prevotella (OR: 0.59, 95% CI: 0.33-1.04, P = 0.067) and Collinsella (OR: 0.57, 95% CI: 0.27-1.24, P = 0.158) did not meet statistical significance. These findings suggest that there may be an association between postoperative gut microbiota, specifically Parabacteroides distasonis, and postoperative delirium. However, further research is needed to confirm these findings and better understand the gut-brain axis's role in postoperative outcomes., (© 2023. The Author(s).) more...
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- 2023
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32. Common challenges in the development of prediction models.
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Houle TT, Smith MR, and Turner DP
- Subjects
- Humans, Weather, Headache, Migraine Disorders
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- 2023
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33. Randomized controlled trial of intrathecal oxytocin on speed of recovery after hip arthroplasty.
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Eisenach JC, Shields JS, Weller RS, Curry RS, Langfitt MK, Henshaw DS, Pollock DC, Edwards CJ, and Houle TT
- Subjects
- Female, Humans, Pain, Postoperative drug therapy, Pain, Postoperative etiology, Oxytocin therapeutic use, Treatment Outcome, Injections, Spinal, Double-Blind Method, Morphine therapeutic use, Analgesics, Opioid therapeutic use, Arthroplasty, Replacement, Hip adverse effects
- Abstract
Abstract: Recovery from surgery is quicker in the postpartum period, and this may reflect oxytocin action in the spinal cord. We hypothesized that intrathecal injection of oxytocin would speed recovery from pain and disability after major surgery. Ninety-eight individuals undergoing elective total hip arthroplasty were randomized to receive either intrathecal oxytocin (100 μg) or saline. Participants completed diaries assessing pain and opioid use daily and disability weekly, and they wore an accelerometer beginning 2 weeks before surgery until 8 weeks after. Groups were compared using modelled, adjusted trajectories of these measures. The study was stopped early due to the lack of funding. Ninety patients received intrathecal oxytocin (n = 44) or saline (n = 46) and were included in the analysis. There were no study drug-related adverse effects. Modelled pain trajectory, the primary analysis, did not differ between the groups, either in pain on day of hospital discharge (intercept: -0.1 [95% CI: -0.8 to 0.6], P = 0.746) or in reductions over time (slope: 0.1 pain units per log of time [95% CI: 0-0.2], P = 0.057). In planned secondary analyses, postoperative opioid use ended earlier in the oxytocin group and oxytocin-treated patients walked nearly 1000 more steps daily at 8 weeks ( P < 0.001) and exhibited a clinically meaningful reduction in disability for the first 21 postoperative days ( P = 0.007) compared with saline placebo. Intrathecal oxytocin before hip replacement surgery does not speed recovery from worst daily pain. Secondary analyses suggest that further study of intrathecal oxytocin to speed functional recovery without worsening pain after surgery is warranted., (Copyright © 2022 International Association for the Study of Pain.) more...
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- 2023
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34. The effects of sugammadex vs. neostigmine on postoperative respiratory complications and advanced healthcare utilisation: a multicentre retrospective cohort study.
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Suleiman A, Munoz-Acuna R, Azimaraghi O, Houle TT, Chen G, Rupp S, Witt AS, Azizi BA, Ahrens E, Shay D, Wongtangman K, Wachtendorf LJ, Tartler TM, Eikermann M, and Schaefer MS
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- Adult, Humans, Neostigmine adverse effects, Sugammadex adverse effects, Cholinesterase Inhibitors adverse effects, Retrospective Studies, Postoperative Complications epidemiology, Postoperative Complications prevention & control, Postoperative Complications chemically induced, Patient Acceptance of Health Care, Respiration Disorders chemically induced, Neuromuscular Blockade adverse effects
- Abstract
Reversing neuromuscular blockade with sugammadex can eliminate residual paralysis, which has been associated with postoperative respiratory complications. There are equivocal data on whether sugammadex reduces these when compared with neostigmine. We investigated the association of the choice of reversal drug with postoperative respiratory complications and advanced healthcare utilisation. We included adult patients who underwent surgery and received general anaesthesia with sugammadex or neostigmine reversal at two academic healthcare networks between January 2016 and June 2021. The primary outcome was postoperative respiratory complications, defined as post-extubation oxygen saturation < 90%, respiratory failure requiring non-invasive ventilation, or tracheal re-intubation within 7 days. Our main secondary outcome was advanced healthcare utilisation, a composite outcome including: 7-day unplanned intensive care unit admission; 30-day hospital readmission; or non-home discharge. In total, 5746 (6.9%) of 83,250 included patients experienced postoperative respiratory complications. This was not associated with the reversal drug (adjusted OR (95%CI) 1.01 (0.94-1.08); p = 0.76). After excluding patients admitted from skilled nursing facilities, 8372 (10.5%) patients required advanced healthcare utilisation, which was not associated with the choice of reversal (adjusted OR (95%CI) 0.95 (0.89-1.01); p = 0.11). Equivalence testing supported an equivalent effect size of sugammadex and neostigmine on both outcomes, and neostigmine was non-inferior to sugammadex with regard to postoperative respiratory complications or advanced healthcare utilisation. Finally, there was no association between the reversal drug and major adverse cardiovascular events (adjusted OR 1.07 (0.94-1.21); p = 0.32). Compared with neostigmine, reversal of neuromuscular blockade with sugammadex was not associated with a reduction in postoperative respiratory complications or post-procedural advanced healthcare utilisation., (© 2022 Association of Anaesthetists.) more...
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- 2023
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35. Association of sugammadex reversal of neuromuscular block and postoperative length of stay in the ambulatory care facility: a multicentre hospital registry study.
