Palliative care patients' attitudes and openness towards psilocybin-assisted psychotherapy for existential distress.

Introduction: Patients with incurable illnesses often experience existential distress, profoundly impacting their well-being. Current medical approaches have limitations in addressing these burdens. Psilocybin, a promising psychedelic compound, may offer therapeutic benefits. This pilot survey study aimed to investigate the attitudes and openness toward psilocybin-assisted psychotherapy (PAT) among patients with incurable illnesses. The objective is to assess patients' attitudes toward PAT and identify potential barriers and concerns, including exploring the association between beliefs in psilocybin's therapeutic benefits and interest in receiving this treatment. Methods: The survey study was conducted at the Tampa General Hospital Palliative Care Outpatient office in the United States. Participants were 32 English-fluent patients, aged 18 or older, with incurable illnesses. The survey included demographic questions, a validated tool to measure existential distress, and questions about knowledge and concerns regarding psilocybin. Attitudes toward PAT and interest in its future use were assessed using Likert scale responses. Results: Among the 31 analyzed participants, 51.6% expressed interest in future psilocybin treatment, while 32.3% did not indicate interest. Belief in the psilocybin's therapeutic benefits for stress and anxiety significantly correlated with interest in use. Concerns included risk of psychosis, lack of trained providers, and potential for exploitation. No demographic factors were associated with interest or levels of distress. Conclusions: This pilot study provides insights into the attitudes and concerns toward PAT among patients with incurable illnesses. Over half of participants expressed interest. However, concerns regarding its use were identified, with patients' concern for the risk of exploitation associated with PAT as an especially novel concern documented in this patient population. This highlighted the need for further education of risks and benefits or PAT by trained clinicians and rigorous training of clinicians with the establishment of safeguards against exploitation. Further research is necessary to explore the potential benefits of PAT and related non-psilocybin psychedelic compounds in addressing existential distress among patients with incurable illnesses.

Robotics vs Laparoscopy in Foregut Surgery: Systematic Review and Meta-Analysis Analyzing Hiatal Hernia Repair and Heller Myotomy.

BACKGROUND: Laparoscopic surgery remains the mainstay of treating foregut pathologies. Several studies have shown improved outcomes with the robotic approach. A systematic review and meta-analysis comparing outcomes of robotic and laparoscopic hiatal hernia repairs (HHR) and Heller myotomy (HM) repairs is needed. STUDY DESIGN: PubMed, Embase and Scopus databases were searched for studies published between January 2010 and November 2022. The risk of bias was assessed using the Cochrane ROBINS-I tool. Assessed outcomes included intra- and post-operative outcomes. We pooled the dichotomous data using the Mantel-Haenszel random effects model to report odds ratio (OR) and 95% confidence intervals (95% CIs) and continuous data to report mean difference (MD) and 95% CIs. RESULTS: Twenty-two comparative studies enrolling 196,339 patients were included. Thirteen (13,426 robotic, 168,335 laparoscopic patients) studies assessed HHR outcomes, while nine (2,384 robotic, 12,225 laparoscopic patients) assessed HM outcomes. Robotic HHR had a non-significantly shorter length of hospital stay (LOS) [MD -0.41 (95% CI -0.87, -0.05)], fewer conversions to open [OR 0.22 (95% CI 0.03, 1.49)], and lower morbidity rates [OR 0.76 (95% CI 0.47, 1.23)]. Robotic HM led to significantly fewer esophageal perforations [OR 0.36 (95% CI 0.15, 0.83)], reinterventions [OR 0.18 (95% CI 0.07, 0.47)] a non-significantly shorter LOS [MD -0.31 (95% CI -0.62, 0.00)]. Both robotic HM and HHR had significantly longer operative times. CONCLUSIONS: Laparoscopic and robotic HHR and HM repairs have similar safety profiles and perioperative outcomes. Randomized controlled trials are warranted to compare the two methods, given the low to moderate quality of included studies.

Association of Common Foods with Inflammation and Mortality: Analysis from a Large Prospective Cohort Study.

