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Holzer KJ, Bartosiak KA, Calfee RP, Hammill CW, Haroutounian S, Kozower BD, Cordner TA, Lenard EM, Freedland KE, Tellor Pennington BR, Wolfe RC, Miller JP, Politi MC, Zhang Y, Yingling MD, Baumann AA, Kannampallil T, Schweiger JA, McKinnon SL, Avidan MS, Lenze EJ, Abraham J. Perioperative mental health intervention for depression and anxiety symptoms in older adults study protocol: design and methods for three linked randomised controlled trials. BMJ Open 2024; 14:e082656. [PMID: 38569683 DOI: 10.1136/bmjopen-2023-082656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Abstract
INTRODUCTION Preoperative anxiety and depression symptoms among older surgical patients are associated with poor postoperative outcomes, yet evidence-based interventions for anxiety and depression have not been applied within this setting. We present a protocol for randomised controlled trials (RCTs) in three surgical cohorts: cardiac, oncological and orthopaedic, investigating whether a perioperative mental health intervention, with psychological and pharmacological components, reduces perioperative symptoms of depression and anxiety in older surgical patients. METHODS AND ANALYSIS Adults ≥60 years undergoing cardiac, orthopaedic or oncological surgery will be enrolled in one of three-linked type 1 hybrid effectiveness/implementation RCTs that will be conducted in tandem with similar methods. In each trial, 100 participants will be randomised to a remotely delivered perioperative behavioural treatment incorporating principles of behavioural activation, compassion and care coordination, and medication optimisation, or enhanced usual care with mental health-related resources for this population. The primary outcome is change in depression and anxiety symptoms assessed with the Patient Health Questionnaire-Anxiety Depression Scale from baseline to 3 months post surgery. Other outcomes include quality of life, delirium, length of stay, falls, rehospitalisation, pain and implementation outcomes, including study and intervention reach, acceptability, feasibility and appropriateness, and patient experience with the intervention. ETHICS AND DISSEMINATION The trials have received ethics approval from the Washington University School of Medicine Institutional Review Board. Informed consent is required for participation in the trials. The results will be submitted for publication in peer-reviewed journals, presented at clinical research conferences and disseminated via the Center for Perioperative Mental Health website. TRIAL REGISTRATION NUMBERS NCT05575128, NCT05685511, NCT05697835, pre-results.
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Affiliation(s)
- Katherine J Holzer
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Kimberly A Bartosiak
- Department of Orthopaedics, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Ryan P Calfee
- Department of Orthopaedics, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Chet W Hammill
- Department of Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Benjamin D Kozower
- Department of Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Theresa A Cordner
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Emily M Lenard
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Kenneth E Freedland
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Bethany R Tellor Pennington
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Rachel C Wolfe
- Department of Pharmacy, Barnes-Jewish Hospital, St Louis, Missouri, USA
| | - J Philip Miller
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| | - Mary C Politi
- Department of Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Yi Zhang
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Michael D Yingling
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Ana A Baumann
- Department of Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| | - Julia A Schweiger
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Sherry L McKinnon
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
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Fritz BA, Pugazenthi S, Budelier TP, Tellor Pennington BR, King CR, Avidan MS, Abraham J. User-Centered Design of a Machine Learning Dashboard for Prediction of Postoperative Complications. Anesth Analg 2024; 138:804-813. [PMID: 37339083 PMCID: PMC10730770 DOI: 10.1213/ane.0000000000006577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
BACKGROUND Machine learning models can help anesthesiology clinicians assess patients and make clinical and operational decisions, but well-designed human-computer interfaces are necessary for machine learning model predictions to result in clinician actions that help patients. Therefore, the goal of this study was to apply a user-centered design framework to create a user interface for displaying machine learning model predictions of postoperative complications to anesthesiology clinicians. METHODS Twenty-five anesthesiology clinicians (attending anesthesiologists, resident physicians, and certified registered nurse anesthetists) participated in a 3-phase study that included (phase 1) semistructured focus group interviews and a card sorting activity to characterize user workflows and needs; (phase 2) simulated patient evaluation incorporating a low-fidelity static prototype display interface followed by a semistructured interview; and (phase 3) simulated patient evaluation with concurrent think-aloud incorporating a high-fidelity prototype display interface in the electronic health record. In each phase, data analysis included open coding of session transcripts and thematic analysis. RESULTS During the needs assessment phase (phase 1), participants voiced that (a) identifying preventable risk related to modifiable risk factors is more important than nonpreventable risk, (b) comprehensive patient evaluation follows a systematic approach that relies heavily on the electronic health record, and (c) an easy-to-use display interface should have a simple layout that uses color and graphs to minimize time and energy spent reading it. When performing simulations using the low-fidelity prototype (phase 2), participants reported that (a) the machine learning predictions helped them to evaluate patient risk, (b) additional information about how to act on the risk estimate would be useful, and (c) correctable problems related to textual content existed. When performing simulations using the high-fidelity prototype (phase 3), usability problems predominantly related to the presentation of information and functionality. Despite the usability problems, participants rated the system highly on the System Usability Scale (mean score, 82.5; standard deviation, 10.5). CONCLUSIONS Incorporating user needs and preferences into the design of a machine learning dashboard results in a display interface that clinicians rate as highly usable. Because the system demonstrates usability, evaluation of the effects of implementation on both process and clinical outcomes is warranted.
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Affiliation(s)
| | | | | | | | | | | | - Joanna Abraham
- From the Department of Anesthesiology
- Institute for Informatics, Washington University School of Medicine, St. Louis, Missouri
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Holzer KJ, Todorovic MS, Wilson EA, Steinberg A, Avidan MS, Haroutounian S. Cognitive flexibility training for chronic pain: a randomized clinical study. Pain Rep 2024; 9:e1120. [PMID: 38352025 PMCID: PMC10863938 DOI: 10.1097/pr9.0000000000001120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/12/2023] [Accepted: 10/09/2023] [Indexed: 02/16/2024] Open
Abstract
Introduction Previous studies suggest an association between cognitive flexibility and development of chronic pain after surgery. It is not known whether cognitive flexibility can be improved in patients with chronic pain. Objectives This study tested whether a neurocognitive training program results in improved cognitive flexibility and pain in patients with chronic pain. Methods We conducted a single-center, prospective, randomized study investigating 5-week daily neurocognitive training in patients with chronic pain. Participants (n = 145) were randomized into neurocognitive training or care as usual, and they completed assessments at baseline, posttreatment, and 3 months. The treatment group was asked to spend 35 minutes daily completing a program with tasks on cognitive flexibility, memory, attention, and speed. The primary outcome was performance on the neurocognitive performance test (NCPT). Secondary outcomes included levels of pain interference and severity. Results At 5 weeks, the treatment group showed greater improvements on NCPT compared with the control group (d = 0.37); effect size was smaller at 3 months (d = 0.18). The treatment group reported lower pain severity at 5 weeks (d = 0.16) and 3 months (d = 0.39) than the control group, but pain interference was only lower at 3 months (d = 0.20). Conclusions Outcomes suggest that using neurocognitive training to modify cognitive flexibility in patients with chronic pain may improve pain severity. This study provided effect size estimates to inform sample size calculations for randomized controlled trials to test the effectiveness of neurocognitive interventions for the prevention and treatment of chronic pain.
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Affiliation(s)
- Katherine J. Holzer
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Marko S. Todorovic
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Elizabeth A. Wilson
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Aaron Steinberg
- Emergency Department, SSM Health St. Mary's Hospital, St. Louis, MO, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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Pennington BRT, Holzer KJ, Fritz BA, Haroutounian S, Xu KY, Tedder A, Kronzer A, Avidan MS, Lenze EJ. Brain-Hazardous Medications and Potential Subadequate Antidepressant Dosing in Older Surgical Patients Receiving Home Antidepressants: An Observational Study of a Large US Health System. Anesth Analg 2024:00000539-990000000-00794. [PMID: 38507476 DOI: 10.1213/ane.0000000000006952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
BACKGROUND Older surgical patients with depression often experience poor postoperative outcomes. Poor outcomes may stem from brain-hazardous medications and subadequate antidepressant dosing. METHODS This was a retrospective, observational cohort study covering the period between January 1, 2021 and December 31, 2021. Patients ≥60 years of age who underwent inpatient surgery and had an overnight stay at an integrated academic health care system comprising 14 hospitals were eligible. We analyzed the prevalence of home central nervous system (CNS)-active potentially inappropriate medication (PIM) and potential subadequate antidepressant dosing in older surgical patients receiving home antidepressants. Univariable and multivariable regression models were used to identify factors associated with home CNS-active PIM prescribing and potential subadequate antidepressant dosing. Additionally, outcomes were compared among patients receiving and not receiving CNS-active PIMs and patients receiving and not receiving subadequate antidepressant dosing. RESULTS A total of 8031 patients were included in this study (47% female, mean age = 70 years) of whom 2087 (26%) were prescribed antidepressants. Roughly one-half (49%, 95% confidence interval [CI], 46.5-50.1) of patients receiving home antidepressants were also receiving ≥1 CNS-active PIM and 29% (95% CI, 27.0-29.3) were receiving a potential subadequate dose. Factors associated with an increased likelihood of receiving a home CNS-active PIM included female sex (adjusted odds ratio [aOR], 1.46), anxiety (aOR, 2.43), asthma or chronic obstructive pulmonary disease (aOR, 1.39), and serotonin-norepinephrine reuptake inhibitor use (aOR, 1.54). Patients aged ≥75 years (aOR, 1.57), black race (aOR, 1.48) and those with congestive heart failure (aOR, 1.33) were more likely to be prescribed a potential subadequate antidepressant dose. Patients receiving potential subadequate antidepressant doses were discharged home less often (64% vs 73%), had a longer hospital length of stay (9 days vs 7 days), and a higher mortality rate (18% vs 10%) compared to patients receiving adequate home antidepressant doses (P-value for all <0.01). No differences in these outcomes were found among patients receiving home antidepressants with or without CNS-active PIMs. CONCLUSIONS Older surgical patients receiving antidepressants are frequently prescribed brain-hazardous medications and potentially subadequate antidepressant doses. Those receiving subadequate antidepressant doses may be at risk for worse postoperative outcomes compared to patients receiving adequate doses. The role of preoperative medication optimization to improve outcomes for older surgical patients should be evaluated.
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Affiliation(s)
| | - Katherine J Holzer
- From the Department of Anesthesiology Washington University School of Medicine, St Louis, Missouri
| | - Bradley A Fritz
- From the Department of Anesthesiology Washington University School of Medicine, St Louis, Missouri
| | - Simon Haroutounian
- From the Department of Anesthesiology Washington University School of Medicine, St Louis, Missouri
| | - Kevin Y Xu
- Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri
| | - Amanda Tedder
- Department of Pharmacy, Barnes-Jewish Hospital, St Louis, Missouri
| | - Alex Kronzer
- From the Department of Anesthesiology Washington University School of Medicine, St Louis, Missouri
| | - Michael S Avidan
- From the Department of Anesthesiology Washington University School of Medicine, St Louis, Missouri
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri
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Tripathi S, Fritz BA, Abdelhack M, Avidan MS, Chen Y, King CR. Multi-view representation learning for tabular data integration using inter-feature relationships. J Biomed Inform 2024; 151:104602. [PMID: 38346530 DOI: 10.1016/j.jbi.2024.104602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVE An applied problem facing all areas of data science is harmonizing data sources. Joining data from multiple origins with unmapped and only partially overlapping features is a prerequisite to developing and testing robust, generalizable algorithms, especially in healthcare. This integrating is usually resolved using meta-data such as feature names, which may be unavailable or ambiguous. Our goal is to design methods that create a mapping between structured tabular datasets derived from electronic health records independent of meta-data. METHODS We evaluate methods in the challenging case of numeric features without reliable and distinctive univariate summaries, such as nearly Gaussian and binary features. We assume that a small set of features are a priori mapped between two datasets, which share unknown identical features and possibly many unrelated features. Inter-feature relationships are the main source of identification which we expect. We compare the performance of contrastive learning methods for feature representations, novel partial auto-encoders, mutual-information graph optimizers, and simple statistical baselines on simulated data, public datasets, the MIMIC-III medical-record changeover, and perioperative records from before and after a medical-record system change. Performance was evaluated using both mapping of identical features and reconstruction accuracy of examples in the format of the other dataset. RESULTS Contrastive learning-based methods overall performed the best, often substantially beating the literature baseline in matching and reconstruction, especially in the more challenging real data experiments. Partial auto-encoder methods showed on-par matching with contrastive methods in all synthetic and some real datasets, along with good reconstruction. However, the statistical method we created performed reasonably well in many cases, with much less dependence on hyperparameter tuning. When validating feature match output in the EHR dataset we found that some mistakes were actually a surrogate or related feature as reviewed by two subject matter experts. CONCLUSION In simulation studies and real-world examples, we find that inter-feature relationships are effective at identifying matching or closely related features across tabular datasets when meta-data is not available. Decoder architectures are also reasonably effective at imputing features without an exact match.
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Affiliation(s)
- Sandhya Tripathi
- Department of Anesthesiology, Washington University in St Louis, MO, USA.
| | - Bradley A Fritz
- Department of Anesthesiology, Washington University in St Louis, MO, USA
| | - Mohamed Abdelhack
- Krembil Centre for NeuroInformatics, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in St Louis, MO, USA
| | - Yixin Chen
- Department of Computer Science and Engineering, Washington University in St Louis, MO, USA
| | - Christopher R King
- Department of Anesthesiology, Washington University in St Louis, MO, USA
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Abraham J, Holzer KJ, Lenard EM, Meng A, Pennington BRT, Wolfe RC, Haroutounian S, Calfee R, Hammil CW, Kozower BD, Cordner TA, Schweiger J, McKinnon S, Yingling M, Baumann AA, Politi MC, Kannampallil T, Miller JP, Avidan MS, Lenze EJ. A Perioperative Mental Health Intervention for Depressed and Anxious Older Surgical Patients: Results From a Feasibility Study. Am J Geriatr Psychiatry 2024; 32:205-219. [PMID: 37798223 PMCID: PMC10852892 DOI: 10.1016/j.jagp.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/02/2023] [Accepted: 09/06/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVES The perioperative period is challenging and stressful for older adults. Those with depression and/or anxiety have an increased risk of adverse surgical outcomes. We assessed the feasibility of a perioperative mental health intervention composed of medication optimization and a wellness program following principles of behavioral activation and care coordination for older surgical patients. METHODS We included orthopedic, oncologic, and cardiac surgical patients aged 60 and older. Feasibility outcomes included study reach, the number of patients who agreed to participate out of the total eligible; and intervention reach, the number of patients who completed the intervention out of patients who agreed to participate. Intervention efficacy was assessed using the Patient Health Questionnaire for Anxiety and Depression (PHQ-ADS). Implementation potential and experiences were collected using patient surveys and qualitative interviews. Complementary caregiver feedback was also collected. RESULTS Twenty-three out of 28 eligible older adults participated in this study (mean age 68.0 years, 65% women), achieving study reach of 82% and intervention reach of 83%. In qualitative interviews, patients (n = 15) and caregivers (complementary data, n = 5) described overwhelmingly positive experiences with both the intervention components and the interventionist, and reported improvement in managing depression and/or anxiety. Preliminary efficacy analysis indicated improvement in PHQ-ADS scores (F = 12.13, p <0.001). CONCLUSIONS The study procedures were reported by participants as feasible and the perioperative mental health intervention to reduce anxiety and depression in older surgical patients showed strong implementation potential. Preliminary data suggest its efficacy for improving depression and/or anxiety symptoms. A randomized controlled trial assessing the intervention and implementation effectiveness is currently ongoing.
