The relationship between obstructive sleep apnoea and postoperative delirium and pain: an observational study of a surgical cohort.

Patients with obstructive sleep apnoea are at increased risk of adverse postoperative outcomes, such as cardiac and respiratory complications. It has been hypothesised that obstructive sleep apnoea also increases the risk for postoperative delirium and acute postoperative pain. We conducted a retrospective, observational study investigating the relationship of obstructive sleep apnoea with postoperative delirium and acute postoperative pain severity. Patients were classified as being at high risk for obstructive sleep apnoea if they had been diagnosed with this condition, or if they were positive for more than four factors using the 'STOP-BANG' screening tool. Adjusted logistic regression was used to investigate the association between obstructive sleep apnoea and postoperative delirium, and multivariable linear regression to study the relationship between obstructive sleep apnoea and postoperative pain severity. The incidence of postoperative delirium was 307 in 1441 patients (21.3%; 95%CI 19.2-23.5%). In unadjusted analysis, high risk for obstructive sleep apnoea was associated with delirium, with an odds ratio (95%CI) of 1.77 (1.22-2.57; p = 0.003). After adjustment for pre-specified variables, the association was not statistically significant with odds ratio 1.34 (0.80-2.23; p = 0.27). The mean (SD) maximum pain (resting or provoked) reported for the entire cohort was 63.8 (27.9) mm on a 0-100 mm visual analogue scale. High risk for obstructive sleep apnoea was not associated with postoperative pain severity (ß-coefficient 2.82; 95%CI, -2.34-7.97; p = 0.28). These findings suggest that obstructive sleep apnoea is unlikely to be a strong risk factor for postoperative delirium or acute postoperative pain severity.

Intraoperative ketamine for prevention of depressive symptoms after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial.

BACKGROUND: Ketamine is a general anaesthetic with anti-depressant effects at subanaesthetic doses. We hypothesised that intraoperative administration of ketamine would prevent or mitigate postoperative depressive symptoms in surgical patients. METHODS: We conducted an international, randomised clinical trial testing the effects of intraoperative administration of ketamine [0.5 mg kg-1 (Lo-K) or 1.0 mg kg-1 (Hi-K)] vs control [saline placebo (P)] in patients ≥60 yr old undergoing major surgery with general anaesthesia. We administered the Patient Health Questionnaire-8 before the operation, on postoperative day (POD) 3 (primary outcome), and on POD30 to assess depressive symptoms, a secondary outcome of the original trial. RESULTS: There was no significant difference on POD3 in the proportion of patients with symptoms suggestive of depression between the placebo [23/156 (14.7%)] and combined ketamine (Lo-K plus Hi-K) [61/349 (17.5%)] groups [difference = -2.7%; 95% confidence interval (CI), 5.0% to -9.4%; P=0.446]. Of the total cohort, 9.6% (64/670; 95% CI, 7.6-12.0%) had symptoms suggestive of depression before operation, which increased to 16.6% (84/505; 95% CI, 13.6-20.1%) on POD3, and decreased to 11.9% (47/395; 95% CI, 9.1-15.5%) on POD30. Of the patients with depressive symptoms on POD3 and POD30, 51% and 49%, respectively, had no prior history of depression or depressive symptoms. CONCLUSIONS: Major surgery is associated with new-onset symptoms suggestive of depression in patients ≥60 yr old. Intraoperative administration of subanaesthetic ketamine does not appear to prevent or improve depressive symptoms. CLINICAL TRIALS REGISTRATION: NCT01690988.

Association between intraoperative electroencephalographic suppression and postoperative mortality.