Some dietary patterns are associated with inflammation, while others lower inflammation and improve health. However, many people cannot follow a complete, healthy diet. Therefore, this study's aim was to identify specific foods associated chronic inflammation and mortality. The study used Multi-Ethnic Study of Atherosclerosis (MESA) research materials from the NHLBI Biologic Specimen and Data Repository Information Coordinating Center. Three plant-based and three animal-based MESA food categories were chosen based on perceived availability in the western diet. The assessed food categories were avocado, ham, sausage, eggs, greens, and broccoli. Inflammatory markers assessed were interleukin-6 (IL-6), fibrinogen antigen, C-reactive protein, D-Dimer, interleukin-2, matrix metalloproteinase 3, necrosis factor-a soluble receptors, oxidized LDL (oxLDL), and total homocysteine. The primary outcome was the multivariable association of foods and inflammatory markers with all-cause mortality. All inflammatory makers, except oxLDL, were associated with mortality in univariate analysis. The effect was largest with IL-6 and D-dimer. The category of broccoli had the most consistent association in univariate analyses with lower inflammation and lower mortality odds. Low and high broccoli consumption versus no consumption were associated with lower mortality odds in the multivariable models with IL-6 and D-dimer. Consumption of the MESA-defined food category "broccoli" (i.e., broccoli, cabbage, cauliflower, brussels sprouts, sauerkraut, and kimchee) was associated with lower inflammation and lower mortality odds. These findings should be validated in randomized controlled trials testing a "food is medicine" approach to identify which, if any, of these foods may have potential as an herbal therapeutic for chronic inflammation.

Pelvic Incidence as a Predictor of Proximal Junctional Failure in Patients Undergoing Anterior Column Realignment with Anterior Longitudinal Ligament Release to Restore Lordosis in Adult Spinal Deformity: A Retrospective Cohort Study.

OBJECTIVE: To identify variables that may contribute to the development of proximal junctional failure (PJF) in patients with long lumbo-sacral and thoraco-lumbo-pelvic constructs undergoing anterior column realignment (ACR) with anterior longitudinal ligament release (ALLR). METHODS: Data of patients with adult spinal deformity who underwent ACR with ALLR at L3-4 were collected retrospectively from medical records and a prospectively maintained spine research database between 2016 and 2022. RESULTS: Eleven (41%) developed PJF at a mean of 24 ± 21 months from the index surgery. The cohort was then divided into 2 groups for analysis, 13 subjects in the high pelvic incidence (PI) group (defined as PI ≥ 55°) and 14 subjects in the low PI group (defined as PI < 55°). Visual Analog Scale for back pain and Oswestry Disability Index decreased from 9.5 to 2.1 and 61 to 10 in the high PI group, and from 8.9 to 2.4 and 60.9 to 10.3 in the low PI group, respectively. PI (P = 0.004), sacral slope (P = 0.005), and postoperative PI-lumbar lordosis mismatch (P = 0.02) were found to be significant predictors of PJF. The receiver operator curve revealed a cutoff PI value ≤ 53° (95% confidence interval: 52°-64°), below which the risk of PJF becomes significantly higher in patients undergoing ACR with ALLR at L3-4. CONCLUSIONS: PI may be a predictor of PJF and highly correlates with ACR-ALLR levels. In patients undergoing L3-4 ACR-ALLR, a PI value of ≤53° is associated with a significantly elevated risk of PJF. Preoperative planning of ACR-ALLR level based on normal sagittal alignment in otherwise healthy individuals may mitigate the risk of PJF development in patients with adult spinal deformity treated with ACR-ALLR.

Breastfeeding Ability After Breast Reductions: What does the Literature Tell us in 2023?