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Azimaraghi O, Ahrens E, Wongtangman K, Witt AS, Rupp S, Suleiman A, Tartler TM, Wachtendorf LJ, Fassbender P, Choice C, Houle TT, Eikermann M, and Schaefer MS
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- Humans, Aged, Sugammadex pharmacology, Postoperative Nausea and Vomiting epidemiology, Postoperative Nausea and Vomiting prevention & control, Postoperative Nausea and Vomiting chemically induced, Length of Stay, Anesthesia Recovery Period, Ambulatory Care, Registries, Hospitals, Cholinesterase Inhibitors pharmacology, Neostigmine adverse effects, Neuromuscular Blockade methods
- Abstract
Background: Encapsulation of rocuronium or vecuronium with sugammadex can reverse neuromuscular block faster than neostigmine reversal. This pharmacodynamic profile might facilitate patient discharge after ambulatory surgery., Methods: We included patients who underwent ambulatory surgery with general anaesthesia and neuromuscular block between 2016 and 2021 from hospital registries at two large academic healthcare networks in the USA. The primary outcome was postoperative length of stay in the ambulatory care facility (PLOS-ACF). We examined post hoc whether the type of reversal affects postoperative nausea and vomiting and direct hospital costs., Results: Among the 29 316 patients included, 8945 (30.5%) received sugammadex and 20 371 (69.5%) received neostigmine for reversal. PLOS-ACF and costs were lower in patients who received sugammadex vs neostigmine (adjusted difference in PLOS-ACF: -9.5 min; 95% confidence interval [95% CI], -10.5 to -8.5 min; adjusted difference in direct hospital costs: -US$77; 95% CI, -$88 to -$66; respectively; P<0.001). The association was magnified in patients over age 65 yr, with ASA physical status >2 undergoing short procedures (<2 h) (adjusted difference in PLOS-ACF: -18.2 min; 95% CI, -23.8 to -12.4 min; adjusted difference in direct hospital costs: -$176; 95% CI, -$220 to -$128; P<0.001). Sugammadex use was associated with reduced postoperative nausea and vomiting (17.2% vs 19.6%, P<0.001), which mediated its effects on length of stay., Conclusions: Reversal with sugammadex compared with neostigmine was associated with a small decrease in postoperative length of stay in the ambulatory care unit. The effect was magnified in older and high-risk patients, and can be explained by reduced postoperative nausea and vomiting. Sugammadex reversal in ambulatory surgery may also help reduce cost of care., (Copyright © 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.) more...
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- 2023
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36. Mechanisms of change in posttraumatic headache-related disability: A mediation model.
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Nabity PS, Reed DE, McGeary CA, Houle TT, Jaramillo CA, Resick PA, Eapen BC, Litz BT, Mintz J, Penzien DB, Keane TM, Young-McCaughan S, Peterson AL, and McGeary DD
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- Humans, Headache etiology, Headache therapy, Headache psychology, Psychotherapy, Cognitive Behavioral Therapy, Tension-Type Headache, Post-Traumatic Headache
- Abstract
Objective: To explore whether the association between change in headache management self-efficacy and posttraumatic headache-related disability is partially mediated by a change in anxiety symptom severity., Background: Many cognitive-behavioral therapy treatments for headache emphasize stress management, which includes anxiety management strategies; however, little is currently known about mechanisms of change in posttraumatic headache-related disability. Increasing our understanding of mechanisms could lead to improvements in treatments for these debilitating headaches., Methods: This study is a secondary analysis of veterans (N = 193) recruited to participate in a randomized clinical trial of cognitive-behavioral therapy, cognitive processing therapy, or treatment as usual for persistent posttraumatic headache. The direct relationship between headache management self-efficacy and headache-related disability, along with partial mediation through change in anxiety symptoms was tested., Results: The mediated latent change direct, mediated, and total pathways were statistically significant. The path analysis supported a significant direct pathway between headache management self-efficacy and headache-related disability (b = -0.45, p < 0.001; 95% confidence interval [CI: -0.58, -0.33]). The total effect of change of headache management self-efficacy scores on change in Headache Impact Test-6 scores was significant with a moderate-to-strong effect (b = -0.57, p = 0.001; 95% CI [-0.73, -0.41]). There was also an indirect effect through anxiety symptom severity change (b = -0.12, p = 0.003; 95% CI [-0.20, -0.04])., Conclusions: In this study, most of the improvements in headache-related disability were related to increased headache management self-efficacy with mediation occurring through change in anxiety. This indicates that headache management self-efficacy is a likely mechanism of change of posttraumatic headache-related disability with decreases in anxiety explaining part of the improvement in headache-related disability., (© 2023 American Headache Society.) more...
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- 2023
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37. Comparison of the effects of sugammadex versus neostigmine for reversal of neuromuscular block on hospital costs of care.