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Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO; Institute for Informatics (JA, TK, JPM), Data Science and Biostatistics, Washington University School of Medicine, St. Louis, MO.
| | - Katherine J Holzer
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO
| | - Emily M Lenard
- Department of Psychiatry (EML, JS, MY, EJ), Washington University School of Medicine, St. Louis, MO
| | - Alicia Meng
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO
| | - Bethany R Tellor Pennington
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO
| | - Rachel C Wolfe
- Department of Pharmacy (RCW), Barnes-Jewish Hospital, St. Louis, MO
| | - Simon Haroutounian
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO
| | - Ryan Calfee
- Department of Orthopaedic Surgery (RC), Washington University School of Medicine, St. Louis, MO
| | - Chet W Hammil
- Department of Surgery (CWH, BDK, AAB, MCP), Washington University School of Medicine, St. Louis, MO
| | - Benjamin D Kozower
- Department of Surgery (CWH, BDK, AAB, MCP), Washington University School of Medicine, St. Louis, MO
| | - Theresa A Cordner
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO
| | - Julia Schweiger
- Department of Psychiatry (EML, JS, MY, EJ), Washington University School of Medicine, St. Louis, MO
| | - Sherry McKinnon
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO
| | - Michael Yingling
- Department of Psychiatry (EML, JS, MY, EJ), Washington University School of Medicine, St. Louis, MO
| | - Ana A Baumann
- Department of Surgery (CWH, BDK, AAB, MCP), Washington University School of Medicine, St. Louis, MO
| | - Mary C Politi
- Department of Surgery (CWH, BDK, AAB, MCP), Washington University School of Medicine, St. Louis, MO
| | - Thomas Kannampallil
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO; Institute for Informatics (JA, TK, JPM), Data Science and Biostatistics, Washington University School of Medicine, St. Louis, MO
| | - J Philip Miller
- Institute for Informatics (JA, TK, JPM), Data Science and Biostatistics, Washington University School of Medicine, St. Louis, MO
| | - Michael S Avidan
- Department of Anesthesiology (JA, KJH, AM, BRTP, SH, TAC, SM, TK, MSA), Washington University School of Medicine, St. Louis, MO
| | - Eric J Lenze
- Department of Psychiatry (EML, JS, MY, EJ), Washington University School of Medicine, St. Louis, MO
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Wasilczuk AZ, Rinehart C, Aggarwal A, Stone ME, Mashour GA, Avidan MS, Kelz MB, Proekt A. Hormonal basis of sex differences in anesthetic sensitivity. Proc Natl Acad Sci U S A 2024; 121:e2312913120. [PMID: 38190526 PMCID: PMC10801881 DOI: 10.1073/pnas.2312913120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/20/2023] [Indexed: 01/10/2024] Open
Abstract
General anesthesia-a pharmacologically induced reversible state of unconsciousness-enables millions of life-saving procedures. Anesthetics induce unconsciousness in part by impinging upon sexually dimorphic and hormonally sensitive hypothalamic circuits regulating sleep and wakefulness. Thus, we hypothesized that anesthetic sensitivity should be sex-dependent and modulated by sex hormones. Using distinct behavioral measures, we show that at identical brain anesthetic concentrations, female mice are more resistant to volatile anesthetics than males. Anesthetic sensitivity is bidirectionally modulated by testosterone. Castration increases anesthetic resistance. Conversely, testosterone administration acutely increases anesthetic sensitivity. Conversion of testosterone to estradiol by aromatase is partially responsible for this effect. In contrast, oophorectomy has no effect. To identify the neuronal circuits underlying sex differences, we performed whole brain c-Fos activity mapping under anesthesia in male and female mice. Consistent with a key role of the hypothalamus, we found fewer active neurons in the ventral hypothalamic sleep-promoting regions in females than in males. In humans, we demonstrate that females regain consciousness and recover cognition faster than males after identical anesthetic exposures. Remarkably, while behavioral and neurocognitive measures in mice and humans point to increased anesthetic resistance in females, cortical activity fails to show sex differences under anesthesia in either species. Cumulatively, we demonstrate that sex differences in anesthetic sensitivity are evolutionarily conserved and not reflected in conventional electroencephalographic-based measures of anesthetic depth. This covert resistance to anesthesia may explain the higher incidence of unintended awareness under general anesthesia in females.
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Affiliation(s)
- Andrzej Z. Wasilczuk
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA19104
- Neuroscience of Unconsciousness and Reanimation Research Alliance, Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA19104
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA19104
| | - Cole Rinehart
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA19104
- Neuroscience of Unconsciousness and Reanimation Research Alliance, Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA19104
| | - Adeeti Aggarwal
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA19104
- Neuroscience of Unconsciousness and Reanimation Research Alliance, Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA19104
- Department of Neuroscience, University of Pennsylvania, Philadelphia, PA19104
| | - Martha E. Stone
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA19104
- Neuroscience of Unconsciousness and Reanimation Research Alliance, Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA19104
- Department of Neuroscience, University of Pennsylvania, Philadelphia, PA19104
| | - George A. Mashour
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI48105
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO63110
| | - Max B. Kelz
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA19104
- Neuroscience of Unconsciousness and Reanimation Research Alliance, Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA19104
- Department of Neuroscience, University of Pennsylvania, Philadelphia, PA19104
- Mahoney Institute for Neurosciences, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA19104
| | - Alex Proekt
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA19104
- Neuroscience of Unconsciousness and Reanimation Research Alliance, Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA19104
- Department of Neuroscience, University of Pennsylvania, Philadelphia, PA19104
- Mahoney Institute for Neurosciences, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA19104
| | - ReCCognition Study Group
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA19104
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI48105
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO63110
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Abdelhack M, Tripathi S, Chen Y, Avidan MS, King CR. Social Vulnerability and Surgery Outcomes: A Cross-sectional Analysis. Res Sq 2023:rs.3.rs-3580911. [PMID: 38077013 PMCID: PMC10705703 DOI: 10.21203/rs.3.rs-3580911/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
Background Post-operative complications present a challenge to the healthcare system due to the high unpredictability of their incidence. However, the socioeconomic factors that relate to postoperative complications are still unclear as they can be heterogeneous based on communities, types of surgical services, and sex and gender. Methods In this study, we conducted a large population cross-sectional analysis of social vulnerability and the odds of various post-surgical complications. We built statistical logistic regression models of postsurgical complications with social vulnerability index as the independent variable along with sex interaction. Results We found that social vulnerability was associated with abnormal heart rhythm with socioeconomic status and housing status being the main association factors. We also found associations of the interaction of social vulnerability and female sex with an increase in odds of heart attack and surgical wound infection. Conclusions Our results indicate that social vulnerability measures such as socioeconomic status and housing conditions could be related to health outcomes. This suggests that the domain of preventive medicine should place social vulnerability as a priority to achieve its goals.
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Affiliation(s)
- Mohamed Abdelhack
- Department of Anesthesiology, Washington University School of Medicine, St. Louis MO
- Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, Toronto, ON
| | - Sandhya Tripathi
- Department of Anesthesiology, Washington University School of Medicine, St. Louis MO
| | - Yixin Chen
- Department of Computer Science, Washington University in St. Louis, St. Louis MO
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis MO
| | - Christopher R King
- Department of Anesthesiology, Washington University School of Medicine, St. Louis MO
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9
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Hu X, Pennington BRT, Avidan MS, Kheterpal S, deBourbon NG, Politi MC. Description of the Content and Quality of Publicly Available Information on the Internet About Inhaled Volatile Anesthesia and Total Intravenous Anesthesia: Descriptive Study. JMIR Perioper Med 2023; 6:e47714. [PMID: 37917148 PMCID: PMC10654911 DOI: 10.2196/47714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/29/2023] [Accepted: 09/19/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND More than 300 million patients undergo surgical procedures requiring anesthesia worldwide annually. There are 2 standard-of-care general anesthesia administration options: inhaled volatile anesthesia (INVA) and total intravenous anesthesia (TIVA). There is limited evidence comparing these methods and their impact on patient experiences and outcomes. Patients often seek this information from sources such as the internet. However, the majority of websites on anesthesia-related topics are not comprehensive, updated, and fully accurate. The quality and availability of web-based patient information about INVA and TIVA have not been sufficiently examined. OBJECTIVE This study aimed to (1) assess information on the internet about INVA and TIVA for availability, readability, accuracy, and quality and (2) identify high-quality websites that can be recommended to patients to assist in their anesthesia information-seeking and decision-making. METHODS Web-based searches were conducted using Google from April 2022 to November 2022. Websites were coded using a coding instrument developed based on the International Patient Decision Aids Standards criteria and adapted to be appropriate for assessing websites describing INVA and TIVA. Readability was calculated with the Flesch-Kincaid (F-K) grade level and the simple measure of Gobbledygook (SMOG) readability formula. RESULTS A total of 67 websites containing 201 individual web pages were included for coding and analysis. Most of the websites provided a basic definition of general anesthesia (unconsciousness, n=57, 85%; analgesia, n=47, 70%). Around half of the websites described common side effects of general anesthesia, while fewer described the rare but serious adverse events, such as intraoperative awareness (n=31, 46%), allergic reactions or anaphylaxis (n=29, 43%), and malignant hyperthermia (n=18, 27%). Of the 67 websites, the median F-K grade level was 11.3 (IQR 9.5-12.8) and the median SMOG score was 13.5 (IQR 12.2-14.4), both far above the American Medical Association (AMA) recommended reading level of sixth grade. A total of 51 (76%) websites distinguished INVA versus TIVA as general anesthesia options. A total of 12 of the 51 (24%) websites explicitly stated that there is a decision to be considered about receiving INVA versus TIVA for general anesthesia. Only 10 (20%) websites made any direct comparisons between INVA and TIVA, discussing their positive and negative features. A total of 12 (24%) websites addressed the concept of shared decision-making in planning anesthesia care, but none specifically asked patients to think about which features of INVA and TIVA matter the most to them. CONCLUSIONS While the majority of websites described INVA and TIVA, few provided comparisons. There is a need for high-quality patient education and decision support about the choice of INVA versus TIVA to provide accurate and more comprehensive information in a format conducive to patient understanding.
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Affiliation(s)
- Xinwen Hu
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, MO, United States
| | - Bethany R Tellor Pennington
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, MO, United States
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, MO, United States
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | | | - Mary C Politi
- Department of Surgery, Washington University in St Louis School of Medicine, St Louis, MO, United States
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10
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Srifuengfung M, Abraham J, Avidan MS, Lenze EJ. Perioperative Anxiety and Depression in Older Adults: Epidemiology and Treatment. Am J Geriatr Psychiatry 2023; 31:996-1008. [PMID: 37482501 PMCID: PMC10592367 DOI: 10.1016/j.jagp.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/20/2023] [Accepted: 07/03/2023] [Indexed: 07/25/2023]
Abstract
The intervals before and after major surgery is a high-risk period for older adults; in this setting, anxiety and depression are common and serious problems. We comprehensively reviewed current evidence on perioperative anxiety and depression in older adults, focusing on epidemiology, impact, correlates, medication risks, and treatment. Principles of perioperative mental healthcare are proposed based on the findings. Prevalence estimates of clinically significant anxiety and depression range from 5% to 45% for anxiety and 6% to 52% for depression, depending on surgical populations and measurement tools. Anxiety and depression may increase risk for surgical complications and reduce patient participation during rehabilitation. Medical comorbidities, pain, insomnia, cognitive impairment, and delirium are common co-occurring problems. Concomitant uses of central nervous system acting medications (benzodiazepines, anticholinergics, and opioids) amplify the risks of delirium and falls. Based on these findings, we propose that anxiety and depression care should be part of perioperative management in older adults; components include education, psychological support, opioid-sparing pain management, sleep management, deprescribing central nervous system active medications, and continuation and optimization of existing antidepressants. More research is needed to test and improve these care strategies.
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Affiliation(s)
- Maytinee Srifuengfung
- Department of Psychiatry (MS, EJL), Washington University School of Medicine, St. Louis, MO; Department of Psychiatry (MS), Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Joanna Abraham
- Department of Anesthesiology (JA, MSA), Washington University School of Medicine, St. Louis, MO; Institute for Informatics (JA), Washington University School of Medicine, St. Louis, MO
| | - Michael S Avidan
- Department of Anesthesiology (JA, MSA), Washington University School of Medicine, St. Louis, MO
| | - Eric J Lenze
- Department of Psychiatry (MS, EJL), Washington University School of Medicine, St. Louis, MO
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11
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Abraham J, Meng A, Baumann A, Holzer KJ, Lenard E, Freedland KE, Lenze EJ, Avidan MS, Politi MC. A multi- and mixed-method adaptation study of a patient-centered perioperative mental health intervention bundle. BMC Health Serv Res 2023; 23:1175. [PMID: 37891574 PMCID: PMC10612159 DOI: 10.1186/s12913-023-10186-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Anxiety and depression are common among older adults and can intensify during perioperative periods, but few mental health interventions are designed for older surgical patients' unique needs. As part of the feasibility trial, we developed and adapted a perioperative mental health (PMH) bundle for older patients comprised of behavioral activation (BA) and medication optimization (MO) to ameliorate anxiety and depressive symptoms before, during, and after cardiac, orthopedic, and oncologic surgery. METHODS We used mixed-methods including workshop studios with patients, caregivers, clinicians, researchers, and interventionists; intervention refinement and reflection meetings; patient case review meetings; intervention session audio-recordings and documentation forms; and patient and caregiver semi-structured interviews. We used the results to refine our PMH bundle. We used multiple analytical approaches to report the nature of adaptations, including hybrid thematic analysis and content analysis informed by the Framework for Reporting Adaptations and Modifications - Expanded. RESULTS Adaptations were categorized by content (intervention components), context (how the intervention is delivered, based on the study, target population, intervention format, intervention delivery mode, study setting, study personnel), training, and evaluation. Of 51 adaptations, 43.1% involved content, 41.2% involved context, and 15.7% involved training and evaluation. Several key adaptations were noted: (1) Intervention content was tailored to patient preferences and needs (e.g., rewording elements to prevent stigmatization of mental health needs; adjusting BA techniques and documentation forms to improve patient buy-in and motivation). (2) Cohort-specific adaptations were recommended based on differing patient needs. (3) Compassion was identified by patients as the most important element. CONCLUSIONS We identified evidence-based mental health intervention components from other settings and adapted them to the perioperative setting for older adults. Informed by mixed-methods, we created an innovative and pragmatic patient-centered intervention bundle that is acceptable, feasible, and responsive to the needs of older surgical populations. This approach allowed us to identify implementation strategies to improve the reach, scalability, and sustainability of our bundle, and can guide future patient-centered intervention adaptations. CLINICAL TRIALS REGISTRATION NCT05110690 (11/08/2021).
