Association of Frailty and the Expanded Operative Stress Score with Preoperative Acute Serious Conditions, Complications, and Mortality in Males Compared to Females: A Retrospective Observational Study.

OBJECTIVE: The aim of this study was to expand Operative Stress Score (OSS) increasing procedural coverage and assessing OSS and frailty association with Preoperative Acute Serious Conditions (PASC), complications and mortality in females versus males. SUMMARY BACKGROUND DATA: Veterans Affairs male-dominated study showed high mortality in frail veterans even after very low stress surgeries (OSS1). METHODS: Retrospective cohort using NSQIP data (2013-2019) merged with 180-day postoperative mortality from multiple hospitals to evaluate PASC, 30-day complications and 30-, 90-, and 180-day mortality. RESULTS: OSS expansion resulted in 98.2% case coverage versus 87.0% using the original. Of 82,269 patients (43.8% male), 7.9% were frail/very frail. Males had higher odds of PASC [adjusted odds ratio (aOR) = 1.31, 95% confidence interval (CI) = 1.21-1.41, P < 0.001] and severe/life-threatening Clavien-Dindo IV (CDIV) complications (aOR = 1.18, 95% CI = 1.09-1.28, P < 0.001). Although mortality rates were higher (all time-points, P < 0.001) in males versus females, mortality was similar after adjusting for frailty, OSS, and case status primarily due to increased male frailty scores. Additional adjustments for PASC and CDIV resulted in a lower odds of mortality in males (30-day, aOR = 0.81, 95% CI = 0.71-0.92, P = 0.002) that was most pronounced for males with PASC compared to females with PASC (30-day, aOR = 0.75, 95% CI = 0.56-0.99, P = 0.04). CONCLUSIONS: Similar to the male-dominated Veteran population, private sector, frail patients have high likelihood of postoperative mortality, even after low-stress surgeries. Preoperative frailty screening should be performed regardless of magnitude of the procedure. Despite males experiencing higher adjusted odds of PASC and CDIV complications, females with PASC had higher odds of mortality compared to males, suggesting differences in the aggressiveness of care provided to men and women.

A Retrospective Cohort Study to Evaluate Adding Biomarkers to the Risk Analysis Index of Frailty.

INTRODUCTION: The Risk Analysis Index (RAI) is a frailty assessment tool associated with adverse postoperative outcomes including 180 and 365-d mortality. However, the RAI has been criticized for only containing subjective inputs rather than including more objective components such as biomarkers. METHODS: We conducted a retrospective cohort study to assess the benefit of adding common biomarkers to the RAI using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. RAI plus body mass index (BMI), creatinine, hematocrit, and albumin were evaluated as individual and composite variables on 180-d postoperative mortality. RESULTS: Among 480,731 noncardiac cases in VASQIP from 2010 to 2014, 324,320 (67%) met our inclusion criteria. Frail patients (RAI ≥30) made up to 13.0% of the sample. RAI demonstrated strong discrimination for 180-d mortality (c = 0.839 [0.836-0.843]). Discrimination significantly improved with the addition of Hematocrit (c = 0.862 [0.859-0.865]) and albumin (c = 0.870 [0.866-0.873]), but not for body mass index (BMI) or creatinine. However, calibration plots demonstrate that the improvement was primarily at high RAI values where the model overpredicts observed mortality. CONCLUSIONS: While RAI's ability to predict the risk of 180-d postoperative mortality improves with the addition of certain biomarkers, this only observed in patients classified as very frail (RAI >49). Because very frail patients have significantly elevated observed and predicted mortality, the improved discrimination is likely of limited clinical utility for a frailty screening tool.

Interpreting the risk analysis index of frailty in the context of surgical oncology.

BACKGROUND AND OBJECTIVES: The Risk Analysis Index (RAI) accurately predicts adverse postoperative outcomes but the inclusion of cancer status in the RAI has raised two key concerns about its suitability for use in surgical oncology: (1) the potential over classification of cancer patients as frail, and (2) the potential overestimation of postoperative mortality for patients with surgically curable cancers. METHODS: We performed a retrospective cohort analysis to assess the RAI's power to appropriately identify frailty and predict postoperative mortality in cancer patients. We assessed discrimination for mortality and calibration across five RAI models-the complete RAI and four variants that removed different cancer-related variables. RESULTS: We found that the presence of disseminated cancer was a key variable driving the RAI's power to predict postoperative mortality. The model including only this variable [RAI (disseminated cancer)] was similar to the complete RAI in the overall sample (c = 0.842 vs. 0.840) and outperformed the complete RAI in the cancer subgroup (c = 0.736 vs 0.704, respectively, p < 0.0001, Max R2 = 19.3% vs. 15.1%, respectively). CONCLUSION: The RAI demonstrates somewhat less discrimination when applied exclusively to cancer patients, but remains a strong predictor of postoperative mortality, especially in the setting of disseminated cancer.