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Wachtendorf LJ, Tartler TM, Ahrens E, Witt AS, Azimaraghi O, Fassbender P, Suleiman A, Linhardt FC, Blank M, Nabel SY, Chao JY, Goriacko P, Mirhaji P, Houle TT, Schaefer MS, and Eikermann M
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- Adult, Humans, Neostigmine adverse effects, Sugammadex adverse effects, Hospital Costs, Rocuronium, Neuromuscular Blockade adverse effects, Neuromuscular Nondepolarizing Agents
- Abstract
Background: Sugammadex reversal of neuromuscular block facilitates recovery of neuromuscular function after surgery, but the drug is expensive. We evaluated the effects of sugammadex on hospital costs of care., Methods: We analysed 79 474 adult surgical patients who received neuromuscular blocking agents and reversal from two academic healthcare networks between 2016 and 2021 to calculate differences in direct costs. We matched our data with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) to calculate differences in total costs in US dollars. Perioperative risk profiles were defined based on ASA physical status and admission status (ambulatory surgery vs hospitalisation)., Results: Based on our registry data analysis, administration of sugammadex vs neostigmine was associated with lower direct costs (-1.3% lower costs; 95% confidence interval [CI], -0.5 to -2.2%; P=0.002). In the HCUP-NIS matched cohort, sugammadex use was associated with US$232 lower total costs (95% CI, -US$376 to -US$88; P=0.002). Subgroup analysis revealed that sugammadex was associated with US$1042 lower total costs (95% CI, -US$1198 to -US$884; P<0.001) in patients with lower risk. In contrast, sugammadex was associated with US$620 higher total costs (95% CI, US$377 to US$865; P<0.001) in patients with a higher risk (American Society of Anesthesiologists physical status ≥3 and preoperative hospitalisation)., Conclusions: The effects of using sugammadex on costs of care depend on patient risk, defined based on comorbidities and admission status. We observed lower costs of care in patients with lower risk and higher costs of care in hospitalised surgical patients with severe comorbidities., (Copyright © 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.) more...
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- 2023
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38. Preoperative Heart Failure Treatment Prevents Postoperative Cardiac Complications in Patients With Lower Risk: A Retrospective Cohort Study.
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Shay D, Ng PY, Dudzinski DM, Grabitz SD, Mitchell JD, Xu X, Houle TT, Bhatt DL, and Eikermann M
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- Humans, Retrospective Studies, Postoperative Complications, Risk Factors, Heart Diseases, Heart Failure, Myocardial Infarction
- Abstract
Objective: The objective of this study was to identify undertreated subgroups of patients with heart failure who would benefit from better perioperative optimization., Summary of Background Data: Patients with heart failure have increased risks of postoperative cardiac complications after noncardiac surgery., Methods: In this analysis of hospital registry data of 130,677 patients undergoing noncardiac surgery, the exposure was preoperative history of heart failure. The outcome, cardiac complications, was defined as a composite of myocardial infarction, cardiac arrest, acute heart failure, and mortality within 30 postoperative days., Results: History of heart failure (n = 10,256; 7.9%) was associated with increased risk of cardiac complications [8.1% vs 1.1%; adjusted odds ratio, 2.28 (95% CI, 2.02-2.56); P < 0.001). Patients with heart failure and who carried a lower risk profile had increased risks of postoperative cardiac complications secondary to heart failure [adjusted absolute risk difference, 1.7% (95% CI, 1.4%-2.0%, lower risk); P < 0.001 vs 0.5% (95% CI, -0.6% to 1.6%, higher risk); P = 0.38]. Patients with heart failure and lower risk received a lower level of health care utilization preoperatively, and less frequently received anti-heart failure medications (59% vs 72% and 61% vs 82%; both P < 0.001). These preventive therapies significantly decreased the risk of cardiac complications in patients with heart failure., Conclusions: In patients with heart failure who have a lower preoperative risk profile, clinicians often make insufficient attempts to optimize their clinical condition preoperatively. Preoperative preventive treatment reduces the risk of postoperative cardiac complications in these lower-risk patients with heart failure., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.) more...
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- 2023
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39. Nighttime dexmedetomidine for delirium prevention in non-mechanically ventilated patients after cardiac surgery (MINDDS): A single-centre, parallel-arm, randomised, placebo-controlled superiority trial.
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Qu JZ, Mueller A, McKay TB, Westover MB, Shelton KT, Shaefi S, D'Alessandro DA, Berra L, Brown EN, Houle TT, and Akeju O
- Abstract
Background: The delirium-sparing effect of nighttime dexmedetomidine has not been studied after surgery. We hypothesised that a nighttime dose of dexmedetomidine would reduce the incidence of postoperative delirium as compared to placebo., Methods: This single-centre, parallel-arm, randomised, placebo-controlled superiority trial evaluated whether a short nighttime dose of intravenous dexmedetomidine (1 μg/kg over 40 min) would reduce the incidence of postoperative delirium in patients 60 years of age or older undergoing elective cardiac surgery with cardiopulmonary bypass. Patients were randomised to receive dexmedetomidine or placebo in a 1:1 ratio. The primary outcome was delirium on postoperative day one. Secondary outcomes included delirium within three days of surgery, 30-, 90-, and 180-day abbreviated Montreal Cognitive Assessment scores, Patient Reported Outcome Measures Information System quality of life scores, and all-cause mortality. The study was registered as NCT02856594 on ClinicalTrials.gov on August 5, 2016, before the enrolment of any participants., Findings: Of 469 patients that underwent randomisation to placebo (n = 235) or dexmedetomidine (n = 234), 75 met a prespecified drop criterion before the study intervention. Thus, 394 participants (188 dexmedetomidine; 206 placebo) were analysed in the modified intention-to-treat cohort (median age 69 [IQR 64, 74] years; 73.1% male [n = 288]; 26·9% female [n = 106]). Postoperative delirium status on day one was missing for 30 (7.6%) patients. Among those in whom it could be assessed, the primary outcome occurred in 5 of 175 patients (2.9%) in the dexmedetomidine group and 16 of 189 patients (8.5%) in the placebo group (OR 0.32, 95% CI: 0.10-0.83; P = 0.029). A non-significant but higher proportion of participants experienced delirium within three days postoperatively in the placebo group (25/177; 14.1%) compared to the dexmedetomidine group (14/160; 8.8%; OR 0.58; 95% CI, 0.28-1.15). No significant differences between groups were observed in secondary outcomes or safety., Interpretation: Our findings suggested that in elderly cardiac surgery patients with a low baseline risk of postoperative delirium and extubated within 12 h of ICU admission, a short nighttime dose of dexmedetomidine decreased the incidence of delirium on postoperative day one. Although non-statistically significant, our findings also suggested a clinical meaningful difference in the three-day incidence of postoperative delirium., Funding: National Institute on Aging (R01AG053582)., Competing Interests: A.M. reports receiving funding from Roche Diagnostics and the University of Chicago for statistical consulting projects related to biomarkers in preeclampsia. T.T.H. reports receiving personal fees from Anesthesiology and Headache. L.B. receives salary support from K23 HL128882/NHLBI NIH. L.B. receives technologies and devices from iNO Therapeutics LLC, Praxair Inc., Masimo Corp., and grants from “Fast Grants for COVID-19 Research” at Mercatus Center of George Mason University and from iNO Therapeutics LLC. E.N.B. is a cofounder of PASCALL, a company developing closed-loop physiological control systems, and a cofounder of Neuradia, a company promoting the recovery of consciousness. E.N.B. and O.A. are listed as inventors on brain monitoring patents assigned to Massachusetts General Hospital. No other disclosures were reported., (© 2022 The Author(s).) more...