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Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA.
- Institute for Informatics, Data Science and Biostatistics, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA.
- Division of Biology and Biomedical Sciences, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA.
| | - Alicia Meng
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Ana Baumann
- Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Katherine J Holzer
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Emily Lenard
- Department of Psychiatry, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Kenneth E Freedland
- Department of Psychiatry, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Eric J Lenze
- Department of Psychiatry, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Michael S Avidan
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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King CR, Gregory S, Fritz BA, Budelier TP, Ben Abdallah A, Kronzer A, Helsten DL, Torres B, McKinnon S, Goswami S, Mehta D, Higo O, Kerby P, Henrichs B, Wildes TS, Politi MC, Abraham J, Avidan MS, Kannampallil T. An Intraoperative Telemedicine Program to Improve Perioperative Quality Measures: The ACTFAST-3 Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2332517. [PMID: 37738052 PMCID: PMC10517374 DOI: 10.1001/jamanetworkopen.2023.32517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/30/2023] [Indexed: 09/23/2023] Open
Abstract
Importance Telemedicine for clinical decision support has been adopted in many health care settings, but its utility in improving intraoperative care has not been assessed. Objective To pilot the implementation of a real-time intraoperative telemedicine decision support program and evaluate whether it reduces postoperative hypothermia and hyperglycemia as well as other quality of care measures. Design, Setting, and Participants This single-center pilot randomized clinical trial (Anesthesiology Control Tower-Feedback Alerts to Supplement Treatments [ACTFAST-3]) was conducted from April 3, 2017, to June 30, 2019, at a large academic medical center in the US. A total of 26 254 adult surgical patients were randomized to receive either usual intraoperative care (control group; n = 12 980) or usual care augmented by telemedicine decision support (intervention group; n = 13 274). Data were initially analyzed from April 22 to May 19, 2021, with updates in November 2022 and February 2023. Intervention Patients received either usual care (medical direction from the anesthesia care team) or intraoperative anesthesia care monitored and augmented by decision support from the Anesthesiology Control Tower (ACT), a real-time, live telemedicine intervention. The ACT incorporated remote monitoring of operating rooms by a team of anesthesia clinicians with customized analysis software. The ACT reviewed alerts and electronic health record data to inform recommendations to operating room clinicians. Main Outcomes and Measures The primary outcomes were avoidance of postoperative hypothermia (defined as the proportion of patients with a final recorded intraoperative core temperature >36 °C) and hyperglycemia (defined as the proportion of patients with diabetes who had a blood glucose level ≤180 mg/dL on arrival to the postanesthesia recovery area). Secondary outcomes included intraoperative hypotension, temperature monitoring, timely antibiotic redosing, intraoperative glucose evaluation and management, neuromuscular blockade documentation, ventilator management, and volatile anesthetic overuse. Results Among 26 254 participants, 13 393 (51.0%) were female and 20 169 (76.8%) were White, with a median (IQR) age of 60 (47-69) years. There was no treatment effect on avoidance of hyperglycemia (7445 of 8676 patients [85.8%] in the intervention group vs 7559 of 8815 [85.8%] in the control group; rate ratio [RR], 1.00; 95% CI, 0.99-1.01) or hypothermia (7602 of 11 447 patients [66.4%] in the intervention group vs 7783 of 11 672 [66.7.%] in the control group; RR, 1.00; 95% CI, 0.97-1.02). Intraoperative glucose measurement was more common among patients with diabetes in the intervention group (RR, 1.07; 95% CI, 1.01-1.15), but other secondary outcomes were not significantly different. Conclusions and Relevance In this randomized clinical trial, anesthesia care quality measures did not differ between groups, with high confidence in the findings. These results suggest that the intervention did not affect the targeted care practices. Further streamlining of clinical decision support and workflows may help the intraoperative telemedicine program achieve improvement in targeted clinical measures. Trial Registration ClinicalTrials.gov Identifier: NCT02830126.
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Affiliation(s)
- Christopher R. King
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Stephen Gregory
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Thaddeus P. Budelier
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Daniel L. Helsten
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Brian Torres
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Sherry McKinnon
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Shreya Goswami
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Divya Mehta
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Omokhaye Higo
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Paul Kerby
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Bernadette Henrichs
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Troy S. Wildes
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha
| | - Mary C. Politi
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University School of Medicine in St Louis, St Louis, Missouri
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13
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Pennington BRT, Politi MC, Abdallah AB, Janda AM, Eshun-Wilsonova I, deBourbon NG, Siderowf L, Klosterman H, Kheterpal S, Avidan MS. A survey of surgical patients' perspectives and preferences towards general anesthesia techniques and shared-decision making. BMC Anesthesiol 2023; 23:277. [PMID: 37592215 PMCID: PMC10433576 DOI: 10.1186/s12871-023-02219-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/23/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The decision about which type of general anesthetic to administer is typically made by the clinical team without patient engagement. This study examined patients' preferences, experiences, attitudes, beliefs, perceptions, and perceived social norms about anesthesia and about engaging in the decision regarding general anesthetic choice with their clinician. METHODS We conducted a survey in the United States, sent to a panel of surgical patients through Qualtrics (Qualtrics, Provo, UT) from March 2022 through May 2022. Questions were developed based on the Theory of Planned Behavior and validated measures were used when available. A patient partner who had experienced both intravenous and inhaled anesthesia contributed to the development and refinement of the questions. RESULTS A total of 806 patients who received general anesthesia for an elective procedure in the last five years completed the survey. 43% of respondents preferred a patient-led decision making role and 28% preferred to share decision making with their clinical team, yet only 7.8% reported being engaged in full shared decision making about the anesthesia they received. Intraoperative awareness, pain, nausea, vomiting and quickly returning to work and usual household activities were important to respondents. Waking up in the middle of surgery was the most commonly reported concern, despite this experience being reported only 8% of the time. Most patients (65%) who searched for information about general anesthesia noted that it took a lot of effort to find the information, and 53% agreed to feeling frustrated during the search. CONCLUSIONS Most patients prefer a patient-led or shared decision making process when it comes to their anesthetic care and want to be engaged in the decision. However, only a small percentage of patients reported being fully engaged in the decision. Further studies should inform future shared decision-making tools, informed consent materials, educational materials and framing of anesthetic choices for patients so that they are able to make a choice regarding the anesthetic they receive.
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Affiliation(s)
| | - Mary C Politi
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Allison M Janda
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Lilly Siderowf
- College of Arts and Sciences, Washington University, St. Louis, MO, USA
| | | | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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14
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Lou SS, Baratta LR, Lew D, Harford D, Avidan MS, Kannampallil T. Anesthesia Clinical Workload Estimated From Electronic Health Record Documentation vs Billed Relative Value Units. JAMA Netw Open 2023; 6:e2328514. [PMID: 37566415 PMCID: PMC10422189 DOI: 10.1001/jamanetworkopen.2023.28514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/03/2023] [Indexed: 08/12/2023] Open
Abstract
Importance Accurate measurements of clinical workload are needed to inform health care policy. Existing methods for measuring clinical workload rely on surveys or time-motion studies, which are labor-intensive to collect and subject to biases. Objective To compare anesthesia clinical workload estimated from electronic health record (EHR) audit log data vs billed relative value units. Design, Setting, and Participants This cross-sectional study of anesthetic encounters occurring between August 26, 2019, and February 9, 2020, used data from 8 academic hospitals, community hospitals, and surgical centers across Missouri and Illinois. Clinicians who provided anesthetic services for at least 1 surgical encounter were included. Data were analyzed from January 2022 to January 2023. Exposure Anesthetic encounters associated with a surgical procedure were included. Encounters associated with labor analgesia and endoscopy were excluded. Main Outcomes and Measures For each encounter, EHR-derived clinical workload was estimated as the sum of all EHR actions recorded in the audit log by anesthesia clinicians who provided care. Billing-derived clinical workload was measured as the total number of units billed for the encounter. A linear mixed-effects model was used to estimate the relative contribution of patient complexity (American Society of Anesthesiology [ASA] physical status modifier), procedure complexity (ASA base unit value for the procedure), and anesthetic duration (time units) to EHR-derived and billing-derived workload. The resulting β coefficients were interpreted as the expected effect of a 1-unit change in each independent variable on the standardized workload outcome. The analysis plan was developed after the data were obtained. Results A total of 405 clinicians who provided anesthesia for 31 688 encounters were included in the study. A total of 8 288 132 audit log actions corresponding to 39 131 hours of EHR use were used to measure EHR-derived workload. The contributions of patient complexity, procedural complexity, and anesthesia duration to EHR-derived workload differed significantly from their contributions to billing-derived workload. The contribution of patient complexity toward EHR-derived workload (β = 0.162; 95% CI, 0.153-0.171) was more than 50% greater than its contribution toward billing-derived workload (β = 0.106; 95% CI, 0.097-0.116; P < .001). In contrast, the contribution of procedure complexity toward EHR-derived workload (β = 0.033; 95% CI, 0.031-0.035) was approximately one-third its contribution toward billing-derived workload (β = 0.106; 95% CI, 0.104-0.108; P < .001). Conclusions and Relevance In this cross-sectional study of 8 hospitals, reimbursement for anesthesiology services overcompensated for procedural complexity and undercompensated for patient complexity. This method for measuring clinical workload could be used to improve reimbursement valuations for anesthesia and other specialties.
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Affiliation(s)
- Sunny S. Lou
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
- Institute for Informatics, Washington University School of Medicine, St Louis, Missouri
| | - Laura R. Baratta
- Institute for Informatics, Washington University School of Medicine, St Louis, Missouri
| | - Daphne Lew
- Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri
| | - Derek Harford
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
- Institute for Informatics, Washington University School of Medicine, St Louis, Missouri
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Guay CS, Hight D, Gupta G, Kafashan M, Luong AH, Avidan MS, Brown EN, Palanca BJA. Breathe-squeeze: pharmacodynamics of a stimulus-free behavioural paradigm to track conscious states during sedation ☆. Br J Anaesth 2023; 130:557-566. [PMID: 36967282 DOI: 10.1016/j.bja.2023.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 01/03/2023] [Accepted: 01/16/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Conscious states are typically inferred through responses to auditory tasks and noxious stimulation. We report the use of a stimulus-free behavioural paradigm to track state transitions in responsiveness during dexmedetomidine sedation. We hypothesised that estimated dexmedetomidine effect-site (Ce) concentrations would be higher at loss of responsiveness (LOR) compared with return of responsiveness (ROR), and both would be lower than comparable studies that used stimulus-based assessments. METHODS Closed-Loop Acoustic Stimulation during Sedation with Dexmedetomidine data were analysed for secondary analysis. Fourteen healthy volunteers were asked to perform the breathe-squeeze task of gripping a dynamometer when inspiring and releasing it when expiring. LOR was defined as five inspirations without accompanied squeezes; ROR was defined as the return of five inspirations accompanied by squeezes. Brain states were monitored using 64-channel EEG. Dexmedetomidine was administered as a target-controlled infusion, with Ce estimated from a pharmacokinetic model. RESULTS Counter to our hypothesis, mean estimated dexmedetomidine Ce was lower at LOR (0.92 ng ml-1; 95% confidence interval: 0.69-1.15) than at ROR (1.43 ng ml-1; 95% confidence interval: 1.27-1.58) (paired t-test; P=0.002). LOR was characterised by progressively increasing fronto-occipital EEG power in the 0.5-8 Hz band and loss of occipital alpha (8-12 Hz) and global beta (16-30 Hz) power. These EEG changes reverted at ROR. CONCLUSIONS The breathe-squeeze task can effectively track changes in responsiveness during sedation without external stimuli and might be more sensitive to state changes than stimulus-based tasks. It should be considered when perturbation of brain states is undesirable. CLINICAL TRIAL REGISTRATION NCT04206059.
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Affiliation(s)
- Christian S Guay
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, MA, USA.
| | - Darren Hight
- Department of Anaesthesiology & Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gaurang Gupta
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - MohammadMehdi Kafashan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Anhthi H Luong
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Emery N Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Ben Julian A Palanca
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA; Center on Biological Rhythms and Sleep, Washington University in St. Louis, St. Louis, MO, USA
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Tellor Pennington BR, Colquhoun DA, Neuman MD, Politi MC, Janda AM, Spino C, Thelen-Perry S, Wu Z, Kumar SS, Gregory SH, Avidan MS, Kheterpal S. Feasibility pilot trial for the Trajectories of Recovery after Intravenous propofol versus inhaled VolatilE anesthesia (THRIVE) pragmatic randomised controlled trial. BMJ Open 2023; 13:e070096. [PMID: 37068889 PMCID: PMC10111921 DOI: 10.1136/bmjopen-2022-070096] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
INTRODUCTION Millions of patients receive general anaesthesia for surgery annually. Crucial gaps in evidence exist regarding which technique, propofol total intravenous anaesthesia (TIVA) or inhaled volatile anaesthesia (INVA), yields superior patient experience, safety and outcomes. The aim of this pilot study is to assess the feasibility of conducting a large comparative effectiveness trial assessing patient experiences and outcomes after receiving propofol TIVA or INVA. METHODS AND ANALYSIS This protocol was cocreated by a diverse team, including patient partners with personal experience of TIVA or INVA. The design is a 300-patient, two-centre, randomised, feasibility pilot trial. Patients 18 years of age or older, undergoing elective non-cardiac surgery requiring general anaesthesia with a tracheal tube or laryngeal mask airway will be eligible. Patients will be randomised 1:1 to propofol TIVA or INVA, stratified by centre and procedural complexity. The feasibility endpoints include: (1) proportion of patients approached who agree to participate; (2) proportion of patients who receive their assigned randomised treatment; (3) completeness of outcomes data collection and (4) feasibility of data management procedures. Proportions and 95% CIs will be calculated to assess whether prespecified thresholds are met for the feasibility parameters. If the lower bounds of the 95% CI are above the thresholds of 10% for the proportion of patients agreeing to participate among those approached and 80% for compliance with treatment allocation for each randomised treatment group, this will suggest that our planned pragmatic 12 500-patient comparative effectiveness trial can likely be conducted successfully. Other feasibility outcomes and adverse events will be described. ETHICS AND DISSEMINATION This study is approved by the ethics board at Washington University (IRB# 202205053), serving as the single Institutional Review Board for both participating sites. Recruitment began in September 2022. Dissemination plans include presentations at scientific conferences, scientific publications, internet-based educational materials and mass media. TRIAL REGISTRATION NUMBER NCT05346588.
