Loss of SREBP-1c ameliorates iron-induced liver fibrosis by decreasing lipocalin-2.

Sterol regulatory element-binding protein (SREBP)-1c is involved in cellular lipid homeostasis and cholesterol biosynthesis and is highly increased in nonalcoholic steatohepatitis (NASH). However, the molecular mechanism by which SREBP-1c regulates hepatic stellate cells (HSCs) activation in NASH animal models and patients have not been fully elucidated. In this study, we examined the role of SREBP-1c in NASH and the regulation of LCN2 gene expression. Wild-type and SREBP-1c knockout (1cKO) mice were fed a high-fat/high-sucrose diet, treated with carbon tetrachloride (CCl4), and subjected to lipocalin-2 (LCN2) overexpression. The role of LCN2 in NASH progression was assessed using mouse primary hepatocytes, Kupffer cells, and HSCs. LCN2 expression was examined in samples from normal patients and those with NASH. LCN2 gene expression and secretion increased in CCl4-induced liver fibrosis mice model, and SREBP-1c regulated LCN2 gene transcription. Moreover, treatment with holo-LCN2 stimulated intracellular iron accumulation and fibrosis-related gene expression in mouse primary HSCs, but these effects were not observed in 1cKO HSCs, indicating that SREBP-1c-induced LCN2 expression and secretion could stimulate HSCs activation through iron accumulation. Furthermore, LCN2 expression was strongly correlated with inflammation and fibrosis in patients with NASH. Our findings indicate that SREBP-1c regulates Lcn2 gene expression, contributing to diet-induced NASH. Reduced Lcn2 expression in 1cKO mice protects against NASH development. Therefore, the activation of Lcn2 by SREBP-1c establishes a new connection between iron and lipid metabolism, affecting inflammation and HSCs activation. These findings may lead to new therapeutic strategies for NASH.

Thrap3 promotes nonalcoholic fatty liver disease by suppressing AMPK-mediated autophagy.

Autophagy functions in cellular quality control and metabolic regulation. Dysregulation of autophagy is one of the major pathogenic factors contributing to the progression of nonalcoholic fatty liver disease (NAFLD). Autophagy is involved in the breakdown of intracellular lipids and the maintenance of healthy mitochondria in NAFLD. However, the mechanisms underlying autophagy dysregulation in NAFLD remain unclear. Here, we demonstrate that the hepatic expression level of Thrap3 was significantly increased in NAFLD conditions. Liver-specific Thrap3 knockout improved lipid accumulation and metabolic properties in a high-fat diet (HFD)-induced NAFLD model. Furthermore, Thrap3 deficiency enhanced autophagy and mitochondrial function. Interestingly, Thrap3 knockout increased the cytosolic translocation of AMPK from the nucleus and enhanced its activation through physical interaction. The translocation of AMPK was regulated by direct binding with AMPK and the C-terminal domain of Thrap3. Our results indicate a role for Thrap3 in NAFLD progression and suggest that Thrap3 is a potential target for NAFLD treatment.

LY6D is crucial for lipid accumulation and inflammation in nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) is a serious metabolic disorder characterized by excess fat accumulation in the liver. Over the past decade, NAFLD prevalence and incidence have risen globally. There are currently no effective licensed drugs for its treatment. Thus, further study is required to identify new targets for NAFLD prevention and treatment. In this study, we fed C57BL6/J mice one of three diets, a standard chow diet, high-sucrose diet, or high-fat diet, and then characterized them. The mice fed a high-sucrose diet had more severely compacted macrovesicular and microvesicular lipid droplets than those in the other groups. Mouse liver transcriptome analysis identified lymphocyte antigen 6 family member D (Ly6d) as a key regulator of hepatic steatosis and the inflammatory response. Data from the Genotype-Tissue Expression project database showed that individuals with high liver Ly6d expression had more severe NAFLD histology than those with low liver Ly6d expression. In AML12 mouse hepatocytes, Ly6d overexpression increased lipid accumulation, while Ly6d knockdown decreased lipid accumulation. Inhibition of Ly6d ameliorated hepatic steatosis in a diet-induced NAFLD mouse model. Western blot analysis showed that Ly6d phosphorylated and activated ATP citrate lyase, which is a key enzyme in de novo lipogenesis. In addition, RNA- and ATAC-sequencing analyses revealed that Ly6d drives NAFLD progression by causing genetic and epigenetic changes. In conclusion, Ly6d is responsible for the regulation of lipid metabolism, and inhibiting Ly6d can prevent diet-induced steatosis in the liver. These findings highlight Ly6d as a novel therapeutic target for NAFLD.