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- 2022
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40. Efficacy of preemptive analgesia treatments for the management of postoperative pain: a network meta-analysis.
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Xuan C, Yan W, Wang D, Li C, Ma H, Mueller A, Chin V, Houle TT, and Wang J
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- Humans, Analgesics, Opioid, Gabapentin therapeutic use, Ibuprofen therapeutic use, Network Meta-Analysis, Pain, Postoperative drug therapy, Pain, Postoperative prevention & control, Pain, Postoperative chemically induced, Analgesia, Epidural, Postoperative Nausea and Vomiting chemically induced
- Abstract
Background: Preemptive analgesia may improve postoperative pain management, but the optimal regimen is unclear. This study aimed to compare the effects and adverse events of preemptive analgesia on postoperative pain and opioid consumption., Methods: In this network meta-analysis, 19 preemptive analgesia regimens were compared. Two authors independently searched databases, selected studies, and extracted data. Primary outcomes were the intensity of postoperative pain and opioid consumption. Secondary outcomes included the time to first analgesia rescue and incidence of postoperative nausea or vomiting (PONV)., Results: In total, 188 studies were included (13 769 subjects). Ten of 19 regimens reduced postoperative pain intensity compared with placebo, with mean differences 100-point scale ranging from -4.79 (95% confidence interval [CI]: -8.61 to -0.96.) for gabapentin at 48 h to -21.99 (95% CI: -36.97 to -7.02) for lornoxicam at 6 h. Eight regimens reduced opioid consumption compared with placebo, with mean differences ranging from -0.48 mg (95% CI: -0.89 to -0.08) i.v. milligrams of morphine equivalents (IMME) for acetaminophen at 12 h to -2.27 IMME (95% CI: -3.07 to -1.46) for ibuprofen at 24 h. Five regimens delayed rescue analgesia from 1.75 (95% CI: 0.59-2.91) h for gabapentin to 7.35 (95% CI: 3.66-11.04) h for epidural analgesia. Five regimens had a lower incidence of PONV compared with placebo, ranging from an odds ratio of 0.22 (95% CI: 0.11-0.42) for ibuprofen to 0.59 (95% CI: 0.40-0.87) for pregabalin., Conclusions: Use of preemptive analgesia reduces postoperative pain, opioid consumption, and postoperative nausea or vomiting, and delays rescue analgesia., Systematic Review Protocol: PROSPERO CRD42021232593., (Copyright © 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.) more...
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- 2022
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41. Mindfulness-Based Interdisciplinary Pain Management Program for Complex Polymorbid Pain in Veterans: A Randomized Controlled Trial.
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McGeary DD, Jaramillo C, Eapen B, Blount TH, Nabity PS, Moreno J, Pugh MJ, Houle TT, Potter JS, Young-McCaughan S, Peterson AL, Villarreal R, Brackins N, Sikorski Z, Johnson TR, Tapia R, Reed D, Caya CA, Bomer D, Simmonds M, and McGeary CA more...
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- Analgesics, Opioid, Humans, Pain, Pain Management, Mindfulness, Opioid-Related Disorders, Veterans
- Abstract
Objective: To evaluate the effects of interdisciplinary pain management on pain-related disability and opioid reduction in polymorbid pain patients with 2 or more comorbid psychiatric conditions., Design: Two-arm randomized controlled trial testing a 3-week intervention with assessments at pre-treatment, post-treatment, 6-month, and 12-month follow-up., Setting: Department of Veterans Affairs medical facility., Participants: 103 military veterans (N=103) with moderate (or worse) levels of pain-related disability, depression, anxiety, and/or posttraumatic stress disorder randomly assigned to usual care (n=53) and interdisciplinary pain management (n=50). All participants reported recent persistent opioid use. Trial participants had high levels of comorbid medical and mental health conditions., Interventions: Experimental arm-a 3-week, interdisciplinary pain management program guided by a structured manual; comparison arm-usual care in a large Department of Veterans Affairs medical facility., Main Outcome Measures: Oswestry Disability Index (pain disability); Timeline Followback Interview and Medication Event Monitoring System (opioid use). Analysis used generalized linear mixed model with all posttreatment observations (posttreatment, 6-month follow-up, 12-month follow-up) entered simultaneously to create a single posttreatment effect., Results: Veterans with polymorbid pain randomized to the interdisciplinary pain program reported significantly greater decreases in pain-related disability compared to veterans randomized to treatment as usual (TAU) at posttreatment, 6-month, and 12-month follow-up. Aggregated mean pain disability scores (ie, a summary effect of all posttreatment observations) for the interdisciplinary pain program were -9.1 (95% CI: -14.4, -3.7, P=.001) points lower than TAU. There was no difference between groups in the proportion of participants who resumed opioid use during trial participation (32% in both arms)., Conclusion: These findings offer the first evidence of short- and long-term interdisciplinary pain management efficacy in polymorbid pain patients, but more work is needed to examine how to effectively decrease opioid use in this population., (Published by Elsevier Inc.) more...
