Phencyclidine Positivity on Urine Drug Screening in Patients Treated for Alcohol Withdrawal on a Dual-diagnosis Medically Assisted Withdrawal Unit.

OBJECTIVES: Little contemporary research has explored phencyclidine (PCP) use in people with alcohol use disorder. Therefore, we sought to determine the prevalence of PCP positivity on urine toxicology screening among patients admitted for alcohol withdrawal, identify correlates of PCP positivity, and investigate PCP positivity's relationship to length of stay (LOS) and risk of facility readmission. METHODS: This was a retrospective study of patients admitted to a dual-diagnosis medically assisted withdrawal unit for alcohol withdrawal from 2014 to 2019. Univariate tests and logistic regression were used to investigate potential correlates of PCP positivity on admission toxicology screening (primary outcome). Multivariable linear regression models and survival analyses analyzing LOS and risk of readmission (secondary outcomes) were also developed. RESULTS: Ninety of 3731 patients (2.4%) screened positive for PCP. There were significant associations on univariate testing between PCP positivity and age, race, homeless status, and urine toxicology positivity for amphetamines, benzodiazepines, barbiturates, cocaine, tetrahydrocannabinol, and oxycodone. On multivariate logistic regression, only tetrahydrocannabinol, barbiturates, and cocaine positivity were associated with PCP positivity. Multivariate logistic regression and survival analysis found no statistically significant associations between PCP positivity and LOS or risk of readmission. CONCLUSIONS: This study provides rare analysis of contemporary data on PCP use among patients undergoing medically assisted alcohol withdrawal. Phencyclidine positivity was uncommon, but use appears considerably higher among this patient population than the general population. There was no significant association between PCP positivity and LOS or readmission risk.

Antemortem Health System Utilization in People Experiencing Homelessness Who Died in the Emergency Department.

People experiencing homelessness (PEH) have high rates of mortality, medical and psychiatric comorbidities, and emergency department utilization. In this study, a health system's emergency department encounters were evaluated to identify PEH who died in the emergency department. Patient demographics, medical history, prehospital and emergency department characteristics, and health care utilization patterns were collected. Descriptive statistics were calculated. We identified 48 PEH pronounced dead in the emergency department; mean age at death was 46.5. Forty-four (92%) decedents presented in cardiac arrest, 12 (25%) of which were substance use-related; 4 (8%) presented with trauma. Out of 44 patients presenting in cardiac arrest, (20.5%) had bystander cardiopulmonary resuscitation (CPR) performed before arrival of emergency medical services. In the year prior to death, 15 (32%) decedents had no documented health care utilization, while 16 (33%) had 10 or more emergency department/outpatient visits. Our study is the first to characterize PEH who died in the emergency department, analyzing the pre-hospital and in-hospital characteristics and antemortem health system utilization in this population. A sizeable proportion of deceased PEH had no health system contact in the 12 months prior to death, suggesting that those with high mortality risk may underutilize health services. Conversely, a similar proportion of decedents had extensive (more than 10) health system utilization in the year prior to death, representing possible opportunities to reduce mortality.

First in Human Subjects Testing of the UroMonitor: A Catheter-free Wireless Ambulatory Bladder Pressure Monitor.

PURPOSE: Urodynamics is the standard method of diagnosing bladder dysfunction, but involves catheters and retrograde bladder filling. With these artificial conditions, urodynamics cannot always reproduce patient complaints. We have developed a wireless, catheter-free intravesical pressure sensor, the UroMonitor, which enables catheter-free telemetric ambulatory bladder monitoring. The purpose of this study was twofold: to evaluate accuracy of UroMonitor pressure data, and assess safety and feasibility of use in humans. MATERIALS AND METHODS: Eleven adult female patients undergoing urodynamics for overactive bladder symptoms were enrolled. After baseline urodynamics, the UroMonitor was transurethrally inserted into the bladder and position was confirmed cystoscopically. A second urodynamics was then performed with the UroMonitor simultaneously transmitting bladder pressure. Following removal of urodynamics catheters, the UroMonitor transmitted bladder pressure during ambulation and voiding in private. Visual analogue pain scales (0-5) were used to assess patient discomfort. RESULTS: The UroMonitor did not significantly alter capacity, sensation, or flow during urodynamics. The UroMonitor was also easily inserted and removed in all subjects. The UroMonitor reproduced bladder pressure, capturing 98% (85/87) of voiding and nonvoiding urodynamic events. All subjects voided with only the UroMonitor in place with low post-void residual volume. Median ambulatory pain score with the UroMonitor was rated 0 (0-2). There were no post-procedural infections or changes to voiding behavior. CONCLUSIONS: The UroMonitor is the first device to enable catheter-free telemetric ambulatory bladder pressure monitoring in humans. The UroMonitor appears safe and well tolerated, does not impede lower urinary tract function, and can reliably identify bladder events compared to urodynamics.

