Symptom dimensions of anxiety following myocardial infarction: associations with depressive symptoms and prognosis.

OBJECTIVE: Differential associations of symptom dimensions with prognosis in myocardial infarction (MI) patients have been shown for depression, but no studies have focused on anxiety dimensions. The aim of this study was to assess the association between somatic and psychological symptoms of anxiety following acute MI with adverse prognosis and to assess the overlap between anxiety and depression dimensions. METHOD: Patients (n = 418) were assessed on demographic and clinical variables. The Hamilton Anxiety and Depression Rating Scales were used to measure anxiety and depression 2 months post-MI. Mean follow-up period was 3.8 years and the endpoint consisted of all-cause mortality and recurrent MI. RESULTS: After adjustment for demographic and clinical variables, somatic anxiety was significantly associated with recurrent MI and mortality (HR: 1.32; 95% CI [1.03, 1.69]; p = .03), and a trend was shown for an association between psychological anxiety and outcome (HR: 1.29; 95% CI [0.99, 1.67]; p = .06). The total anxiety score of the HARS was the strongest predictor of recurrent MI and mortality (HR: 1.38; 95% CI [1.07, 1.78]; p = .02). The HARS and the HDRS were highly correlated (r = .86; p < .01). Dimensions consisting of psychological distress (HR: 1.29; 95% CI [1.02, 1.63]; p = .03) and cardiopulmonary/autonomic symptoms (HR: 1.36; 95% CI [1.06, 1.75]; p = .02) also predicted outcome in adjusted analyses. CONCLUSIONS: Anxiety was associated with adverse prognosis in MI patients with significant associations for somatic anxiety and total anxiety. When combining anxiety and depression items, psychological distress and cardiopulmonary/autonomic symptoms predicted recurrent MI and mortality. Future research might better focus on dimensions of anxiety and depression simultaneously in MI patients.

Changes in cognitive versus somatic symptoms of depression and event-free survival following acute myocardial infarction in the Enhancing Recovery In Coronary Heart Disease (ENRICHD) study.

BACKGROUND: Randomized controlled trials focusing on the effects of antidepressant treatment in cardiac patients have found modest effects on depressive symptoms but not on cardiac outcomes. A secondary analysis was conducted on data from the Enhancing Recovery in Coronary Heart Disease trial to assess whether changes in somatic or cognitive depressive symptoms following acute MI predicted event-free survival and whether the results differed per treatment arm (cognitive behavior therapy or care as usual). METHODS: Patients who met depression criteria and completed the 6th month depression assessment (n=1254) were included in this study. Measurements included demographic and clinical data and the Beck Depression Inventory at baseline and 6 months. The primary endpoint was a composite of recurrent MI and mortality over 2.4 years (standard deviation=0.9 years). RESULTS: Positive changes (per 1 point increase) in somatic depressive symptoms (HR: 0.95; 95% CI: 0.92-0.98; p=0.001) but not in cognitive depressive symptoms (HR: 0.98; 95% CI: 0.96-1.01; p=0.19) were related to a reduced risk of recurrent MI and mortality after adjustment for baseline depression scores. There was a trend for an interaction effect between changes in somatic depressive symptoms and the intervention (p=0.08). After controlling for demographic and clinical variables, the association between changes in somatic depressive symptoms and event-free survival remained significant in the intervention arm (HR: 0.93; 95% CI: 0.88-0.98; p=0.01) only. LIMITATIONS: Secondary analyses. CONCLUSIONS: Changes in somatic depressive symptoms, and not cognitive symptoms, were related to improved outcomes in the intervention arm, independent of demographic and clinical variables.

Type D personality, depressive symptoms and work-related health outcomes.

AIMS: Personality may play a decisive role in perceiving work-related characteristics as stressful, leading to adverse health outcomes. Persons with a Distressed personality (Type D) experience increased negative emotions while inhibiting these emotions in social situations. We investigated the role of Type D personality on adverse health outcomes, sick leave, burnout and disability pension. The mediating role of depressive symptoms on this relation was assessed because Type D represents a vulnerability factor for depression. METHODS: In a cross-sectional community sample of the Dutch population (n = 1,172) Type D personality was related to sick-leave (five categories of days per year), burnout, and disability pension, controlling for confounders. RESULTS: Individuals with Type D personality reported more burnout (27% vs 8%), disability pension (32% vs 11%), and had an increased incidence of short-term sick leave (χ(2 )= 13.1, p = 0.011) as compared to non-Type D's. Type D was significantly related to burnout (odds ratio (OR) = 4.16) and disability pension (OR = 2.62) independent of confounders. The Sobel test indicated significant mediation of depression on the relation between Type D personality and the work-related health outcomes. After mediation Type D personality remained significantly related to burnout, indicating a unique unshared effect. CONCLUSIONS: Type D personality is related to adverse health outcomes in the working population, mediated by depression, which warrants further research for this personality type.

