Evaluating the influence of altered cerebral hemodynamics on cognitive performance in asymptomatic carotid artery stenosis: A systematic review.

OBJECTIVE: Substantial controversy exists regarding asymptomatic carotid stenosis (ACS) and its potential role in the pathophysiology of cognitive impairment. If proven, this hypothesis may suggest an additional definition for symptomatic carotid disease that would alter current management. This study aimed to synthesize the literature evaluating the relationship between impaired cerebral hemodynamics and cognition in patients with ACS. METHODS: A literature search was performed using MEDLINE, Embase, and EBM Reviews through May 2022. We included prospective case-control studies that used validated, objective measure(s) of either global cognition or one or more domains of cognitive function and assessed cerebrovascular reserve (CVR). RESULTS: Five studies were included, comprising a total of 782 patients with moderate (50%-69%) to severe (70%-99%) ACS. Patients with ACS and impaired ipsilateral CVR demonstrated significant cognitive impairment compared with controls. Patients with unilateral or bilateral ACS and normal CVR had cognitive scores similar to controls. Those with bilateral CVR impairment demonstrated the lowest cognitive scores. CONCLUSIONS: This review lends support to the claim that cognitive impairment, likely the result of impaired cerebral hemodynamics, is an under-recognized morbidity in patients with ACS. CVR may serve as an additional tool to determine whether patients are in fact symptomatic from their carotid stenosis and warrant consideration for intervention.

Quality of Life Measures in Aortic Stenosis Research: A Narrative Review.

BACKGROUND: Elderly patients with aortic stenosis (AS) not only have a reduced life expectancy but also a reduced quality of life (QoL). The benefits of an AS intervention may be considered a balance between a good QoL and a reasonably extended life. However, the different questionnaires being used to determine the QoL were generally not developed for the specific situation of patients with AS and come with strengths and considerable weaknesses. The objective of this article was to provide an overview of the available QoL instruments in AS research, describe their strengths and weaknesses, and provide our assessment of the utility of the available scoring instruments for QoL measurements in AS. SUMMARY: We identified and reviewed the following instruments that are used in AS research: Short Form Health Survey (SF-36/SF-12), EuroQol-5D (EQ-5D), the Illness Intrusiveness Rating Scale (IIRS), the HeartQoL, the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Minnesota Living with Heart Failure Questionnaire (MLHF), the MacNew Questionnaire, and the Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ). KEY MESSAGES: There is no standardized assessment of QoL in patients with AS. Many different questionnaires are being used, but they are rarely specific for AS. There is a need for AS-specific research into the QoL of patients as life prolongation may compete for an improved QoL in this elderly patient group.

Cannabis Use: A New Risk Behaviour Among Adults With Congenital Heart Disease.

Background: Cannabis use has increased in Canada and can be associated with adverse cardiovascular events. Given increased use and accessibility to cannabis, there is a need among clinicians to better understand cannabis use in adults with congenital heart disease. Methods: A cross-sectional survey (May to September 2018) was used to investigate cannabis use among 252 patients with adult congenital heart disease in a quaternary care centre. Results: Of the 252 patients, 53 (21%) reported using cannabis. The majority of cannabis users were men (62%), between the ages of 25 and 39 years (mean age = 32 ± 16 years), and more likely to use tobacco (n = 9, 17%; P = 0.001) and alcohol (n = 37, 60%; P = 0.001). Significant differences (P = 0.011) were found between the age of onset for tobacco use among cannabis users (mean age: 16 ± 8 years) and non-cannabis users (mean age: 20 ± 3 years). Users reported consuming cannabis for recreational purposes (n = 29, 55%), anxiety (n = 22, 42%), depression (n = 15, 28%), and pain management (n = 4, 8%). Conclusions: This study supports our clinical experience that a high proportion of patients with adult congenital heart disease use cannabis. Cannabis users represent a patient population who may demonstrate less optimal health behaviours, including tobacco and alcohol use. Assessment of cannabis use should be an integral part of risk behaviour and cardiovascular risk profile at each clinic visit. Given the current legalization of cannabis in Canada and the growing increase of cannabis use, educational support should be provided to patients and caregivers.