Stress, social support, and racial differences: Dominant drivers of exclusive breastfeeding.

Exclusive breastfeeding is recommended for 6 months; however, many childbearing people wean their infants before 6 months. Psychosocial factors such as stress, social support and race are significant determinants of breastfeeding; however, few studies have longitudinally explored the effect of perceived stress and various forms of social support on exclusive breastfeeding. We used quantitative methodologies to examine exclusive breastfeeding, perceived stress and social support among 251 participants from the Postpartum Mothers Mobile Study. Participants between 18 and 44 years were recruited during pregnancy (irrespective of parity) and completed surveys in real-time via Ecological Momentary Assessment up to 12 months postpartum from December 2017 to August 2021. We measured perceived stress with the adapted Perceived Stress Scale and perceived social support with the Multi-dimensional Social Support Scale. Received social support was measured using a single question on breastfeeding support. We conducted a mixed-effects logistic regression to determine the effect of stress, race and social support on exclusive breastfeeding over 6 months. We examined the moderation effect of perceived social support and breastfeeding support in the relationship between perceived stress and exclusive breastfeeding. Black, compared with White, participants were less likely to breastfeed exclusively for 6 months. Participants who reported higher perceived stress were less likely to breastfeed exclusively for 6 months. Perceived social support moderated the relationship between perceived stress and exclusive breastfeeding (odds ratio: 0.01, 95% confidence interval: 0.001-0.072). However, breastfeeding support directly increased the likelihood of exclusive breastfeeding over 6 months. Perceived stress is negatively associated with exclusive breastfeeding. Birthing people who intend to breastfeed may benefit from perinatal support programs that include components to buffer stress.

Opportunities to More Comprehensively Assess Sexual Violence Experience in Veterans Health Administration Medical Records Data.

INTRODUCTION: Experience of sexual violence (SV) is prevalent among the Veteran population and associated with many negative mental and physical health outcomes including suicidal behavior, obesity, post-traumatic stress disorder, anxiety, depression, and poor sexual and reproductive functioning. Although Veterans of any gender may experience SV, women Veterans are particularly at risk. Research on SV among Veterans has focused primarily on the experience of SV during military service (military sexual trauma, MST), although Veterans may also experience SV prior to and following military service. The aim of the current study was to construct a more comprehensive method of identifying SV among Veterans Health Administration (VHA) patients as documented in medical records in a national cohort of 325,907 Veterans who used VHA care between 2000 and 2018 in order to inform future research in this area. METHOD: We used three indicators to identify SV in VHA medical records: (a) the MST screen, (b) the sexual violence item of the intimate partner violence (IPV) screen, and (c) International Classification of Disorders (ICD) codes (versions 9 and 10) representing adult sexual abuse and assault. Univariate descriptive analyses were conducted to determine the exclusivity and overlap of the SV measures. RESULTS: The universal MST screen was the most commonly identified indicator of SV in the data. However, including the IPV and ICD indicators identified an additional 5% of Veterans who had experienced SV, accounting for thousands of patients. DISCUSSION: The results of the current study indicate that using the three-pronged approach of SV collection is a more comprehensive method of identifying patient SV experience through VHA medical records and contributes uniquely to the methodology of studying social factors' impact on health care. Clinical screening and documentation of SV allow for the assessment of health impacts and trends through examination of medical records data.

Impact of a Dyadic Intervention on Family Supporter Involvement in Helping Adults Manage Type 2 Diabetes.