Are There Differences in the Cranial Base of Humans and Apes?

PURPOSE: Differences in skull-base angles between humans, other hominid species and apes might account for the ability of humans to develop complex speech. This study compared midline skull base angles, and angles related to insertion of skull base musculature between these species. METHODS: 126 human adult, 29 adolescent, 19 children, and 13 fetus skulls were compared to 32 ape and a subset of non-human antiquity hominid casts of skulls (13). Cranial base measurements were taken using an eMicroscribe 3d G2 digitizer. Midline and muscle insertion measurements were obtained. RESULTS: There were statistical differences in both the midline angles of the skull base (humans, 119o; apes, 130o) and in the Skull base angles related to points of muscle insertion (humans, 113o; apes, 124o), with humans exhibiting a more acute angle than the apes and other non-human hominids. There were no differences between human adults and children CONCLUSION: Acute angle differentiation of the midline skull base between humans and apes was confirmed with an alternate measurement method. Whether these angular differences are the primary reason for the lower position of the larynx in humans and the potential for more complex speech is still in debate.

Papillary Renal Cell Carcinoma With Microcystic Architecture Is Strongly Associated With Extrarenal Invasion and Metastatic Disease.

Papillary renal cell carcinoma (PRCC) is well-recognized as a morphologically and molecularly heterogenous group of kidney tumors with variable clinical behavior. Our goal was to analyze a unique histologic pattern of PRCC we have observed in routine practice to evaluate for potential clinical significance or distinct molecular signature. We identified 42 cases of PRCC showing a morphologically distinct architecture characterized by numerous epithelial-lined cysts containing the papillary tumor (herein called "microcysts"), which are typically separated by fibrous stroma. Of the initial 42 case test set with microcystic features, 23 (55%) were stage pT3a or higher. Most tumors had strong and diffuse cytoplasmic immunoreactivity for CK7 (93%, 37/40) and AMACR (100%, 40/40). Fumarate hydratase staining was retained in all cases tested (39/39). We performed next-generation sequencing on 15 of these cases with available tissue and identified chromosomal alterations commonly reported in historically "type 1" PRCC, notably multiple chromosomal gains, particularly of chromosomes 7 and 17, and MET alterations. However, alterations in pathways associated with more aggressive behavior (including SETD2, CDKN2A, and members of the NRF pathway) were also identified in 6 of 15 cases tested (40%). Given this molecular and immunophenotypic data, we subsequently reviewed an additional group of 60 consecutive pT2b-pT3 PRCCs to allow for comparisons between cases with and without microcysts, to assess for potential associations with other recently described histologic patterns (ie, "unfavorable architecture": micropapillary, solid, and hobnail), and to assess interobserver reproducibility for diagnosing architectural patterns and grade. Of the total combined 102 PRCCs, 67 (66%) had microcystic architecture within the intrarenal component but were commonly admixed with other patterns (39% had micropapillary, 31% solid, and 31% hobnail). Twenty-seven cases (26%) had metastatic disease, and 24 of these 27 (89%) had microcystic architecture in the intrarenal tumor. Within the pT3 subset, 21 of 22 cases with metastases (95%) had extrarenal invasion as either individual microcysts in renal sinus fat or aggregates of microcysts bulging beyond the confines of the capsule. Backward elimination and stepwise regression methods to detect features significantly associated with adverse outcome identified solid architecture (hazard ratio [HR]: 6.3; confidence interval [CI]: 2.1-18.8; P=0.001), hobnail architecture (HR: 5.3; CI: 1.7-16.7; P=0.004), and microcystic architecture at the tumor-stromal interface (HR: 4.2; CI: 1.1-16.7; P=0.036) as strongest. Of architectural patterns and grade, the microcystic pattern had a substantial interobserver agreement (κ score=0.795) that was highest among the 6 observers. In summary, PRCCs with microcystic architecture represents a subset of historically "type 1" PRCC with a predilection for morphologically distinctive extrarenal involvement and metastatic disease. Microcysts co-vary with other "unfavorable" architectural patterns also associated with higher risk for aggressive disease (ie, micropapillary, hobnail, and solid), but microcysts were more common and have superior interobserver reproducibility. These findings suggest that microcystic PRCC should be recognized as a potentially aggressive histologic pattern of growth in PRCC.