INTRODUCTION: Reduction mammaplasties are routinely performed on women of child-bearing age, yet there still exists some uncertainty regarding a patient's ability to breastfeed following the procedure. This is due to inconsistent definitions of "successful" breastfeeding, a variety of pedicles implemented, and inadequate follow-up in the published literature. Our aim was to summarize the current data and provide clear recommendations for counseling patients on expected breastfeeding outcomes following reduction mammaplasty. METHODS: A systematic review and meta-analysis in accordance with the PRISMA guidelines was conducted. We included papers that reported proportion of breastfeeding ability following reduction mammaplasty. RESULTS: We identified 33 papers that met our inclusion criteria. We found that women who undergo reduction mammaplasty are at a 3.5 times increased odds of not being able to breastfeed compared to controls. Overall, reduction mammaplasty patients have a breastfeeding success rate of 62%. The breastfeeding success rate for patients with inferior pedicles was 64%, superior pedicles was 59%, and lateral pedicles was 55%. No conclusions could be drawn regarding medial, central, vertical, and horizontal pedicles on breastfeeding ability. CONCLUSION: Current data suggest that women undergoing reduction mammaplasty have an increased odds of unsuccessful breastfeeding when compared to similar women who have not undergone the procedure. Based on the current literature, pedicle type does play a role in rate of breastfeeding success, although there is a need for further research on the aforementioned pedicles. Physicians should be aware of the likelihood of successful breastfeeding following reduction mammaplasty so that patients can be more thoroughly counseled prior to a decision for surgery. LEVEL OF EVIDENCE I: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparing Outcomes of Musculoskeletal Radiographs from In-Person and Telemedicine Primary Care Cohorts, April 2019-June 2021.

PURPOSE: Musculoskeletal conditions are a common reason for primary care visits, and they are being increasingly addressed at televisits. We therefore examined outcomes of musculoskeletal radiographs ordered at in-person and telemedicine primary care visits, which have implications for patient care and the economic impact of telemedicine. METHODS: We performed a retrospective cohort study of musculoskeletal radiograph orders placed April 1, 2019-March 31, 2021 at a major academic health system. Radiology reports were classified as normal or abnormal based on the radiologist's impression. Findings were compared using c2 tests. RESULTS: The main outcome was radiographic abnormalities. A secondary outcome was the effect of social determinants of health and medical comorbidities on telemedicine utilization. A total of 1580 radiographs were reviewed. Compared with televisits occurring after onset of the SARS-Cov2-19 pandemic, radiographs ordered at in-person visits had higher odds of being abnormal (OR 2.51, 95% CI 1.33-4.75; P = .004). When comparing radiographic outcomes at in-person visits before and after the pandemic's onset, those ordered afterward had higher odds of being abnormal (OR 1.88, 95% CI 1.30-2.71; P < .001). Social determinants of health and medical comorbidities were not associated with telemedicine utilization. CONCLUSIONS: After the onset of the SARS-Cov2-19 pandemic, radiographs ordered at in-person visits had higher odds of being abnormal compared with televisits. These findings indicate that prudence should be applied to ordering musculoskeletal radiographs in telemedicine encounters.

A Retrospective Analysis of Vitamin D Levels in Hospitalized COVID-19 Patients With Suspected Pulmonary Embolism.

Introduction Despite using anti-coagulation therapy in hospitalized coronavirus disease 2019 (COVID-19) patients, they have high rates of pulmonary embolism (PE) and deep vein thrombosis (DVT). The main objective of this study was to evaluate the association between vitamin D deficiency and thrombotic events (defined as the occurrence of a new PE or DVT) in hospitalized COVID-19 patients. Materials and Methods This was a retrospective, cross-sectional study of 208 hospitalized COVID-19 patients who received a computed tomographic pulmonary angiography (CTPA) based on clinical suspicion of PE between January 1, 2020, and February 5, 2021. A <20 ng/mL serum vitamin D level was used to categorize vitamin D deficiency. Nonparametric tests and multivariate binary logistic regression were used to evaluate the association between serum vitamin D levels and clinical outcomes. Results The mean vitamin D level was 26.7±13.0 ng/mL (n=208), and approximately one-third of patients were vitamin D deficient (n=68, 32.7%). No association was found between vitamin D deficiency and the occurrence of thrombotic events. The incidence of PE was 19.1% in vitamin D deficient patients compared to 11.4% in vitamin D sufficient patients (p=0.13). Vitamin D deficiency was positively associated with ICU admission (OR 3.047, 95%CI 1.57-5.91, p=0.001) and mortality (OR 3.76, 95%CI 1.29-11.01, p=0.016). Conclusions This study found no association between vitamin D deficiency and the occurrence of a new PE or DVT in hospitalized COVID-19 patients. Patients with vitamin D deficiency were more likely to be admitted to the ICU and had increased overall mortality.