BACKGROUND: Family support for adults' diabetes care is associated with improved self-management and outcomes, but healthcare providers lack structured ways to engage those supporters. OBJECTIVE: Assess the impact of a patient-supporter diabetes management intervention on supporters' engagement in patients' diabetes care, support techniques, and caregiving experience. DESIGN: Multivariate regression models examined between-group differences in support-related measures observed as part of a larger trial randomizing participants to a dyadic intervention versus usual care. PARTICIPANTS: A total of 239 adults with type 2 diabetes and either A1c >8% or systolic blood pressure >160mmHg enrolled with a family supporter. INTERVENTION: Health coaches provided training on positive support techniques and facilitated self-management information sharing and goal-setting. MAIN MEASURES: Patient and supporter reports at baseline and 12 months of supporter roles in diabetes care and caregiving experience. RESULTS: At 12 months, intervention-assigned patients had higher odds of reporting increased supporter involvement in remembering medical appointments (AOR 2.74, 95% CI 1.44, 5.21), performing home testing (AOR 2.40, 95% CI 1.29, 4.46), accessing online portals (AOR 2.34, 95% CI 1.29, 4.30), deciding when to contact healthcare providers (AOR 2.12, 95% CI 1.15, 3.91), and refilling medications (AOR 2.10, 95% CI 1.14, 3.89), but not with attending medical appointments or with healthy eating and exercise. Intervention-assigned patients reported increased supporter use of autonomy supportive communication (+0.27 points on a 7-point scale, p=0.02) and goal-setting techniques (+0.30 points on a 5-point scale, p=0.01). There were no differences at 12 months in change scores measuring supporter distress about patients' diabetes or caregiving burden. Intervention-assigned supporters had significantly larger increases in satisfaction with health system support for their role (+0.88 points on a 10-point scale, p=0.01). CONCLUSIONS: A dyadic patient-supporter intervention led to increased family supporter involvement in diabetes self-management and increased use of positive support techniques, without increasing caregiver stress.

Preinjury Health Status of Adults With Traumatic Brain Injury: A Preliminary Matched Case-Control Study.

OBJECTIVE: To discern whether there is evidence that individuals who sustained a traumatic brain injury (TBI) had the greater odds of preexisting health conditions and/or poorer health behaviors than matched controls without TBI. SETTING: Brain Injury Inpatient Rehabilitation Unit at Mount Sinai Hospital. Midlife in the United States (MIDUS) control data were collected via random-digit-dialing phone survey. PARTICIPANTS: TBI cases were enrolled in the TBI Health Study and met at least 1 of the following 4 injury severity criteria: abnormal computed tomography scan; Glasgow Coma Scale score between 3 and 12; loss of consciousness greater than 30 minutes; or post-TBI amnesia longer than 24 hours. Sixty-two TBI cases and 171 matched MIDUS controls were included in the analyses; controls were excluded if they reported having a history of head injury. DESIGN: Matched case-control study. MAIN MEASURES: Self-reported measures of depression symptoms, chronic pain, health status, alcohol use, smoking status, abuse of controlled substances, physical activity, physical health composite score, and behavioral health composite score. RESULTS: Pre-index injury depression was nearly 4 times higher in TBI cases than in matched controls (OR= 3.98, 95% CI, 1.71-9.27; P = .001). We found no significant differences in the odds of self-reporting 3 or more medical health conditions in year prior to index injury (OR = 1.52; 95% CI, 0.82-2.81; P = .183) or reporting more risky health behaviors (OR = 1.48; 95% CI; 0.75-2.91; P = .254]) in individuals with TBI than in controls. CONCLUSION: These preliminary findings suggest that the odds of depression in the year prior to index injury far exceed those reported in matched controls. Further study in larger samples is required to better understand the relative odds of prior health problems in those who sustain a TBI, with a goal of elucidating the implications of preinjury health on post-TBI disease burden.

Rates of New Human Papillomavirus Detection and Loss of Detection in Middle-aged Women by Recent and Past Sexual Behavior.

BACKGROUND: Understanding the source of newly detected human papillomavirus (HPV) in middle-aged women is important to inform preventive strategies, such as screening and HPV vaccination. METHODS: We conducted a prospective cohort study in Baltimore, Maryland. Women aged 35-60 years underwent HPV testing and completed health and sexual behavior questionnaires every 6 months over a 2-year period. New detection/loss of detection rates were calculated and adjusted hazard ratios were used to identify risk factors for new detection. RESULTS: The new and loss of detection analyses included 731 women, and 104 positive for high-risk HPV. The rate of new high-risk HPV detection was 5.0 per 1000 woman-months. Reporting a new sex partner was associated with higher detection rates (adjusted hazard ratio, 8.1; 95% confidence interval, 3.5-18.6), but accounted only for 19.4% of all new detections. Among monogamous and sexually abstinent women, new detection was higher in women reporting ≥5 lifetime sexual partners than in those reporting <5 (adjusted hazard ratio, 2.2; 95% confidence interval, 1.2-4.2). CONCLUSION: Although women remain at risk of HPV acquisition from new sex partners as they age, our results suggest that most new detections in middle-aged women reflect recurrence of previously acquired HPV.