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- 2022
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42. Lifestyle factors and migraine.
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Seng EK, Martin PR, and Houle TT
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- Diet, Exercise, Humans, Sleep, Life Style, Migraine Disorders drug therapy
- Abstract
Migraine, a common and disabling neurological disorder, is among the top reasons for outpatient visits to general neurologists. In addition to pharmacotherapy, lifestyle interventions are a mainstay of treatment. High-quality daily diary studies and intervention studies indicate intraindividual variations in the associations between lifestyle factors (such as stress, sleep, diet, and physical activity) and migraine attack occurrence. Behaviour change interventions can directly address overlapping lifestyle factors; combination approaches could capitalise on multiple mechanisms. These findings provide useful directions for integration of lifestyle management into routine clinical care and for future research., Competing Interests: Declaration of interests EKS received research funding from the NINDS K23 NS096107 career development award, which contributed to all of her professional activity during the time of writing this Review. EKS has also received grants or contracts from the National Center for Complementary and Integrative Health (R01AT011-01A1, MPI: Seng & Shallcross) and the Veterans Health Administration (Headache Center of Excellence; Health Services Research & Development IRP 20-002 PI: Damush). She has consulted for GlaxoSmithKline and Click Therapeutics. She has received payment for lectures at Elmhurst Hospital. She has received support for travel for the American Headache Society, American Psychological Association, and International Congress of Behavioral Medicine. She has participated on an advisory board for AbbVie. She serves in leadership roles in the International Society of Behavioral Medicine, Society for Health Psychology, American Psychological Association, American Headache Society, and Society of Behavioral Medicine. MRT and TTH declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.) more...
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- 2022
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43. Preoperative Treatment of Severe Diabetes Mellitus and Hypertension Mitigates Healthcare Disparities and Prevents Adverse Postoperative Discharge to a Nursing Home.
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Wachtendorf LJ, Azimaraghi O, Rangasamy V, Sane M, Subramaniam B, Vazquez R, Wongtangman K, Houle TT, Bellin EY, Akeju O, Straker T, Chambers TT, Oriol NE, and Eikermann M
- Subjects
- Adult, Databases, Factual, Healthcare Disparities, Humans, Nursing Homes, Patient Discharge, Retrospective Studies, Diabetes Mellitus epidemiology, Hypertension epidemiology
- Abstract
Objective: To evaluate whether patients of Black race are at higher risk of adverse postoperative discharge to a nursing home, and if a higher prevalence of severe diabetes mellitus and hypertension are contributing., Background: It is unclear whether a patient's race predicts adverse discharge to a nursing home after surgery, and if preexisting diseases are contributing., Methods: A total of 368,360 adults undergoing surgery between 2007 and 2020 across 2 academic healthcare networks in New England were included. Patients of self-identified Black or White race were compared. The primary outcome was postoperative discharge to a nursing facility. Mediation analysis was used to examine the impact of preexisting severe diabetes mellitus and hypertension on the primary association., Results: In all, 10.3% (38,010/368,360) of patients were Black and 26,434 (7.2%) patients were discharged to a nursing home. Black patients were at increased risk of postoperative discharge to a nursing facility (adjusted absolute risk difference: 1.9%; 95% confidence interval: 1.6%-2.2%; P <0.001). A higher prevalence of preexisting severe diabetes mellitus and hypertension in Black patients mediated 30.2% and 15.6% of this association. Preoperative medication-based treatment adherent to guidelines in patients with severe diabetes mellitus or hypertension mitigated the primary association ( P -for-interaction <0.001). The same pattern of effect mitigation by pharmacotherapy was observed for the endpoint 30-day readmission., Conclusions: Black race was associated with postoperative discharge to a nursing facility compared to White race. Optimized preoperative assessment and treatment of diabetes mellitus and hypertension improves surgical outcomes and provides an opportunity to the surgeon to help eliminate healthcare disparities., Competing Interests: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. B.S. reports receipt of grants from NIH [PI (principal investigator)], Mallinckrodt Pharmaceuticals, DL Biotech, MASIMO, Merck & Co., and Edwards Lifesciences. T.T.H. reports receipt of grants from NINDS (PI) and NIGMS; personal fees from the journals Headache: The Journal of Head and Face Pain , and Anesthesiology for statistical consulting, and personal fees from Cephalagia for expedited peer review outside the submitted work. M.E. reports receipt of grants from Merck & Co., personal fees (honoraria) from Merck, funding from Jeffrey and Judith Buzen, holds equity in Calabash Bioscience and serves as Associate Editor for the British Journal of Anaesthesia . No other disclosures were reported. The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.) more...
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- 2022
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44. An electroencephalogram biomarker of fentanyl drug effects.
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Balanza GA, Bharadwaj KM, Mullen AC, Beck AM, Work EC, McGovern FJ, Houle TT, Eric TP, and Purdon PL
- Abstract
Opioid drugs influence multiple brain circuits in parallel to produce analgesia as well as side effects, including respiratory depression. At present, we do not have real-time clinical biomarkers of these brain effects. Here, we describe the results of an experiment to characterize the electroencephalographic signatures of fentanyl in humans. We find that increasing concentrations of fentanyl induce a frontal theta band (4 to 8 Hz) signature distinct from slow-delta oscillations related to sleep and sedation. We also report that respiratory depression, quantified by decline in an index of instantaneous minute ventilation, occurs at ≈1700-fold lower concentrations than those that produce sedation as measured by reaction time. The electroencephalogram biomarker we describe could facilitate real-time monitoring of opioid drug effects and enable more precise and personalized opioid administration., (© The Author(s) 2022. Published by Oxford University Press on behalf of National Academy of Sciences.) more...