Assessment of L5-S1 anterior lumbar interbody fusion stability in the setting of lengthening posterior instrumentation constructs: a cadaveric biomechanical study.

OBJECTIVE: Excessive stress and motion at the L5-S1 level can lead to degenerative changes, especially in patients with posterior instrumentation suprajacent to L5. Attention has turned to utilization of L5-S1 anterior lumbar interbody fusion (ALIF) to stabilize the lumbosacral junction. However, questions remain regarding the effectiveness of stand-alone ALIF in the setting of prior posterior instrumented fusions terminating at L5. The purpose of this study was to assess the biomechanical stability of an L5-S1 ALIF with increasing lengths of posterior thoracolumbar constructs. METHODS: Seven human cadaveric spines (T9-sacrum) were instrumented with pedicle screws from T10 to L5 and mounted to a 6 degrees-of-freedom robot. Posterior fusion construct lengths (T10-L5, T12-L5, L2-5, and L4-5) were instrumented to each specimen, and torque-fusion level relationships were determined for each construct in flexion-extension, axial rotation, and lateral bending. A stand-alone L5-S1 ALIF was then instrumented, and L5-S1 motion was measured as increasing pure moments (2 to 12 Nm) were applied. Motion reduction was calculated by comparing L5-S1 motion across the ALIF and non-ALIF states. RESULTS: The average motion at L5-S1 in axial rotation, flexion-extension, and lateral bending was assessed for each fusion construct with and without ALIF. After adding ALIF to a posterior fusion, L5-S1 motion was significantly reduced relative to the non-ALIF state in all but one fused surgical condition (p < 0.05). Longer fusions with ALIF produced larger L5-S1 motions, and in some cases resulted in motions higher than native state motion. CONCLUSIONS: Posterior fusion constructs up to L4-5 could be appropriately stabilized by a stand-alone L5-S1 ALIF when using a nominal threshold of 80% reduction in native motion as a potential positive indicator of fusion. The results of this study allow conclusions to be drawn from a biomechanical standpoint; however, the clinical implications of these data are not well defined. These findings, when taken in appropriate clinical context, can be used to better guide clinicians seeking to treat L5-S1 pathology in patients with prior posterior thoracolumbar constructs.

Real-world experience of using combinatorial pharmacogenomic test in children and adolescents with depression and anxiety.

OBJECTIVE: To evaluate the real-world impact of using a commercially available combinatorial pharmacogenomic (CPGx) test on medication management and clinical outcomes in children and adolescents treated at a tertiary care psychiatry practice. METHODS: A retrospective cohort study using our prospectively maintained database of patients undergoing CPGx testing was performed. Only patients with clinical data at the time of ordering CPGx test (pre-baseline), potential medication change visit (baseline) and 8-weeks follow-up (post-baseline) visit were included. Clinical Global Impression (CGI) scores for each visit were calculated. Appropriate statistical analysis, including one-sample t-test, paired t-test and Chi-square test was performed. RESULTS: Based on the inclusion criteria, 281 (75.9%) of the 370 patients with CPGx testing were included. Their mean age was 15.8 ± 4.5 years (111 females; 39.5%). The average number of medications significantly increased to 2.4 ± 1.2 on the post-baseline visit [t(280) = 8.34, p < 0.001). Medications were added in 123 (43.7%), replaced in 92 (32.7%) patients and remained unchanged in rest. There was no significant association between medication-related adverse effects and psychotropic medication change group (p = 0.27). The study population showed a significant improvement (p < 0.001) in the CGI severity, efficacy, and global improvement indices. CONCLUSION: In our experience of using CPGx test in a large cohort of children and adolescents during routine clinical practice, three-quarter of them underwent medication change. Additionally, we noted an improvement in clinical outcomes without impacting adverse effects. While the role of clinical judgement in medication changes in our cohort is likely, CPGx may supplement clinical decision making. However, the best use and benefit of CPGx in routine clinical practice needs further investigation.