Implementing a Stepwise Shivering Protocol During Targeted Temperature Management.

Background: Shivering is often encountered in patients undergoing targeted temperature management (TTM) after cardiac arrest. The most efficient, safe way to prevent shivering during TTM is not clearly defined. Objective: The purpose of this study was to evaluate the impact of shivering management using a stepwise shivering protocol on time to target temperature (TT), medication utilization and nursing confidence. Methods: Single-center, retrospective chart review of all post-cardiac arrest patients who underwent TTM between 2016 and 2021. The primary outcome is a comparison of time to TT pre- and post-protocol implementation. Secondary objectives compared nursing confidence and medication utilization pre- and post-shivering protocol implementation. Results: Fifty-seven patients were included in the pre-protocol group and thirty-seven were in the post-protocol group. The median (IQR) time to TT was 195 (250) minutes and 165 (170), respectively (p = 0.190). The average doses of acetaminophen was 285 mg pre- vs 1994 mg post- (p <0.001, buspirone 47 mg pre- vs 127 mg post- (p < 0.001), magnesium 0.9 g pre-vs 2.8 g post- (p < 0.001), and fentanyl 1564 mcg pre- vs 2286 mcg post- (p=0.023). No difference was seen for midazolam and cisatracurium. Nurses reported feeling confident with his/her ability to manage shivering during TTM 38.5% of the time pre-protocol compared to 60% post-protocol (p = 0.306). Conclusion: Implementation of a stepwise approach to prevent and treat shivering improved time to TT in our institution, although this finding was not statistically significant. The stepwise protocol supported a reduced amount of high-risk medication use and increased nursing confidence in shivering management.

Patient perceptions of urgency of their pelvic floor disorders during the COVID-19 pandemic.

INTRODUCTION AND HYPOTHESIS: During the COVID-19 pandemic, many surgical societies released guidelines that included cancellation of elective cases. The aim of this study was to better understand our patients' perceptions of the severity of their pelvic floor disorders (PFDs) and to determine what factors influenced this perception. We also aimed to better understand who might be amenable to telemedicine visits and what factors influenced this decision. METHODS: This is a cross-sectional quality improvement study that included women at least 18 years of age diagnosed with a pelvic floor disorder being evaluated within a university Female Pelvic Medicine and Reconstructive Surgery clinic during the COVID-19 pandemic. Patients whose appointments and procedures were being cancelled were queried on whether they would be willing to answer a telephone questionnaire developed by the clinical and research teams. We gathered descriptive data from 97 female patients with PFDs using a primary phone questionnaire. The data were analyzed using proportions and descriptive statistics. RESULTS: Of the 97 patients, the majority (79%) viewed their conditions as non-urgent. Factors that influenced patients' perception of urgency included race (p=0.037), health status (p≤0.001), a history of diabetes (p=0.011), and willingness to attend an in-person appointment (p=0.010). Further, 52% of respondents were willing to attend a tele-health appointment. Statistically significant factors influencing this decision were ethnicity (p=0.019), marital status (p=0.019), and willingness to attend an in-person appointment (p=0.011). CONCLUSION: The majority of women did not view their conditions as urgent during the COVID-19 pandemic and were amenable to a telehealth appointment.

Effect of Resident Involvement in Ophthalmic Surgery on Patient Outcomes: A Systematic Review and Meta-analysis.