BACKGROUND: Low bispectral index values frequently reflect EEG suppression and have been associated with postoperative mortality. This study investigated whether intraoperative EEG suppression was an independent predictor of 90 day postoperative mortality and explored risk factors for EEG suppression. METHODS: This observational study included 2662 adults enrolled in the B-Unaware or BAG-RECALL trials. A cohort was defined with >5 cumulative minutes of EEG suppression, and 1:2 propensity-matched to a non-suppressed cohort (≤5 min suppression). We evaluated the association between EEG suppression and mortality using multivariable logistic regression, and examined risk factors for EEG suppression using zero-inflated mixed effects analysis. RESULTS: Ninety day postoperative mortality was 3.9% overall, 6.3% in the suppressed cohort, and 3.0% in the non-suppressed cohort {odds ratio (OR) [95% confidence interval (CI)]=2.19 (1.48-3.26)}. After matching and multivariable adjustment, EEG suppression was not associated with mortality [OR (95% CI)=0.83 (0.55-1.25)]; however, the interaction between EEG suppression and mean arterial pressure (MAP) <55 mm Hg was [OR (95% CI)=2.96 (1.34-6.52)]. Risk factors for EEG suppression were older age, number of comorbidities, chronic obstructive pulmonary disease, and higher intraoperative doses of benzodiazepines, opioids, or volatile anaesthetics. EEG suppression was less likely in patients with cancer, preoperative alcohol, opioid or benzodiazepine consumption, and intraoperative nitrous oxide exposure. CONCLUSIONS: Although EEG suppression was associated with increasing anaesthetic administration and comorbidities, the hypothesis that intraoperative EEG suppression is a predictor of postoperative mortality was only supported if it was coincident with low MAP. CLINICAL TRIAL REGISTRATION: NCT00281489 and NCT00682825.

Impact of right-handedness on anaesthetic sensitivity, intra-operative awareness and postoperative mortality.

Anatomical, neurological and behavioural research has suggested differences between the brains of right- and non-right-handed individuals, including differences in brain structure, electroencephalogram patterns, explicit memory and sleep architecture. Some studies have also found decreased longevity in left-handed individuals. We therefore aimed to determine whether handedness independently affects the relationship between volatile anaesthetic concentration and the bispectral index, the incidence of definite or possible intra-operative awareness with explicit recall, or postoperative mortality. We studied 5585 patients in this secondary analysis of data collected in a multicentre clinical trial. There were 4992 (89.4%) right-handed and 593 (10.6%) non-right-handed patients. Handedness was not associated with (a) an alteration in anaesthetic sensitivity in terms of the relationship between the bispectral index and volatile anaesthetic concentration (estimated effect on the regression relationship -0.52 parallel shift; 95% CI -1.27 to 0.23, p = 0.17); (b) the incidence of intra-operative awareness with 26/4992 (0.52%) right-handed vs 1/593 (0.17%) non-right-handed (difference = 0.35%; 95% CI -0.45 to 0.63%; p = 0.35); or (c) postoperative mortality rates (90-day relative risk for non-right-handedness 1.19, 95% CI 0.76-1.86; p = 0.45). Thus, no change in anaesthetic management is indicated for non-right-handed patients.

MR imaging of intracranial hemangiopericytomas.

OBJECTIVE: To describe the MR features of primary intracranial hemangiopericytomas (HPCs) on conventional imaging, diffusion and MR spectroscopy and aim to determinate distinguishing features from meningiomas. METHODS: From 2006 to 2012, seven patients with pathologically confirmed primary intracranial HPCs were included. The clinical data, conventional MR findings (n=7), DWI features (n=7) and MR spectroscopy (n=5) were retrospectively analyzed. ADC values of the HPCs (n=7) were measured on ADC map and were compared with that of contralateral normal white matter. RESULTS: Of the seven HPCs, four were anaplastic HPCs (WHO grade III) and three were HPCs (WHO grade II). MR pattern consisted in lobulated or irregular margin tumors in all cases with cross-leaf growth on both side of the falx in two cases. The lesions showed mainly iso signal (n=4) on T1 WI and heterogeneous high signal (n=5) on T2 WI. Heterogenity was mainly related to intra tumoral hemorrhage (n=4), and proeminent intratumoral flow voids (n=3). Marked heterogeneous enhancement (n=5) with dural tail (n=4) was noted. All tumours showed significant peritumoral edema. ADC values of the tumor tissue component range between 0.638 and 1.50×10(-3)mm/s(2) (average = 1,02). Three grade II HPCs showed higher values compared to normal parenchyma ADC (range between 0.772 and 0.930×10(-3)mm/s(2) with average of 0.830), whereas grade III HPCs showed either equal (three cases) or decreased ADC values (one case). MRS showed in all cases markedly increased Cho with lip/lac peak, decreased Cr and almost absent NAA. High mI peak with large glutamine/glutamate were noted in the three grade II HPCs. CONCLUSION: Conventional MR pattern when combined with DWI and MRS findings are highly suggestive of HPC and appear valuable data to differentiate HPCs from meningiomas.