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Affiliation(s)
| | - Douglas A Colquhoun
- Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Mark D Neuman
- Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary C Politi
- Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Allison M Janda
- Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Cathie Spino
- Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Zhenke Wu
- Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Sathish S Kumar
- Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Stephen H Gregory
- Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael S Avidan
- Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sachin Kheterpal
- Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
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Labonte AK, Kafashan M, Huels ER, Blain-Moraes S, Basner M, Kelz MB, Mashour GA, Avidan MS, Palanca BJA. The posterior dominant rhythm: an electroencephalographic biomarker for cognitive recovery after general anaesthesia. Br J Anaesth 2023; 130:e233-e242. [PMID: 35183346 PMCID: PMC9900730 DOI: 10.1016/j.bja.2022.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/22/2021] [Accepted: 01/09/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The posterior dominant rhythm (PDR) was the first oscillatory pattern noted in the EEG. Evoked by wakeful eyelid closure, these oscillations dissipate over seconds during loss of arousal. The peak frequency of the PDR maintains stability over years, suggesting utility as a state biomarker in the surveillance of acute cognitive impairments. This EEG signature has not been systematically investigated for tracking cognitive dysfunction after anaesthetic-induced loss of consciousness. METHODS This substudy of Reconstructing Consciousness and Cognition (NCT01911195) investigated the PDR and cognitive function in 60 adult volunteers randomised to either 3 h of isoflurane general anaesthesia or resting wakefulness. Serial measurements of EEG power and cognitive task performance were assessed relative to pre-intervention baseline. Mixed-effects models allowed quantification of PDR and neurocognitive trajectories after return of responsiveness (ROR). RESULTS Individuals in the control group showed stability in the PDR peak frequency over several hours (median difference/inter-quartile range [IQR] of 0.02/0.20 Hz, P=0.39). After isoflurane general anaesthesia, the PDR peak frequency was initially reduced at ROR (median difference/IQR of 0.88/0.65 Hz, P<0.001). PDR peak frequency recovered at a rate of 0.20 Hz h-1. After ROR, the PDR peak frequency correlated with reaction time and accuracy on multiple cognitive tasks (P<0.001). CONCLUSION The temporal trajectory of the PDR peak frequency could be a useful perioperative marker for tracking cognitive dysfunction on the order of hours after surgery, particularly for cognitive domains of working memory, visuomotor speed, and executive function. CLINICAL TRIAL REGISTRATION NCT01911195.
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Affiliation(s)
- Alyssa K Labonte
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - MohammadMehdi Kafashan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Center on Biological Rhythms and Sleep, Washington University School of Medicine in St. Louis, Missouri
| | - Emma R Huels
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Anesthesiology, Center for Consciousness Science and Neuroscience Graduate Program, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stefanie Blain-Moraes
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
| | - Mathias Basner
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Max B Kelz
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - George A Mashour
- Department of Anesthesiology, Center for Consciousness Science and Neuroscience Graduate Program, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Center on Biological Rhythms and Sleep, Washington University School of Medicine in St. Louis, Missouri; Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Ben Julian A Palanca
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Center on Biological Rhythms and Sleep, Washington University School of Medicine in St. Louis, Missouri; Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA.
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18
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Huels ER, Kafashan M, Hickman LB, Ching S, Lin N, Lenze EJ, Farber NB, Avidan MS, Hogan RE, Palanca BJA. Central-positive complexes in ECT-induced seizures: Possible evidence for thalamocortical mechanisms. Clin Neurophysiol 2023; 146:77-86. [PMID: 36549264 PMCID: PMC10273093 DOI: 10.1016/j.clinph.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 10/20/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Central-positive complexes (CPCs) are elicited during electroconvulsive therapy (ECT) as generalized high-amplitude waveforms with maximum positive voltage over the vertex. While these complexes have been qualitatively assessed in previous literature, quantitative analyses are lacking. This study aims to characterize CPCs across temporal, spatial, and spectral domains. METHODS High-density 64-electrode electroencephalogram (EEG) recordings during 50 seizures acquired from 11 patients undergoing right unilateral ECT allowed for evaluation of spatiotemporal characteristics of CPCs via source localization and spectral analysis. RESULTS Peak-amplitude CPC scalp topology was consistent across seizures, showing maximal positive polarity over the midline fronto-central region and maximal negative polarity over the suborbital regions. The sources of these peak potentials were localized to the bilateral medial thalamus and cingulate cortical regions. Delta, beta, and gamma oscillations were correlated with the peak amplitude of CPCs during seizures induced during ketamine, whereas delta and gamma oscillations were associated with CPC peaks during etomidate anesthesia (excluding the dose-charge titration). CONCLUSIONS Our findings demonstrate the consistency of CPC presence across participant, stimulus charge, time, and anesthetic agent, with peaks localized to bilateral medial thalamus and cingulate cortical regions and associated with delta, beta, and gamma band oscillations (depending on the anesthetic condition). SIGNIFICANCE The consistency and reproducibility of CPCs offers ECT as a new avenue for studying the dynamics of generalized seizure activity and thalamocortical networks.
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Affiliation(s)
- Emma R Huels
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, USA; Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Center for Consciousness Science, University of Michigan, Ann Arbor, MI, USA
| | - MohammadMehdi Kafashan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Center on Biological Rhythms and Sleep, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - L Brian Hickman
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - ShiNung Ching
- Department of Electrical & Systems Engineering, Washington University in St. Louis, St. Louis, MO, USA; Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Nan Lin
- Department of Mathematics and Statistics, Washington University in St. Louis, St. Louis, MO, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Nuri B Farber
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - R Edward Hogan
- Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Ben Julian A Palanca
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Center on Biological Rhythms and Sleep, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA; Neuroimaging Labs Research Center, Washington University School of Medicine in St. Louis, St. Louis, MO, USA.
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19
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Labonte AK, Kafashan MM, Huels ER, Blain-Moraes S, Basner M, Kelz MB, Mashour GA, Avidan MS, Palanca BJA. The posterior dominant rhythm: an electroencephalographic surrogate for cognitive recovery after general anaesthesia. Br J Anaesth 2023. [DOI: 10.1016/j.bja.2022.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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20
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Abraham J, Meng A, Baumann-Walker A, Holzer K, Lenard E, Freedland KE, Lenze EJ, Avidan MS, Politi MC. A Patient-Centered Perioperative Mental Health Intervention Bundle: A Multi- and Mixed-Method Adaptation Study. Res Sq 2023:rs.3.rs-2451723. [PMID: 36711989 PMCID: PMC9882664 DOI: 10.21203/rs.3.rs-2451723/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background Anxiety and depression are common among older adults and can intensify during perioperative periods, but few mental health interventions are designed for older surgical patients' unique needs. We developed and adapted a perioperative mental health (PMH) bundle for older patients comprised of behavioral activation (BA) and medication optimization (MO) to ameliorate anxiety and depressive symptoms before, during, and after cardiac, orthopedic, and oncologic surgery. Methods We used mixed-methods including workshop studios with patients, caregivers, clinicians, researchers, and interventionists; intervention refinement and reflection meetings; patient case review meetings; intervention session audio-recordings and documentation forms; and patient and caregiver semi-structured interviews. We used the results to refine our PMH bundle. We used multiple analytical approaches to report the nature of adaptations, including hybrid thematic analysis and content analysis informed by the Framework for Reporting Adaptations and Modifications - Expanded. Results Adaptations were categorized by content (intervention components), context (how the intervention is delivered, based on the study, target population, intervention format, intervention delivery mode, study setting, study personnel), training, and evaluation. Of 51 adaptations, 43.1% involved content, 41.2% involved context, and 15.7% involved training and evaluation. Several key adaptations were noted: 1) Intervention content was tailored to patient preferences and needs (e.g., rewording elements to prevent stigmatization of mental health needs; adjusting BA techniques and documentation forms to improve patient buy-in and motivation). 2) Cohort-specific adaptations were recommended based on differing patient needs. 3) Compassion was identified by patients as the most important element. Conclusions We identified evidence-based mental health intervention components from other settings and adapted them to the perioperative setting for older adults. Informed by mixed-methods, we created an innovative and pragmatic patient-centered intervention bundle that is acceptable, feasible, and responsive to the needs of older surgical populations. This approach allowed us to identify implementation strategies to improve the reach, scalability, and sustainability of our bundle, and can guide future patient-centered intervention adaptations.
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Deschamps A, Saha T, El-Gabalawy R, Jacobsohn E, Overbeek C, Palermo J, Robichaud S, Dumont AA, Djaiani G, Carroll J, Kavosh MS, Tanzola R, Schmitt EM, Inouye SK, Oberhaus J, Mickle A, Ben Abdallah A, Avidan MS, Clinical Trials Group CPA. Protocol for the electroencephalography guidance of anesthesia to alleviate geriatric syndromes (ENGAGES-Canada) study: A pragmatic, randomized clinical trial. F1000Res 2023; 8:1165. [PMID: 31588356 PMCID: PMC6760454 DOI: 10.12688/f1000research.19213.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
Background: There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery. There is limited evidence in this regard for cardiac surgery. A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death. However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes. Methods: The Electroe ncephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes ( ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites. The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery. One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25). The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients. The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review. Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation. Discussion: The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD. Registration: ClinicalTrials.gov ( NCT02692300) 26/02/2016.
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Affiliation(s)
- Alain Deschamps
- Department of Anesthesiology and Pain Medicine, Montreal Heart Institute and Universite de Montreal, Montreal, Quebec, H1T 1C8, Canada,
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Kingston, Ontario, Canada
| | - Renée El-Gabalawy
- Department of Clinical Health Psychology, Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric Jacobsohn
- Departments of Anesthesia and Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles Overbeek
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer Palermo
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | | | - Andrea Alicia Dumont
- Montreal Health Innovation Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - George Djaiani
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Jo Carroll
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Morvarid S. Kavosh
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rob Tanzola
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Kingston, Ontario, Canada
| | - Eva M. Schmitt
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Angela Mickle
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
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Deschamps A, Saha T, El-Gabalawy R, Jacobsohn E, Overbeek C, Palermo J, Robichaud S, Dumont AA, Djaiani G, Carroll J, Kavosh MS, Tanzola R, Schmitt EM, Inouye SK, Oberhaus J, Mickle A, Ben Abdallah A, Avidan MS, Clinical Trials Group CPA. Protocol for the electroencephalography guidance of anesthesia to alleviate geriatric syndromes (ENGAGES-Canada) study: A pragmatic, randomized clinical trial. F1000Res 2023; 8:1165. [PMID: 31588356 PMCID: PMC6760454 DOI: 10.12688/f1000research.19213.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2019] [Indexed: 01/27/2023] Open
Abstract
Background: There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery. There is limited evidence in this regard for cardiac surgery. A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death. However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes. Methods: The Electroe ncephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes ( ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites. The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery. One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25). The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients. The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review. Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation. Discussion: The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD. Registration: ClinicalTrials.gov ( NCT02692300) 26/02/2016.
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Affiliation(s)
- Alain Deschamps
- Department of Anesthesiology and Pain Medicine, Montreal Heart Institute and Universite de Montreal, Montreal, Quebec, H1T 1C8, Canada,
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Kingston, Ontario, Canada
| | - Renée El-Gabalawy
- Department of Clinical Health Psychology, Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric Jacobsohn
- Departments of Anesthesia and Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles Overbeek
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer Palermo
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada
| | | | - Andrea Alicia Dumont
- Montreal Health Innovation Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - George Djaiani
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Jo Carroll
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Morvarid S. Kavosh
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rob Tanzola
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Kingston, Ontario, Canada
| | - Eva M. Schmitt
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Sharon K. Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Angela Mickle
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St-Louis, Missouri, USA
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Guay CS, Kafashan M, Huels ER, Jiang Y, Beyoglu B, Spencer JW, Geczi K, Apakama G, Ju YES, Wildes TS, Avidan MS, Palanca BJA. Postoperative Delirium Severity and Recovery Correlate With Electroencephalogram Spectral Features. Anesth Analg 2023; 136:140-151. [PMID: 36130079 PMCID: PMC9653519 DOI: 10.1213/ane.0000000000006075] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Delirium is an acute syndrome characterized by inattention, disorganized thinking, and an altered level of consciousness. A reliable biomarker for tracking delirium does not exist, but oscillations in the electroencephalogram (EEG) could address this need. We evaluated whether the frequencies of EEG oscillations are associated with delirium onset, severity, and recovery in the postoperative period. METHODS Twenty-six adults enrolled in the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES; ClinicalTrials.gov NCT02241655) study underwent major surgery requiring general anesthesia, and provided longitudinal postoperative EEG recordings for this prespecified substudy. The presence and severity of delirium were evaluated with the confusion assessment method (CAM) or the CAM-intensive care unit. EEG data obtained during awake eyes-open and eyes-closed states yielded relative power in the delta (1-4 Hz), theta (4-8 Hz), and alpha (8-13 Hz) bands. Discriminability for delirium presence was evaluated with c-statistics. To account for correlation among repeated measures within patients, mixed-effects models were generated to assess relationships between: (1) delirium severity and EEG relative power (ordinal), and (2) EEG relative power and time (linear). Slopes of ordinal and linear mixed-effects models are reported as the change in delirium severity score/change in EEG relative power, and the change in EEG relative power/time (days), respectively. Bonferroni correction was applied to confidence intervals (CIs) to account for multiple comparisons. RESULTS Occipital alpha relative power during eyes-closed states offered moderate discriminability (c-statistic, 0.75; 98% CI, 0.58-0.87), varying inversely with delirium severity (slope, -0.67; 98% CI, -1.36 to -0.01; P = .01) and with severity of inattention (slope, -1.44; 98% CI, -2.30 to -0.58; P = .002). Occipital theta relative power during eyes-open states correlated directly with severity of delirium (slope, 1.28; 98% CI, 0.12-2.44; P = .007), inattention (slope, 2.00; 98% CI, 0.48-3.54; P = .01), and disorganized thinking (slope, 3.15; 98% CI, 0.66-5.65; P = .01). Corresponding frontal EEG measures recapitulated these relationships to varying degrees. Severity of altered level of consciousness correlated with frontal theta relative power during eyes-open states (slope, 11.52; 98% CI, 6.33-16.71; P < .001). Frontal theta relative power during eyes-open states correlated inversely with time (slope, -0.05; 98% CI, -0.12 to -0.04; P = .002). CONCLUSIONS Presence, severity, and core features of postoperative delirium covary with spectral features of the EEG. The cost and accessibility of EEG facilitate the translation of these findings to future mechanistic and interventional trials.