Contexte: La consommation de cannabis, en hausse au Canada, a été associée à des manifestations cardiovasculaires indésirables. Puisque l'usage et la disponibilité du cannabis ont augmenté, il est nécessaire pour les cliniciens de mieux comprendre cet usage chez les adultes qui présentent une cardiopathie congénitale. Méthodologie: Nous avons mené une enquête transversale (mai à septembre 2018) sur l'usage du cannabis auprès de 252 adultes atteints d'une cardiopathie congénitale dans un centre de soins quaternaires. Résultats: Cinquante-trois patients sur 252 (21 %) ont indiqué consommer du cannabis. Les utilisateurs de cannabis étaient en majorité des hommes (62 %), ils étaient âgés de 25 à 39 ans (âge moyen de 32 ans ± 16), et ils étaient plus susceptibles de consommer du tabac (n = 9; 17 %; p = 0,001) et de l'alcool (n = 37; 60 %; p = 0,001). Une différence significative a été notée entre l'âge au moment de commencer l'usage de tabac chez les utilisateurs de cannabis (âge moyen de 16 ± 8 ans) et chez les non-utilisateurs (âge moyen de 20 ± 3 ans). Les personnes consommaient du cannabis pour un usage récréatif (n = 29; 55 %), ou pour la prise en charge de l'anxiété (n = 22; 42 %), de la dépression (n = 15; 28 %) ou de la douleur (n = 4; 8 %). Conclusion: Notre étude corrobore notre expérience clinique, selon laquelle une proportion importante des adultes atteints d'une cardiopathie congénitale consomment du cannabis. Les patients qui font usage de cannabis constituent une population qui pourrait adopter des comportements moins favorables pour la santé, comme la consommation d'alcool et de produits de tabac. Une évaluation de l'usage de cannabis devrait faire partie intégrante du profil de comportements à risque et du risque cardiovasculaire réalisé à chacune des visites des patients. Étant donné la légalisation du cannabis au Canada et l'augmentation constante de son usage, un soutien éducatif devrait être offert aux patients et à leurs proches.

Support for health care workers and psychological distress: thinking about now and beyond the COVID-19 pandemic. / Soutien aux travailleurs de la santé et détresse psychologique : réflexion sur la situation actuelle et la période suivant la pandémie de COVID-19.

INTRODUCTION: This study explores the relationship between emotional support, perceived risk and mental health outcomes among health care workers, who face high rates of burnout and mental distress since the beginning of the COVID-19 pandemic. METHODS: A cross-sectional, multicentred online survey of health care workers in the Greater Toronto Area, Ontario, Canada, during the first wave of the COVID-19 pandemic evaluated coping strategies, confidence in infection control, impact of previous work during the 2003 SARS outbreak and emotional support. Mental health outcomes were assessed using the Generalized Anxiety Disorder scale, the Impact of Event Scale - Revised and the Patient Health Questionnaire (PHQ-9). RESULTS: Of 3852 participants, 8.2% sought professional mental health services while 77.3% received emotional support from family, 74.0% from friends and 70.3% from colleagues. Those who felt unsupported in their work had higher odds ratios of experiencing moderate and severe symptoms of anxiety (odds ratio [OR] = 2.23; 95% confidence interval [CI]: 1.84-2.69), PTSD (OR = 1.88; 95% CI: 1.58-2.25) and depression (OR = 1.88; 95% CI: 1.57-2.25). Nearly 40% were afraid of telling family about the risks they were exposed to at work. Those who were able to share this information demonstrated lower risk of anxiety (OR = 0.58; 95% CI: 0.48-0.69), PTSD (OR = 0.48; 95% CI: 0.41-0.56) and depression (OR = 0.55; 95% CI: 0.47-0.65). CONCLUSION: Informal sources of support, including family, friends and colleagues, play an important role in mitigating distress and should be encouraged and utilized more by health care workers.

Surviving SARS and living through COVID-19: Healthcare worker mental health outcomes and insights for coping.