[Update on the management of desmoids tumors]. / Mise à jour sur la prise en charge des tumeurs desmoïdes.

Desmoids tumors are rare fibrous tumors of soft tissue. These tumors are located in the abdominal wall, abdomen or extra abdominal. Parietal location is very common among pregnant women and in postpartum period. Hormonal factors are implicated as well. Starting from the observation of 30-year-old patient, in whom a soft tissue mass in the abdominal wall was discovered in the post-partum period, we then emphasize the potential role of cross sectional imaging (ultrasound, CT and especially MRI) in the diagnostic approach, which was confirmed by postoperative pathological examination.

Diagnostic concordance of DSM-III-R, DSM-IV, and ICD-10 inhalant use disorders.

The diagnostic concordance of DSM-III-R, DSM-IV, and ICD-10 inhalant use disorders was assessed using the sample of lifetime inhalant users (n=76) participating in the DSM-IV Field Trial for Substance Use Disorders. Substantially smaller proportions of lifetime inhalant users met DSM-IV inhalant abuse or dependence criteria than met comparable DSM-III-R or ICD-10 criteria. DSM-III-R and ICD-10 performed similarly, although DSM-III-R tended to be more inclusive vis-à-vis diagnoses of inhalant dependence. Kappa coefficients indicated a moderate degree of concordance between the three nosologies for inhalant use disorder diagnosis rates. Inclusion of possible withdrawal symptomatology criteria (that are not normally included) in the DSM-IV and ICD-10 criteria sets for inhalant dependence exerted little effect on diagnosis rates.

Substance dependence and other psychiatric disorders among drug dependent subjects: race and gender correlates.

Persons in drug treatment with drug dependence were interviewed with the NIMH Diagnostic Interview Schedule to ascertain DSM-III-R disorders. Lifetime prevalence rates were 64% for alcohol dependence, 44% for antisocial personality disorder (ASPD), 39% for phobic disorders, 24% for major depression, 12% for dysthymia, 10% for generalized anxiety disorder, 3% for panic disorder, 3% for mania, 3% for obsessive compulsive disorder, 2% for bulimia, 1% for schizophrenia, and 1% for anorexia. When stratified by race and age, significant main effects were seen, but there were no significant interactions except in "any non-substance disorder" and in the mean number of non-substance use disorders. Caucasians had a higher mean number of drug dependence disorders and higher overall rates of "any other" disorder than African-Americans, and Caucasians and males had higher mean numbers of non-substance use disorders than African-Americans and females, respectively. This was related to rates of alcohol, cannabis, and hallucinogen dependence, and ASPD rates that were higher among men than women and higher among Caucasian respondents than African-American for alcohol, cannabis, hallucinogen, opiate and sedative dependence, major depression, dysthymia, and generalized anxiety disorder. In contrast, women had higher rates than men of amphetamine dependence, phobic disorder, major depression, dysthymia, panic disorder, obsessive compulsive disorder, and mania. African-Americans had higher rates than Caucasians of amphetamine, cocaine, and phencyclidine dependence, but for no comorbid disorders were the rates higher among African-Americans than Caucasians. The differences according to gender in rates of disorders among substance dependent persons are consistent with the results of general population surveys, but the differences in rates according to race are in contrast to these same community surveys. Limitations in the utility of the concept of race as a valid category diminish the generalizability of the findings; however, one possible explanation is differential treatment seeking in African-American and Caucasian populations that would result in the differences seen.

Psychiatric disorders among drug dependent subjects: are they primary or secondary?