Machine learning-featured Secretogranin V is a circulating diagnostic biomarker for pancreatic adenocarcinomas associated with adipopenia.

Background: Pancreatic cancer is one of the most fatal malignancies of the gastrointestinal cancer, with a challenging early diagnosis due to lack of distinctive symptoms and specific biomarkers. The exact etiology of pancreatic cancer is unknown, making the development of reliable biomarkers difficult. The accumulation of patient-derived omics data along with technological advances in artificial intelligence is giving way to a new era in the discovery of suitable biomarkers. Methods: We performed machine learning (ML)-based modeling using four independent transcriptomic datasets, including GSE16515, GSE62165, GSE71729, and the pancreatic adenocarcinoma (PAC) dataset of the Cancer Genome Atlas. To find candidates for circulating biomarkers, we exported expression profiles of 1,703 genes encoding secretory proteins. Integrating three transcriptomic datasets into either a training or test set, ML-based modeling distinguishing PAC from normal was carried out. Another ML-model classifying long-lived and short-lived patients with PAC was also built to select prognosis-associated features. Finally, circulating level of SCG5 in the plasma was determined from the independent cohort (non-tumor = 25 and pancreatic cancer = 25). We also investigated the impact of SCG5 on adipocyte biology using recombinant protein. Results: Three distinctive ML-classifiers selected 29-, 64- and 18-featured genes, recognizing the only common gene, SCG5. As per the prediction of ML-models, the SCG5 transcripts was significantly reduced in PAC and decreased further with the progression of the tumor, indicating its potential as a diagnostic as well as prognostic marker for PAC. External validation of SCG5 using plasma samples from patients with PAC confirmed that SCG5 was reduced significantly in patients with PAC when compared to controls. Interestingly, plasma SCG5 levels were correlated with the body mass index and age of donors, implying pancreas-originated SCG5 could regulate energy metabolism systemically. Additionally, analyses using publicly available Genotype-Tissue Expression datasets, including adipose tissue histology and pancreatic SCG5 expression, further validated the association between pancreatic SCG5 expression and the size of subcutaneous adipocytes in humans. However, we could not observe any definite effect of rSCG5 on the cultured adipocyte, in 2D in vitro culture. Conclusion: Circulating SCG5, which may be associated with adipopenia, is a promising diagnostic biomarker for PAC.

Favipiravir and its potentials in COVID-19 pandemic: An update

The COVID-19 pandemic has caused millions of deaths and hundreds of millions of confirmed infections worldwide. This pandemic has prompted researchers to produce medications or vaccines to reduce or stop the progression and spread of this disease. A variety of previously licensed and marketed medications are being tested for the treatment and recurrence of SARS-CoV2, including favipiravir (Avigan). Favipiravir was recognized as an influenza antiviral drug in Japan in 2014, and has been known to have a potential in vitro activity against SARS-CoV-2, in addition to its broad therapeutic safety scope. Favipiravir was recently approved and officially used in many countries worldwide. Our review provides insights and up-to-date knowledge of the current role of favipiravir in the treatment of COVID-19 infection, focusing on preclinical and ongoing clinical trials, evidence of its efficacy against SARS-CoV-2 in COVID-19, side effects, anti-viral mechanism, and the pharmacokinetic properties of the drug in the treatment of COVID-19. Due to its teratogenic effects, favipiravir cannot be offered to expectant or pregnant mothers. The practical efficacy of such an intervention regimen will depend on its dose, treatment duration, and cost as well as difficulties in application.

Sarcopenia and Muscle Aging: A Brief Overview.