Reported firearm access among patients admitted to a dual diagnosis medically-assisted withdrawal unit over five years.

Background: Up to one-third of firearm-related suicides were carried out by individuals who had consumed alcohol shortly before their death. Despite the critical role of firearm access screening in suicide risk assessment, few studies have examined firearm access among patients with substance use disorders. This study examines the rates of firearm access among those admitted to a co-occurring diagnosis unit over a five year period. Methods: All patients admitted to a co-occurring disorders inpatient unit from 2014 to mid-2020 were included. An analysis contrasting the differences among patients reporting firearms was performed. A multivariable logistic regression model using factors from initial admission were chosen based on clinical relevance, past firearms research, and statistical significance on bivariate analysis was used. Results: Over the study period there were 7332 admissions representing 4055 patients. Documentation of firearm access was completed in 83.6% of admissions. Firearm access was reported in 9.4% of admissions. Patients reporting firearm access were more likely to report never having suicidal ideation (p = 0.001), be married (p = <0.001), and report no past history of suicide attempts (p = <0.001). The full logistic regression model revealed that being married (OR: 2.29 and p < 0.0001) and employed (OR: 1.51 and p = 0.024) were factors associated with firearms access. Conclusions: This is one of the largest reports assessing factors associated with firearm access among those admitted to a co-occurring disorders unit. Firearm access rates in this population appear lower than rates in the general population. The roles employment and marital status play in firearm access deserve future attention.

Transurethral versus suprapubic catheterization to test urethral function in rats.

Transurethral and suprapubic catheterization have both been used to test urethral function in rats; however, it is unknown whether these methods affect urethral function or if the order of catheterization affects the results. The aim of this cross-over designed experiment was to compare the effects of catheterization methods and order on leak point pressure (LPP) testing. LPP and simultaneous external urethral sphincter electromyography (EUS EMG) were recorded in anesthetized female virgin Sprague-Dawley rats in a cross-over design to test the effects of transurethral and suprapubic catheterization. There was no significant difference in peak bladder pressure during LPP testing whether measured with a transurethral or suprapubic catheter. There was no significant difference in peak bladder pressure between the first and second catheter insertions. However, peak EMG firing rate, as well as peak EMG amplitude and EMG amplitude difference between peak and baseline were significantly higher after the first catheter insertion compared to the second insertion, regardless of the catheter method. Our results suggest that route of catheterization does not alter urethral function, e.g. create a functional partial outlet obstruction. Either catheterization method could be used for LPP and/or EUS EMG testing in rats.

Chemopreventive Effect of Statin on Hepatocellular Carcinoma in Patients With Nonalcoholic Steatohepatitis Cirrhosis.

INTRODUCTION: To estimate the annual incidence of hepatocellular carcinoma (HCC) in patients with nonalcoholic steatohepatitis (NASH) with advanced liver fibrosis, to determine the risk factors for the development of HCC, and to evaluate the chemoprotective effect of statin use stratified by fibrosis stage. METHODS: We conducted a retrospective study at 2 US tertiary academic centers, including patients with NASH-related advanced liver fibrosis (bridging fibrosis [F3] and cirrhosis [F4]) followed between July 2002 and June 2016. Patients were followed from the date of diagnosis to the time of last abdominal imaging, liver transplantation, or HCC diagnosis. Multivariable Cox regression analysis was performed to evaluate the risk factors associated with HCC development, stratified by fibrosis stage. RESULTS: A total of 1,072 patients were included: 122 patients with F3 fibrosis and 950 patients with cirrhosis. No HCC was observed during 602 person-year follow-up among F3 patients. Among patients with cirrhosis, HCC developed in 82 patients with the annual incidence rate of 1.90 per 100 person-years (95% confidence interval [CI], 1.53-2.35). Multivariable analysis in patients with cirrhosis demonstrated that HCC development was associated with male sex (hazard ratio [HR] 4.06, 95% CI, 2.54-6.51, P < 0.001), older age (HR, 1.05, 95% CI, 1.03-1.08, P < 0.001), and CTP score (HR, 1.38, 95% CI, 1.18-1.60, P < 0.001). Statin use was associated with a lower risk of developing HCC (HR, 0.40, 95% CI, 0.24-0.67, P = 0.001). Each 365 increment in cumulative defined daily dose of statin use reduced HCC risk by 23.6%. DISCUSSION: Our findings suggest that patients with NASH and bridging fibrosis have a low risk of HCC. Dose-dependent statin use reduced HCC risk significantly in patients with NASH cirrhosis.