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Affiliation(s)
- Christian S Guay
- From the Department of Anesthesiology
- Center on Biological Rhythms and Sleep, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - MohammadMehdi Kafashan
- From the Department of Anesthesiology
- Center on Biological Rhythms and Sleep, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Emma R Huels
- Neuroscience Graduate Program
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | | | - Bora Beyoglu
- Baylor Scott and White Research Institute, Plano, Texas
| | | | - Kristin Geczi
- From the Department of Anesthesiology
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Yo-El S Ju
- From the Department of Anesthesiology
- Center on Biological Rhythms and Sleep, Washington University School of Medicine in St Louis, St Louis, Missouri
- Department of Neurology
- Hope Center for Neurological Disorders
| | | | - Michael S Avidan
- From the Department of Anesthesiology
- Center on Biological Rhythms and Sleep, Washington University School of Medicine in St Louis, St Louis, Missouri
- Department of Psychiatry
| | - Ben Julian A Palanca
- Department of Psychiatry
- Division of Biology and Biomedical Sciences
- Department of Biomedical Engineering; Washington University School of Medicine in St Louis, St Louis, Missouri
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Abraham J, Bartek B, Meng A, Ryan King C, Xue B, Lu C, Avidan MS. Integrating machine learning predictions for perioperative risk management: Towards an empirical design of a flexible-standardized risk assessment tool. J Biomed Inform 2023; 137:104270. [PMID: 36516944 DOI: 10.1016/j.jbi.2022.104270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/02/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Surgical patients are complex, vulnerable, and prone to postoperative complications that can potentially be mitigated with quality perioperative risk assessment and management. Several institutions have incorporated machine learning (ML) into their patient care to improve awareness and support clinician decision-making along the perioperative spectrum. Recent research suggests that ML risk prediction can support perioperative patient risk monitoring and management across several situations, including the operating room (OR) to intensive care unit (ICU) handoffs. OBJECTIVES Our study objectives were threefold: (1) evaluate whether ML-generated postoperative predictions are concordant with clinician-generated risk rankings for acute kidney injury, delirium, pneumonia, deep vein thrombosis, and pulmonary embolism, and establish their associated risk factors; (2) ascertain clinician end-user suggestions to improve adoption of ML-generated risks and their integration into the perioperative workflow; and (3) develop a user-friendly visualization format for a tool to display ML-generated risks and risk factors to support postoperative care planning, for example, within the context of OR-ICU handoffs. METHODS Graphical user interfaces for postoperative risk prediction models were assessed for end-user usability through cognitive walkthroughs and interviews with anesthesiologists, surgeons, certified registered nurse anesthetists, registered nurses, and critical care physicians. Thematic analysis relying on an explanation design framework was used to identify feedback and suggestions for improvement. RESULTS 17 clinicians participated in the evaluation. ML estimates of complication risks aligned with clinicians' independent rankings, and related displays were perceived as valuable for decision-making and care planning for postoperative care. During OR-ICU handoffs, the tool could speed up report preparation and remind clinicians to address patient-specific complications, thus providing more tailored care information. Suggestions for improvement centered on electronic tool delivery; methods to build trust in ML models; modifiable risks and risk mitigation strategies; and additional patient information based on individual preferences (e.g., surgical procedure). CONCLUSIONS ML estimates of postoperative complication risks can provide anticipatory guidance, potentially increasing the efficiency of care planning. We have offered an ML visualization framework for designing future ML-augmented tools and anticipate the development of tools that recommend specific actions to the user based on ML model output.
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Affiliation(s)
- Joanna Abraham
- Institute for Informatics, School of Medicine, Washington University in St Louis, MO, United States; Department of Anesthesiology, School of Medicine, Washington University in St Louis, MO, United States.
| | - Brian Bartek
- Institute for Informatics, School of Medicine, Washington University in St Louis, MO, United States
| | - Alicia Meng
- Department of Anesthesiology, School of Medicine, Washington University in St Louis, MO, United States
| | - Christopher Ryan King
- Department of Anesthesiology, School of Medicine, Washington University in St Louis, MO, United States
| | - Bing Xue
- Department of Electrical & Systems Engineering, McKelvey School of Engineering, Washington University in St Louis, MO, United States
| | - Chenyang Lu
- Department of Computer Science & Engineering, McKelvey School of Engineering, Washington University in St Louis, MO, United States
| | - Michael S Avidan
- Department of Anesthesiology, School of Medicine, Washington University in St Louis, MO, United States
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Abraham J, Meng A, Montes de Oca A, Politi M, Wildes T, Gregory S, Henrichs B, Kannampallil T, Avidan MS. An ethnographic study on the impact of a novel telemedicine-based support system in the operating room. J Am Med Inform Assoc 2022; 29:1919-1930. [PMID: 35985294 PMCID: PMC10161534 DOI: 10.1093/jamia/ocac138] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/07/2022] [Accepted: 08/04/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The Anesthesiology Control Tower (ACT) for operating rooms (ORs) remotely assesses the progress of surgeries and provides real-time perioperative risk alerts, communicating risk mitigation recommendations to bedside clinicians. We aim to identify and map ACT-OR nonroutine events (NREs)-risk-inducing or risk-mitigating workflow deviations-and ascertain ACT's impact on clinical workflow and patient safety. MATERIALS AND METHODS We used ethnographic methods including shadowing ACT and OR clinicians during 83 surgeries, artifact collection, chart reviews for decision alerts sent to the OR, and 10 clinician interviews. We used hybrid thematic analysis informed by a human-factors systems-oriented approach to assess ACT's role and impact on safety, conducting content analysis to assess NREs. RESULTS Across 83 cases, 469 risk alerts were triggered, and the ACT sent 280 care recommendations to the OR. 135 NREs were observed. Critical factors facilitating ACT's role in supporting patient safety included providing backup support and offering a fresh-eye perspective on OR decisions. Factors impeding ACT included message timing and ACT and OR clinician cognitive lapses. Suggestions for improvement included tailoring ACT message content (structure, timing, presentation) and incorporating predictive analytics for advanced planning. DISCUSSION ACT served as a safety net with remote surveillance features and as a learning healthcare system with feedback/auditing features. Supporting strategies include adaptive coordination and harnessing clinician/patient support to improve ACT's sustainability. Study insights inform future intraoperative telemedicine design considerations to mitigate safety risks. CONCLUSION Incorporating similar remote technology enhancement into routine perioperative care could markedly improve safety and quality for millions of surgical patients.
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Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Institute for Informatics, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Division of Biology and Biomedical Sciences, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Alicia Meng
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Arianna Montes de Oca
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Mary Politi
- Department of Surgery, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Troy Wildes
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Stephen Gregory
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Bernadette Henrichs
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Goldfarb School of Nursing, Barnes-Jewish College, St. Louis, Missouri, USA
| | - Thomas Kannampallil
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Institute for Informatics, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Division of Biology and Biomedical Sciences, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Computer Science & Engineering, McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Michael S Avidan
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
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Chang AY, Aaby P, Avidan MS, Benn CS, Bertozzi SM, Blatt L, Chumakov K, Khader SA, Kottilil S, Nekkar M, Netea MG, Sparrow A, Jamison DT. One vaccine to counter many diseases? Modeling the economics of oral polio vaccine against child mortality and COVID-19. Front Public Health 2022; 10:967920. [PMID: 36276367 PMCID: PMC9580701 DOI: 10.3389/fpubh.2022.967920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/31/2022] [Indexed: 01/25/2023] Open
Abstract
Introduction Recent reviews summarize evidence that some vaccines have heterologous or non-specific effects (NSE), potentially offering protection against multiple pathogens. Numerous economic evaluations examine vaccines' pathogen-specific effects, but less than a handful focus on NSE. This paper addresses that gap by reporting economic evaluations of the NSE of oral polio vaccine (OPV) against under-five mortality and COVID-19. Materials and methods We studied two settings: (1) reducing child mortality in a high-mortality setting (Guinea-Bissau) and (2) preventing COVID-19 in India. In the former, the intervention involves three annual campaigns in which children receive OPV incremental to routine immunization. In the latter, a susceptible-exposed-infectious-recovered model was developed to estimate the population benefits of two scenarios, in which OPV would be co-administered alongside COVID-19 vaccines. Incremental cost-effectiveness and benefit-cost ratios were modeled for ranges of intervention effectiveness estimates to supplement the headline numbers and account for heterogeneity and uncertainty. Results For child mortality, headline cost-effectiveness was $650 per child death averted. For COVID-19, assuming OPV had 20% effectiveness, incremental cost per death averted was $23,000-65,000 if it were administered simultaneously with a COVID-19 vaccine <200 days into a wave of the epidemic. If the COVID-19 vaccine availability were delayed, the cost per averted death would decrease to $2600-6100. Estimated benefit-to-cost ratios vary but are consistently high. Discussion Economic evaluation suggests the potential of OPV to efficiently reduce child mortality in high mortality environments. Likewise, within a broad range of assumed effect sizes, OPV (or another vaccine with NSE) could play an economically attractive role against COVID-19 in countries facing COVID-19 vaccine delays. Funding The contribution by DTJ was supported through grants from Trond Mohn Foundation (BFS2019MT02) and Norad (RAF-18/0009) through the Bergen Center for Ethics and Priority Setting.
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Affiliation(s)
- Angela Y. Chang
- Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark,Department of Clinical Research, University of Southern Denmark, Odense, Denmark,*Correspondence: Angela Y. Chang
| | - Peter Aaby
- Bandim Health Project, Department of Clinical Research, University of Southern Denmark, Odense, Denmark,Bandim Health Project, Bissau, Guinea-Bissau
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, United States
| | - Christine S. Benn
- Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark,Bandim Health Project, Department of Clinical Research, University of Southern Denmark, Odense, Denmark,Bandim Health Project, Bissau, Guinea-Bissau
| | - Stefano M. Bertozzi
- School of Public Health, University of California, Berkeley, Berkeley, CA, United States,School of Public Health, University of Washington, Seattle, WA, United States,Instituto Nacional de Salud Pública, Cuernavaca, Mexico
| | - Lawrence Blatt
- Aligos Therapeutics, South San Francisco, CA, United States,Global Virus Network, Baltimore, MD, United States
| | - Konstantin Chumakov
- Global Virus Network, Baltimore, MD, United States,Food and Drug Administration Office of Vaccine Research and Review, Silver Spring, MD, United States
| | - Shabaana A. Khader
- Department of Molecular Microbiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Shyam Kottilil
- Global Virus Network, Baltimore, MD, United States,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Madhav Nekkar
- School of Public Health, University of California, Berkeley, Berkeley, CA, United States
| | - Mihai G. Netea
- Global Virus Network, Baltimore, MD, United States,Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands,Department of Immunology and Metabolism, Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Annie Sparrow
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Dean T. Jamison
- Department of Epidemiology and Biostatistics and Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States
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Fuller BM, Pappal RD, Mohr NM, Roberts BW, Faine B, Yeary J, Sewatsky T, Johnson NJ, Driver BE, Ablordeppey E, Drewry AM, Wessman BT, Yan Y, Kollef MH, Carpenter CR, Avidan MS. Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study. Crit Care Med 2022; 50:1449-1460. [PMID: 35866657 PMCID: PMC10040234 DOI: 10.1097/ccm.0000000000005626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES In mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence. DESIGN An a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial. SETTING The ED of three academic medical centers. PATIENTS Mechanically ventilated adult patients that received neuromuscular blockers. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% ( n = 13), the majority of whom received rocuronium ( n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% ( n = 12/230) experienced AWP, compared with 0.6% ( n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11-67.15). Patients experiencing AWP had a higher mean ( sd ) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01). CONCLUSIONS AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.
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Affiliation(s)
- Brian M Fuller
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Ryan D Pappal
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Brett Faine
- Departments of Emergency Medicine and Pharmacy, Roy J. and Lucille A. Carver College of Medicine, University of Iowa College of Pharmacy, Iowa City, IA
| | - Julianne Yeary
- Emergency Department, Charles F. Knight Emergency and Trauma Center, Barnes Jewish Hospital, St. Louis, MO
| | - Thomas Sewatsky
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Nicholas J Johnson
- Departments of Emergency Medicine and Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington/Harborview Medical Center, Seattle, WA
| | - Brian E Driver
- Department of Emergency Medicine, University of Minnesota School of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Enyo Ablordeppey
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian T Wessman
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Division of Biostatistics, Washington University School of Medicine, St. Louis, MO
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO
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28
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Kafashan M, Brian Hickman L, Labonte AK, Huels ER, Maybrier H, Guay CS, Subramanian S, Farber NB, Ching S, Hogan RE, Kelz MB, Avidan MS, Mashour GA, Palanca BJA. Quiescence during burst suppression and postictal generalized EEG suppression are distinct patterns of activity. Clin Neurophysiol 2022; 142:125-132. [PMID: 36030576 PMCID: PMC10287541 DOI: 10.1016/j.clinph.2022.07.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 06/15/2022] [Accepted: 07/17/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Periods of low-amplitude electroencephalographic (EEG) signal (quiescence) are present during both anesthetic-induced burst suppression (BS) and postictal generalized electroencephalographic suppression (PGES). PGES following generalized seizures induced by electroconvulsive therapy (ECT) has been previously linked to antidepressant response. The commonality of quiescence during both BS and PGES motivated trials to recapitulate the antidepressant effects of ECT using high doses of anesthetics. However, there have been no direct electrographic comparisons of these quiescent periods to address whether these are distinct entities. METHODS We compared periods of EEG quiescence recorded from two human studies: BS induced in 29 healthy adult volunteers by isoflurane general anesthesia and PGES in 11 patients undergoing right unilateral ECT for treatment-resistant depression. An automated algorithm allowed detection of EEG quiescence based on a 10-microvolt amplitude threshold. Spatial, spectral, and temporal analyses compared quiescent epochs during BS and PGES. RESULTS The median (interquartile range) voltage for quiescent periods during PGES was greater than during BS (1.81 (0.22) microvolts vs 1.22 (0.33) microvolts, p < 0.001). Relative power was greater for quiescence during PGES than BS for the 1-4 Hz delta band (p < 0.001), at the expense of power in the theta (4-8 Hz, p < 0.001), beta (13-30 Hz, p = 0.04) and gamma (30-70 Hz, p = 0.006) frequency bands. Topographic analyses revealed that amplitude across the scalp was consistently higher for quiescent periods during PGES than BS, whose voltage was within the noise floor. CONCLUSIONS Quiescent epochs during PGES and BS have distinct patterns of EEG signals across voltage, frequency, and spatial domains. SIGNIFICANCE Quiescent epochs during PGES and BS, important neurophysiological markers for clinical outcomes, are shown to have distinct voltage and frequency characteristics.
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Affiliation(s)
- MohammadMehdi Kafashan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - L Brian Hickman
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Neurology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA
| | - Alyssa K Labonte
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Neuroscience Graduate Program, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Emma R Huels
- Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, USA; Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Hannah Maybrier
- Psychological & Brain Sciences Department, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Christian S Guay
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Picower Institute for Learning & Memory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Subha Subramanian
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Nuri B Farber
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - ShiNung Ching
- Department of Electrical & Systems Engineering, Washington University in St. Louis, St. Louis, MO, USA; Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - R Edward Hogan
- Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Max B Kelz
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - George A Mashour
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Ben J A Palanca
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Electrical & Systems Engineering, Washington University in St. Louis, St. Louis, MO, USA; Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA.
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Vail EA, Avidan MS. Trials with 'non-significant' results are not insignificant trials: a common significance threshold distorts reporting and interpretation of trial results. Br J Anaesth 2022; 129:643-646. [PMID: 35871898 DOI: 10.1016/j.bja.2022.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/09/2022] [Accepted: 06/23/2022] [Indexed: 11/02/2022] Open
Abstract
We discuss a newly published study examining how phrases are used in clinical trials to describe results when the estimated P-value is close to (slightly above or slightly below) 0.05, which has been arbitrarily designated by convention as the boundary for 'statistical significance'. Terms such as 'marginally significant', 'trending towards significant', and 'nominally significant' are well represented in biomedical literature, but are not actually scientifically meaningful. Acknowledging that 'statistical significance' remains a major determinant of publication, we propose that scientific journals de-emphasise the use of P-values for null hypothesis significance testing, a purpose for which they were never intended, and avoid the use of these ambiguous and confusing terms in scientific articles. Instead, investigators could simply report their findings: effect sizes, P-values, and confidence intervals (or their Bayesian equivalents), and leave it to the discerning reader to infer the clinical applicability and importance. Our goal should be to move away from describing studies (or trials) as positive or negative based on an arbitrary P-value threshold, and rather to judge whether the scientific evidence provided is informative or uninformative.