The Correlation Between Case Total Work Relative Value Unit, Operative Stress, and Patient Frailty: Retrospective Cohort Study.

OBJECTIVE: Assess the relationships between case total work relative value units (wRVU), patient frailty, and the physiologic stress of surgical interventions. SUMMARY OF BACKGROUND DATA: Surgeon reimbursement is frequently apportioned by wRVU. These subjective, procedure-specific valuations generated by physician survey estimate the intensity and time for typical patient care services. We hypothesized wRVU would not adequately account for patient-specific factors, such as frailty, that modify the required physician work, regardless of procedural complexity. METHODS: Using National and Veterans Affairs Surgical Quality Improvement Programs (2015-2018), we evaluated the correlation between case total wRVU, patient frailty (risk analysis index) and physiologic surgical stress (operative stress score). RESULTS: Of 4,111,371 (86%) cases, the correlation between total wRVU and operative stress was moderate [ρs = 0.587 (95% confidence interval, 0.586-0.587)], but negligible with frailty ρ = 0.177 (95% confidence interval, 0.176-0.178)]. Very high operative stress procedures [n = 34,047 (1%)] generated a mean total wRVU of 55.1 (standard deviation, 12.9), comprising 7%, 2%, and 1% of thoracic, vascular, and general surgical cases, respectively. Very frail patients [n = 152,535 (4%)] accounted for 9% of thoracic, 9% of vascular, 4% of general, 5% of urologic, and 4% of neurologic surgical cases, generating 21.0 (standard deviation, 12.4) mean total wRVU. Some nonfrail patients undergoing low operative stress procedures [n = 60,128 (2%)] nonetheless generated the highest quintile wRVU; these comprised >15% of plastic, gynecologic, and urologic surgical cases. CONCLUSIONS: Surgeon reimbursement correlates with operative stress but not patient frailty. The total wRVU does not adequately reflect patient-specific factors that increase the physician workload required to render optimal care to complex patients.

Medication Treatment of Active Opioid Use Disorder in Veterans With Cirrhosis.

INTRODUCTION: Although opioid use disorder (OUD) is common in patients with cirrhosis, it is unclear how medication treatment for OUD (MOUD) is used in this population. We aimed to assess the factors associated with MOUD and mortality in a cohort of Veterans with cirrhosis and OUD. METHODS: Within the Veterans Health Administration Corporate Data Warehouse, we developed a cohort of Veterans with cirrhosis and active OUD, using 2 outpatient or 1 inpatient International Classification of Diseases, ninth revision codes from 2011 to 2015 to define each condition. We assessed MOUD initiation with methadone or buprenorphine over the 180 days following the first OUD International Classification of Diseases, ninth revision code in the study period. We fit multivariable regression models to assess the association of sociodemographic and clinical factors with receiving MOUD and the associations between MOUD and subsequent clinical outcomes, including new hepatic decompensation and mortality. RESULTS: Among 5,600 Veterans meeting criteria for active OUD and cirrhosis, 722 (13%) were prescribed MOUD over 180 days of follow-up. In multivariable modeling, MOUD was significantly, positively associated with age (adjusted odds ratio [AOR] per year: 1.04, 95% confidence interval (CI): 1.01-1.07), hepatitis C virus (AOR = 2.15, 95% CI = 1.37-3.35), and other substance use disorders (AOR = 1.47, 95% CI = 1.05-2.04) negatively associated with alcohol use disorder (AOR = 0.70, 95% CI = 0.52-0.95), opioid prescription (AOR = 0.51, 95% CI = 0.38-0.70), and schizophrenia (AOR = 0.59, 95% CI = 0.37-0.95). MOUD was not significantly associated with mortality (adjusted hazards ratio = 1.20, 95% CI = 0.95-1.52) or new hepatic decompensation (OR = 0.57, CI = 0.30-1.09). DISCUSSION: Few Veterans with active OUD and cirrhosis received MOUD, and those with alcohol use disorder, schizophrenia, and previous prescriptions for opioids were least likely to receive these effective therapies.

Impact of Alcohol Use Disorder Treatment on Clinical Outcomes Among Patients With Cirrhosis.