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- 2022
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45. Atogepant - an orally-administered CGRP antagonist - attenuates activation of meningeal nociceptors by CSD.
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Strassman AM, Melo-Carrillo A, Houle TT, Adams A, Brin MF, and Burstein R
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- Animals, Bayes Theorem, Male, Nerve Fibers, Unmyelinated, Piperidines pharmacology, Pyridines pharmacology, Pyrroles pharmacology, Rats, Rats, Sprague-Dawley, Spiro Compounds pharmacology, Calcitonin Gene-Related Peptide antagonists & inhibitors, Migraine Disorders drug therapy, Migraine Disorders prevention & control, Nociceptors
- Abstract
Background: This study investigated the mechanism of action of atogepant, a small-molecule CGRP receptor antagonist recently approved for the preventive treatment of episodic migraine, by assessing its effect on activation of mechanosensitive C- and Aδ-meningeal nociceptors following cortical spreading depression., Methods: Single-unit recordings of trigeminal ganglion neurons (32 Aδ and 20 C-fibers) innervating the dura was used to document effects of orally administered atogepant (5 mg/kg) or vehicle on cortical spreading depression-induced activation in anesthetized male rats., Results: Bayesian analysis of time effects found that atogepant did not completely prevent the activation of nociceptors at the tested dose, but it significantly reduced response amplitude and probability of response in both the C- and the Aδ-fibers at different time intervals following cortical spreading depression induction. For C-fibers, the reduction in responses was significant in the early phase (first hour), but not delayed phase of activation, whereas in Aδ-fibers, significant reduction in activation was apparent in the delayed phase (second and third hours) but not early phase of activation., Conclusions: These findings identify differences between the actions of atogepant, a small molecule CGRP antagonist (partially inhibiting both Aδ and C-fibers) and those found previously for fremanezumab, a CGRP-targeted antibody (inhibiting Aδ fibers only) and onabotulinumtoxinA (inhibiting C-fibers only)- suggesting that these agents differ in their mechanisms for the preventive treatment of migraine. more...
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- 2022
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46. Cognitive Behavioral Therapy for Veterans With Comorbid Posttraumatic Headache and Posttraumatic Stress Disorder Symptoms: A Randomized Clinical Trial.
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McGeary DD, Resick PA, Penzien DB, McGeary CA, Houle TT, Eapen BC, Jaramillo CA, Nabity PS, Reed DE 2nd, Moring JC, Bira LM, Hansen HR, Young-McCaughan S, Cobos BA, Mintz J, Keane TM, and Peterson AL
- Subjects
- Adult, Comorbidity, Headache epidemiology, Headache etiology, Headache therapy, Humans, Male, Treatment Outcome, Brain Concussion complications, Brain Concussion epidemiology, Brain Concussion therapy, Cognitive Behavioral Therapy, Stress Disorders, Post-Traumatic complications, Stress Disorders, Post-Traumatic epidemiology, Stress Disorders, Post-Traumatic therapy, Veterans psychology
- Abstract
Importance: Posttraumatic headache is the most disabling complication of mild traumatic brain injury. Posttraumatic stress disorder (PTSD) symptoms are often comorbid with posttraumatic headache, and there are no established treatments for this comorbidity., Objective: To compare cognitive behavioral therapies (CBTs) for headache and PTSD with treatment per usual (TPU) for posttraumatic headache attributable to mild traumatic brain injury., Design, Setting, and Participants: This was a single-site, 3-parallel group, randomized clinical trial with outcomes at posttreatment, 3-month follow-up, and 6-month follow-up. Participants were enrolled from May 1, 2015, through May 30, 2019; data collection ended on October 10, 2019. Post-9/11 US combat veterans from multiple trauma centers were included in the study. Veterans had comorbid posttraumatic headache and PTSD symptoms. Data were analyzed from January 20, 2020, to February 2, 2022., Interventions: Patients were randomly assigned to 8 sessions of CBT for headache, 12 sessions of cognitive processing therapy for PTSD, or treatment per usual for headache., Main Outcomes and Measures: Co-primary outcomes were headache-related disability on the 6-Item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5) assessed from treatment completion to 6 months posttreatment., Results: A total of 193 post-9/11 combat veterans (mean [SD] age, 39.7 [8.4] years; 167 male veterans [87%]) were included in the study and reported severe baseline headache-related disability (mean [SD] HIT-6 score, 65.8 [5.6] points) and severe PTSD symptoms (mean [SD] PCL-5 score, 48.4 [14.2] points). For the HIT-6, compared with usual care, patients receiving CBT for headache reported -3.4 (95% CI, -5.4 to -1.4; P < .01) points lower, and patients receiving cognitive processing therapy reported -1.4 (95% CI, -3.7 to 0.8; P = .21) points lower across aggregated posttreatment measurements. For the PCL-5, compared with usual care, patients receiving CBT for headache reported -6.5 (95% CI, -12.7 to -0.3; P = .04) points lower, and patients receiving cognitive processing therapy reported -8.9 (95% CI, -15.9 to -1.9; P = .01) points lower across aggregated posttreatment measurements. Adverse events were minimal and similar across treatment groups., Conclusions and Relevance: This randomized clinical trial demonstrated that CBT for headache was efficacious for disability associated with posttraumatic headache in veterans and provided clinically significant improvement in PTSD symptom severity. Cognitive processing therapy was efficacious for PTSD symptoms but not for headache disability., Trial Registration: ClinicalTrials.gov Identifier: NCT02419131. more...