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Affiliation(s)
- Emily A Vail
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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Riedel B, Dubowitz J, Yeung J, Jhanji S, Kheterpal S, Avidan MS. On the horns of a dilemma: choosing total intravenous anaesthesia or volatile anaesthesia. Br J Anaesth 2022; 129:284-289. [PMID: 35835606 DOI: 10.1016/j.bja.2022.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/01/2022] [Accepted: 06/03/2022] [Indexed: 11/02/2022] Open
Abstract
There are two established techniques of delivering general anaesthesia: propofol-based total intravenous anaesthesia (TIVA) and volatile agent-based inhaled anaesthesia. Both techniques are offered as standard of care and have an established safety track record lasting more than 30 years. However, it is not currently known whether the choice of anaesthetic technique results in a fundamentally different patient experience or affects early, intermediate-term, and longer-term postoperative outcomes. This editorial comments on a recently published study that suggests that inhaled volatile anaesthesia might be associated with fewer postoperative surgical complications than propofol-based TIVA for patients undergoing colorectal cancer surgery. We consider the strengths and limitations of the study, place these findings in the context of the broader evidence, and discuss how the current controversies regarding anaesthetic technique can be resolved, thereby helping to bring precision medicine into the modern practice of perioperative care.
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Affiliation(s)
- Bernhard Riedel
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.
| | - Julia Dubowitz
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Joyce Yeung
- Department of Critical Care Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Shaman Jhanji
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden Hospital, London, UK; Division of Cancer Biology, Institute of Cancer Research, London, UK
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, MO, USA
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Wixson MC, Mitchell AD, Markowitz SD, Malicke KM, Avidan MS, Mashour GA. Raising Anesthesiology Diversity and Antiracism: Launching a National Initiative. Anesth Analg 2022; 134:1185-1188. [PMID: 35595691 DOI: 10.1213/ane.0000000000005817] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Matthew C Wixson
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Allison D Mitchell
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Scott D Markowitz
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Kate M Malicke
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - George A Mashour
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
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32
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Jiao Y, Xue B, Lu C, Avidan MS, Kannampallil T. Continuous real-time prediction of surgical case duration using a modular artificial neural network. Br J Anaesth 2022; 128:829-837. [PMID: 35090725 PMCID: PMC9074795 DOI: 10.1016/j.bja.2021.12.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/07/2021] [Accepted: 12/24/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Real-time prediction of surgical duration can inform perioperative decisions and reduce surgical costs. We developed a machine learning approach that continuously incorporates preoperative and intraoperative information for forecasting surgical duration. METHODS Preoperative (e.g. procedure name) and intraoperative (e.g. medications and vital signs) variables were retrieved from anaesthetic records of surgeries performed between March 1, 2019 and October 31, 2019. A modular artificial neural network was developed and compared with a Bayesian approach and the scheduled surgical duration. Continuous ranked probability score (CRPS) was used as a measure of time error to assess model accuracy. For evaluating clinical performance, accuracy for each approach was assessed in identifying cases that ran beyond 15:00 (commonly scheduled end of shift), thus identifying opportunities to avoid overtime labour costs. RESULTS The analysis included 70 826 cases performed at eight hospitals. The modular artificial neural network had the lowest time error (CRPS: mean=13.8; standard deviation=35.4 min), which was significantly better (mean difference=6.4 min [95% confidence interval: 6.3-6.5]; P<0.001) than the Bayesian approach. The modular artificial neural network also had the highest accuracy in identifying operating theatres that would overrun 15:00 (accuracy at 1 h prior=89%) compared with the Bayesian approach (80%) and a naïve approach using the scheduled duration (78%). CONCLUSIONS A real-time neural network model using preoperative and intraoperative data had significantly better performance than a Bayesian approach or scheduled duration, offering opportunities to avoid overtime labour costs and reduce the cost of surgery by providing superior real-time information for perioperative decision support.
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Affiliation(s)
- York Jiao
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, MO, USA.
| | - Bing Xue
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, USA
| | - Chenyang Lu
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Institute for Informatics, Washington University School of Medicine in St Louis, St Louis, MO, USA
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Fritz BA, King CR, Mehta D, Somerville E, Kronzer A, Ben Abdallah A, Wildes T, Avidan MS, Lenze EJ, Stark S. Association of a Perioperative Multicomponent Fall Prevention Intervention With Falls and Quality of Life After Elective Inpatient Surgical Procedures. JAMA Netw Open 2022; 5:e221938. [PMID: 35275166 PMCID: PMC8917421 DOI: 10.1001/jamanetworkopen.2022.1938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Falls after elective inpatient surgical procedures are common and have physical, emotional, and financial consequences. Close interactions between patients and health care teams before and after surgical procedures may offer opportunities to address modifiable risk factors associated with falls. OBJECTIVE To assess whether a multicomponent intervention that incorporates education, home medication review, and home safety assessment is associated with reductions in the incidence of falls after elective inpatient surgical procedures. DESIGN, SETTING, AND PARTICIPANTS This prospective propensity score-matched cohort study was a prespecified secondary analysis of data from the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomized clinical trial, which was conducted at a single academic medical center between January 16, 2015, and May 7, 2018. Patients in the intervention group of the present study were enrolled in either arm of the ENGAGES clinical trial. Patients in the control group were selected from the Systematic Assessment and Targeted Improvement of Services Following Yearly Surgical Outcomes Surveys prospective observational cohort study, which created a registry of patient-reported postoperative outcomes at the same single center. The propensity score-matched cohort in the present study included 1396 patients (698 pairs) selected from a pool of 2013 eligible patients. All patients underwent elective surgical procedures with general anesthesia and had a hospital stay of 2 or more days. Data were analyzed from January 2, 2020, to January 11, 2022. INTERVENTIONS The multicomponent safety intervention (offered to all patients in the ENGAGES clinical trial) included patient education on fall prevention techniques, home medication review by a geriatric psychiatrist (with communication of recommended changes to the surgeon), a self-administered home safety assessment, and targeted occupational therapy home visits with home hazard removal (offered to patients with a preoperative history of falls). MAIN OUTCOMES AND MEASURES The primary outcome was patient-reported falls within 1 year after an elective inpatient surgical procedure. The secondary outcome was quality of life 1 year after an elective surgical procedure, which was measured using the physical and mental composite summary scores on the Veterans RAND 12-item health survey (score range, 0-100 points, with 0 indicating lowest quality of life and 100 indicating highest quality of life). RESULTS Among 1396 patients, the median age was 69 years (IQR, 64-75 years), and 739 patients (52.9%) were male. With regard to race, 5 patients (0.4%) were Asian, 97 (6.9%) were Black or African American, 2 (0.1%) were Native Hawaiian or Pacific Islander, 1237 (88.6%) were White, 3 (0.2%) were of other race, and 52 (3.7%) were of unknown race; with regard to ethnicity, 12 patients (0.9%) were Hispanic or Latino, 1335 (95.6%) were non-Hispanic or non-Latino, and 49 (3.5%) were of unknown ethnicity. Adherence to individual intervention components was modest (from 22.9% for completion of the self-administered home safety assessment to 28.2% for implementation of the geriatric psychiatrist's recommended medication changes). Falls within 1 year after surgical procedures were reported by 228 of 698 patients (32.7%) in the intervention group and 225 of 698 patients (32.2%) in the control group. No significant difference was found in falls between the 2 groups (standardized risk difference, 0.4%; 95% CI, -4.5% to 5.3%). After adjusting for preoperative quality of life, patients in the intervention group had higher physical composite summary scores (3.8 points; 95% CI, 2.4-5.1 points) and higher mental composite summary scores (5.7 points; 95% CI, 4.7-6.7 points) at 1 year compared with patients in the control group. CONCLUSIONS AND RELEVANCE In this cohort study, a multicomponent safety intervention was not associated with reductions in falls within the first year after an elective surgical procedure; however, an increase in quality of life at 1 year was observed. These results suggest a need for other interventions, such as those designed to increase adherence, to lower the incidence of falls after surgical procedures.
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Affiliation(s)
- Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Christopher R. King
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Divya Mehta
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Emily Somerville
- Program in Occupational Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Troy Wildes
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Eric J. Lenze
- Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Susan Stark
- Program in Occupational Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri
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Affiliation(s)
- Michael S. Avidan
- Department of Anesthesiology, Washington University School
of Medicine
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35
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Schulman-Green D, Hshieh T, Adamis D, Avidan MS, Blazer DG, Fick DM, Oh E, Morandi A, Price C, Verghese J, Schmitt EM, Jones RN, Inouye SK. Domains of delirium severity in Alzheimer's disease and related dementias. J Am Geriatr Soc 2021; 70:1495-1503. [PMID: 34951704 PMCID: PMC9106827 DOI: 10.1111/jgs.17624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/11/2021] [Accepted: 12/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The ability to rate delirium severity is key to providing optimal care for persons with Alzheimer's Disease and Related Dementias (ADRD). Such ratings would allow clinicians to assess response to treatment, recovery time and prognosis, nursing burden and staffing needs, and to provide nuanced, appropriate patient-centered care. Given the lack of existing tools, we defined content domains for a new delirium severity instrument for use in individuals with mild to moderate ADRD, the DEL-S-AD. METHODS We built upon our previous study in which we created a content domain framework to inform development of a general delirium severity instrument, the DEL-S. We engaged a new expert panel to discuss issues of measurement in delirium and dementia and to determine which content domains from the prior framework were useful in characterizing delirium severity in ADRD. We also asked panelists to identify new domains. Our panel included eight interdisciplinary members with expertise in delirium and dementia. Panelists participated in two rounds of review followed by two surveys over 2 months. RESULTS Panelists endorsed the same content domains as for general delirium severity, including Cognitive, Level of Consciousness, Inattention, Psychiatric-Behavioral, Emotional Dysregulation, Psychomotor Features, and Functional; however, they excluded six of the original subdomains which they considered unhelpful in the context of ADRD: cognitive impairment; anxiety; fear/sense of unease; depression; gait/walking; and incontinence. Debated measurement challenges included assessment at one point in time versus over time, accounting for differences in clinical settings, and accurate assessment of symptoms related to delirium versus dementia. CONCLUSIONS By capturing a range of characteristics of delirium severity potentially present in patients with ADRD, a population that may already have attention, functional, and emotional changes at baseline, the DEL-S-AD provides a novel rating tool that will be useful for clinical and research purposes to improve patient care.
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Affiliation(s)
| | - Tammy Hshieh
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Dimitrios Adamis
- Sligo Mental Health Services, Sligo, Ireland.,Research and Academic Institute of Athens, Athens, Greece
| | - Michael S Avidan
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Dan G Blazer
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Donna M Fick
- Penn State Ross and Carol Nese College of Nursing, University Park, Pennsylvania, USA
| | - Esther Oh
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alessandro Morandi
- Fondazione Teresa Camplani, Cremona, Italy.,Parc Sanitari Pere Virgili and Vall d'Hebrón Institute of Research, Barcelona, Spain
| | - Catherine Price
- University of Florida College of Public Health and Health Professions, Gainesville, Florida, USA
| | - Joe Verghese
- Albert Einstein School of Medicine, Bronx, New York, USA
| | - Eva M Schmitt
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Richard N Jones
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Sharon K Inouye
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Holzer KJ, Haroutounian S, Meng A, Wilson EA, Steinberg A, Avidan MS, Kozower BD, Abraham J. Ascertaining Design and Implementation Requirements for a Perioperative Neurocognitive Training Intervention for the Prevention of Persistent Pain After Surgery. Pain Med 2021; 23:1355-1365. [PMID: 34931687 PMCID: PMC9607951 DOI: 10.1093/pm/pnab347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 12/03/2021] [Accepted: 12/14/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Persistent postsurgical pain (PPSP) is a common complication that impacts quality of life, often necessitating long-term opioid treatment. Certain neurocognitive factors, including reduced performance on cognitive flexibility tasks, are associated with increased risk of PPSP. We examine the perceptions of surgical patients and clinicians with regard to perioperative pain management activities and needs; patient acceptance and use of a perioperative neurocognitive training intervention; and implementation feasibility. METHODS We conducted both individual and focus group interviews with patients undergoing thoracic surgery and clinicians in an academic medical center. The Consolidated Framework for Intervention Research guided the development of interview questions related to the adoption and implementation of a neurocognitive intervention to mitigate PPSP. A thematic analysis was used to analyze the responses. RESULTS Forty patients and 15 clinicians participated. Interviews revealed that there is minimal discussion between clinicians and patients about PPSP. Most participants were receptive to a neurocognitive intervention to prevent PPSP, if evidence demonstrating its effectiveness were available. Potential barriers to neurocognitive training program adoption included fatigue, cognitive overload, lack of familiarity with the technology used for delivering the intervention, and immediate postoperative pain and stress. Implementation facilitators would include patient education about the intervention, incentives for its use, and daily reminders. CONCLUSION The study identified several guiding principles for addressing patients' and clinicians' barriers to effectively implementing a neurocognitive training intervention to mitigate PPSP after surgery. To ensure the sustainability of neurocognitive interventions for preventing PPSP, such interventions would need to be adapted to meet patients' and clinicians' needs within the perioperative context.
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Affiliation(s)
| | | | | | | | | | | | | | - Joanna Abraham
- Correspondence to: Joanna Abraham, FAMIA, PhD, Department of Anesthesiology, Institute for Informatics, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8054, St. Louis, M0 63110, USA. Tel: 314-362-5129; E-mail:
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Oberhaus J, Wang W, Mickle AM, Becker J, Tedeschi C, Maybrier HR, Upadhyayula RT, Muench MR, Lin N, Schmitt EM, Inouye SK, Avidan MS. Evaluation of the 3-Minute Diagnostic Confusion Assessment Method for Identification of Postoperative Delirium in Older Patients. JAMA Netw Open 2021; 4:e2137267. [PMID: 34902038 PMCID: PMC8669542 DOI: 10.1001/jamanetworkopen.2021.37267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Delirium is a common postoperative complication in older patients that often goes undetected and might lead to worse outcomes. The 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) might be a practical tool for routine clinical diagnosis of delirium. OBJECTIVE To assess the 3D-CAM for detecting postoperative delirium compared with the long-form CAM used for research purposes. DESIGN, SETTING, AND PARTICIPANTS This cohort study of older patients enrolled in ongoing clinical trials between 2015 and 2018 was conducted at a single tertiary US hospital. Included participants were aged 60 years or older undergoing major elective surgical procedures that required at least a 2-day hospital stay. Data were analyzed between February and April 2019. EXPOSURES Surgical procedures of at least 2 hours in length requiring general anesthesia with planned extubation. MAIN OUTCOMES AND MEASURES Patients were concurrently assessed for delirium using the 3D-CAM assessment and the long-form CAM, scored based on a standardized cognitive assessment. Agreement between these 2 methods was tested using Cohen κ with repeated measures, a generalized linear mixed-effects model, and Bland-Altman analysis. RESULTS Sixteen raters conducted 471 concurrent CAM and 3D-CAM interviews including 299 patients (mean [SD] age, 69 [6.5] years), the majority of whom were men (152 [50.8%]), were White (263 [88.0%]), and had noncardiac operations (211 [70.6%]). Both instruments had good intraclass correlation (0.84 for the CAM and 0.98 for the 3D-CAM). Cohen κ demonstrated good overall agreement between the CAM and 3D-CAM (κ = 0.71; 95% CI, 0.58 to 0.83). According to the mixed-effects model, there was statistically significant disagreement between the 3D-CAM and CAM (estimated difference in fixed effect, -0.68; 95% CI, -1.32 to -0.05; P = .04). Bland-Altman analysis showed the probability of a delirium diagnosis with the 3D-CAM was more than twice the probability of a delirium diagnosis with the CAM (probability ratio, 2.78; 95% CI, 2.44 to 3.23). CONCLUSIONS AND RELEVANCE The 3D-CAM instrument demonstrated agreement with the long-form CAM and might provide a pragmatic and sensitive clinical tool for detecting postoperative delirium, with the caveat that the 3D-CAM might overdiagnose delirium.