BACKGROUND AND AIMS: Despite the significant medical and economic consequences of coexisting alcohol use disorder (AUD) in patients with cirrhosis, little is known about AUD treatment patterns and their impact on clinical outcomes in this population. We aimed to characterize the use of and outcomes associated with AUD treatment in patients with cirrhosis. APPROACH AND RESULTS: This retrospective cohort study included Veterans with cirrhosis who received Veterans Health Administration care and had an index diagnosis of AUD between 2011 and 2015. We assessed the baseline factors associated with AUD treatment (pharmacotherapy or behavioral therapy) and clinical outcomes for 180 days following the first AUD diagnosis code within the study time frame. Among 93,612 Veterans with cirrhosis, we identified 35,682 with AUD, after excluding 2,671 who had prior diagnoses of AUD and recent treatment. Over 180 days following the index diagnosis of AUD, 5,088 (14%) received AUD treatment, including 4,461 (12%) who received behavioral therapy alone, 159 (0.4%) who received pharmacotherapy alone, and 468 (1%) who received both behavioral therapy and pharmacotherapy. In adjusted analyses, behavioral and/or pharmacotherapy-based AUD treatment was associated with a significant reduction in incident hepatic decompensation (6.5% vs. 11.6%, adjusted odds ratio [AOR], 0.63; 95% confidence interval [CI], 0.52, 0.76), a nonsignificant decrease in short-term all-cause mortality (2.6% vs. 3.9%, AOR, 0.79; 95% CI, 0.57, 1.08), and a significant decrease in long-term all-cause mortality (51% vs. 58%, AOR, 0.87; 95% CI, 0.80, 0.96). CONCLUSIONS: Most Veterans with cirrhosis and coexisting AUD did not receive behavioral therapy or pharmacotherapy treatment for AUD over a 6-month follow-up. The reductions in hepatic decompensation and mortality suggest that future studies should focus on delivering evidence-based AUD treatments to patients with coexisting AUD and cirrhosis.

Recalibration and External Validation of the Risk Analysis Index: A Surgical Frailty Assessment Tool.

OBJECTIVE AND BACKGROUND: The Risk Analysis Index (RAI) predicts 30-, 180-, and 365-day mortality based on variables constitutive of frailty. Initially validated, in a single-center Veteran hospital, we sought to improve model performance by recalibrating the RAI in a large, veteran surgical registry, and to externally validate it in both a national surgical registry and a cohort of surgical patients for whom RAI was measured prospectively before surgery. METHODS: The RAI was recalibrated among development and confirmation samples within the Veterans Affairs Surgical Quality Improvement Program (VASQIP; 2010-2014; N = 480,731) including major, elective noncardiac surgery patients to create the revised RAI (RAI-rev), comparing discrimination and calibration. The model was tested externally in the American College of Surgeons National Surgical Quality Improvement Program dataset (NSQIP; 2005-2014; N = 1,391,785), and in a prospectively collected cohort from the Nebraska Western Iowa Health Care System VA (NWIHCS; N = 6,856). RESULTS: Recalibrating the RAI significantly improved discrimination for 30-day [c = 0.84-0.86], 180-day [c = 0.81-0.84], and 365-day mortality [c = 0.78-0.82] (P < 0.001 for all) in VASQIP. The RAI-rev also had markedly better calibration (median absolute difference between observed and predicted 180-day mortality: decreased from 8.45% to 1.23%). RAI-rev was highly predictive of 30-day mortality (c = 0.87) in external validation with excellent calibration (median absolute difference between observed and predicted 30-day mortality: 0.6%). The discrimination was highly robust in men (c = 0.85) and women (c = 0.89). Discrimination also improved in the prospectively measured cohort from NWIHCS for 180-day mortality [c = 0.77 to 0.80] (P < 0.001). CONCLUSIONS: The RAI-rev has improved discrimination and calibration as a frailty-screening tool in surgical patients. It has robust external validity in men and women across a wide range of surgical settings and available for immediate implementation for risk assessment and counseling in preoperative patients.

Pain Catastrophizing and Arthritis Self-Efficacy as Mediators of Sleep Disturbance and Osteoarthritis Symptom Severity.