The relationship between substance use disorders and comorbid psychiatric conditions was investigated among 425 persons in drug treatment who met DSM-III-R criteria for drug dependence. Using the NIMH Diagnostic Interview Schedule to ascertain DSM-III-R psychiatric disorders among these drug dependent subjects, lifetime prevalence rates were 64% for alcohol abuse/dependence, 44% for antisocial personality disorder, 39% for phobic disorders, 24% for major depression, 12% for dysthymia, and 10% for generalized anxiety disorder. We found that antisocial personality disorder and phobias generally had onsets prior to the onset of drug dependence (that is, they were primary disorders). The majority of drug dependent persons with generalized anxiety disorder reported an onset after the onset of drug dependence (that is, they had secondary generalized anxiety). Alcohol dependence, depression, and dysthymia were divided nearly evenly between earlier (primary disorder) and later (secondary disorder). These results are consistent with the body of literature indicating the importance of antisocial syndromes in the etiology of substance abuse and the literature indicating the complex, varying nature of the relationship of psychiatric disorders to substance dependence. Finally, a precise nomenclature for "age of onset," "primary," and "secondary" was developed for this study that is critical to understanding these issues and is recommended for other studies.

The effects of psychiatric comorbidity on response to an HIV prevention intervention.

Drug abusers with psychiatric comorbidity are at high risk for becoming exposed to HIV. To address this compelling public health issue, our randomized HIV prevention study compares the effectiveness of the NIDA standard HIV testing and counseling protocol to a four session, peer-delivered, educational intervention for out-of-treatment cocaine users with and without antisocial personality disorder (ASPD) and major depression. Among the 966 out-of-treatment cocaine users who have completed the 3 month follow-up, all groups, regardless of assignment to standard vs. peer-delivered intervention or psychiatric status, improved significantly in: crack cocaine use, injection drug use, number of IDU sex partners and overall number of sex partners, but not in condom use. Nevertheless, when stratified by psychiatric status, ASPD was associated with significantly less improvement in crack cocaine use (P = 0.04) and with a trend for less improvement in having multiple sex partners and having IDU sex partners (P = 0.06 and 0.08, respectively). ASPD status was not associated with change in injection drug use or condom use. Depression was associated with a trend (P = 0.07) for greater improvement in crack cocaine use but not in any of the other behaviors. When examining the standard and peer intervention groups separately, no consistent differences in the association of psychiatric comorbidity with outcome were discerned between the two groups. We conclude that persons with ASPD and depression respond well to standard HIV prevention interventions, but these psychiatric disorders respectively attenuate and enhance response somewhat. Behavioral interventions tailored for persons with these conditions may be indicated if long-term change in HIV risk behaviors is to be achieved.

Problem gambling and comorbid psychiatric and substance use disorders among drug users recruited from drug treatment and community settings.

Little is known about gambling rates of drug users recruited from drug treatment compared with those recruited from the community. We use the Diagnostic Interview Schedule (DIS) to provide lifetime prevalence estimates of problem gambling (i.e., at least one gambling problem) and DSM-III-R pathological gambling (i.e., at least four gambling problems) and describe the association between gambling and psychiatric disorders for drug users recruited from drug treatment settings (n = 512) and from the community (n = 478). We also report the relative risk of being a recreational and problem gambler in this sample. The sample was first interviewed in 1989-90 as a part of two NIDA-funded St. Louis-based studies. The prevalence of problem gambling in the overall sample was 22% and the prevalence of pathological gambling was 11%. There were no statistically significant differences in problem and pathological gambling rates for subjects recruited from drug treatment and those recruited from the community. The conditional prevalence rates, that is, the rate of problem and pathological gambling only among gamblers were 27% and 13.5%, respectively. Major findings indicate that problem gambling was associated with Antisocial Personality Disorder (ASPD), even after controlling for recruitment source and socio-demographic characteristics. In fact, when examining the temporal order of these disorders, we found that pathological gambling was always secondary to ASPD, occurring on average 11.4 years after the onset of ASPD. Problem gamblers, compared with everyone else, were more likely to be male, African-American, recruited from drug treatment, have ASPD and be dependent on illicit drugs. Multinomial logistic regression analysis predicted the relative risk of being a recreational and problem gambler (compared with a nongambler) in this sample according to socio-demographics, ASPD, and dependence on illicit drugs. Results imply that screening for gambling problems will need to be broad-based among drug users.

