Cerebrovascular Events After Cardiovascular Procedures: Risk Factors,Recognition, and Prevention Strategies

Stroke has long been a devastating complication of any cardiovascular procedure that unfavorably affects survival and quality of life. Over time, strategies have been developed to substantially reduce the incidence of stroke after traditional cardiovascular procedures such as coronary artery bypass grafting, isolated valve surgery, and carotid endarterectomy. Subsequently, with the advent of minimally invasive technologies including percutaneous coronary intervention, carotid artery stenting, and transcatheter valve therapies, operators were faced with a new host of procedural risk factors, and efforts again turned toward identifying novel ways to reduce the risk of stroke. Fortunately, by understanding the procedural factors unique to these new techniques and applying many of the lessons learned from prior experiences, we are seeing significant improvements in the safety of these new technologies. In this review, the authors: 1) carefully analyze data from different cardiac procedural experiences ranging from traditional open heart surgery to percutaneous coronary intervention and transcatheter valve therapies; 2) explore the unique risk factors for stroke in each of these areas; and 3) describe how these risks can be mitigated with improved patient selection, adjuvant pharmacotherapy, procedural improvements, and novel technological advancements.     

Improving Beverage Choice in Adults with Developmental Disabilities: Implementation of a Token Reinforcement System in a Community Residential Setting

Journal of Autism and Developmental Disorders - Individuals with developmental disabilities (DD) are twice as likely to have obesity than non-disabled individuals. Replacing the consumption of...     

The association of comorbidity indices and minimal clinically important difference in a population undergoing shoulder arthroplasty

BackgroundShoulder arthroplasty (SA) procedures are increasingly common. The Charlson and Elixhauser indices are ICD-10 based measures used in large databases to describe the patient case mix in terms of secondary medical conditions. There is a paucity of data on the relationship between these indices and patient-reported outcome measures (PROMs) after shoulder arthroplasty.MethodsPatients undergoing SA from 2016-2018 were identified in the electronic medical records. Charlson and Elixhauser comorbidities were used to calculate comorbidity scores according to established algorithms (eg Elixhauser-Walraven). Patient shoulder-specific (American Shoulder and Elbow Surgeons (ASES) score and Shoulder Activity Scale (SAS)) and general health scales (SF-12 Mental Component Score (MCS) and Physical Component Score (PCS) and Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI)) PROMs were obtained from our institution’s shoulder registry. Linear regression models adjusting for age and sex evaluated associations between comorbidity scores and PROMs. Receiver operating characteristic (ROC) curves determined optimal cutoffs, maximizing sensitivity and specificity to identify patients likely to fail to meet minimal clinically important difference (MCID) values.ResultsA total of 1817 SA procedures were identified. Higher Charlson and Elixhauser-Walraven scores were significantly associated with lower baseline SAS and SF-12 PCS. Patients with higher Charlson scores had lower baseline ASES (P = .003) and lower baseline (P = .0002) and 2-year (P = .02) SF-12 MCS. No significant associations were found for PROMIS-PI with either index. The Charlson score better predicted the failure to meet MCID for SF-12 PCS with an AUC of 0.64, compared to 0.55 for Elixhauser-Walraven. Conversely, Elixhauser-Walraven better predicted PROMIS-PI with an AUC of 0.66, compared to 0.53 for Charlson. Moderate AUCs were observed for the remaining PROMs, ranging from 0.57-0.64, with little difference between index scores.ConclusionHigher Charlson and Elixhauser-Walraven scores were associated with lower baseline scores on most PROMs. Generally, the Charlson score performed better than the Elixhauser-Walraven score in predicting worse outcomes at 2 years. Comorbidity indices may be useful as a decision aid to provide appropriate expectations of outcomes for patients undergoing SA.     

Primary cortisol resistance in man. A glucocorticoid receptor-mediated disease.