Depression predicts elevated endothelin-1 in patients with coronary artery disease.

OBJECTIVE: To examine the relationship of depression severity to circulating endothelin-1 (ET-1), which has previously been linked to plaque rupture and postacute coronary syndrome (ACS) survival. Depression carries an independent two- to four-fold increased risk of early morbidity and mortality after ACS. The pathway(s) linking depression to event-free survival remains to be determined. METHODS: Patients with documented history of coronary artery disease (n = 101) provided a resting morning blood sample that was assayed for ET-1, and they completed the Beck Depression Inventory (BDI). ET-1 was treated as a log-transformed continuous variable (logET-1), and as a dichotomous variable using a post-ACS risk threshold previously reported (≥1.16 fmol/mL). RESULTS: BDI score was related to logET-1 in both unadjusted and adjusted models. In addition, unadjusted and adjusted logistic regression models with dichotomous ET-1 revealed that, for each point increase in BDI score, there was approximately a 14% increased likelihood of being at or above ET-1 risk threshold. Secondary logistic regression models demonstrated a >3.5-fold likelihood of being at or above this risk threshold in association with a BDI score of ≥10. CONCLUSIONS: Depression symptom severity predicts ET-1 elevation that has previously been linked to post-ACS survival, with the greatest risk of elevation among those patients with worse depression symptoms. This link may identify a vulnerability to triggered ACS and poorer survival associated with depression. Future research should establish whether the observed relationship of depressive symptoms to ET-1 level mediates the link between depression and survival.

Effect of storage time of transfused plasma on early and late mortality after coronary artery bypass grafting.

OBJECTIVES: Because some concern has been raised about the storage time of red blood cells and outcomes after cardiac surgery, we investigated whether longer storage time of transfused plasma increases the risk for early or late mortality among patients who have undergone coronary artery bypass grafting. METHODS: We retrospectively analyzed the data of all 10,626 patients who underwent isolated coronary artery bypass grafting in Catharina Hospital, Eindhoven, The Netherlands, between January 1998 and December 2007. All patients who received at least 1 unit of plasma intraoperatively or during the first 5 postoperative days were studied. They were divided into 3 groups (only younger plasma, only older plasma, and any older plasma groups) according to the storage time of the plasma (cutoff point, 323 days). RESULTS: After we had excluded 122 patients who were unavailable for follow-up, we found that 375 of the remaining patients (n = 745) received only younger plasma 370 patients received any older plasma, and 200 patients received only older plasma (mean follow-up, 1565 ± 1137 days; median follow-up, 1629 days). The storage time of plasma, when entered as either a continuous variable or a dichotomous variable, was a risk factor for early but not late mortality. Log-rank testing revealed no statistical difference in long-term survival among the groups. CONCLUSIONS: Longer storage time of plasma is a risk factor for early but not late mortality among patients who have undergone coronary artery bypass grafting.

Preoperative prediction of early mortality in patients with low ejection fraction undergoing coronary artery bypass grafting.

BACKGROUND AND AIM OF THE STUDY: Patients with low ejection fraction (EF) undergoing coronary artery bypass grafting (CABG) usually have a higher incidence of mortality and morbidity. In this retrospective study, we sought to detect significant preoperative predictors of early mortality in these patients. METHODS: Patients with an EF of ≤ 30% who underwent isolated CABG in Catharina Hospital, Eindhoven, the Netherlands, between January 1998 and December 2008 (n = 413) were included in this study. All the preoperative patient-related risk factors were entered into a logistic regression analysis model to detect the significant predictors of early mortality. RESULTS: Patients with an EF of ≤ 30% represent 4.1% of the whole CABG population. The overall early mortality in this patient group was 9.1%. Risk factors for early mortality as identified by the univariate analysis were age, chronic obstructive pulmonary disease (COPD), prior CABG, New York Heart association (NYHA) class, emergency operation, preoperative serum creatinine (SeCr), and preoperative hemoglobin (Hb) level. These factors were entered into the multivariate analysis and were all identified as independent risk factors for early mortality. CONCLUSIONS: This study confirmed the impact of some well-known preoperative risk factors on early outcome in patients with low EF undergoing CABG. In addition, we have shown the predictive value of preoperative SeCr and hemoglobin level that have not yet been described.