Peer-delivered interventions reduce HIV risk behaviors among out-of-treatment drug abusers.

OBJECTIVE: The purpose of this chapter is to describe the results of a randomized study (funded by the National Institute on Drug Abuse [NIDA]) comparing a peer-delivered enhanced intervention to the NIDA standard intervention for reducing human immunodeficiency virus (HIV) risk behaviors. METHODS: Data come from the ongoing St. Louis Each One Teach One (EOTO) study on HIV risk behaviors among out-of-treatment crack cocaine users and injecting drug users (IDUs). The study has a randomized prospective design, and for this chapter, three risk behaviors were analyzed--the frequency of crack cocaine use and the number of sex partners and condom use over the past 30-day period. We report the level of risk at baseline and at the three-month follow-up period to determine the proportion of individuals improving or worsening based on a dichotomous outcome in which remaining at low risk or decreasing moderate or high risk behaviors is considered "improving" and increasing risk behavior or remaining at moderate or high risk is considered "worsening". RESULTS: Overall, 80% of the sample "improved" their crack cocaine use, meaning they maintained at low level or reduced their use. Although both the standard and enhanced intervention groups made substantial improvement in their crack cocaine use, individuals in the enhanced intervention group were statistically more likely to reduce their risk than those assigned to the standard intervention (83% vs. 75%, P < 0.05). As for the number of sex partners, 75% of the overall sample improved; that is, they reduced the number of sex partners or remained abstinent or in a one-partner relationship at baseline and follow-up. There was no statistically significant difference between the enhanced and standard groups (76% vs 73%). Stratified by gender, the results showed a trend toward improvement among women assigned to the enhanced intervention compared with those assigned to the standard. In terms of condom use, the overall sample worsened more than it improved (65% vs. 44%), and no differences were found between the enhanced and standard groups. CONCLUSIONS: These findings show that the use of peers as role models in promoting HIV risk reduction is feasible and effective among out-of-treatment drug abusers, particularly for drug use itself. Condom use was found to be more difficult to change than other behaviors. Possible reasons for this lack of improvement and suggestions for future interventions are given.

Effectiveness of HIV risk reduction initiatives among out-of-treatment non-injection drug users.

While attention has been paid recently to the effectiveness of HIV/AIDS interventions among injection drug users, less focus has been given to out-of-treatment noninjecting drug users. This study examines the the NIDA Cooperative Agreement standard intervention versus an enhanced intervention for HIV/AIDS risk among noninjecting drug users. Data come from five sites of the NIDA-funded Cooperative Agreement on HIV risk behaviors. The sample is comprised of those who never injected drugs or reported not injecting in the 12 months prior to the interview; and who completed a three-month follow-up assessment. Three risk behaviors in the prior 30 days were analyzed: frequency of crack/cocaine use, number of sex partners, and frequency of condom use. The levels of both baseline and follow-up risk were analyzed. Individuals remaining at low risk or decreasing risk behaviors were classified as "improved." Those increasing risk behavior or remaining at moderate or high levels were classified as "worsened." Of the 1,434 noninjecting crack/cocaine users, 82% improved crack/cocaine use at the follow-up. The enhanced intervention group showed more improvement in crack/cocaine use than the standard intervention group. Overall, 76% reported reducing sexual partners, maintaining a one-partner relationship, or abstaining from sex at both time periods. Women in the enhanced intervention group improved more than women in the standard intervention (81% versus 75%). In terms of condom use, more respondents worsened than improved (55% versus 45%). This study confirms that HIV/AIDS interventions can reduce crack/cocaine use; however, high-risk sexual behaviors are more difficult to change. Reasons for this lack of improvement and suggestions for future interventions are discussed.

Reliability of self-reported antisocial personality disorder symptoms among substance abusers.