The world is facing the new challenges of an aging population, and understanding the process of aging has therefore become one of the most important global concerns. Sarcopenia is a condition which is defined by the gradual loss of skeletal muscle mass and function with age. In research and clinical practice, sarcopenia is recognized as a component of geriatric disease and is a current target for drug development. In this review we define this condition and provide an overview of current therapeutic approaches. We further highlight recent findings that describe key pathophysiological phenotypes of this condition, including alterations in muscle fiber types, mitochondrial function, nicotinamide adenine dinucleotide (NAD+) metabolism, myokines, and gut microbiota, in aged muscle compared to young muscle or healthy aged muscle. The last part of this review examines new therapeutic avenues for promising treatment targets. There is still no accepted therapy for sarcopenia in humans. Here we provide a brief review of the current state of research derived from various mouse models or human samples that provide novel routes for the development of effective therapeutics to maintain muscle health during aging.

Reliability and Validity of the Vietnamese Depression Interview (VDI).

Current instruments used to aid in the diagnosis of psychological disorders have limited effectiveness with clients from Asian backgrounds. The Vietnamese Depression Interview (VDI) is a diagnostic instrument created to assess the presence of current and lifetime history of major depressive disorder specifically among Vietnamese refugees and immigrants. The purpose of the present study is to provide a description of the VDI, while also noting it as a reliable and valid means by which to assess depression in Vietnamese individuals. Using the Longitudinal, Expert, and All Data (LEAD; Spitzer in Compr Psychiatry 24:399-411, 1983) standard and the VDI, experienced clinicians conducted the diagnosis process with 127 Vietnamese refugees and immigrants. Assessment of the reliability and validity of the VDI yielded good to excellent AUC and kappa values, indicating the reliability of the VDI and the agreement between the LEAD procedure and the VDI. These study results imply that the VDI performs successfully as a diagnostic instrument specifically created for Vietnamese refugees and immigrants in their native language. Current and future contributions of the VDI with Vietnamese individuals are discussed.

The impact of academic calendar cycle on coronary artery bypass outcomes: a comparison of teaching and non-teaching hospitals.

BACKGROUND: The commencement of new academic cycle in July is presumed to be associated with poor patient outcomes, although supportive evidence is limited for cardiac surgery patients. We sought to determine if the new academic cycle affected the outcomes of patients undergoing Coronary Artery Bypass Grafting. METHODS: A retrospective analysis was performed on 10-year nationwide in-hospital data from 1998-2007. Only patients who underwent CABG in the first and final academic 3-month calendar quarter were included. Generalized multivariate regression was used to assess indicators of hospital quality of care such as risk-adjusted mortality, total complications and "failure to rescue" (FTOR) - defined as death after a complication. RESULTS: Of the 1,056,865 CABG operations performed in the selected calendar quarters, 698,942 were at teaching hospitals. The risk-adjusted mortality, complications and FTOR were higher in the beginning of the academic year [Odds ratio = 1.14, 1.04 and 1.19 respectively; p < 0.001 for all] irrespective of teaching status. However, teaching status was associated with lower mortality (OR 0.9) despite a higher complication rate (OR 1.02); [p < 0.05 for both]. The July Effect thus contributed to only a 2.4% higher FTOR in teaching hospitals compared to 19% in non teaching hospitals. CONCLUSIONS: The July Effect is reflective of an overall increase in morbidity in all hospitals at the beginning of the academic cycle and it had a pronounced effect in non-teaching hospitals. Teaching hospitals were associated with lower mortality despite higher complication rates in the beginning of the academic cycle compared to non-teaching hospitals. The July effect thus cannot be attributed to presence of trainees alone. ULTRAMINI ABSTRACT: This study compares the July effect in teaching and non-teaching hospitals and demonstrates that this effect is not unique to teaching hospitals for CABG patients. In fact, teaching hospitals have somewhat better outcomes at the beginning of the academic cycle and the July effect is a much broader seasonal variation.

Cirrhosis as a moderator of outcomes in coronary artery bypass grafting and off-pump coronary artery bypass operations: a 12-year population-based study.