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Affiliation(s)
- Jordan Oberhaus
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Wei Wang
- Department of Mathematics and Statistics, Washington University in St Louis, St Louis, Missouri
| | - Angela M. Mickle
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Jennifer Becker
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Catherine Tedeschi
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Hannah R. Maybrier
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Ravi T. Upadhyayula
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Maxwell R. Muench
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - Nan Lin
- Department of Mathematics and Statistics, Washington University in St Louis, St Louis, Missouri
- Division of Biostatistics, Washington University in St Louis, St Louis, Missouri
| | - Eva M. Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts
| | - Sharon K. Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
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Holzer KJ, Avidan MS, Lenze EJ. Perioperative Mental Health in Older Adults: New Research on Epidemiology and Outcomes. Am J Geriatr Psychiatry 2021; 29:1222-1224. [PMID: 33653599 DOI: 10.1016/j.jagp.2021.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/01/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Katherine J Holzer
- Department of Anesthesiology, Washington University School of Medicine (KJH, MSA), St Louis, MS
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine (KJH, MSA), St Louis, MS
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine (EJL), St Louis, MS.
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Affiliation(s)
- James P Rathmell
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston (J.P.R.); and the Department of Anesthesiology, Washington University School of Medicine, St. Louis (M.S.A.)
| | - Michael S Avidan
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston (J.P.R.); and the Department of Anesthesiology, Washington University School of Medicine, St. Louis (M.S.A.)
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Avidan MS, Mashour GA. Repurposing Propofol as a Prognostic Probe for Return of Consciousness. Am J Respir Crit Care Med 2021; 205:140-142. [PMID: 34818124 PMCID: PMC8787254 DOI: 10.1164/rccm.202111-2504ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Michael S Avidan
- Washington University School of Medicine in Saint Louis, 12275, St Louis, Missouri, United States;
| | - George A Mashour
- University of Michigan Michigan Medicine, 21614, Anesthesiology, Ann Arbor, Michigan, United States
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Rokos A, Mišić B, Berkun K, Duclos C, Tarnal V, Janke E, Picton P, Golmirzaie G, Basner M, Avidan MS, Kelz MB, Mashour GA, Blain-Moraes S. Distinct and Dissociable EEG Networks Are Associated With Recovery of Cognitive Function Following Anesthesia-Induced Unconsciousness. Front Hum Neurosci 2021; 15:706693. [PMID: 34594193 PMCID: PMC8477048 DOI: 10.3389/fnhum.2021.706693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/20/2021] [Indexed: 01/02/2023] Open
Abstract
The temporal trajectories and neural mechanisms of recovery of cognitive function after a major perturbation of consciousness is of both clinical and neuroscientific interest. The purpose of the present study was to investigate network-level changes in functional brain connectivity associated with the recovery and return of six cognitive functions after general anesthesia. High-density electroencephalograms (EEG) were recorded from healthy volunteers undergoing a clinically relevant anesthesia protocol (propofol induction and isoflurane maintenance), and age-matched healthy controls. A battery of cognitive tests (motor praxis, visual object learning test, fractal-2-back, abstract matching, psychomotor vigilance test, digital symbol substitution test) was administered at baseline, upon recovery of consciousness (ROC), and at half-hour intervals up to 3 h following ROC. EEG networks were derived using the strength of functional connectivity measured through the weighted phase lag index (wPLI). A partial least squares (PLS) analysis was conducted to assess changes in these networks: (1) between anesthesia and control groups; (2) during the 3-h recovery from anesthesia; and (3) for each cognitive test during recovery from anesthesia. Networks were maximally perturbed upon ROC but returned to baseline 30-60 min following ROC, despite deficits in cognitive performance that persisted up to 3 h following ROC. Additionally, during recovery from anesthesia, cognitive tests conducted at the same time-point activated distinct and dissociable functional connectivity networks across all frequency bands. The results highlight that the return of cognitive function after anesthetic-induced unconsciousness is task-specific, with unique behavioral and brain network trajectories of recovery.
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Affiliation(s)
- Alexander Rokos
- Integrated Program in Neuroscience, McGill University, Montreal, QC, Canada
| | - Bratislav Mišić
- Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| | | | - Catherine Duclos
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
| | - Vijay Tarnal
- Department of Anesthesiology, Center of Consciousness Science, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Ellen Janke
- Department of Anesthesiology, Center of Consciousness Science, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Paul Picton
- Department of Anesthesiology, Center of Consciousness Science, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Goodarz Golmirzaie
- Department of Anesthesiology, Center of Consciousness Science, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Mathias Basner
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, WA, United States
| | - Max B. Kelz
- Deparment of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - George A. Mashour
- Department of Anesthesiology, Center of Consciousness Science, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Stefanie Blain-Moraes
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
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Whitlock EL, Gross ER, King CR, Avidan MS. Anaesthetic depth and delirium: a challenging balancing act. Br J Anaesth 2021; 127:667-671. [PMID: 34503835 DOI: 10.1016/j.bja.2021.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/07/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022] Open
Abstract
This editorial highlights the findings of the Balanced Anaesthesia Delirium study, a 515-patient substudy of the 6644 patient Balanced Anaesthesia trial, which found that targeting deep anaesthesia in patients undergoing major noncardiac surgery was not associated with significantly increased postoperative death or major morbidity. The substudy found that using bispectral index (BIS) guidance with the intention of deliberately achieving deep volatile agent-based anaesthesia (target BIS reading 35 vs 50) significantly increased delirium incidence (28% vs 19%), although not subsyndromal delirium incidence (45% vs 49%). We discuss the implications of these findings for anaesthetic practice, and address whether the BIS should be used as a guide to deliver precision anaesthesia for delirium prevention. We posit that subpopulation-based differences within this multicentre substudy could have affected delirium occurrence, since the findings appeared to rest on outcomes in patients from East Asia. We conclude that questions of whether and for whom deep anaesthesia is deliriogenic remain unanswered.
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Affiliation(s)
- Elizabeth L Whitlock
- Department of Anesthesia & Perioperative Care, University of California, School of Medicine, San Francisco, CA, USA
| | - Eric R Gross
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - C Ryan King
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
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Vlisides PE, Li D, McKinney A, Brooks J, Leis AM, Mentz G, Tsodikov A, Zierau M, Ragheb J, Clauw DJ, Avidan MS, Vanini G, Mashour GA. The Effects of Intraoperative Caffeine on Postoperative Opioid Consumption and Related Outcomes After Laparoscopic Surgery: A Randomized Controlled Trial. Anesth Analg 2021; 133:233-242. [PMID: 33939649 DOI: 10.1213/ane.0000000000005532] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Surgical patients are vulnerable to opioid dependency and related risks. Clinical-translational data suggest that caffeine may enhance postoperative analgesia. This trial tested the hypothesis that intraoperative caffeine would reduce postoperative opioid consumption. The secondary objective was to assess whether caffeine improves neuropsychological recovery postoperatively. METHODS This was a single-center, randomized, placebo-controlled trial. Participants, clinicians, research teams, and data analysts were all blinded to the intervention. Adult (≥18 years old) surgical patients (n = 65) presenting for laparoscopic colorectal and gastrointestinal surgery were randomized to an intravenous caffeine citrate infusion (200 mg) or dextrose 5% in water (40 mL) during surgical closure. The primary outcome was cumulative opioid consumption through postoperative day 3. Secondary outcomes included subjective pain reporting, observer-reported pain, delirium, Trail Making Test performance, depression and anxiety screens, and affect scores. Adverse events were reported, and hemodynamic profiles were also compared between the groups. RESULTS Sixty patients were included in the final analysis, with 30 randomized to each group. The median (interquartile range) cumulative opioid consumption (oral morphine equivalents, milligrams) was 77 mg (33-182 mg) for caffeine and 51 mg (15-117 mg) for placebo (estimated difference, 55 mg; 95% confidence interval [CI], -9 to 118; P = .092). After post hoc adjustment for baseline imbalances, caffeine was associated with increased opioid consumption (87 mg; 95% CI, 26-148; P = .005). There were otherwise no differences in prespecified pain or neuropsychological outcomes between the groups. No major adverse events were reported in relation to caffeine, and no major hemodynamic perturbations were observed with caffeine administration. CONCLUSIONS Caffeine appears unlikely to reduce early postoperative opioid consumption. Caffeine otherwise appears well tolerated during anesthetic emergence.
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Affiliation(s)
- Phillip E Vlisides
- From the Department of Anesthesiology.,Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, Michigan
| | - Duan Li
- From the Department of Anesthesiology.,Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, Michigan
| | | | | | | | | | - Alexander Tsodikov
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | | | | | - Daniel J Clauw
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor, Michigan
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Giancarlo Vanini
- From the Department of Anesthesiology.,Neuroscience Graduate Program, University of Michigan, Ann Arbor, Michigan
| | - George A Mashour
- From the Department of Anesthesiology.,Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, Michigan.,Neuroscience Graduate Program, University of Michigan, Ann Arbor, Michigan
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Fritz BA, King CR, Mickle AM, Wildes TS, Budelier TP, Oberhaus J, Park D, Maybrier HR, Ben Abdallah A, Kronzer A, McKinnon SL, Torres BA, Graetz TJ, Emmert DA, Palanca BJ, Stevens TW, Stark SL, Lenze EJ, Avidan MS. Effect of electroencephalogram-guided anaesthesia administration on 1 yr mortality: 1 yr follow-up of a randomised clinical trial. Br J Anaesth 2021; 127:386-395. [PMID: 34243940 DOI: 10.1016/j.bja.2021.04.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/25/2021] [Accepted: 04/23/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Intraoperative EEG suppression duration has been associated with postoperative delirium and mortality. In a clinical trial testing anaesthesia titration to avoid EEG suppression, the intervention did not decrease the incidence of postoperative delirium, but was associated with reduced 30 day mortality. The present study evaluated whether the EEG-guided anaesthesia intervention continued to be associated with reduced 1 yr mortality. METHODS This manuscript reports 1 yr follow-up of patients from a single-centre RCT, including a post-hoc secondary outcome (1 yr mortality) in addition to pre-specified secondary outcomes. The trial included patients aged 60 yr or older undergoing surgery with general anaesthesia between January 2015 and May 2018. Patients were randomised to receive EEG-guided anaesthesia or usual care. The previously reported primary outcome was postoperative delirium. The outcome of the current study was all-cause 1 yr mortality. RESULTS Of the 1232 patients enrolled, 614 patients were randomised to EEG-guided anaesthesia and 618 patients to usual care. One year mortality was 57/591 (9.6%) in the guided group and 62/601 (10.3%) in the usual-care group. No significant difference in mortality was observed (adjusted absolute risk difference, -0.7%; 99.5% confidence interval, -5.8% to 4.3%; P=0.68). CONCLUSIONS An EEG-guided anaesthesia intervention aiming to decrease duration of EEG suppression during surgery did not significantly decrease 1 yr mortality. These findings, in the context of other studies, do not provide supportive evidence for EEG-guided anaesthesia to prevent intermediate term postoperative death. CLINICAL TRIAL REGISTRATION NCT02241655.
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Affiliation(s)
- Bradley A Fritz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Christopher R King
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Angela M Mickle
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Thaddeus P Budelier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jordan Oberhaus
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Park
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Hannah R Maybrier
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sherry L McKinnon
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Brian A Torres
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Thomas J Graetz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel A Emmert
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ben J Palanca
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Tracey W Stevens
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Susan L Stark
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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Kaiser HA, Knapp J, Sleigh J, Avidan MS, Stüber F, Hight D. [The quantitative EEG in electroencephalogram-based brain monitoring during general anesthesia]. Anaesthesist 2021; 70:531-547. [PMID: 33970302 PMCID: PMC8108440 DOI: 10.1007/s00101-021-00960-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2021] [Indexed: 11/12/2022]
Abstract
The electroencephalogram (EEG) is increasingly being used in the clinical routine of anesthesia in German-speaking countries. In over 90% of patients the frontal EEG changes somewhat predictably in response to administration of the normally used anesthetic agents (propofol and volatile gasses). An adequate depth of anesthesia and appropriate concentrations of anesthetics in the brain generate mostly frontal oscillations between 8 and 12 Hz as well as slow delta waves between 0.5 and 4 Hz. The frontal EEG channel is well-suited for avoidance of insufficient depth of anesthesia and excessive administration of anesthetics. This article explains the clinical interpretation of the most important EEG patterns and the biophysical background. Also discussed are important limitations and pitfalls for the clinical routine, which the anesthetist should know in order to utilize the EEG as an admittedly incomplete but clinically extremely important parameter for the level of consciousness.