OBJECTIVE: Explore how previous work during the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak affects the psychological response of clinical and non-clinical healthcare workers (HCWs) to the current COVID-19 pandemic. METHODS: A cross-sectional, multi-centered hospital online survey of HCWs in the Greater Toronto Area, Canada. Mental health outcomes of HCWs who worked during the COVID-19 pandemic and the SARS outbreak were assessed using Impact of Events-Revised scale (IES-R), Generalized Anxiety Disorder scale (GAD-7), and Patient Health Questionnaire (PHQ-9). RESULTS: Among 3852 participants, moderate/severe scores for symptoms of post- traumatic stress disorder (PTSD) (50.2%), anxiety (24.6%), and depression (31.5%) were observed among HCWs. Work during the 2003 SARS outbreak was reported by 1116 respondents (29.1%), who had lower scores for symptoms of PTSD (P = .002), anxiety (P < .001), and depression (P < .001) compared to those who had not worked during the SARS outbreak. Multivariable logistic regression analysis showed non-clinical HCWs during this pandemic were at higher risk of anxiety (OR, 1.68; 95% CI, 1.19-2.15, P = .01) and depressive symptoms (OR, 2.03; 95% CI, 1.34-3.07, P < .001). HCWs using sedatives (OR, 2.55; 95% CI, 1.61-4.03, P < .001), those who cared for only 2-5 patients with COVID-19 (OR, 1.59; 95% CI, 1.06-2.38, P = .01), and those who had been in isolation for COVID-19 (OR, 1.36; 95% CI, 0.96-1.93, P = .05), were at higher risk of moderate/severe symptoms of PTSD. In addition, deterioration in sleep was associated with symptoms of PTSD (OR, 4.68, 95% CI, 3.74-6.30, P < .001), anxiety (OR, 3.09, 95% CI, 2.11-4.53, P < .001), and depression (OR 5.07, 95% CI, 3.48-7.39, P < .001). CONCLUSION: Psychological distress was observed in both clinical and non-clinical HCWs, with no impact from previous SARS work experience. As the pandemic continues, increasing psychological and team support may decrease the mental health impacts.

Quality of life after transcatheter or surgical aortic valve replacement using the Toronto Aortic Stenosis Quality of Life Questionnaire.

BACKGROUND: The Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ) is a validated instrument for assessing quality of life (QoL) in patients with severe aortic stenosis (AS). In this study, we evaluated health status outcomes, based on the TASQ, in patients with severe AS undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). METHODS: The TASQ registry was a prospective observational registry. Patients with severe AS from nine centres in Europe and one in Canada underwent either SAVR or transfemoral TAVR. Patients completed the TASQ, Kansas City Cardiomyopathy Questionnaire and Short Form-12 V.2 prior to the intervention, predischarge, and at 30-day and 3-month follow-ups. Primary end point was the TASQ score. RESULTS: In both the TAVR (n=137) and SAVR (n=137) cohorts, significant increases were observed in all three scores. The overall TASQ score improved as did all but one of the individual domains at 3 months after the intervention (p<0.001). TASQ health expectations were the only domain which worsened (p<0.001). Across TASQ subscores, significant changes were evident from the time of discharge in the TAVR and 30-day follow-up in the SAVR cohort. In a categorical analysis of the TASQ, 39.7% of the TAVR group and 35.0% of the SAVR group had a substantially improved health status at 3 months compared with baseline. CONCLUSIONS: The TASQ captured changes in QoL among patients with severe AS who were treated with TAVR or SAVR. QoL improved substantially after either intervention, as indicated by changes in the TASQ overall score at 3 months. TRIAL REGISTRATION NUMBER: NCT03186339.

Aortic valve replacement: validation of the Toronto Aortic Stenosis Quality of Life Questionnaire.