Elastin homeostasis is altered with pelvic organ prolapse in cultures of vaginal cells from a lysyl oxidase-like 1 knockout mouse model.

Pelvic organ prolapse (POP) decreases quality of life for many women, but its pathophysiology is poorly understood. We have previously shown that Lysyl oxidase-like 1 knockout (Loxl1 KO) mice reliably prolapse with age and increased parity, similar to women. Both this model and clinical studies also indicate that altered elastin metabolism in pelvic floor tissues plays a role in POP manifestation, although it is unknown if this is a cause or effect. Using Loxl1 KO mice, we investigated the effects of genetic absence of Loxl1, vaginal parity, and presence of POP on the expression of genes and proteins key to the production and regulation of elastic matrix. Cultured cells isolated from vaginal explants of mice were assayed with Fastin for elastic matrix, as well as RT-PCR and Western blot for expression of genes and proteins important for elastin homeostasis. Elastin synthesis significantly decreased with absence of LOXL1 and increased with parity (p < .001), but not with POP. Cells from prolapsed mice expressed significantly decreased MMP-2 (p < .05) and increased TIMP-4 (p < .05). The results suggest changes to elastin structure rather than amounts in prolapsed mice as well as poor postpartum elastin turnover, resulting in accumulation of damaged elastic fibers leading to abnormal tropoelastin deposition. POP may thus, be the result of an inability to initiate the molecular mechanisms necessary to clear and replace damaged elastic matrix in pelvic floor tissues after vaginal birth.

Incorporating New Technology Into a Surgical Technique: The Learning Curve of a Single Surgeon's Stereo-Electroencephalography Experience.

BACKGROUND: Technological improvements frequently outpace the publication of randomized, controlled trials in surgical patients. This makes the application of new surgical techniques difficult as surgeons solely use clinical experience to guide changes in their practice. OBJECTIVE: To quantitatively examine the learning curve of incorporating new technology into a surgical technique and discuss the clinical significance of incorporating this new technology into daily practice. To identify areas of improvement for operative efficiency and safety. METHODS: A retrospective observational study examining quantitative measures of operative efficiency and safety from 2009 to 2017 in 454 consecutive patients undergoing stereo-electroencephalography depth electrode implantations. RESULTS: The transition to a new robotic technique significantly improved operative times (196 min [95% CI 173-219] vs 115 min [95% CI 111-118], P < .0001). Cumulative sum (CUSUM) analysis demonstrated that mastery of the robotic technique took much longer than the frame-based technique (operative time peak at case 75 vs case 25, plateau of 150 vs 10 cases). Although hemorrhage rates using different vascular imaging techniques did not appear to differ using traditional statistical analysis (magnetic resonance imaging, MRI 22.3%, computed tomography angiography, CTA 17.9%, angiogram 18.1%, likelihood ratio χ2 = 4.84, P = .30), CUSUM analysis suggested MRI as the vascular imaging modality leading to higher hemorrhage and symptomatic hemorrhage rates at our center. CONCLUSION: This experience demonstrates an improvement in operative efficiency through a series of changes made using clinical experience and intuition while transitioning to a completely new paradigm. CUSUM analysis identified potential areas for improvement in both operative efficiency and safety if used in a prospective manner.

Biomechanics of L5/S1 in Long Thoracolumbosacral Constructs: A Cadaveric Study.