BACKGROUND: Cirrhosis substantially affects morbidity and mortality in patients who undergo complex surgical procedures. However, cirrhosis is not included as a parameter in standardized perioperative cardiac risk assessment models. We sought to identify the impact of cirrhosis on coronary artery bypass grafting (CABG) and off-pump CABG (OPCAB) outcomes. METHODS: Using the 1998 to 2009 Nationwide Inpatient Sample databases, we identified 3,046,709 patients who underwent CABG procedures, 744,636 (24.4%) of which were OPCAB; 6,448 (0.3%) had cirrhosis. Using hierarchical multivariable regression models, we analyzed the impact of cirrhosis on in-hospital outcomes: mortality, morbidity, length of stay, hospital charges, and disposition. Severity of liver dysfunction was assessed by the Deyo-Charlson comorbidity index. RESULTS: In the overall CABG group, cirrhosis was independently associated with increased mortality (adjusted odds ratio [AOR] 6.9, 95% confidence interval [CI] 2.8 to 17), morbidity (AOR 1.6, 95% CI 1.3 to 2.0), length of stay (+1.2 days; p < 0.001), and hospital charges (+$22,491; p < 0.001). The prevalence of cirrhosis in the OPCAB group was 0.3% (n = 2,246); the OPCAB subgroup analysis revealed that the presence of cirrhosis did not affect mortality or morbidity unless there was severe liver dysfunction (mortality AOR 5.1, 95% CI 3.7 to 6.9; morbidity AOR 2.1, 95% CI 1.6 to 2.4). However, in the on-pump CABG patients, cirrhosis was associated with increased mortality and morbidity regardless of the severity of liver dysfunction. CONCLUSIONS: The impact of cirrhosis on perioperative outcomes and health care costs is significant; CABG should be performed on carefully selected cirrhotic patients and, whenever possible, without the use of cardiopulmonary bypass.

Impact of surgeon demographics and technique on outcomes after esophageal resections: a nationwide study.

BACKGROUND: Thoracic, cardiac, and general surgeons perform esophageal resections in the United States. This article examines the impact of surgeon subspecialty on outcomes after esophagectomy. METHODS: Esophagectomies performed between 1998 and 2008 were identified in the Nationwide Inpatient Sample. Surgeons were classified as thoracic, cardiac, or general surgeons if greater than 65% of their operative case mix was representative of their specialty. Surgeons with less than 65% of a specialty-specific case mix served as controls. Regression equations calculated the independent effect of surgeon specialty, surgeon volume, and operative approach (transhiatal versus transthoracic) on outcomes. RESULTS: Of the 40,589 patients who underwent esophagectomies, surgeon identifiers were available for 23,529 patients. Based on case mix, thoracic, cardiac, and general surgeons performed 3,027 (12.9%), 688 (2.9%), and 4,086 (17.4%) esophagectomies, respectively. Operative technique did not independently affect risk-adjusted outcomes-mortality, morbidity, and failure to rescue (defined as death after a complication). Surgeon volume independently lowered mortality and failure to rescue by 4% (p ≤ 0.002 for both), but not complications (p = 0.6). High-volume hospitals (>12 procedures/year) independently lowered mortality (adjusted odds ratio [AOR], 0.67, 95% confidence interval [CI], 0.46-0.96), and failure to rescue (AOR, 0.64; 95% CI, 0.44-0.94). Esophageal resections performed by general surgeons were associated with higher mortality (AOR, 1.87; 95% CI 1.02-3.45) and failure to rescue (AOR, 1.95; 95% CI, 1.06-3.61) but not complications (AOR, 0.97; 95% CI, 0.64-1.49). CONCLUSIONS: General surgeons perform the major proportion of esophagectomies in the United States. Surgeon subspecialty is not associated with the risk of complications developing but instead is associated with mortality and failure to rescue from complications. Surgeon subspecialty case mix is an important determinant of outcomes for patients undergoing esophagectomy.

Predictors of in-hospital complications after pericardiectomy: a nationwide outcomes study.