AIMS: There is no quality of life tool specifically developed for patients with severe aortic stenosis (AS) to assess how this chronic condition and its treatment affect patients. The Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ) has been developed to overcome this gap. The results of the validation of the TASQ in patients undergoing treatment for severe AS are presented. METHODS AND RESULTS: Prospective study at 10 centres in Europe and Canada, which enrolled 274 patients with severe symptomatic AS undergoing surgical or transcatheter aortic valve replacement. Mean TASQ score at baseline was 71.2 points and increased to 88.9 three months after aortic valve implantation (P < 0.001). Increases were seen for the emotional impact (32.0 to 39.0; P < 0.001), physical limitations (14.8 to 22.0; P < 0.001), and physical symptoms (8.5 vs. 11.0; P < 0.001) domains. Internal consistency was good/excellent for overall TASQ score (α = 0.891) and for the physical limitation, emotional impact, and social limitation domains (α = 0.815-0.950). Test-retest reliability was excellent or strong for the overall TASQ (intraclass correlation coefficient of 0.883) and for the physical symptoms, physical limitation, emotional impact, and social limitation domains (intraclass correlation coefficient of 0.791-0.895). Responsiveness was medium overall (Cohen's d = 0.637) and medium/large for physical symptoms, emotional impact, and physical limitations (0.661-0.812). Sensitivity to change was significant for physical symptoms, physical limitations (both P < 0.001), emotional impact (P = 0.003), and social limitations (P = 0.038). CONCLUSIONS: The TASQ is a new, brief, self-administered, and clinically relevant health-specific tool to measure changes in quality of life in patients with AS undergoing an intervention.

Toronto aortic stenosis quality of life questionnaire (TASQ): validation in TAVI patients.

BACKGROUND: Aortic stenosis (AS) is a common cardiac condition whose prevalence increases with age. The symptom burden associated with severe aortic stenosis (AS) can introduce significant lifestyle disruptions and if left untreated can lead to a poor prognosis. Quality of life (QoL) is an important consideration in these patients. The TASQ is a QoL tool that was developed for aortic stenosis patients. We evaluated the psychometric properties of this specific questionnaire in patients who underwent transcatheter aortic valve implantation (TAVI), which is a therapeutic option for patients with severe aortic stenosis (AS). METHODS: The properties of the TASQ in measuring QoL were evaluated in AS patients undergoing TAVI. Patients presenting for the TAVI procedure (N = 62) were evaluated pre-TAVI, at discharge, 1-month, and 3-month follow-ups. Demographic information as well as caregiver status, and daily activities were recorded. In addition to the TASQ, they completed the KCCQ (Kansas City Cardiomyopathy Questionnaire) and the IIRS (Illness Intrusiveness Rating Scale). RESULTS: The TASQ is a 16-item self-administered questionnaire that assesses AS-specific QoL across five domains: physical symptoms; physical limitations; emotional impact; social limitations, and health expectations. TASQ subscales are internally consistent (α = 0.74-0.96) and showed significant improvements from baseline across assessments (p < 0.001). Construct validity evidence was demonstrated by correlations consistent with theoretically derived hypotheses across time points. CONCLUSIONS: The TASQ is a brief measure of AS-specific QoL that is sensitive to change in patients undergoing TAVI. Items on the TASQ capture important QoL concerns reported by AS patients, suggesting this is a measure of relevant and meaningful outcomes for this patient population. Detection of early improvements in QoL by the TASQ is promising, with important implications for the evaluation of procedural outcomes in this population.

Trial protocol for the validation of the 'Toronto Aortic Stenosis Quality of Life (TASQ) Questionnaire' in patients undergoing surgical aortic valve replacement (SAVR) or transfemoral (TF) transcatheter aortic valve implantation (TAVI): the TASQ registry.

Background: Patients with severe aortic stenosis (AS) have a reduced life expectancy and quality of life (QoL), owing to advanced age and the presence of multiple comorbidities. Currently, there is no AS-specific QoL measurement tool, which prevents an accurate assessment of how this chronic condition and its treatment affect patients. The Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ) was developed in order to address this deficiency. Methods: The present trial protocol was designed to enable validation of the TASQ, which has been produced in five languages (English, French, German, Italian and Spanish) to increase usability. Patients with severe AS who are undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) will be asked to complete the TASQ and, for comparative purposes, the Kansas City Cardiomyopathy Questionnaire and the general health-related QoL Short Form-12 questionnaire. The questionnaires will be completed prior to the intervention, at discharge, as well as at 30 days and 3 months follow-up. A total of 290 patients will be recruited across one Canadian and nine European centres. Overall, the protocol validation aims to include 120 patients undergoing transfemoral TAVI (TF-TAVI), 120 undergoing SAVR and up to 50 being treated medically. The primary objective of the registry is to validate the TASQ in five different languages. The secondary objective is to assess the utility of the TASQ for assessing differences in QoL outcome between patients undergoing TF-TAVI, SAVR or medical management for their AS. Discussion: Validation and roll-out of the TASQ will enable clinicians to capture an accurate assessment of how AS and its management affects the QoL of patients and will help them to determine the most appropriate treatment strategy for individual patients. Trial registration number: NCT03186339.