STUDY DESIGN: In vitro cadaveric biomechanical study. OBJECTIVES: Despite numerous techniques employed to establish solid lumbosacral fixation, there are little biomechanical data correlating fixation methods at L5/S1 to thoracolumbosacral (TLS) construct length. We aimed to determine the optimal construct with the hypothesis that under physiological loads, lumbosacral constructs can be stabilized by L5/S1 anterior lumbar interbody fusion (ALIF) alone, without iliac screw fixation (ISF), and that TLS constructs would require ISF, with or without ALIF. METHODS: By using a robot capable of motion in 6 axes, force-moment sensor, motion-tracking camera system and software, we simulated the spinal loading effects in flexion-extension, axial rotation, and lateral bending, and compared torques in different construct groups of T4-S1, T10-S1, and L2-S1. By conducting multidirectional flexibility testing we assessed the effects of constructs of various lengths on the L5/S1 segment. RESULTS: L2-S1 constructs may be equivalently stabilized by L5/S1 ALIF alone without ISF. Longer TLS constructs exerted increasing motion at L5/S1, exhibiting trends in favor of ISF when extending to T10 and statistically improved fixation when extending to T4. Lastly, TLS constructs with ISF exhibited a statistically significant reduction in L5-S1 range of motion from the addition of ALIF when extending to T4-pelvis but not T10-pelvis. CONCLUSIONS: We found that ALIF alone may sufficiently support the L2-S1 construct, reducing L5/S1 range of motion and transmitting loads instead to the sacropelvis. Furthermore, ALIF was found to add significant stability to the T4-pelvis construct when added to ISF. This difference was not significant for the T10-pelvis construct.

Targets without tolerances: improper evaluation of medical personnel.

BACKGROUND: Mandated assessment of medical personnel by comparing individual performance averages to external targets is standard practice in many health care systems. This method of assessment uses only raw or adjusted averages without considering the associated variation. Failure to correctly incorporate variation in the assessment of medical personnel results in evaluations which are neither accurate nor fair with respect to assessing personnel performance. METHODS: Accepted statistical methods for process evaluation and quality control, including regression, control charts, and adjusted means comparisons will be used to analyze hospital length of stay (LOS) patient data for the period between January and October 2010 for 12 physicians in the Cardiothoracic Surgery service line at the Cleveland Clinic. RESULTS: The analysis and interpretation of physician performance data using both targets and tolerances results in physician performance ratings which differ significantly from performance ratings based only on targets. CONCLUSIONS: Failure to include variation when assessing medical personnel performance results in a system of ranking, rewarding, and punishing based primarily on blind chance instead of one based on actual personnel performance.

Patient activation, knowledge, and health literacy association with self-management behaviors in persons with heart failure.

BACKGROUND: More evidence is needed about factors that influence self-management behaviors in persons with heart failure. OBJECTIVE: To test a correlational mediation model of the independent variables of health literacy, patient activation, and heart failure knowledge with heart failure self-management behaviors. METHODS: The study used a prospective, cross-sectional, correlational design. Correlation and multiple regression were used to analyze associations among variables. RESULTS: Of 151 participants, 57% were male, and mean age was 68 years. Heart failure self-management behaviors was positively correlated with patient activation level (p = .0008), but not with health literacy or heart failure knowledge. CONCLUSIONS: Persons with heart failure may better manage their condition if sufficiently activated, regardless of their level of health literacy or knowledge of heart failure disease and management processes.

Predictors of response to fixed-dose vasopressin in adult patients with septic shock.

BACKGROUND: Vasopressin is often utilized for hemodynamic support in patients with septic shock. However, the most appropriate patient to initiate therapy in is unknown. This study was conducted to determine factors associated with hemodynamic response to fixed-dose vasopressin in patients with septic shock. METHODS: Single-center, retrospective cohort of patients receiving fixed-dose vasopressin for septic shock for at least 6 h with concomitant catecholamines in the medical, surgical, or neurosciences intensive care unit (ICU) at a tertiary care center. Patients were classified as responders or non-responders to fixed-dose vasopressin. Response was defined as a decrease in catecholamine dose requirements and achievement of mean arterial pressure ≥ 65 mmHg at 6 h after initiation of vasopressin. RESULTS: A total of 938 patients were included: 426 responders (45%), 512 non-responders (55%). Responders had lower rates of in-hospital (57 vs. 72%; P < 0.001) and ICU mortality (50 vs. 68%; P < 0.001), and increased ICU-free days at day 14 and hospital-free days at day 28 (2.3 ± 3.8 vs. 1.6 ± 3.3; P < 0.001 and 4.2 ± 7.2 vs. 2.8 ± 6.0; P < 0.001, respectively). On multivariable analysis, non-medical ICU location was associated with increased response odds (OR 1.70; P = 0.0049) and lactate at vasopressin initiation was associated with decreased response odds (OR 0.93; P = 0.0003). Factors not associated with response included APACHE III score, SOFA score, corticosteroid use, and catecholamine dose. CONCLUSION: In this evaluation, 45% responded to the addition of vasopressin with improved outcomes compared to non-responders. The only factors found to be associated with vasopressin response were ICU location and lactate concentration.