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- 2022
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47. Mechanical Power during General Anesthesia and Postoperative Respiratory Failure: A Multicenter Retrospective Cohort Study.
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Santer P, Wachtendorf LJ, Suleiman A, Houle TT, Fassbender P, Costa EL, Talmor D, Eikermann M, Baedorf-Kassis E, and Schaefer MS
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- Adult, Anesthesia, General adverse effects, Humans, Respiration, Artificial, Retrospective Studies, Tidal Volume, Respiratory Insufficiency epidemiology, Ventilator-Induced Lung Injury
- Abstract
Background: Mechanical power during ventilation estimates the energy delivered to the respiratory system through integrating inspiratory pressures, tidal volume, and respiratory rate into a single value. It has been linked to lung injury and mortality in the acute respiratory distress syndrome, but little evidence exists regarding whether the concept relates to lung injury in patients with healthy lungs. This study hypothesized that higher mechanical power is associated with greater postoperative respiratory failure requiring reintubation in patients undergoing general anesthesia., Methods: In this multicenter, retrospective study, 230,767 elective, noncardiac adult surgical out- and inpatients undergoing general anesthesia between 2008 and 2018 at two academic hospital networks in Boston, Massachusetts, were included. The risk-adjusted association between the median intraoperative mechanical power, calculated from median values of tidal volume (Vt), respiratory rate (RR), positive end-expiratory pressure (PEEP), plateau pressure (Pplat), and peak inspiratory pressure (Ppeak), using the following formula: mechanical power (J/min) = 0.098 × RR × Vt × (PEEP + ½[Pplat - PEEP] + [Ppeak - Pplat]), and postoperative respiratory failure requiring reintubation within 7 days, was assessed., Results: The median intraoperative mechanical power was 6.63 (interquartile range, 4.62 to 9.11) J/min. Postoperative respiratory failure occurred in 2,024 (0.9%) patients. The median (interquartile range) intraoperative mechanical power was higher in patients with postoperative respiratory failure than in patients without (7.67 [5.64 to 10.11] vs. 6.62 [4.62 to 9.10] J/min; P < 0.001). In adjusted analyses, a higher mechanical power was associated with greater odds of postoperative respiratory failure (adjusted odds ratio, 1.31 per 5 J/min increase; 95% CI, 1.21 to 1.42; P < 0.001). The association between mechanical power and postoperative respiratory failure was robust to additional adjustment for known drivers of ventilator-induced lung injury, including tidal volume, driving pressure, and respiratory rate, and driven by the dynamic elastic component (adjusted odds ratio, 1.35 per 5 J/min; 95% CI, 1.05 to 1.73; P = 0.02)., Conclusions: Higher mechanical power during ventilation is statistically associated with a greater risk of postoperative respiratory failure requiring reintubation., (Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved.) more...
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- 2022
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48. Association Between Intraoperative Arterial Hypotension and Postoperative Delirium After Noncardiac Surgery: A Retrospective Multicenter Cohort Study.
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Wachtendorf LJ, Azimaraghi O, Santer P, Linhardt FC, Blank M, Suleiman A, Ahn C, Low YH, Teja B, Kendale SM, Schaefer MS, Houle TT, Pollard RJ, Subramaniam B, Eikermann M, and Wongtangman K
- Subjects
- Adult, Anesthesia, General adverse effects, Arterial Pressure, Humans, Intraoperative Complications diagnosis, Intraoperative Complications epidemiology, Postoperative Complications diagnosis, Postoperative Complications epidemiology, Postoperative Complications etiology, Retrospective Studies, Delirium diagnosis, Delirium epidemiology, Delirium etiology, Hypotension diagnosis, Hypotension etiology
- Abstract
Background: It is unclear whether intraoperative arterial hypotension is associated with postoperative delirium. We hypothesized that intraoperative hypotension within a range frequently observed in clinical practice is associated with increased odds of delirium after surgery., Methods: Adult noncardiac surgical patients undergoing general anesthesia at 2 academic medical centers between 2005 and 2017 were included in this retrospective cohort study. The primary exposure was intraoperative hypotension, defined as the cumulative duration of an intraoperative mean arterial pressure (MAP) <55 mm Hg, categorized into and short (<15 minutes; median [interquartile range {IQR}], 2 [1-4] minutes) and prolonged (≥15 minutes; median [IQR], 21 [17-31] minutes) durations of intraoperative hypotension. The primary outcome was a new diagnosis of delirium within 30 days after surgery. In secondary analyses, we assessed the association between a MAP decrease of >30% from baseline and postoperative delirium. Multivariable logistic regression adjusted for patient- and procedure-related factors, including demographics, comorbidities, and markers of procedural severity, was used., Results: Among 316,717 included surgical patients, 2183 (0.7%) were diagnosed with delirium within 30 days after surgery; 41.7% and 2.6% of patients had a MAP <55 mm Hg for a short and a prolonged duration, respectively. A MAP <55 mm Hg was associated with postoperative delirium compared to no hypotension (short duration of MAP <55 mm Hg: adjusted odds ratio [ORadj], 1.22; 95% confidence interval [CI], 1.11-1.33; P < .001 and prolonged duration of MAP <55 mm Hg: ORadj, 1.57; 95% CI, 1.27-1.94; P < .001). Compared to a short duration of a MAP <55 mm Hg, a prolonged duration of a MAP <55 mm Hg was associated with greater odds of postoperative delirium (ORadj, 1.29; 95% CI, 1.05-1.58; P = .016). The association between intraoperative hypotension and postoperative delirium was duration-dependent (ORadj for every 10 cumulative minutes of MAP <55 mm Hg: 1.06; 95% CI, 1.02-1.09; P =.001) and magnified in patients who underwent surgeries of longer duration (P for interaction = .046; MAP <55 mm Hg versus no MAP <55 mm Hg in patients undergoing surgery of >3 hours: ORadj, 1.40; 95% CI, 1.23-1.61; P < .001). A MAP decrease of >30% from baseline was not associated with postoperative delirium compared to no hypotension, also when additionally adjusted for the cumulative duration of a MAP <55 mm Hg (short duration of MAP decrease >30%: ORadj, 1.13; 95% CI, 0.91-1.40; P = .262 and prolonged duration of MAP decrease >30%: ORadj, 1.19; 95% CI, 0.95-1.49; P = .141)., Conclusions: In patients undergoing noncardiac surgery, a MAP <55 mm Hg was associated with a duration-dependent increase in odds of postoperative delirium. This association was magnified in patients who underwent surgery of long duration., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.) more...