It is estimated that from 20 to 60% of substance abusers meet criteria for Antisocial Personality Disorder (APD). An accurate and reliable diagnosis is important because persons meeting criteria for APD, by the nature of their disorder, are less likely to change behaviors and more likely to relapse to both substance abuse and high risk behaviors. To understand more about the reliability of the disorder and symptoms of APD, the Diagnostic Interview Schedule Version III-R (DIS) was administered to 453 substance abusers ascertained from treatment programs and from the general population (St Louis Epidemiological Catchment Area (ECA) follow-up study). Estimates of the 1 week, test-retest reliability for the childhood conduct disorder criterion, the adult antisocial behavior criterion, and APD diagnosis fell in the good agreement range, as measured by kappa. The internal consistency of these DIS symptoms was adequate to acceptable. Individual DIS criteria designed to measure childhood conduct disorder ranged from fair to good for most items; reliability was slightly higher for the adult antisocial behavior symptom items. Finally, self-reported 'liars' were no more unreliable in their reports of their behaviors than 'non-liars'.

Cocaine users with antisocial personality improve HIV risk behaviors as much as those without antisocial personality.

Previous work has documented that antisocial personality disorder (APD) is associated with increased rates of HIV risk behaviors and with worse substance abuse treatment outcomes. The question addressed by this paper is whether cocaine users with APD respond to an HIV risk-reduction intervention as well as cocaine users without the disorder. The study subjects were 333 cocaine users followed up at 18 months as part of a NIDA-funded treatment demonstration project. The total sample improved across a wide range of HIV risk behaviors. Improving significantly (P < 0.05) from baseline to the 18-month follow-up were several drug-related behaviors: cocaine use; current cocaine dependence; use of drugs other than cocaine drug injection; injection equipment sharing; and use of syringes that were not cleaned. Several sex-related HIV risk behaviors also improved significantly: having multiple sex partners; being intoxicated during sex; giving drugs for sex; receiving money for sex; and receiving drugs for sex. When the sample was stratified by APD status, very similar improvement was seen in respondents with and without APD. To examine further the relationship of APD to change in HIV risk behaviors, separate logistic regression models of improving and worsening HIV risk behaviors were tested. What the authors found was no association of APD with improvement in HIV risk behaviors but a significant association of APD with worsening HIV risk behaviors. It appears that cocaine users with APD improve their HIV risk behaviors just as much as those without APD but may be at higher HIV risk for the development of such behaviors.

Achieving a 96.6 percent follow-up rate in a longitudinal study of drug abusers.

Longitudinal studies can be hampered by poor follow-up rates, seriously reducing generalizability of the findings. Understanding the barriers, as well as approaches to overcome and adapt to these impediments, resulted in a 96.6% 18 month follow-up rate of 479 drug abusers enrolled in an NIDA funded demonstration project aimed at reducing HIV transmission among St. Louis' most vulnerable drug-using population. In this paper, we discuss the importance of phone and systems tracking, creative team work and persistence and procedures for tracking out-of-treatment drug-users by analyzing the efforts needed to reach the study subjects. We also compared the characteristics of hard-to-reach respondents with those who were less difficult. The results revealed that employment status was the only characteristic associated with being hard-to-reach. Gender, race, age, education and psychiatric status did not discriminate recruitment difficulty in this sample. The study findings suggest that although unemployment predicted recruitment difficulty, and that the locator information provided by the respondent can be very helpful, a comprehensive tracking strategy as well as persistence and creative team work are the most important determinants of the rate of success of a follow-up investigation.

Aluminas with dispersoids. Tribologic properties and in vivo aging.

Three base alumina ceramics with dispersoids: monoclinic zirconia alumina (A5Z), tetragonal zirconia alumina (A20Z) and aluminalon (Aa20) have been investigated because of their improved mechanical properties with reference to pure alumina (AI203). Bending strength and fracture toughness are twice higher than alumina for the most toughened. These two parameters were measured by four-points bending tests after 1 week, 1, 2, 3, 6, 12 months of non loaded in vivo aging in wistar rats. They showed a little decrease for AI203 and Aa20 and a total stability for A5Z and A20Z even after one year. For tribologic study of the ceramic/polyethylene combination, cylinder against plane and pin on flat tests were conducted on an alternative movement with hip parameters of speed and load in presence of ringer solution. For the most representative test (pin on disk), the friction coefficients were nearly the same for all materials but UHMWPE wear volume was twice lower against A20Z than against AI203. A20Z/UHMWPE combination would be very interesting as new friction couple for total hip arthroplasty. Further studies are currently conducted.