OBJECTIVE: Advances in medical care had caused a paradigm shift in the indications for pericardiectomy. We evaluated the current predictors of in-hospital complications for pericardiectomy. METHODS: Patients who underwent pericardiectomy between 1998 and 2008 were identified from the US Nationwide Inpatient Sample. Risk-adjusted logistic regression model was used to analyze the predictors of surgical outcomes. RESULTS: A total of 13,593 patients underwent pericardiectomy during this period. Pericardiectomy was performed for constrictive pericarditis (28%; n = 3851), pericardial calcification (15%; n = 2061), secondary malignancies (3%; n = 456), adhesive pericarditis (2%; n = 318), and other causes (40%; n = 5461). Unadjusted mortality and complication rates were approximately 8% and 48%, respectively. Fourteen percent of patients required blood transfusion. Only 62% were routinely discharged home. After risk adjustment, age, female gender, comorbidity index, and the primary diagnosis independently predicted in-hospital mortality and overall complication rates (P < .05). Calcific pericarditis was the only etiology associated with lower risk-adjusted mortality (odds ratio [OR], 0.48), operative complications (OR, 0.32), overall complications (OR, 0.32), incidence of transfusion (OR, 0.38), and highest routine discharge rates (OR, 1.84); P < .001 for all. Constrictive pericarditis had the highest requirement for cardiopulmonary bypass (OR, 6.41; P < .01) and incidence of bleeding complications (OR, 2.61; P < .01). CONCLUSIONS: Morbidity remains high for pericardiectomy. In addition to age, gender, and comorbidities, attention should be given to etiology during surgical planning or referral. This significantly influences the requirement for cardiopulmonary bypass, chances of bleeding complications, and transfusion requirements.

Development, reliability, and validity of the Posttraumatic Stress Disorder Interview for Vietnamese refugees: a diagnostic instrument for Vietnamese refugees.

The Posttraumatic Stress Disorder Interview for Vietnamese Refugees (PTSD-IVR) was created specifically to assess for the presence of current and lifetime history of premigration, migration, encampment, and postmigration traumas in Vietnamese refugees. The purpose of the present study was to describe the development of and investigate the interrater and test-retest reliability of the PTSD-IVR and its validity in relation to the diagnoses obtained from the Longitudinal, Expert, and All Data (LEAD; Spitzer, 1983) standard. Clinicians conducted the diagnosis process with 127 Vietnamese refugees using the LEAD standard and the PTSD-IVR. Assessment of the reliability and validity of the PTSD-IVR yielded good to excellent AUC (area under the receiver operating characteristic curve; .86, .87) and κ values (.66, .74) indicating the reliability of the PTSD-IVR and the agreement between the LEAD procedure and the PTSD-IVR. The results of the present study suggest that the PTSD-IVR performs successfully as a diagnostic instrument specifically created for Vietnamese refugees in their native language.

Gender as a moderator between having an anxiety disorder diagnosis and coronary artery bypass grafting surgery (CABG) outcomes in rural patients.

PURPOSE: This paper examines gender as a moderating variable between having an anxiety disorder diagnosis and coronary artery bypass grafting surgery (CABG) outcomes in rural patients. METHODS: Using the 2008 Nationwide Inpatient Sample (NIS) database, 17,885 discharge records of patients who underwent a primary CABG surgery were identified. Independent variables included age, gender, race, median household income based on patient's ZIP code, primary expected payer, the Deyo, Cherkin, and Ciol Comorbidity Index, and an anxiety comorbidity diagnosis. Outcome variables included in-hospital length of stay and patient disposition (routine and nonroutine discharge). A 2 × 2 analysis of variance and logistic regression analyses were used to assess the interaction between gender and an anxiety disorder diagnosis on in-hospital length of stay and patient disposition. FINDINGS: Twenty-seven percent of rural patients undergoing a CABG operation had a comorbid anxiety diagnosis. Rural patients who had nonroutine discharge were more likely to have comorbid anxiety diagnosis compared to rural patients who had a routine discharge. There was a significant interaction effect between having an anxiety diagnosis and gender on length of hospital stay but not for patient disposition. CONCLUSIONS: Three findings were noteworthy. First, anxiety disorder is prevalent in rural patients who are undergoing a CABG operation. Second, anxiety was a significant independent predictor of both length of hospital stay and nonroutine discharge for patients receiving CABG surgery. Last, having an anxiety disorder diagnosis increased hospital stay for both males and females; however, females seemed to be impacted more than males.