The effect of preoperative cognitive impairment and type of vascular surgery procedure on postoperative delirium with associated cost implications.

OBJECTIVE: Postoperative delirium (POD) has a high prevalence among vascular surgery patients, increasing morbidity, mortality, and length of stay. We prospectively studied preoperative risk factors for delirium that can be assessed by the surgical team to identify high-risk patients and assessed its impact on hospital costs. METHODS: There were 173 elective vascular surgery patients assessed preoperatively for cognitive function using the Montreal Cognitive Assessment (MoCA) and the Confusion Assessment Method for POD, which was verified by chart and clinical review. Demographic information, medications, and a history of substance abuse, psychiatric disorders, and previous delirium were prospectively recorded. An accompanying retrospective chart review of an additional 434 (elective and emergency) vascular surgery patients provided supplemental cost information related to sitter use and prolonged hospitalization secondary to three factors: delirium alone, dementia alone, and delirium and dementia. RESULTS: Prospective screening of 173 patients (73.4% male; age, 69.9 ± 10.97 years) identified that 119 (68.8%) had MoCA scores <24, indicating cognitive impairment, with 7.5% having severe impairment (dementia). Patients who underwent amputation had significantly (P < .000) lower MoCA scores (17 of 30) compared with open surgery and endovascular aneurysm repair patients (23.7 of 30). The incidence of delirium was 11.6% in the elective cohort. Regression analysis identified predictors of delirium to be type of surgical procedure, including lower limb amputation (odds ratio [OR], 16.67; 95% confidence interval [CI], 3.41-71.54; P < .000) and open aortic repair (OR, 5.33; 95% CI, 1.91-14.89; P < .000); cognitive variables (dementia: OR, 5.63; 95% CI, 2.08-15.01; P < .001); MoCA scores ≤15, indicating moderate to severe impairment (OR, 6.13; 95% CI, 1.56-24.02; P = .02); and previous delirium (OR, 2.98; 95% CI, 1.11-7.96; P = .03). Retrospective review (N = 434) identified differences in sitter needs for patients with both delirium and dementia (mean, 13.6 days), delirium alone (mean, 3.9 days), or dementia alone (mean, <1 day [17.7 hours]). Fifteen patients required >200 hours (8.3 days), accounting for 69.7% of sitter costs for the surgical unit; 43.7% of costs were accounted for by patients with pre-existing cognitive impairment. CONCLUSIONS: POD is predicted by type of vascular surgery procedure, impaired cognition (MoCA), and previous delirium. Costs and morbidity related to delirium are greatest for those with impaired cognitive burden. Preoperative MoCA screening can identify those at highest risk, allowing procedure modification and informed care.

Postoperative Pain Management Strategies and Delirium After Transapical Aortic Valve Replacement: A Randomized Controlled Trial.