OBJECTIVE: Sleep and pain-related experiences are consistently associated, but the pathways linking these experiences are not well understood. We evaluated whether pain catastrophizing and arthritis self-efficacy mediate the association between sleep disturbance and osteoarthritis (OA) symptom severity in patients with knee OA. METHODS: We analyzed cross-sectional baseline data collected from Veterans Affairs (VA) patients enrolled in a clinical trial examining the effectiveness of a positive psychology intervention in managing pain from knee OA. Participants indicated how often in the past two weeks they were bothered by trouble falling asleep, staying asleep, or sleeping too much. We used validated scales to assess the primary outcome (OA symptom severity) and potential mediators (arthritis self-efficacy and pain catastrophizing). To test the proposed mediation model, we used parallel multiple mediation analyses with bootstrapping, controlling for sociodemographic and clinical characteristics with bivariate associations with OA symptom severity. RESULTS: The sample included 517 patients (Mage = 64 years, 72.9% male, 52.2% African American). On average, participants reported experiencing sleep disturbance at least several days in the past two weeks (M = 1.41, SD = 1.18) and reported moderate OA symptom severity (M = 48.22, SD = 16.36). More frequent sleep disturbance was associated with higher OA symptom severity directly (b = 3.08, P <0.001) and indirectly, through higher pain catastrophizing (b = 0.60, 95% confidence interval [CI] = 0.20 to 1.11) and lower arthritis self-efficacy (b = 0.84, 95% CI = 0.42 to 1.42). CONCLUSIONS: Pain catastrophizing and arthritis self-efficacy partially mediated the association between sleep disturbance and OA symptom severity. Behavioral interventions that address pain catastrophizing and/or self-efficacy may buffer the association between sleep disturbance and OA symptom severity.

Continuing education for systematic reviews: a prospective longitudinal assessment of a workshop for librarians.

OBJECTIVE: This prospective, longitudinal study explored the impact of a continuing education class on librarians' knowledge levels about and professional involvement with systematic reviews. Barriers to systematic review participation and the presence of formal systematic review services in libraries were also measured. METHODS: Participants completed web-based surveys at three points in time: pre-class, post-class, and six-months' follow-up. Descriptive statistics were calculated for demographics and survey questions. Linear mixed effects models assessed knowledge score changes over time. RESULTS: Of 160 class attendees, 140 (88%) completed the pre-class survey. Of those 140, 123 (88%) completed the post-class survey, and 103 (74%) completed the follow-up survey. There was a significant increase (p<0.00001) from pre-class to post-class in knowledge test scores, and this increase was maintained at follow-up. At post-class, 69% or more of participants intended to promote peer review of searches, seek peer review of their searches, search for grey literature, read or follow published guidelines on conduct and documentation of systematic reviews, and ask for authorship on a systematic review. Among librarians who completed a systematic review between post-class and follow-up, 73% consulted published guidelines, 52% searched grey literature, 48% sought peer review, 57% asked for authorship, and 70% received authorship. CONCLUSIONS: Attendance at this continuing education class was associated with positive changes in knowledge about systematic reviews and in librarians' systematic review-related professional practices. This suggests that in-depth professional development classes can help librarians develop skills that are needed to meet library patrons' changing service needs.

Characteristics of Opioid Prescriptions to Veterans With Cirrhosis.

BACKGROUND & AIMS: Despite increased risks for adverse effects in patients with cirrhosis, little is known about opioid prescriptions for this population. We aimed to assess time trends in opioid prescribing and factors associated with receiving opioids among patients with cirrhosis. METHODS: Among Veterans with cirrhosis, identified using national Veterans Health Administration data (2005-2014), we assessed characteristics of patients and their prescriptions for opioids. We calculated the annual proportion of patients receiving any opioid prescription. Among opioid recipients, we assessed prescriptions that were long-term (>90 days' supply), for high doses (>100 MME/day), or involved combinations of opioids and acetaminophen or benzodiazepine. We evaluated patient characteristics independently associated with long-term and any opioid prescriptions using mixed-effects regression models. RESULTS: Among 127,239 Veterans with cirrhosis, 97,974 (77.0%) received a prescription for an opioid. Annual opioid prescriptions increased from 36% in 2005 to 47% in 2014 (P < .01). Among recipients of opioids, the proportions of those receiving long-term prescriptions increased from 47% in 2005 to 54% in 2014 (P < .01), and19%-21% received prescriptions for high-dose opioids. Prescriptions for combinations of opioids and acetaminophen decreased from 68% in 2005 to 50% in 2014 (P < .01) and for combinations of opioids and benzodiazepines decreased from 24% to 19% over this time (P < .01). Greater probability of long-term opioid prescriptions was independently associated with younger age, female sex, white race, hepatitis C, prior hepatic decompensation, hepatocellular carcinoma, mental health disorders, nicotine use disorders, medical comorbidities, surgery, and pain-related conditions. CONCLUSION: Among Veterans with cirrhosis, 36%-47% were prescribed opioids in each year. Mental health disorders and hepatic decompensation were independently associated with long-term opioid prescriptions.