PURPOSE: To determine the effect of resident- vs attending-led surgeries on patient outcomes in ophthalmic surgery. DESIGN: Systematic review and meta-analysis. METHODS: Two independent authors searched PubMed, EMBASE, and Cochrane Library from inception to March 2022. Categorical data from studies were pooled to report odds ratio (OR) and 95% CIs. Continuous data were analyzed to yield standardized mean difference (SMD) and 95% CIs. Propensity-matched studies were analyzed separately. Study quality was assessed using the Newcastle-Ottawa Scale. RESULTS: Twenty-four studies were included in this meta-analysis. Seventeen of the 20 outcomes had no significant differences between the 2 cohorts. Notably, many critical cataract surgery-related outcomes showed no significant differences, including posterior capsular tear, lens fragment retainment, and retinal detachment. Among propensity-scored studies, the resident-led surgeries had longer operative duration (SMD 0.81, 95% CI 0.29, 1.33; 3 studies [260 patients], I2 = 74%) and had an increased risk of an unplanned return to the operating room (OR 2.58, 95% CI 1.31, 5.06; 4 studies [342 patients], I2 = 0%). Among 2 non-propensity-scored, resident-led surgeries had increased incidence of choroidal detachment or choroidal effusion (OR 2.28, 95% 1.02, 5.09; 2 studies [401 patients], I2 = 19%). No significant difference was found for ocular hypotony. Significant heterogeneity existed among propensity-scored studies. CONCLUSIONS: Resident-led surgeries appear overall safe, effective, and comparable to attending-led surgeries with respect to commonly encountered perioperative complications. Specific differences in outcomes exhibit significant heterogeneity and small sample sizes, and may be of unclear or equivocal clinical significance.

Improved Outcomes with Concurrent Instrumentation and Fusion of the Sacroiliac Joint in Patients with Long Lumbosacral Constructs.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: Spinal fusion, specifically constructs connected to pelvic bones, has been consistently reported as a predisposing factor to sacroiliac joint (SIJ) pain. The aim of this study is to compare SIJ outcomes in patients with constructs to the pelvis following instrumentation vs instrumentation plus fusion of the SIJ. METHODS: Data of study subjects was extracted from a prospectively maintained database as well as retrospectively collected from records at a tertiary academic medical center in the United States between 2018 and 2020. RESULTS: A cohort of 103 patients was divided into 2 groups: 65 in Group 1 [S2AI screw without fusion device] and 38 in Group 2 [S2AI screw with fusion device]. None of the patients in Group 2 developed postoperative SIJ pain compared to 44.6% in Group 1. Sacroiliac joint fusion occurred in all Group 2 but none of Group 1 patients. The postoperative Visual Analogue Scale (VAS) for lower extremity (LE) pain (.8 vs .5; P = .03) and postoperative Oswestry Disability Index (ODI) (18.7 vs 14.2; P < .01) were significantly higher in Group 1. The rate of distal junctional break, failure, and/or kyphosis (DJBFK) and time to DJBFK were not significantly different between the two groups, and the rate of DJBFK did not change in the presence of multiple covariates. CONCLUSION: The SIJs carry the heavy load of long lumbosacral fusion constructs extending to the pelvis. Simultaneous SIJ instrumentation and fusion decreases the risk of disability, prevents the development of postoperative SIJ pain, and may also protect the S2AI screw from loosening and failure.

Socioeconomic differences in prostate cancer treatment: A systematic review and meta-analysis.

BACKGROUND: Since the 1990s, most nations have had a reduction or stabilisation in prostate cancer mortality. However, socioeconomic differences in disease specific mortality and survival have persisted. This has been partially attributed to differences in treatment choices. The aim of this systematic review and meta-analysis was to describe and quantify socioeconomic differences in use of prostate cancer treatment in the literature. METHODS: MEDLINE, CINAHL and Embase were searched from 01 January 2000-01 April 2021 to identify articles that reported use of prostate cancer treatment by socioeconomic status. Random effects meta-analysis was used to analyse socioeconomic differences in treatment where there was more than one study for treatment type. A modified version of the Newcastle-Ottawa Scale was used to assess risk of bias. RESULTS: Out of 7267 articles identified, eight met the inclusion criteria and six were analysed using meta-analysis. Meta-analysis could only be completed for non-active treatment (watchful waiting/active surveillance). Lower education was associated with non-active treatment (OR=0.90, [95% CI 0.83-0.98], p=0.02, I2=67%), however, level of income was not (OR=0.87, [CI 0.75-1.02], p=0.08, I2=94%). Sensitivity analysis of studies where active surveillance was the outcome (n=3), indicated no associations with level of income (OR=0.91, [95% CI 0.82-1.01], p=0.08, I2=52%) or education (OR=0.88, [95% CI 0.70-1.10], p=0.25, I2=79%). All studies were assessed as high-risk of bias. DISCUSSION: The relationship between socioeconomic status and prostate cancer treatment depended on the socioeconomic variable being used, the treatment type and how it was defined in research. Considerable methodological limitations were identified. Further research should improve on previous findings and address current gaps.