Morbid obesity is associated with increased resource utilization in coronary artery bypass grafting.

BACKGROUND: Studies have shown good outcomes for morbidly obese patients who undergo cardiac surgery. However, little is known about how much additional resource utilization treating these challenging patients requires. We hypothesized that morbidly obese patients (body mass index ≥40 kg/m(2)) undergoing coronary artery bypass grafting needed longer operating room times and had longer hospital and intensive care unit stays than non-morbidly obese patients. METHODS: We reviewed data from all morbidly obese patients (n = 56, body mass index = 42.7 ± 2.6 kg/m(2)) who underwent coronary artery bypass grafting at our institution between 1999 and 2009. These patients' outcomes were compared with those of non-morbidly obese patients (n = 168, body mass index = 30.0 ± 2.8 kg/m(2)) who were propensity-matched 3:1 with the morbidly obese patients. RESULTS: Of the 14 preoperative characteristics examined, only 1, creatinine level, differed significantly between the two groups (p = 0.02). Intraoperative and postoperative complication rates and the mortality rate were similar between groups (p > 0.09). However, morbidly obese patients had longer operating times (449 ± 70 versus 420 ± 59 minutes; p = 0.002), intensive care unit stays (5.2 versus 3.3 days; p < 0.005), and postoperative hospital stays (14.2 versus 9.5 days; p < 0.005) than the non-morbidly obese patients. CONCLUSIONS: Although good outcomes can be achieved for morbidly obese patients who undergo coronary artery bypass grafting, these patients require considerably more resource utilization in the operating room and intensive care unit, and they spend more time in the hospital after surgery. At a cardiac surgical operating room cost of approximately $50 per minute and $4,500 per intensive care unit day, the financial implications for morbidly obese patients who need coronary artery bypass grafting are not insignificant.

Outcomes of concomitant aortic valve replacement and coronary artery bypass grafting at teaching hospitals versus nonteaching hospitals.

OBJECTIVE: Hospitals with a high volume and academic status produce better patient outcomes than other hospitals after complex surgical procedures. Risk models show that concomitant aortic valve replacement and coronary artery bypass grafting pose a greater risk than isolated coronary artery bypass grafting or aortic valve replacement. We examined the relationship of hospital teaching status and the presence of a thoracic surgery residency program with aortic valve replacement/coronary artery bypass grafting outcomes. METHODS: By using the Nationwide Inpatient Sample database, we identified patients who underwent concomitant aortic valve replacement/coronary artery bypass grafting from 1998 to 2007 at nonteaching hospitals, teaching hospitals without a thoracic surgery residency program, and teaching hospitals with a thoracic surgery residency program. Multivariate analysis was performed to identify intergroup differences. Risk-adjusted multivariable logistic regression analysis was used to assess independent predictors of in-hospital mortality and complication rates. RESULTS: The 3 groups of patients did not differ significantly in their baseline characteristics. Patients who underwent aortic valve replacement/coronary artery bypass grafting had higher overall risk-adjusted complication rates in nonteaching hospitals (odds ratio 1.58; 95% confidence interval, 1.39-1.80; P < .0001) and teaching hospitals without a thoracic surgery residency program (odds ratio 1.42; 95% confidence interval, 1.26-1.60; P < .0001) than in thoracic surgery residency program hospitals. However, no difference was observed in the adjusted mortality rate for nonteaching hospitals (odds ratio 0.95; 95% confidence interval, 0.87-1.04; P = .25) or teaching hospitals without a thoracic surgery residency program (odds ratio 1.00; 95% confidence interval, 0.92-1.08; P = .98) when compared with thoracic surgery residency program hospitals. Robust statistical models were used for analysis, with c-statistics of 0.98 (complications) and 0.82 (mortality). CONCLUSION: Patients who require complex cardiac operations may have better outcomes when treated at teaching hospitals with a thoracic surgery residency program.

Endovascular versus open repair of ruptured descending thoracic aortic aneurysms: a nationwide risk-adjusted study of 923 patients.