Outcomes of dogs with recurrent idiopathic pericardial effusion treated with a 3-port right-sided thoracoscopic subtotal pericardiectomy.

OBJECTIVE: To describe a 3-port right-sided thoracoscopic subtotal pericardiectomy (TSP) to treat dogs with recurrent idiopathic pericardial effusion (RIPE) and report their long-term survival. STUDY DESIGN: Retrospective case series. ANIMALS: Sixteen client-owned dogs. METHODS: Medical records were searched for dogs with idiopathic pericardial effusion that recurred after 1 or more pericardiocenteses and treated with a 3-port right-sided technique (1 subxiphoid camera port and 2 instrument ports on the right side of the dog). Follow-up consisted of direct examination or communication with referring veterinarians or owners. RESULTS: Thoracoscopic subtotal pericardiectomy was successfully completed in all dogs, with no surgical complications. The median duration of postoperative follow-up was 191.5 days (range, 5-1345). The median survival time (MST) after surgery was 365 days (range, 5-1345); MST of dogs with a histopathological diagnosis of neoplasia (n = 4) was 76 days, whereas dogs with no evidence of neoplasia had an MST of 367 days (n = 12, P = .14). Recurrent pleural effusion was the ultimate cause of death or reason for euthanasia in 8 of 16 dogs. CONCLUSION: The technique described here resulted in similar surgical times and outcomes for dogs undergoing TSP for RIPE compared with previous studies. Neoplasia was identified in 4 of 16 dogs. CLINICAL SIGNIFICANCE: Thoracoscopic subtotal pericardiectomy can be readily performed with only 2 instrument ports, both on the same side of the dog, and without 1-lung ventilation. Recurrent pleural effusion led to the death of half of the dogs in this series.

Quality of Sleep and Coexistent Psychopathology Have Significant Impact on Fatigue Burden in Patients With Inflammatory Bowel Disease.

BACKGROUND: Fatigue is common in inflammatory bowel disease (IBD) patients and is associated with factors such as psychopathology, sleep quality, and disease activity. GOAL: To investigate the combined role of all the above factors in the burden of fatigue among IBD patients. STUDY: We conducted an observational study of adult patients enrolled in an IBD clinical research registry at a tertiary care clinic. Fatigue burden was defined by Item 1 of the Short-form IBD Questionnaire (SIBDQ), which is scored on a 7-point Likert scale. Crohn's disease (CD) and ulcerative colitis (UC) disease activity were measured with the Harvey-Bradshaw Index or the UC Activity Index, respectively. Labs were obtained to assess anemia, vitamin deficiencies, and inflammatory markers. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Use of psychotropic medications and narcotics was used as proxy measure of psychopathology and pain. RESULTS: Among 685 IBD patients enrolled in the registry, 631 (238 UC, 393 CD) had a complete SIBDQ. High fatigue burden was found in 57.5% of patients (64.4% CD, 46.2% UC). Fatigue burden was significantly associated with sleep disturbance (PSQI), SIBDQ, and disease activity. CD patients had more fatigue burden than UC patients. Multivariate regression showed that poor quality of life, sleep disturbance, and being on a psychotropic medication are significantly associated with fatigue burden for both UC and CD. CONCLUSION: Because fatigue is common in IBD patients, these findings suggest that attention to quality of sleep and psychopathology is as important as medical disease management.

Modified cranial closing wedge ostectomy in 25 dogs.