Novel biomarkers of inflammation in heart failure with preserved ejection fraction: analysis from a large prospective cohort study.

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) is a syndrome with a heterogeneous cluster of causes, including non-resolving inflammation, endothelial dysfunction, and multi-organ defects. The present study's objective was to identify novel predictors of HFpEF. METHODS: The study analyzed the Multi-Ethnic Study of Atherosclerosis (MESA) to assess the association of specific markers of inflammation with new onset of HFpEF (interleukin-2 [IL-2], matrix metalloproteinase 3 [MMP3], large low-density lipoprotein cholesterol [LDL-C], and medium high-density lipoprotein cholesterol [HDL-C]). The study included men and women 45 to 84 years of age without cardiovascular disease at baseline. The primary outcome was the multivariate association of the hypothesized markers of inflammation with new-onset of HFpEF versus participants without new-onset heart failure. Participants with missing data were excluded. RESULTS: The present analysis included 6814 participants, 53% female, with a mean age of 62 years. Among the entire cohort, HFpEF was diagnosed in 151 (2.2%) participants and heart failure with reduced ejection fraction (HFrEF) was diagnosed in 146 (2.1%) participants. Participants were followed for the outcome of heart failure for a median 13.9 years. Baseline IL-2 was available for 2861 participants. The multivariate analysis included 2792 participants. Of these, 2668 did not develop heart failure, 62 developed HFpEF, 47 developed HFrEF, and 15 developed unclassified heart failure. In the multivariate regression model, IL-2 was associated with new-onset HFpEF (OR, 1.00058; 95% confidence interval, 1.00014 to 1.00102, p = 0.009) but not new-onset HFrEF. In multivariate analysis, MMP3, large LDL-C, and medium HDL-C were not associated with HFpEF or HFrEF. CONCLUSION: These findings portend IL-2 as an important component of suboptimal inflammation in the pathogenesis of HFpEF.

A retrospective comparison of outcomes after open anterior and posterior component separation by a single surgical team.

PURPOSE: While both anterior and posterior component separation techniques aid the repair of large ventral hernias, their outcomes can be remarkably dissimilar in terms of wound morbidity. We describe outcomes after open component separation by a single surgical team over the entire breadth of our experience. METHODS: We queried a prospectively maintained database for ventral hernias who received an open bilateral component separation between January 2014 and January 2020. A retrospective review was performed to analyze patient demographics, perioperative events, adverse outcomes, and recurrence. RESULTS: One hundred twenty-seven patients met the inclusion criteria of which 44 underwent anterior component separation (ACS) and 83 underwent posterior component separation (PCS). The two groups were broadly similar in terms of demographic and hernia-related variables. Mesh:defect area ratios, operative time, and estimated intraoperative blood loss were higher in the PCS group. The ACS group had more frequent use of drains which remained in situ for longer, along with a longer hospital stay. Surgical site occurrences (SSOs), including those needing procedural intervention (SSOPIs) were significantly more common after ACS. This group was also more likely to undergo a reoperation within 30 days of index repair. A single recurrence was noted in the ACS group after a mean follow-up duration of 43 months. CONCLUSIONS: Open PCS may be more technically demanding than ACS, but it has a lower risk of postoperative morbidity and reoperation. While we now utilize PCS more frequently in our practice, ACS remains an important tool in our armamentarium.