OBJECTIVE: Recent studies support the use of endovascular treatment for ruptured abdominal aortic aneurysms, but few studies have examined the use of thoracic endovascular aortic repair (TEVAR) for ruptured descending thoracic aortic aneurysm. We evaluated nationwide data regarding short-term outcomes of TEVAR and open aortic repair (OAR) for ruptured descending thoracic aortic aneurysm. METHODS: From US Nationwide Inpatient Sample data, we identified 923 patients who underwent ruptured descending thoracic aortic aneurysm repair in 2006-2008 and who had no concomitant aortic disorders. Of these patients, 364 (39.4%) underwent TEVAR and 559 (60.6%) underwent OAR. Multivariable regression was used to assess the effect of TEVAR versus OAR after adjusting for potential confounding factors. Outcomes assessed were in-hospital mortality, complications, failure to rescue (defined as the mortality among patients in whom a complication develops), and disposition. Backward stepwise logistic regression was used to identify independent predictors of outcomes for each approach. RESULTS: Patients undergoing TEVAR were older (72 ± 12 years vs 65 ± 15 years; P < .001) and had a higher Deyo comorbidity index (4.19 ± 1.79 vs 3.14 ± 2.05; P < .001) than patients undergoing OAR. Unadjusted mortality was 23.4% (85/364) for TEVAR and 28.6% (160/559) for OAR. After risk adjustment, the odds of mortality, complications, and failure to rescue were similar for TEVAR and OAR (P > .1 for all), but patients undergoing TEVAR had a greater chance of routine discharge (odds ratio [OR] = 3.3; P < .001). An interaction was identified that linked hospital size and operative approach with risk of complications (P < .001). In smaller hospitals, TEVAR was associated with lower complication rates than OAR (OR = 0.21; P < .05). Regression analysis revealed that smaller hospital size predicted significantly higher rates of mortality (OR = 2.4; P < .05), complications (OR = 4.0; P < .005), and failure to rescue (OR = 51.12; P < .001) in those undergoing OAR but not in those undergoing TEVAR. Preexisting renal disorders substantially increased mortality risk (OR = 10.81; P < .001) and failure to rescue (OR = 309.54; P < .001) in patients undergoing TEVAR. CONCLUSIONS: Nationwide data for ruptured descending thoracic aortic aneurysm reveal equivalent mortality, complication rates, and failure to rescue for TEVAR and OAR but more frequent routine discharge with TEVAR. Unlike OAR outcomes, TEVAR outcomes were not poorer in smaller hospitals, where TEVAR produced fewer complications than OAR. Therefore, TEVAR may be an ideal alternative to OAR for ruptured descending thoracic aortic aneurysm, particularly in small hospitals where expertise in OAR may be lacking and immediate transfer to a higher echelon of care may not be feasible.

Randomized controlled trial of brief cognitive behavioral intervention for depression and anxiety symptoms preoperatively in patients undergoing coronary artery bypass graft surgery.

OBJECTIVE: The goal of this study was to examine the feasibility, acceptability, and efficacy of a brief, tailored cognitive-behavioral intervention for patients with symptoms of preoperative depression or anxiety before undergoing a coronary artery bypass graft (CABG) operation. METHODS: Patients were recruited from a university teaching hospital between February 2007 and May 2009. Patients were randomly assigned to receive treatment as usual (TAU) or a cognitive behavioral therapy (CBT) intervention called Managing Anxiety and Depression using Education and Skills (MADES). A total of 100 subjects were randomized into the study. Length of hospital stay was assessed with a 1-way analysis of variance. Depression, anxiety, and quality of life were assessed with mixed-model repeated measures analyses. RESULTS: Overall, the intervention was feasible, and patients had a positive impression of the MADES. Patients in the TAU group stayed longer in the hospital than did those in the MADES group (7.9 days ± 2.6 vs 9.2 days ± 3.5; P = .049). Depressive symptoms increased at time of hospital discharge for the TAU group, whereas the MADES group had a decrease in depressive symptoms at the time of discharge. Quality of life and anxiety symptoms improved in both groups at 3 to 4 weeks of follow-up. However, the MADES group had greater improvements than did the TAU group. CONCLUSIONS: This study demonstrated that brief, tailored CBT targeting preoperative depression and anxiety is both feasible and acceptable for patients undergoing CABG surgery. Most important, this intervention improved depressive and anxiety symptoms, as well as quality of life. Moreover, it reduced in-hospital length of stay. This study found that a cognitive-behavioral intervention for patients undergoing CABG surgery for symptoms of preoperative depression/anxiety is both feasible and acceptable. Most important, this intervention improved depressive and anxiety symptoms, as well as quality of life. It also reduced in-hospital length of stay.