OBJECTIVE: To describe the planning of a modified cranial closing wedge ostectomy (mCCWO) and determine the accuracy of execution without intraoperative jigs or alignment guides. STUDY DESIGN: Retrospective study. ANIMALS: Twenty-five client-owned dogs (32 stifles) with cranial cruciate ligament disease. METHODS: Medical records of dogs treated with mCCWO between July 2014 and December 2016 were reviewed. Preoperative, postoperative, and 8-week-recheck radiographs were reviewed to measure changes in the conformation of the proximal tibia. The accuracy of execution was assessed by comparing planned and actual postoperative tibial plateau angle (TPA) and the lengths of bone contact along osteotomy lines. Radiographic healing and clinical outcome were subjectively evaluated 8 weeks after surgery. RESULTS: Preoperative planning of mCCWO decreased the cranial wedge length by a mean of 23% compared with the traditional CCWO planning. Mean TPA decreased from 40.69 ° (range 28-63) to 6.94 ° (range 2-20) after surgery (P < .001). Mean tibial length decreased by 0.5 mm (±0.16, P = .003), from 138 mm (range 65-267) to 137.5 mm (range 65-265) after mCCWO. The tibial long axis (TLA) shifted by a mean of 3.47 ° (range 0-10). Planned and actual postoperative TPA differed by -0.66 ° (±0.47, P = .034). The proximal and distal apposing osteotomies differed in length by 1.81 mm (±0.35). No bone healing complications or implant failures were diagnosed, and all dogs returned to subjectively satisfactory function by 8 weeks after surgery. CONCLUSION: The preoperative planning and methods of execution of the mCCWO resulted in differences in target TPA and postoperative TPA, differences in lengths of proximal and distal osteotomies, and tibial shortening that did not appear clinically significant in this study. CLINICAL SIGNIFICANCE: mCCWO can be planned and accurately executed without consideration of TLA shift or the intraoperative use of alignment guides or jigs.

The role of family history of depression and the menopausal transition in the development of major depression in midlife women: Study of women's health across the nation mental health study (SWAN MHS).

BACKGROUND: This study evaluated whether family history of depression predicts major depression in midlife women above and beyond static risk factors (such as personal history of depression prior to midlife) and risks that may change dynamically across midlife (such as menopausal, psychosocial, and health profiles). METHODS: Participants were 303 African American and Caucasian women (42-52 years at baseline) recruited into the Study of Women's Health across the Nation (SWAN) Mental Health Study (MHS) in Pittsburgh. Major depression was assessed annually with Structured Clinical Interviews for DSM-IV. Family mental health history was collected at the ninth or tenth annual follow-up. Random effects logistic regression was used to assess the relationship between family history of depression and midlife depression, controlling for baseline sociodemographic characteristics and time-varying risk factors. RESULTS: Family history of depression was associated with midlife depression after adjusting for participant's history of major depression prior to midlife, trait anxiety and baseline age, and time-varying menopausal status, body mass index, very upsetting life events, and chronic difficulties (OR = 2.24, 95% CI = 1.17-4.29, P = .02). Higher odds of major depression were found when women were late perimenopausal or postmenopausal relative to when they were premenopausal or early perimenopausal (OR = 3.01, 95% CI = 1.76-5.15, P < .0001). However, menopausal status was only associated with major depression among women without a family history. CONCLUSIONS: Family history of depression predicts major depression in midlife women independent of the menopausal transition and other time-varying covariates. Notably, the menopausal transition was associated with increased risk only among women without a family history of depression.

Testing a Positive Psychological Intervention for Osteoarthritis.

OBJECTIVE: Osteoarthritis is a leading cause of disability for which there is no cure. Psychosocial-oriented treatments are underexplored. We developed and tested an intervention to build positive psychological skills (e.g., gratitude) to reduce osteoarthritis symptom severity, including pain and functioning, and to improve psychosocial well-being in patients with knee or hip osteoarthritis. DESIGN: Two-arm randomized design with six-month follow-up. SETTING: An academic Veterans Affairs Medical Center. SUBJECTS: Patients aged 50 years or older with knee or hip osteoarthritis and pain ratings of 4 or higher. METHODS: Patients (N = 42) were randomized to a six-week program containing positive skill-building activities or neutral control activities tailored to the patient population. Adherence was assessed by telephone each week. We assessed osteoarthritis symptom severity (WOMAC Osteoarthritis Index) and measures of well-being (positive affect, negative affect, and life satisfaction) at baseline and by telephone one, three, and six months after the program ended. We used linear mixed models to examine changes over time. RESULTS: The majority (64%) of patients completed more than 80% of their weekly activities. Patients in the positive (vs neutral) program reported significantly more improvement over time in osteoarthritis symptom severity (P = 0.02, Cohen's d = 0.86), negative affect (P = 0.03, Cohen's d = 0.50), and life satisfaction (P = 0.02, Cohen's d = 0.36). CONCLUSIONS: The study successfully engaged patients with knee or hip osteoarthritis in a six-week intervention to build positive psychological skills. Improving osteoarthritis symptom severity and measures of psychosocial well-being, the intervention shows promise as a tool for chronic pain management.