Predictors of quality of life in 102 patients with treated Cushing's disease.

OBJECTIVE: To identify predictors for quality of life (QoL) in treated Cushing's disease (CD) and quantify patients' assessment of their disease status. CONTEXT: Significant reductions in QoL exist in CD patients despite treatment. Identifying predictors of QoL is paramount to the long-term management of these patents. DESIGN: A cross-sectional study was conducted of patients with treated CD. Patients completed a medical history questionnaire and three validated quality of life assessments: Cushing's QoL Questionnaire (CushingQoL), Hospital Anxiety and Depression Scale (HADS) and Nottingham Health Profile (NHP). PATIENTS: 102 patients (75·7% female, mean time since surgery 7·4 years) with treated CD were included. MEASUREMENTS: Patients were categorized by biochemical and self-identified disease status. Mean CushingQoL, anxiety and depression scores were compared by unpaired t-tests. Multiple linear regressions were performed on the whole cohort to assess for predictors of impaired QoL. RESULTS: Ninety-two per cent of the cohort met criteria for biochemical remission, but only 80·4% felt they had achieved remission. Among those with biochemical remission, those who also self-identified as being in remission had higher CushingQoL scores than those who self-identified as having persistent disease (P = 0·042). Anxiety (P = 0·032) and depression (P = 0·018) scores were lower, and CushingQoL scores were higher (P = 0·05) in patients who self-identified as being in remission compared to persistence. Recovery time, BMI, gender and age were also predictors for QoL. CONCLUSION: Our study identifies the discordance that can exist between biochemical and self-assessed disease status and demonstrates its impact on QoL in patients with CD. These findings highlight the importance of incorporating patients' disease perceptions in their management.

Long-term effects of single or multiple neonatal sevoflurane exposures on rat hippocampal ultrastructure.

BACKGROUND: Neonatal exposure to general anesthetics may pose significant neurocognitive risk. Human epidemiological studies demonstrate higher rates of learning disability among children with multiple, but not single, exposures to anesthesia. The authors employ a rat model to provide a histological correlate for these population-based observations. The authors examined long-term differences in hippocampal synaptic density, mitochondrial density, and dendritic spine morphology. METHODS: Twenty male rat pups (n = 5/condition) were exposed to 2.5% sevoflurane under one of four conditions: single 2-h exposure on postnatal day 7 (P7); single 6-h exposure on P7; repeated 2-h exposures on P7, P10, and P13 for a cumulative 6 h of general anesthetics; or control exposure to 30% oxygen on P7, P10, and P13. RESULTS: Repeated exposure to general anesthetics resulted in greater synaptic loss relative to a single 2-h exposure (P < 0.001). The magnitude of synaptic loss induced by three 2-h exposures (1.977 ± 0.040 µm [mean ± SEM]) was more profound than that of a single 6-h exposure (2.280 ± 0.045 µm, P = 0.022). Repeated exposures did not alter the distribution of postsynaptic density length, indicating a uniform pattern of loss across spine types. In contrast, mitochondrial toxicity was best predicted by the cumulative duration of exposure. Relative to control (0.595 ± 0.017), both repeated 2-h exposures (0.479 ± 0.015) and a single 6-h exposure (0.488 ± 0.013) were associated with equivalent reductions in the fraction of presynaptic terminals containing mitochondria (P < 0.001). CONCLUSION: This suggests a "threshold effect" for general anesthetic-induced neurotoxicity, whereby even brief exposures induce long-lasting alterations in neuronal circuitry and sensitize surviving synapses to subsequent loss.

The implication of frailty on preoperative risk assessment.

PURPOSE OF REVIEW: Frailty, a state of decreased homeostatic reserve, is characterized by dysregulation across multiple physiologic and molecular pathways. It is particularly relevant to the perioperative period, during which patients are subject to high levels of stress and inflammation. This review aims to familiarize the anesthesiologist with the most current concepts regarding frailty and its emerging role in preoperative assessment and risk stratification. RECENT FINDINGS: Current literature has established frailty as a significant predictor of operative complications, institutionalization, and death among elderly surgical patients. A variety of scoring systems have been proposed to preoperatively identify and assess frail patients, though they differ in their clinical utility and prognostic ability. Additionally, evidence suggests an evolving potential for preoperative intervention and modification of the frailty syndrome. SUMMARY: The elderly are medically complex and heterogeneous with respect to operative risk. Recent advances in the concept of frailty provide an evidence-based framework to guide the anesthesiologist in the perioperative management, evaluation, and risk stratification of older surgical patients.

Can routine preoperative data predict adverse outcomes in the elderly? Development and validation of a simple risk model incorporating a chart-derived frailty score.

BACKGROUND: Frailty has emerged as an important predictor of operative risk among elderly surgical patients. However, the complexity of prospective frailty scores has limited their widespread use. Our goal was to develop two frailty-based surgical risk models using only routine preoperative data. Our hypothesis was that these models could easily integrate into an electronic medical record to predict 30-day morbidity and mortality. STUDY DESIGN: American College of Surgeons NSQIP Participant Use Data Files from 2005 to 2010 were reviewed, and patients 65 years and older who underwent elective lower gastrointestinal surgery were identified. Two multivariate logistic regression models were constructed and internally cross-validated. The first included simple functional data, a comorbidity index based on the Charlson Comorbidity Index, demographics, BMI, and laboratory data (ie, albumin <3.4 g/dL, hematocrit <35%, and creatinine >2 mg/dL). The second model contained only parameters that can directly autopopulate from an electronic medical record (ie, demographics, laboratory data, BMI, and American Society of Anesthesiologists score). To assess diagnostic accuracy, receiver operating characteristic curves were constructed. RESULTS: There were 76,106 patients who met criteria for inclusion. Thirty-day mortality was seen in 2,853 patients or 3.7% of the study population and 18,436 patients (24.2%) experienced a major complication. The c-statistic of the first expanded model was 0.813 for mortality and 0.629 for morbidity. The second simplified model had a c-statistic of 0.795 for mortality and 0.621 for morbidity. Both models were well calibrated per the Hosmer-Lemeshow test. CONCLUSIONS: Our work demonstrates that routine preoperative data can approximate frailty and predict geriatric-specific surgical risk. The models' predicative powers were comparable with that of established prospective frailty scores. Our calculator could be used as a low-cost simple screen for high-risk individuals who might require additional evaluation or specialized services.