Prediction of depression and anxiety via patient-assessed tremor severity, not physician-reported motor symptom severity, in patients with Parkinson's disease or essential tremor who have undergone deep brain stimulation.

OBJECTIVEDeep brain stimulation (DBS) is an effective therapy for movement disorders such as idiopathic Parkinson's disease (PD) and essential tremor (ET). However, some patients who demonstrate benefit on objective motor function tests do not experience postoperative improvement in depression or anxiety, 2 important components of quality of life (QOL). Thus, to examine other possible explanations for the lack of a post-DBS correlation between improved objective motor function and decreased depression or anxiety, the authors investigated whether patient perceptions of motor symptom severity might contribute to disease-associated depression and anxiety.METHODSThe authors performed a retrospective chart review of PD and ET patients who had undergone DBS at the Cleveland Clinic in the period from 2009 to 2013. Patient demographics, diagnosis (PD, ET), motor symptom severity, and QOL measures (Primary Care Evaluation of Mental Disorders 9-item Patient Health Questionnaire [PHQ-9] for depression, Generalized Anxiety Disorder 7-item Scale [GAD-7], and patient-assessed tremor scores) were collected at 4 time points: preoperatively, postoperatively, 1-year follow-up, and 2-year follow-up. Multivariable prediction models with solutions for fixed effects were constructed to assess the correlation of predictor variables with PHQ-9 and GAD-7 scores. Predictor variables included age, sex, visit time, diagnosis (PD vs ET), patient-assessed tremor, physician-reported tremor, Unified Parkinson's Disease Rating Scale part III (UPDRS-III) score, and patient-assessed tremor over time.RESULTSSeventy PD patients and 17 ET patients were included in this analysis. Mean postoperative and 1-year follow-up UPDRS-III and physician-reported tremor scores were significantly decreased compared with preoperative scores (p < 0.0001). Two-year follow-up physician-reported tremor was also significantly decreased from preoperative scores (p < 0.0001). Only a diagnosis of PD (p = 0.0047) and the patient-assessed tremor rating (p < 0.0001) were significantly predictive of depression. A greater time since surgery, in general, significantly decreased anxiety scores (p < 0.0001) except when a worsening of patient-assessed tremor was reported over the same time period (p < 0.0013).CONCLUSIONSPatient-assessed tremor severity alone was predictive of depression in PD and ET following DBS. This finding suggests that a patient's perception of illness plays a greater role in depression than objective physical disability regardless of the time since surgical intervention. In addition, while anxiety may be attenuated by DBS, patient-assessed return of tremor over time can increase anxiety, highlighting the importance of long-term follow-up for behavioral health features in chronic neurological disorders. Together, these data suggest that the patient experience of motor symptoms plays a role in depression and anxiety-a finding that warrants consideration when evaluating, treating, and following movement disorder patients who are candidates for DBS.

Association of Thoracic Epidural Pain Management with Urinary Retention after Complex Abdominal Wall Reconstruction.

The association of thoracic epidural analgesia and urinary retention after complex abdominal wall reconstruction (CAWR) is unknown. The purpose of this study was to investigate the association between the presence of a thoracic epidural, timing of Foley catheter removal, and the rates of urinary retention and catheter-associated urinary tract infections (CAUTIs) in patients undergoing CAWR. All patients undergoing CAWR, who had an epidural catheter for postoperative pain management at our institution from September 2015 through April 2016, were prospectively followed. Patients were divided into two groups. Group 1 had their Foley catheters removed on postoperative day one, whereas Group 2 had their Foley catheters removed after epidural removal. The incidence of urinary retention and CAUTI were compared between the two groups. A total of 67 patients met inclusion criteria; 27 (40.3%) patients were in Group 1. Patients in Group 1 were significantly more likely to experience urinary retention requiring Foley catheter replacement (P = 0.02). There was no statistically significant difference in the rate of CAUTI between the two groups (P = 0.51). Patients undergoing CAWR with thoracic epidural pain management are at risk of experiencing postoperative urinary retention. Foley catheter removal after epidural removal does not place the patient at an increased risk for CAUTI and therefore should be strongly considered in this patient population.