Effect of duration of red blood cell storage on early and late mortality after coronary artery bypass grafting.

OBJECTIVES: Recently, concern has been expressed about the transfusion of older red blood cells after cardiac surgery. We tested the hypothesis that longer storage of transfused red blood cells increases the risk of early and late mortality in patients who undergo coronary artery bypass grafting. METHODS: We retrospectively analyzed data of patients who underwent isolated coronary artery bypass grafting between January 1998 and December 2007 in Catharina Hospital, Eindhoven, The Netherlands, and received up to 10 U of red blood cells intraoperatively or during the first 5 postoperative days. The patients were divided into 3 groups according to the storage time of the red blood cells, with a cutoff point of 14 days, as follows: "only younger blood" (n = 1422), "only older blood" (n = 1719), and at least 1 U of older RBCs ("any older blood"; n = 2175). RESULTS: The mean follow-up time was 1693 ± 1058 days (range, 0-3708 days). The median follow-up time was 1629 days. Univariate and multivariate logistic regression analyses revealed that the number of transfused units but not the storage time of blood entered either as a continuous variable or as a dichotomous variable with a cutoff point of 14 days was a risk factor for early mortality. Neither the number of transfused units nor the storage time was an independent risk factor for late mortality. Log-rank testing revealed no statistical difference in survival among the groups. CONCLUSIONS: The storage time of transfused red blood cells is not a risk factor for early or late mortality in patients who undergo coronary artery bypass grafting.

Differential associations between specific depressive symptoms and cardiovascular prognosis in patients with stable coronary heart disease.

OBJECTIVES: The purpose of this research was to evaluate the relationship between cognitive and somatic depressive symptoms and cardiovascular prognosis. BACKGROUND: Depression in patients with stable coronary heart disease (CHD) is associated with poor cardiac prognosis. Whether certain depressive symptoms are more cardiotoxic than others is unknown. METHODS: In the Heart and Soul Study, 1,019 patients with stable CHD were assessed using the Patient Health Questionnaire to determine the presence of the 9 depressive symptoms included in the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition. The mean age of the patients was 67 years, and 82% were men. A comparison was made on a new cardiovascular event (myocardial infarction, stroke, transient ischemic attack, or congestive heart failure) or death (mean follow-up duration 6.1 +/- 2.0 years) on the basis of cognitive and somatic sum scores and for patients with or without each of those specific depressive symptoms. Demographic characteristics, cardiac risk factors, and cardiac medications were controlled for. RESULTS: After adjustment for demographic data and cardiac risk factors, each somatic symptom was associated with 14% greater risk for events (hazard ratio [HR]: 1.14; 95% confidence interval [CI]: 1.05 to 1.24; p = 0.002). Fatigue (HR: 1.34; 95% CI: 1.07 to 1.67; p = 0.01), appetite problems (HR: 1.46; 95% CI: 1.12 to 1.91; p = 0.005), and sleeping difficulties (HR: 1.26; 95% CI: 1.00 to 1.58; p = 0.05) were most strongly predictive of cardiovascular events. In contrast, cognitive symptoms (HR: 1.08; 95% CI: 0.99 to 1.17; p = 0.09) were not significantly associated with cardiovascular events. CONCLUSIONS: In patients with stable CHD, somatic symptoms of depression were more strongly predictive of cardiovascular events than cognitive symptoms, although the CIs surrounding these estimates had substantial overlap. These findings are highly consistent with those of previous studies. Further research is needed to understand the pathophysiological processes by which somatic depressive symptoms contribute to prognosis in patients with CHD.

The impact of new-onset postoperative atrial fibrillation on mortality after coronary artery bypass grafting.