OBJECTIVE(S): This study was designed to compare 2 different perioperative analgesia strategies with respect to the incidence of postoperative delirium after a transapical approach for transcatheter aortic valve replacement (TAVR). The authors hypothesized that perioperative thoracic paravertebral analgesia with a local anesthetic would decrease opioid consumption and in turn reduce the incidence of postoperative delirium when compared with systemic opioid-based analgesia after a transapical TAVR procedure. DESIGN: Prospective, randomized controlled clinical trial. SETTING: Tertiary referral center, university hospital. PARTICIPANTS: The study comprised 44 patients undergoing a transapical TAVR procedure. Patients with a history of serious mental illness, delirium, and severe dementia and/or patients with contraindications to regional anesthesia were excluded. INTERVENTIONS: Patients were randomly assigned to either the paravertebral group (perioperative continuous thoracic paravertebral block with local anesthetic) or the patient-controlled analgesia group (systemically administered opioids) using a computer-generated randomization code in blocks of four patients. MEASUREMENTS AND MAIN RESULTS: Assessment of postoperative delirium was performed by trained research staff using the confusion assessment method for intensive care unit preoperatively and postoperatively every 12 hours or more often if needed according to the patient's condition during the first 7 postoperative days or until discharge. Pain was assessed with a 10 cm Visual Analog Scale pain score system during the 48 hours postoperatively. The sedation level was assessed using the Sedation Agitation Scale during the same period. Overall postoperative delirium was detected in 12/44 (27%) patients, with 7/22 (32%) in the patient-controlled analgesia and 5/22 (23%) in the paravertebral groups, respectively (p = 0.73). Both groups were similar with respect to demographic data, preoperative medications, and comorbidities. Paravertebral analgesia was associated with an opioid-sparing effect during surgery and during the 48-hour postoperative period. Sedation and pain scores were similar between the 2 groups. In addition, paravertebral analgesia was associated with earlier extubation times; however, the overall morbidity and mortality were similar between the 2 groups. CONCLUSIONS: Paravertebral analgesia in patients undergoing transapical TAVR procedures appears to have an opioid-sparing effect. However, it did not translate into a statistically significant decrease in the rate of postoperative delirium.

Suicide deaths by intentional self-poisoning in people with cardiovascular disease.

OBJECTIVE: We aimed to characterize self-poisoning deaths in people with cardiovascular disease (CVD) and compare to other suicide decedent groups. METHODS: Suicide deaths by self-poisoning in people with CVD (n = 151) were compared to suicide deaths by other methods in people with CVD (n = 260) and suicide deaths by self-poisoning in people without CVD (n = 509). Sub-analysis of the CVD self-poisoning group compared people with depression and without depression. Toxicology reports were compared between intentional self-poisoning groups. RESULTS: A higher proportion of suicide deaths were due to self-poisoning in the CVD group compared to the non-CVD group. People with CVD were less likely to have any identified stressor (excluding medical stressor) prior to dying from self-poisoning compared to those without CVD. Female sex, past suicide attempts, living circumstances, and comorbid substance abuse were each significantly associated with self-poisoning as the method of suicide in people with CVD. Opioid, any antidepressants, benzodiazepines, and tricyclic antidepressants (TCAs) were commonly identified as lethal in people with CVD. Compared to people in the CVD self-poisoning without depression group, people in the CVD self-poisoning with depression group were more likely to have lethal levels of TCAs. CONCLUSIONS: Our findings characterize suicide deaths in people with CVD, and identified notable differences based on method of death and presence of depression.

Time to Consultation-Liaison Psychiatry Service Referral as a Predictor of Length of Stay.

OBJECTIVES: The aim of this study was to determine the relationship between the time to referral (TTR) to psychiatric consultation and the length of stay (LOS) after adjusting for medical comorbity. METHODS: Using a naturalistic study design, we collected and analyzed inpatient consultation-liaison psychiatry service data over a 12-month period from 2 Canadian hospital sites. Data collected included demographic characteristics, referral characteristics, Charlson Comorbidity Index to measure medical comorbidity severity, psychiatric diagnoses, type of psychiatric intervention, and time variables, namely TTR and LOS. We modeled the relationship LOS and TTR after adjusting for Charlson Index using a 3-component finite mixture of exponential regression models. RESULTS: A total of 814 patients were included. The median LOS was 12 days (interquartile range : 4-28 days). Median TTR was 3 days (interquartile range: 1,9), and median Charlson Index was 5 (interquartile range 3,6). Bivariate analysis indicated a strong positive correlation among LOS and TTR (Spearman correlation: 0.77, p < 0.0001) and Charlson Index(Spearman correlation: 0.34, p < 0.0001), respectively. After controlling for Charlson Index, we observe that TTR was significantly associated with LOS in each of the 3 components of the mixture of exponential regression models. Persons with longer TTR have longer expected LOS. Graphical summaries suggest that the mixture of exponential regression model provides a good fit to these LOS response data. CONCLUSIONS: Patients with longer TTR had significantly longer LOS. The association between TTR and LOS holds after controlling for severity of medical comorbidity. Our results support the role of integrated and proactive consultation-liaison psychiatry programs aimed at reducing TTR to improve LOS outcomes.