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Affiliation(s)
- H A Kaiser
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Freiburgstr., 3010, Bern, Schweiz.
| | - J Knapp
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Freiburgstr., 3010, Bern, Schweiz
| | - J Sleigh
- Department of Anaesthesia, Waikato Clinical School, University of Auckland, Hamilton, Neuseeland
| | - M S Avidan
- Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Ave., MO 63110, St. Louis, USA
| | - F Stüber
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Freiburgstr., 3010, Bern, Schweiz
| | - D Hight
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Freiburgstr., 3010, Bern, Schweiz
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46
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Sindhar S, Kallogjeri D, Wildes TS, Avidan MS, Piccirillo JF. Association of Preoperative Functional Performance With Outcomes After Surgical Treatment of Head and Neck Cancer: A Clinical Severity Staging System. JAMA Otolaryngol Head Neck Surg 2021; 145:1128-1136. [PMID: 31045219 DOI: 10.1001/jamaoto.2019.1035] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Patients with head and neck cancers have comorbidities and other constitutional symptoms known to be associated with adverse postoperative outcomes, but the role of functional performance is not well studied. Objective To explore the addition of functional performance to other clinical factors for association with 3 patient outcomes: 30-day unplanned readmission (UR), 90-day medical complications, and overall survival (OS). Design, Setting, and Participants This retrospective cohort study was conducted in a single tertiary care center with patients surgically treated for squamous cell cancer of the lip, oral cavity, pharynx, or larynx from January 2012 to December 2016. All analysis took place between January 2018 and November 2018. Data from 2 registries were analyzed, supplemented with medical record review. Logistic regression analysis was used to explore association of preoperative functional performance with outcomes. Conjunctive consolidation was used to create a useful clinical severity staging system, which included functional performance (estimated from metabolic equivalent [MET] score: <4, light-intensity activities; ≥4 at least moderate-intensity activities); overall comorbidity severity; preoperative weight loss; and TNM tumor staging. Logistic regression was used to assess the prognostic accuracy of the clinical severity staging system for 30-day UR and 90-day complications, and Cox proportional hazard regression for OS. Exposures All patients underwent surgical treatment for head and neck cancer. Main Outcomes and Measures The primary outcomes were 30-day UR and 90-day complications; the secondary outcome was OS. Results For the 657 patients included, the mean (SD) age was 62.0 (11.3) years; 73% were men (n = 477), and 88% were white (n = 580). A total of 75 (11%) had a 30-day UR; 204 (31%) developed a 90-day complication; and 127 (19%) patients died during the observation period. Individually, poor functional performance (<4 METs), high comorbidity burden, preoperative weight loss, and advanced TNM stage were associated with all 3 outcomes; the increased risk for each outcome ranged from 1.5 to 3.0 times the reference range. Using these 4 variables in combination, the 4-category clinical severity staging system demonstrated a strong association between severity stage and all 3 adverse outcomes: 30-day UR (C statistic, 0.63), 90-day complications (C statistic, 0.63), and OS (C statistic, 0.68). Conclusions and Relevance Poor preoperative functional performance, high comorbidity burden, preoperative weight loss, and advanced tumor stage were all associated with worse patient outcomes after head and neck cancer surgery. The model incorporating all 4 of these factors developed in this study may facilitate patient-centered risk assessment and patient-physician shared preoperative decision making.
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Affiliation(s)
- Sampat Sindhar
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis Missouri
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis Missouri.,Statistics Editor, JAMA Otolaryngology-Head & Neck Surgery
| | - Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jay F Piccirillo
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis Missouri.,Editor, JAMA Otolaryngology-Head & Neck Surgery
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47
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Chumakov K, Avidan MS, Benn CS, Bertozzi SM, Blatt L, Chang AY, Jamison DT, Khader SA, Kottilil S, Netea MG, Sparrow A, Gallo RC. Old vaccines for new infections: Exploiting innate immunity to control COVID-19 and prevent future pandemics. Proc Natl Acad Sci U S A 2021; 118:e2101718118. [PMID: 34006644 PMCID: PMC8166166 DOI: 10.1073/pnas.2101718118] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The COVID-19 pandemic triggered an unparalleled pursuit of vaccines to induce specific adaptive immunity, based on virus-neutralizing antibodies and T cell responses. Although several vaccines have been developed just a year after SARS-CoV-2 emerged in late 2019, global deployment will take months or even years. Meanwhile, the virus continues to take a severe toll on human life and exact substantial economic costs. Innate immunity is fundamental to mammalian host defense capacity to combat infections. Innate immune responses, triggered by a family of pattern recognition receptors, induce interferons and other cytokines and activate both myeloid and lymphoid immune cells to provide protection against a wide range of pathogens. Epidemiological and biological evidence suggests that the live-attenuated vaccines (LAV) targeting tuberculosis, measles, and polio induce protective innate immunity by a newly described form of immunological memory termed "trained immunity." An LAV designed to induce adaptive immunity targeting a particular pathogen may also induce innate immunity that mitigates other infectious diseases, including COVID-19, as well as future pandemic threats. Deployment of existing LAVs early in pandemics could complement the development of specific vaccines, bridging the protection gap until specific vaccines arrive. The broad protection induced by LAVs would not be compromised by potential antigenic drift (immune escape) that can render viruses resistant to specific vaccines. LAVs might offer an essential tool to "bend the pandemic curve," averting the exhaustion of public health resources and preventing needless deaths and may also have therapeutic benefits if used for postexposure prophylaxis of disease.
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Affiliation(s)
- Konstantin Chumakov
- Food and Drug Administration Office of Vaccine Research and Review, Global Virus Network Center of Excellence, Silver Spring, MD 20993
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in St. Louis, St Louis, MO 63130
| | - Christine S Benn
- Department of Clinical Research, Global Virus Network Center of Excellence, University of Southern Denmark, 5230 Odense, Denmark
- Danish Institute for Advanced Study, University of Southern Denmark, 5230 Odense, Denmark
| | - Stefano M Bertozzi
- School of Public Health, Global Virus Network, University of California, Berkeley, CA 94704
- School of Public Health, University of Washington, Seattle, WA 98195
- El Centro de Investigación en Evaluación y Encuestas, Instituto Nacional de Salud Pública, 62100 Cuernavaca, Mexico
| | - Lawrence Blatt
- Aligos Therapeutics, Global Virus Network Center of Excellence, San Francisco, CA 94080
| | - Angela Y Chang
- Danish Institute for Advanced Study, University of Southern Denmark, 5230 Odense, Denmark
| | - Dean T Jamison
- Institute for Global Health Sciences, Global Virus Network, University of California, San Francisco, CA 94158
| | - Shabaana A Khader
- Department of Molecular Microbiology, Washington University in St. Louis School of Medicine, St. Louis, MO 63130
| | - Shyam Kottilil
- Institute of Human Virology, Global Virus Network Center of Excellence, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Mihai G Netea
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Global Virus Network Center of Excellence, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Department of Immunology and Metabolism, Life and Medical Sciences Institute, University of Bonn, 53113 Bonn, Germany
| | - Annie Sparrow
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Robert C Gallo
- Institute of Human Virology, Global Virus Network Center of Excellence, University of Maryland School of Medicine, Baltimore, MD 21201;
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48
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Whitlock EL, Diaz-Ramirez LG, Smith AK, Boscardin WJ, Covinsky KE, Avidan MS, Glymour MM. Association of Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention With Memory Decline in Older Adults Undergoing Coronary Revascularization. JAMA 2021; 325:1955-1964. [PMID: 34003225 PMCID: PMC8132142 DOI: 10.1001/jama.2021.5150] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE It is uncertain whether coronary artery bypass grafting (CABG) is associated with cognitive decline in older adults compared with a nonsurgical method of coronary revascularization (percutaneous coronary intervention [PCI]). OBJECTIVE To compare the change in the rate of memory decline after CABG vs PCI. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of community-dwelling participants in the Health and Retirement Study, who underwent CABG or PCI between 1998 and 2015 at age 65 years or older. Data were modeled for up to 5 years preceding and 10 years following revascularization or until death, drop out, or the 2016-2017 interview wave. The date of final follow-up was November 2017. EXPOSURES CABG (including on and off pump) or PCI, ascertained from Medicare fee-for-service billing records. MAIN OUTCOMES AND MEASURES The primary outcome was a summary measure of cognitive test scores and proxy cognition reports that were performed biennially in the Health and Retirement Study, referred to as memory score, normalized as a z score (ie, mean of 0, SD of 1 in a reference population of adults aged ≥72 years). Memory score was analyzed using multivariable linear mixed-effects models, with a prespecified subgroup analysis of on-pump and off-pump CABG. The minimum clinically important difference was a change of 1 SD of the population-level rate of memory decline (0.048 memory units/y). RESULTS Of 1680 participants (mean age at procedure, 75 years; 41% female), 665 underwent CABG (168 off pump) and 1015 underwent PCI. In the PCI group, the mean rate of memory decline was 0.064 memory units/y (95% CI, 0.052 to 0.078) before the procedure and 0.060 memory units/y (95% CI, 0.048 to 0.071) after the procedure (within-group change, 0.004 memory units/y [95% CI, -0.010 to 0.018]). In the CABG group, the mean rate of memory decline was 0.049 memory units/y (95% CI, 0.033 to 0.065) before the procedure and 0.059 memory units/y (95% CI, 0.047 to 0.072) after the procedure (within-group change, -0.011 memory units/y [95% CI, -0.029 to 0.008]). The between-group difference-in-differences estimate for memory decline for PCI vs CABG was 0.015 memory units/y (95% CI, -0.008 to 0.038; P = .21). There was statistically significant increase in the rate of memory decline after off-pump CABG compared with after PCI (difference-in-differences: mean increase in the rate of decline of 0.046 memory units/y [95% CI, 0.008 to 0.084] after off-pump CABG), but not after on-pump CABG compared with PCI (difference-in-differences: mean slowing of decline of 0.003 memory units/y [95% CI, -0.024 to 0.031] after on-pump CABG). CONCLUSIONS AND RELEVANCE Among older adults undergoing coronary revascularization with CABG or PCI, the type of revascularization procedure was not significantly associated with differences in the change of rate of memory decline.
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Affiliation(s)
- Elizabeth L. Whitlock
- Department of Anesthesia & Perioperative Care, University of California, San Francisco
| | | | - Alexander K. Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative, and Extended Care Service, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - W. John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
| | - Kenneth E. Covinsky
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University in St Louis, St Louis, Missouri
| | - M. Maria Glymour
- Department of Epidemiology & Biostatistics, University of California, San Francisco
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Mashour GA, Palanca BJA, Basner M, Li D, Wang W, Blain-Moraes S, Lin N, Maier K, Muench M, Tarnal V, Vanini G, Ochroch EA, Hogg R, Schwartz M, Maybrier H, Hardie R, Janke E, Golmirzaie G, Picton P, McKinstry-Wu AR, Avidan MS, Kelz MB. Recovery of consciousness and cognition after general anesthesia in humans. eLife 2021; 10:59525. [PMID: 33970101 PMCID: PMC8163502 DOI: 10.7554/elife.59525] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 05/06/2021] [Indexed: 12/13/2022] Open
Abstract
Understanding how the brain recovers from unconsciousness can inform neurobiological theories of consciousness and guide clinical investigation. To address this question, we conducted a multicenter study of 60 healthy humans, half of whom received general anesthesia for 3 hr and half of whom served as awake controls. We administered a battery of neurocognitive tests and recorded electroencephalography to assess cortical dynamics. We hypothesized that recovery of consciousness and cognition is an extended process, with differential recovery of cognitive functions that would commence with return of responsiveness and end with return of executive function, mediated by prefrontal cortex. We found that, just prior to the recovery of consciousness, frontal-parietal dynamics returned to baseline. Consistent with our hypothesis, cognitive reconstitution after anesthesia evolved over time. Contrary to our hypothesis, executive function returned first. Early engagement of prefrontal cortex in recovery of consciousness and cognition is consistent with global neuronal workspace theory.
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Affiliation(s)
- George A Mashour
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Ben JA Palanca
- Department of Anesthesiology, Washington University School of MedicineSt. LouisUnited States
| | - Mathias Basner
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Duan Li
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Wei Wang
- Department of Mathematics and Statistics, Washington UniversitySt. LouisUnited States
| | - Stefanie Blain-Moraes
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Nan Lin
- Department of Mathematics and Statistics, Washington UniversitySt. LouisUnited States
| | - Kaitlyn Maier
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Maxwell Muench
- Department of Anesthesiology, Washington University School of MedicineSt. LouisUnited States
| | - Vijay Tarnal
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Giancarlo Vanini
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - E Andrew Ochroch
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Rosemary Hogg
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Marlon Schwartz
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Hannah Maybrier
- Department of Anesthesiology, Washington University School of MedicineSt. LouisUnited States
| | - Randall Hardie
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Ellen Janke
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Goodarz Golmirzaie
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Paul Picton
- Center for Consciousness Science, Department of Anesthesiology, University of Michigan Medical SchoolAnn ArborUnited States
| | - Andrew R McKinstry-Wu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of MedicineSt. LouisUnited States
| | - Max B Kelz
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
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50
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Kannampallil T, Holzer KJ, Abraham J, Naim U, Lenze EJ, Haroutounian S, Avidan MS. Surgical Complications in Older Adults Predict Decline in Self-Perceived Cognitive Function in the Ensuing Year: A Cohort Study. Am J Geriatr Psychiatry 2021; 29:352-361. [PMID: 32981851 DOI: 10.1016/j.jagp.2020.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Surgical complications are common among older adults and are potential indicators of poorer long-term outcomes. The authors examined the effects of in-hospital complications on changes in older adults' self-perceived cognitive function in the year after surgery. METHOD The authors conducted a prospective longitudinal study with 2,155 older adults (age ≥ 65) undergoing surgery, investigating the association between self-reported, in-hospital complications after surgery and Patient-Reported Outcomes Measurement Information System Applied Cognition-Abilities survey (4 items, cognitive function) at 30 days and 1 year after surgery. Surveys were scored on a continuous scale of 0-100, with higher scores representing better self-perceived cognitive functioning. Patient characteristics including demographics, type of complications, surgery type, pain, and activities of daily living were also collected. RESULTS Having one in-hospital complication was associated with a decrease of 1.79 points (95% confidence interval (CI): -2.78, -0.80), indicating lower self-perceived cognitive functioning at 1 year after surgery; having two or more in-hospital complications was associated with 2.82 point (95% CI: -4.50, -1.15) decrease at 1 year after surgery. Models specific to complication type indicated that respiratory [-3.04, (95% CI: -5.50, -0.57)], neural [-2.11, (95% CI: -3.97, -0.25)], and general complications [-2.39, (95% CI: -3.51, -1.28)] were associated with statistically significant decreases in cognitive function. DISCUSSION Older surgical patients who suffer in-hospital complications show greater decline in self-perceived cognitive function during the ensuing year. Geriatric specialists may be able to intervene in the immediate perioperative period to reduce complications and possibly mitigate cognitive decline among older adults.
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Affiliation(s)
- Thomas Kannampallil
- Department of Anesthesiology (TK, KJH, JA, UN, SH, MSA), Washington University School of Medicine, St Louis, MO; Institute for Informatics (TK, JA), Washington University School of Medicine, St Louis, MO.
| | - Katherine J Holzer
- Department of Anesthesiology (TK, KJH, JA, UN, SH, MSA), Washington University School of Medicine, St Louis, MO
| | - Joanna Abraham
- Department of Anesthesiology (TK, KJH, JA, UN, SH, MSA), Washington University School of Medicine, St Louis, MO; Institute for Informatics (TK, JA), Washington University School of Medicine, St Louis, MO
| | - Uzma Naim
- Department of Anesthesiology (TK, KJH, JA, UN, SH, MSA), Washington University School of Medicine, St Louis, MO
| | - Eric J Lenze
- Department of Psychiatry (EJL), Washington University School of Medicine, St Louis, MO
| | - Simon Haroutounian
- Department of Anesthesiology (TK, KJH, JA, UN, SH, MSA), Washington University School of Medicine, St Louis, MO
| | - Michael S Avidan
- Department of Anesthesiology (TK, KJH, JA, UN, SH, MSA), Washington University School of Medicine, St Louis, MO
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