BACKGROUND: New-onset postoperative atrial fibrillation (POAF) is a frequent rhythm disturbance after coronary artery bypass grafting (CABG). This study investigated the independent effect of POAF on early and late mortality after isolated CABG. METHODS: Data of patients who consecutively underwent isolated CABG between January 2003 and December 2007 were prospectively collected. The analysis included 5098 patients with preoperative sinus rhythm and no history of atrial fibrillation. Logistic regression analysis for early mortality and Cox regression analysis for late mortality were performed. Propensity score matching was performed to eliminate the effect of confounders. RESULTS: Median follow-up was 2.5 years. POAF was documented in 1122 patients (22.0%). Early mortality was more frequent in POAF patients (3.1%) vs non-POAF patients (1.6%, p = 0.002), but multivariate logistic regression analysis could not identify POAF as an independent predictor of early mortality (p = 0.169). This outcome did not change after adjusting for quintiles of the propensity score of POAF (p = 0.100). Multivariate Cox proportional hazard analyses demonstrated POAF was an independent predictor of overall and late mortality with hazard ratios of 1.35 (p = 0.012 and p = 0.039, respectively). Analyses after propensity score matching showed that patients with POAF had similar hazard ratios of 1.36 for overall mortality and 1.34 for late mortality (p = 0.009 and p = 0.042, respectively). CONCLUSIONS: POAF is an independent predictor of overall and late mortality after isolated CABG but not of early mortality.

Anxiety and risk of incident coronary heart disease: a meta-analysis.

OBJECTIVES: The purpose of this study was to assess the association between anxiety and risk of coronary heart disease (CHD). BACKGROUND: Less research has focused on the association of anxiety with incident CHD in contrast to other negative emotions, such as depression. METHODS: A meta-analysis of references derived from PubMed, EMBASE, and PsycINFO (1980 to May 2009) was performed without language restrictions. End points were cardiac death, myocardial infarction (MI), and cardiac events. The authors selected prospective studies of (nonpsychiatric) cohorts of initially healthy persons in which anxiety was assessed at baseline. RESULTS: Twenty studies reporting on incident CHD comprised 249,846 persons with a mean follow-up period of 11.2 years. Anxious persons were at risk of CHD (hazard ratio [HR] random: 1.26; 95% confidence interval [CI]: 1.15 to 1.38; p < 0.0001) and cardiac death (HR: 1.48; 95% CI: 1.14 to 1.92; p = 0.003), independent of demographic variables, biological risk factors, and health behaviors. There was a nonsignificant trend for an association between anxiety and nonfatal MI (HR: 1.43; 95% CI: 0.85 to 2.40; p = 0.180). Subgroup analyses did not show any significant differences regarding study characteristics, with significant associations for different types of anxiety, short- and long-term follow-up, and both men and women. CONCLUSIONS: Anxiety seemed to be an independent risk factor for incident CHD and cardiac mortality. Future research should examine the association between anxiety and CHD with valid and reliable anxiety measures and focus on the mechanisms through which anxiety might affect CHD.

Scared to death? Generalized anxiety disorder and cardiovascular events in patients with stable coronary heart disease:The Heart and Soul Study.

CONTEXT: Anxiety is common in patients with coronary heart disease (CHD), but studies examining the effect of anxiety on cardiovascular prognosis and the role of potential mediators have yielded inconsistent results. OBJECTIVES: To evaluate the effect of generalized anxiety disorder (GAD) on subsequent cardiovascular events and the extent to which this association is explained by cardiac disease severity and potential behavioral or biological mediators. DESIGN: Prospective cohort study (Heart and Soul Study). SETTING: Participants were recruited between September 11, 2000, and December 20, 2002, from 12 outpatient clinics in the San Francisco Bay Area and were followed up until March 18, 2009. PARTICIPANTS: One thousand fifteen outpatients with stable CHD followed up for a mean (SD) of 5.6 (1.8) years. MAIN OUTCOME MEASURES: We determined the presence of GAD using the Diagnostic Interview Schedule. Proportional hazards models were used to evaluate the association of GAD with subsequent cardiovascular events and the extent to which this association was explained by potential confounders and mediators. RESULTS: A total of 371 cardiovascular events occurred during 5711 person-years of follow-up. The age-adjusted annual rate of cardiovascular events was 9.6% in the 106 participants with GAD and 6.6% in the 909 participants without GAD (P = .03). After adjustment for demographic characteristics, comorbid conditions (including major depressive disorder), cardiac disease severity, and medication use, GAD remained associated with a 62% higher rate of cardiovascular events (hazard ratio, 1.62; 95% confidence interval, 1.11-2.37; P = .01). Additional adjustment for a variety of potential behavioral and biological mediators had little effect on this association (hazard ratio, 1.74; 95% confidence interval, 1.13-2.67; P = .01). CONCLUSIONS: In outpatients with CHD, a robust association between GAD and cardiovascular events was found that could not be explained by disease severity, health behaviors, or biological mediators. How GAD leads to poor cardiovascular outcomes deserves further study.