Dexmedetomidine versus Propofol Sedation Reduces Delirium after Cardiac Surgery: A Randomized Controlled Trial.

BACKGROUND: Postoperative delirium (POD) is a serious complication after cardiac surgery. Use of dexmedetomidine to prevent delirium is controversial. The authors hypothesized that dexmedetomidine sedation after cardiac surgery would reduce the incidence of POD. METHODS: After institutional ethics review board approval, and informed consent, a single-blinded, prospective, randomized controlled trial was conducted in patients 60 yr or older undergoing cardiac surgery. Patients with a history of serious mental illness, delirium, and severe dementia were excluded. Upon admission to intensive care unit (ICU), patients received either dexmedetomidine (0.4 µg/kg bolus followed by 0.2 to 0.7 µg kg h infusion) or propofol (25 to 50 µg kg min infusion) according to a computer-generated randomization code in blocks of four. Assessment of delirium was performed with confusion assessment method for ICU or confusion assessment method after discharge from ICU at 12-h intervals during the 5 postoperative days. Primary outcome was the incidence of POD. RESULTS: POD was present in 16 of 91 (17.5%) and 29 of 92 (31.5%) patients in dexmedetomidine and propofol groups, respectively (odds ratio, 0.46; 95% CI, 0.23 to 0.92; P = 0.028). Median onset of POD was on postoperative day 2 (1 to 4 days) versus 1 (1 to 4 days), P = 0.027, and duration of POD 2 days (1 to 4 days) versus 3 days (1 to 5 days), P = 0.04, in dexmedetomidine and propofol groups, respectively. CONCLUSIONS: When compared with propofol, dexmedetomidine sedation reduced incidence, delayed onset, and shortened duration of POD in elderly patients after cardiac surgery. The absolute risk reduction for POD was 14%, with a number needed to treat of 7.1.

The effect of bupropion XL and escitalopram on memory and functional outcomes in adults with major depressive disorder: results from a randomized controlled trial.

Decrements in cognitive function are a common feature of Major Depressive Disorder (MDD), and whether distinct classes of antidepressants differentially affect memory in these individuals has not been sufficiently evaluated. In this study we sought to determine the effect of escitalopram and bupropion XL on memory and psychosocial function. Forty-one individuals (18-50 years) with MDD were enrolled in an 8-week, double-blind, double-dummy, randomized controlled comparative trial of bupropion XL and escitalopram. Thirty-six participants completed pre and post memory assessments. Verbal, non-verbal and working memory were evaluated with a comprehensive neuropsychological battery. Psychosocial function was assessed with the Sheehan Disability Scale and Endicott Work Productivity Scale. Escitalopram and bupropion XL significantly improved immediate as well as delayed verbal and nonverbal memory, global function (all p≤0.001), and work productivity (p=0.045), with no significant between-group differences. Improvement in immediate verbal memory exerted a direct influence on improvement in global function (p=0.006). Treatment with either escitalopram or bupropion XL was associated with improvement in memory and psychosocial function in adults with MDD.

Evaluation of professional role competency during psychiatry residency.

OBJECTIVE: The authors sought to determine psychiatry residents' perceptions on the current method of evaluating professional role competency and the use of multi-source feedback (MSF) as an assessment tool. METHOD: Authors disseminated a structured, anonymous survey to 128 University of Toronto psychiatry residents, evaluating the current mode of assessment of the professional role and the use of MSF. RESULTS: The overall response rate was 86%. Fewer than half (44%) of residents felt that their professional role is adequately evaluated, and 84% were in favor of incorporating MSF for the evaluation of this competency. Respondents believed their primary supervisor should have the largest proportional impact on the evaluation (50%), followed by allied heath staff (19%), patients (16%), co-residents (12%), self (11%), and administrative staff (9%). CONCLUSION: On the basis of this needs assessment and the Royal College recommendations, MSF may be considered a potential assessment tool for evaluating psychiatry residents in their professional role.