Staged versus synchronous carotid endarterectomy and coronary artery bypass grafting: analysis of 10-year nationwide outcomes.

BACKGROUND: The timing of operative interventions for patients with concurrent carotid and coronary artery disease is controversial. We evaluated nationwide data regarding staged or synchronous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) and compared the two approaches' outcome profiles. METHODS: From Nationwide Inpatient Sample database 1998 to 2007, we identified 6,153 (28.9%) patients who underwent CEA before or after CABG during the same hospital admission but not on the same day (STAGED) and 16,639 patients who underwent both procedures on the same day (SYNC). Hierarchic multivariable regression was used to assess the independent effect of operative strategy on mortality, neurologic and overall complications, and charges. RESULTS: Mean age (69.5±9.0 years) and Charlson-Deyo score (4.6±1.5) were similar for both groups. Mortality (4.2% vs 4.5%) or neurologic complications (3.5% vs 3.9%) were similar between the STAGED and SYNC groups (p>0.7 for both). The STAGED patients had higher morbidity (48.4% vs 42.6%; odds ratio [OR] 1.8; 95% confidence interval [CI], 1.5 to 2.2; p<0.001) and more cardiac (OR, 1.5; 95% CI, 1.4 to 1.7; p<0.001), wound (OR, 2.1; 95% CI, 1.8 to 2.4; p<0.001), respiratory (OR, 1.2; 95% CI, 1.1 to 1.3; p=0.001), and renal complications (OR, 1.2; 95% CI, 1.03 to 1.3; p<0.001). In SYNC patients, on-pump CABG increased stroke rates (OR, 1.6; 95% CI, 1.3 to 1.9; p<0.001). The STAGED procedures were independently associated with higher hospital charges by $23,328 (p<0.001). CONCLUSIONS: We identified no significant difference in mortality or neurologic complications between STAGED and SYNC approaches. Staged procedures were associated with a greater risk of overall complications and higher hospital charges than SYNC. On-pump CABG was associated with higher stroke rates in SYNC patients.

Heart rate variability (HRV) and posttraumatic stress disorder (PTSD): a pilot study.

Exposure to combat experiences is associated with increased risk of developing Post Traumatic Stress Disorder. Prolonged exposure therapy and cognitive processing therapy have garnered a significant amount of empirical support for PTSD treatment; however, they are not universally effective with some patients continuing to struggle with residual PTSD symptoms. Heart rate variability (HRV) is a measure of the autonomic nervous system functioning and reflects an individual's ability to adaptively cope with stress. A pilot study was undertaken to determine if veterans with PTSD (as measured by the Clinician-Administered PTSD Scale and the PTSD Checklist) would show significantly different HRV prior to an intervention at baseline compared to controls; specifically, to determine whether the HRV among veterans with PTSD is more depressed than that among veterans without PTSD. The study also aimed at assessing the feasibility, acceptability, and potential efficacy of providing HRV biofeedback as a treatment for PTSD. The findings suggest that implementing an HRV biofeedback as a treatment for PTSD is effective, feasible, and acceptable for veterans. Veterans with combat-related PTSD displayed significantly depressed HRV as compared to subjects without PTSD. When the veterans with PTSD were randomly assigned to receive either HRV biofeedback plus treatment as usual (TAU) or just TAU, the results indicated that HRV biofeedback significantly increased the HRV while reducing symptoms of PTSD. However, the TAU had no significant effect on either HRV or symptom reduction. A larger randomized control trial to validate these findings appears warranted.