Thrombocytopenia after aortic valve replacement: comparison between mechanical and biological valves.

BACKGROUND AND AIM OF THE STUDY: Concerns have been recently raised regarding the postoperative decrease in platelet count after aortic valve replacement (AVR). Thus, a retrospective analysis was conducted of patients after AVR with regards to postoperative platelet count. METHODS: The data were analyzed from all patients undergoing AVR with (n = 829) or without (n = 1,230) coronary artery bypass grafting (CABG) at a single center between January 1998 and May 2009. The lowest (minimum) platelet count within the first five postoperative days was determined. RESULTS: The patients received either an ATS mechanical prosthesis (ATS; n = 401), a St. Jude Medical mechanical prosthesis (SJM; n = 791), a Carpentier-Edwards Perimount bioprosthesis (CEP; n = 618), a Medtronic Freestyle stentless bioprosthesis (FRE; n = 213), or a Sorin Freedom Solo stentless bioprosthesis (SFS; n = 36). By using a multivariate linear regression model, the following independent risk factors for a lower postoperative platelet count were revealed: age, body surface area, active endocarditis, preoperative platelet count, duration of extracorporeal circulation, number of grafts, valve size, and units of transfused fresh-frozen plasma and red blood cells. On entering the type of prosthesis into the multivariate linear regression analysis, together with the other risk factors, patients with CEP and FRE valve prostheses had a lower minimum postoperative platelet count than those with mechanical prostheses (ATS and SJM). CONCLUSION: Patients undergoing AVR with the Carpentier-Edwards Perimount bioprosthesis or a Medtronic Freestyle stentless bioprosthesis had a lower minimum platelet count within the first five postoperative days, compared to patients receiving ATS and St. Jude Medical mechanical prostheses. No differences were identified between the Sorin Freedom Solo and all other valve prostheses.

Preoperative ejection fraction as a predictor of survival after coronary artery bypass grafting: comparison with a matched general population.

BACKGROUND: Preoperative left ventricular dysfunction is an established risk factor for early and late mortality after revascularization. This retrospective analysis demonstrates the effects of preoperative ejection fraction on the short-term and long-term survival of patients after coronary artery bypass grafting. METHODS: Early and late mortality were determined retrospectively in 10 626 consecutive patients who underwent isolated coronary bypass between January 1998 and December 2007. The subjects were divided into 3 groups according to their preoperative ejection fraction. Expected survival was estimated by comparison with a general Dutch population group described in the database of the Dutch Central Bureau for Statistics. For each of our groups with a known preoperative ejection fraction, a general Dutch population group was matched for age, sex, and year of operation. RESULTS AND DISCUSSION: One hundred twenty-two patients were lost to follow-up. In 219 patients, the preoperative ejection fraction could not be retrieved. In the remaining patients (n = 10 285), the results of multivariate logistic regression and Cox regression analysis identified the ejection fraction as a predictor of early and late mortality. When we compared long-term survival and expected survival, we found a relatively poorer outcome in all subjects with an ejection fraction of < 50%. In subjects with a preoperative ejection fraction of > 50%, long-term survival exceeded expected survival. CONCLUSIONS: The severity of left ventricular dysfunction was associated with poor survival. Compared with the survival of the matched general population, our coronary bypass patients had a worse outcome only if their preoperative ejection fraction was < 50%.

Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis.