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- 2022
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49. Development and external validation of a prognostic model for ischaemic stroke after surgery.
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Platzbecker K, Grabitz SD, Raub D, Rudolph MI, Friedrich S, Vinzant N, Kurth T, Weimar C, Bhatt DL, Nozari A, Houle TT, Xu X, and Eikermann M
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- Adolescent, Adult, Aged, Aged, 80 and over, Cohort Studies, Female, Follow-Up Studies, Humans, Ischemic Stroke etiology, Logistic Models, Male, Massachusetts, Middle Aged, Prognosis, Risk Assessment methods, Surgical Procedures, Operative methods, Young Adult, Ischemic Stroke epidemiology, Models, Statistical, Postoperative Complications epidemiology, Surgical Procedures, Operative adverse effects
- Abstract
Background: There is an under-recognised patient cohort at elevated risk of postoperative ischaemic stroke. We aimed to develop and validate a prognostic model for the identification of such patients at high risk of ischaemic stroke within 1 yr after noncardiac surgery., Methods: This was a hospital registry study of adult patients undergoing noncardiac surgery between 2005 and 2017 at two independent healthcare networks in Massachusetts, USA without a preoperative indication for therapeutic anticoagulation. Logistic regression was used to fit a model from a priori defined candidate predictors for the outcome 1 yr postoperative ischaemic stroke. To enhance clinical applicability, the model was simplified to a scoring system and externally validated., Results: In the development (n=107 756) and validation (n=141 724) cohorts, 1.4% and 0.5% of patients had an ischaemic stroke up to 1 yr postoperatively. The final model included 13 variables (patient characteristics, comorbidities, procedural factors), considering sub-models conditional on a previous history of ischaemic stroke. Areas under the curve were 0.89 (95% confidence interval 0.89-0.90) and 0.88 (95% confidence interval 0.86-0.89) in the development and validation cohorts. Decision curve analysis indicated positive net benefits superior to other prediction instruments., Conclusions: Stroke after surgery (STRAS) screening can reliably identify patients with a high risk for ischaemic stroke during the first year after surgery. A STRAS-guided risk stratification may inform the recruitment to future randomised trials testing the efficacy of treatments for the prevention of postoperative ischaemic stroke., (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.) more...
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- 2021
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50. Persistent posttraumatic headaches and functioning in veterans: Injury type can matter.
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Nabity PS, Jaramillo CA, Resick PA, McGeary CA, Eapen BC, Straud CL, Hale WJ, Houle TT, Litz BT, Mintz J, Penzien DB, Young-McCaughan S, Keane TM, Peterson AL, and McGeary DD
- Subjects
- Adult, Chronic Disease, Cohort Studies, Depression etiology, Depression physiopathology, Disabled Persons, Humans, Male, Migraine Disorders etiology, Migraine Disorders physiopathology, Stress Disorders, Post-Traumatic etiology, Stress Disorders, Post-Traumatic physiopathology, Young Adult, Blast Injuries complications, Brain Injuries, Traumatic complications, Head Injuries, Closed complications, Post-Traumatic Headache etiology, Post-Traumatic Headache physiopathology, Veterans
- Abstract
Objective: To characterize the relationship between head trauma types (blast injury, blunt injury, combined blast+blunt injury) with subsequent headache presentations and functioning., Background: Posttraumatic headaches (PTHs), the most common sequelae of traumatic brain injury (TBI), are painful and disabling. More than 400,000 veterans report having experienced a TBI, and understanding the predictors of PTHs may guide treatment developments., Methods: This study used a nested-cohort design analyzing baseline data from a randomized clinical trial of cognitive behavioral therapy for PTH (N = 190). Participants had PTH (from blast and/or blunt head trauma) and symptoms of posttraumatic stress disorder (PTSD). The Structured Diagnostic Interview for Headache-Revised and Ohio State University Traumatic Brain Injury Identification Method were used to phenotype headaches and head injury histories, respectively., Results: Individuals with persistent PTHs after a combined blast and blunt head trauma were more likely (OR =3.45; 95% CI [1.41, 8.4]) to experience chronic (vs. episodic) PTHs compared with the blunt trauma only group (23/33, 70% vs. 26/65, 40%, respectively); and they were more likely (OR =2.51; 95% CI [1.07, 5.9]) to experience chronic PTH compared with the blast trauma only group (44/92, 48%). There were no differences between head injury type on headache-related disability, depression symptoms, or severity of PTSD symptoms., Conclusion: The combination of blast and blunt injuries was associated with headache chronicity, but not headache disability. Considering the refractory nature of chronic headaches, the potential added and synergistic effects of distinct head injuries warrant further study., (© 2021 American Headache Society.) more...
- Published
- 2021
- Full Text
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