We have studied a man suspected of having primary cortisol resistance on the basis of high 24-h mean plasma cortisol levels (27.4 micrograms/dl) and no stigmata of Cushing's syndrome. His son had slightly elevated 24-h mean plasma cortisol levels (9.9 micrograms/dl; normal 7.52 micrograms/dl). Both had high plasma protein unbound cortisol and increased urinary free cortisol. Plasma ACTH concentration was high, and both were resistant to adrenal suppression by dexamethasone. The father appeared to have mineralocorticoid excess resulting in hypertension, hypokalemia, and metabolic alkalosis. This was found to be due to markedly elevated plasma levels of deoxycorticosterone and corticosterone. The son, who was normotensive, had mildly increased plasma corticosterone and normal deoxycorticosterone levels. To study the apparent end-organ resistance to cortisol, we examined the glucocorticoid receptor in the white cells and fibroblasts of these patients. In both tissues, using both whole cell and cytosol assays, the glucocorticoid receptor was found to have reduced affinity for dexamethasone. In the cytoxol assays, a reduced receptor number was found as well. We conclude that cortisol resistance is a rare familial syndrome owing to an abnormal glucocorticoid receptor with a decreased affinity for cortisol.     

Office-Based Buprenorphine Versus Clinic-Based Methadone: A Cost-Effectiveness Analysis

The objective of this analysis was to compare the cost-effectiveness of clinic-based methadone maintenance therapy (MMT) and office-based buprenorphine maintenance therapy (BMT) from the perspective of third-party payers in the United States. The authors used a Markov cost-effectiveness model. A hypothetical cohort of 1000 adult, opioid-dependent patients was modeled over a 1-year time horizon. Patients were allowed to transition between the health states of in opioid dependence treatment and either abusing or not abusing opioids, or to have dropped out of treatment. Probabilities were derived from randomized clinical trials comparing methadone and buprenorphine. Costs included drug and administration, clinic visits, and therapy sessions. Effectiveness outcomes examined were (1) retention in the treatment program and (2) opioid abuse–free weeks. For retention in treatment at 1 year, MMT was more costly ($4,613 vs. $4,155) and more effective (20.3% vs. 15.9%) than BMT, resulting in an incremental cost-effectiveness ratio (ICER) of $10,437 per additional patient retained in treatment. MMT was also more effective than BMT in terms of opioid abuse–free weeks (9.2 vs. 9.1 weeks), resulting in an ICER of $8,515 per opioid abuse–free week gained. One-way sensitivity analyses found costs per week of MMT to have the largest impact on the retention-in-treatment outcome, whereas the probability of dropping out with MMT had the greatest impact on opioid abuse–free weeks. The authors conclude that MMT is cost-effective compared with BMT for the treatment of patients with opioid dependence. However, the treatment of substance abuse is complex, and decision makers should also consider individual patient characteristics when making coverage decisions.     

Emotional Maltreatment from Parents, Verbal Peer Victimization, and Cognitive Vulnerability to Depression

Although a number of studies have examined possible developmental antecedents of cognitive vulnerability to depression, most have focused on parental variables. In contrast, the current studies examined the relation between reports by college students of peer victimization during childhood and cognitive vulnerability to depression, as defined by hopelessness (L. Y. Abramson, G. I. Metalsky, & L. B. Alloy, 1989) and Beck's theories (A. T. Beck, 1967, 1987) of depression. Results from both studies supported the hypothesis that peer victimization contributes unique variance to the prediction of cognitive vulnerability beyond that accounted for by parent variables. The implications of these results for third variable accounts involving general parental factors (e.g., genetic transmission of cognitive vulnerability) of the relationship between peer victimization and cognitive vulnerability are discussed.     

Roux-en-Y gastric bypass versus sleeve gastrectomy: what factors influence patient preference?

Background

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the most commonly performed bariatric procedures. RYGB involves altered gastrointestinal anatomy and 2 anastomoses, while SG involves gastric resection. When potential patients view images of the procedures, they may perceive RYGB to involve significant risk compared with SG, in which no significant gastrointestinal alterations are depicted.