OBJECTIVE: To assess the association of anxiety after myocardial infarction (MI) with cardiac prognosis. METHODS: A meta-analysis of references derived from MEDLINE, EMBASE, and PSYCINFO (1975-March 2009) was performed without language restrictions. End point was cardiac outcome defined as all-cause mortality, cardiac mortality, and cardiac events. The authors selected prospective studies with at least 6 months follow-up, and anxiety had to be assessed within 3 months after MI with reliable and valid instruments. RESULTS: Twelve papers met selection criteria. These studies described follow-up (on average, 2.6 years) of 5750 patients with MI. Anxious patients were at risk of adverse events (odds ratio (OR) fixed, 1.36; 95% confidence interval (CI), 1.18-1.56; p < .001). Anxiety was also specifically associated with all-cause mortality (OR fixed, 1.47; 95% CI, 1.02-2.13; p = .04), cardiac mortality (OR fixed, 1.23; 95% CI, 1.03-1.47; p = .02), and new cardiac events (OR fixed, 1.71; 95% CI, 1.31-2.23; p < .001). CONCLUSIONS: Post-MI anxiety is associated with a 36% increased risk of adverse cardiac outcomes in bivariate analyses. Because the existing literature is small and contains several limitations, more research is needed to evaluate the association of anxiety and prognosis in patients with MI and to assess the extent to which this association is independent of clinical variables, such as disease severity, and other psychological variables, especially depression.

The impact of preoperative atrial fibrillation on early and late mortality after coronary artery bypass grafting.

OBJECTIVES: There are still doubts on the effect of preoperative atrial fibrillation (AF) on early and late mortality after coronary artery bypass grafting (CABG). This retrospective study demonstrates the effects of preoperative AF on the short-term and long-term survival after CABG. METHODS: We retrospectively analysed the data of 10626 patients who underwent CABG between January 1998 and December 2007. The data of 221 patients with a history of preoperative AF (2.5%) and 8631 patients with preoperative sinus rhythm were eligible for analysis. Survival of these patient groups was compared to survival of age- and sex-matched groups of the Dutch general population. RESULTS: Mean follow-up duration was 4.6 + or - 2.9 years. Multivariate logistic regression analysis showed preoperative AF to be an independent risk factor for early mortality after CABG, with an odds ratio of 2.06 (95% confidence interval (CI): 1.08-3.95; P=0.029). Multivariate Cox proportional hazard analysis revealed that preoperative AF is an independent risk factor for late mortality after CABG, with a hazard ratio (HR) of 1.67 (95% CI: 1.21-2.31; P=0.002). Using propensity score matching, AF was also an independent risk factor for late mortality after CABG, with an HR of 2.77 (95% CI: 1.6-4.79; P<0.001). In comparison with the general Dutch population, patients with preoperative AF who undergo CABG have a worse long-term survival, while patients with preoperative sinus rhythm experience a better survival. CONCLUSIONS: Preoperative AF is an independent risk factor for early and late mortality after first-time elective CABG.

Analysis of pitfalls encountered by residents in transurethral procedures in master-apprentice type of training.

BACKGROUND AND PURPOSE: Today's simulators are frequently limited in their possibilities to train all aspects of endourological procedures. It is therefore indicated to first make an inventory of training needs before (re)developing simulators. This study examined pitfalls encountered by residents in real-time transurethral procedures. MATERIALS AND METHODS: First, difficulties that residents encounter in transurethral procedures (transurethral resection of the bladder tumor [TURBT], transurethral resection of the prostate [TURP], ureterorenoscopy [URS]) were identified by asking urologists and residents to complete an open questionnaire. Based on their answers a list of pitfalls was designed and tested in 28 pilot observations. Then, two raters (interrater agreement 0.72, 0.70, and 0.75 for TURBT, TURP, and URS, respectively) categorized all observed procedure-related interactions between residents and supervisors in 80 procedures as (1) (type of ) pitfall or (2) no pitfall. RESULTS: Pitfalls most frequently encountered were as follows: (1) planning/anticipation on new situations (median 27.3%, 29.3%, and 31.8% of total pitfalls in TURBT, TURP, and URS, respectively); (2) handling of instruments (11.5%, 10.6%, and 20.0% for TURBT, TURP, and URS); (3) irrigation management for TURBT (7.7%), depth of resection for TURP (8.9%), and use of X-ray for URS (13.3%). CONCLUSION: Designers of endourological simulators should include possibilities to train planning/anticipation on new situations, handling of instruments in all transurethral procedures, and irrigation management in TURBT, depth of resection in TURP, and timing usage of X-ray in URS.

Preoperative atrial fibrillation and elevated C-reactive protein levels as predictors of mediastinitis after coronary artery bypass grafting.

BACKGROUND: Mediastinitis is a serious complication after coronary artery bypass grafting (CABG). We studied the risk factors for the development of postoperative mediastinitis in a large group of patients who underwent isolated CABG at Catharina Hospital, Eindhoven, The Netherlands. METHODS: Data of all patients undergoing an isolated CABG between January 1998 and December 2008 were analyzed. Univariate and multivariate logistic regression analyses were performed to investigate the effect of biomedical variables on the development of mediastinitis. Multivariate analyses were used to test for the confounding effect of various risk factors on outcomes. RESULTS: Mediastinitis was present in 100 out of the 11,748 patients. Preoperative atrial fibrillation [odds ratio = 4.26 (2.26 to 8.02)] and an elevated preoperative C-reactive protein level [odds ratio = 1.013 (1.007 to 1.020)] were important independent predictors of the development of mediastinitis. Other significant risk factors were the following: age, chronic obstructive pulmonary disease, diabetes, morbid obesity, use of extracorporeal circulation, use of bilateral internal mammary arteries, reexploration for ischemia, and perioperative myocardial infarction. CONCLUSIONS: Apart from previously described risk factors for the development of postoperative mediastinitis, we found preoperative atrial fibrillation and an elevated C-reactive protein level to be significant predictors of mediastinitis in patients undergoing CABG.

Type D personality predicts clinical events after myocardial infarction, above and beyond disease severity and depression.

OBJECTIVE: To investigate the effect of Type D personality (high negative affectivity and social inhibition) on cardiac death and/or recurrent myocardial infarction (MI) in patients with acute MI, after adjustment for disease severity and depression. To explore the differential effect of Type D on early (< or = 6 months) versus late (> 6 months) events separately. METHOD: Patients hospitalized for acute MI (N = 473) were recruited between May 2003 and May 2006. Patients were assessed on demographic and clinical variables and completed the Type D Personality Scale within the first week of hospital admission for acute MI; depression severity was assessed with the 17-item Hamilton Depression Rating Scale. The mean follow-up period was 1.8 years. RESULTS: There were 44 events attributable to cardiac death (n = 16) or recurrent MI (n = 28), with 26 early and 18 late events. Type D patients were at cumulative increased risk of death/recurrent MI compared with non-Type D patients (16.3% vs 7.8%; P = .012). Cardiac history, left ventricular ejection fraction, and use of statins were predictors of total and late death/recurrent MI, with statins showing a substantial protective effect. In addition, cardiac history and use of statins were significantly associated with early death/recurrent MI. Type D patients had a 2-fold increased risk of total death/recurrent MI after adjustment for disease severity and depression (HR = 2.23; 95% CI, 1.14-4.35; P = .019) and a more than 3-fold increased risk of late death/recurrent MI (HR = 3.57; 95% CI, 1.23-10.30; P = .019). CONCLUSIONS: Type D was a strong predictor of adverse cardiac outcome after acute MI, above and beyond disease severity and depression severity, and the associated risk was similar to that of traditional cardiovascular risk factors. Type D may be an important psychosocial factor to assess in patients post-MI for risk stratification purposes.

Effect of body mass index on early and late mortality after coronary artery bypass grafting.

BACKGROUND: The effect of obesity on the long-term outcome after coronary artery bypass graft surgery (CABG) remains controversial. We analyzed data of patients undergoing CABG in a single center, to determine the predictive value of body mass index in combination with comorbidities on early and late mortality. METHODS: Early and late mortality of consecutive patients undergoing isolated CABG from January 1998 until December 2007 were determined. Patients were classified into five groups according to preoperative body mass index: underweight, normal weight, overweight, obese, and morbidly obese. RESULTS: After excluding 122 patients who were lost to follow-up and 236 patients with missing preoperative body mass index, 10,268 patients were studied. Multivariate logistic regression analyses showed that underweight was associated with higher early mortality (hazard ratio 2.63; 95% confidence interval: 1.13 to 6.11, p = 0.025). Multivariate Cox regression analyses did reveal morbid obesity as an independent predictor of late mortality (hazard ratio 1.67, 95% confidence interval: 1.15 to 2.43, p = 0.007). CONCLUSIONS: Among patients undergoing isolated CABG, underweight is an independent predictor for early mortality, and morbid obesity is an independent predictor for late mortality.