Antidepressant Therapy in Patients Undergoing Coronary Artery Bypass Grafting: The MOTIV-CABG Trial

The effect of escitalopram in treating mild to moderate depressive disorder and improving the quality of life in patients undergoing coronary artery bypass grafting - a double-blind randomized clinical trial

Introduction

Chronic depression and anxiety can be a risk factor for coronary aArtery bypass grafting (CABG) and is an emerging factor after coronary artery disease when the patient is admitted to the hospital and after surgery. We aimed to assess the effect of Escitalopram in treating mild to moderate depressive disorder and improving the quality of life in patients undergoing CABG.

Methods

In this randomized clinical trial, 50 patients undergoing CABG referred to Tehran Heart Hospital from January 2021 to May 2021 and were suffering from mild to moderate depression were randomly assigned to one of the two groups of Escitalopram or placebo. The level of depression was assessed based on Beck's depression inventory and the quality-of-life status and its domains were assessed based on the SF-36 questionnaire in 2 groups. Measurements were obtained at baseline and at four and eight weeks after treatment. Chi-square, Fisher's exact, paired, and Wilcoxon tests or ANOVA were used as appropriate.

Results

There was no significant difference between the level of depression between the two study groups at baseline (P=0.312). There was no significant difference between the quality of life and its domains in the two study groups at baseline (P=0.607). However, the most important effect of Escitalopram was reducing depression scores in the intervention group at weeks 4 and 8 after treatment compared to the placebo group (P<0.001). The quality of life and its domains were significantly higher in the Escitalopram group eight weeks after treatment (P=0.004). The amount of drug side effects at 2 and 4 weeks after treatment had no significant difference between the groups (P>0.05).

Conclusion

Escitalopram was effective in treating mild to moderate depressive disorder and improving quality of life in patients undergoing CABG.

Clinical trial registration

https://irct.behdasht.gov.ir/, identifier IRCT20140126016374N2.

Preoperative psychological symptoms and chronic postsurgical pain: analysis of the prospective China Surgery and Anaesthesia Cohort study

BACKGROUND

Both preoperative psychological symptoms and chronic postsurgical pain (CPSP) are prevalent conditions and major concerns among surgery patients, with inconclusive associations.

METHODS

Based on the China Surgery and Anaesthesia Cohort (CSAC), we recruited 8350 surgery patients (40-65 yr old) from two medical centres between July 2020 and March 2023. Patients with preoperative psychological symptoms (i.e. anxiety, depression, stress reaction, and poor sleep quality) were identified using corresponding well-established scales. We then examined the associations of individual preoperative psychological symptoms and major patterns of preoperative psychological symptoms (identified by k-means clustering analysis) with CPSP, and different pain trajectories within 3 months. Lastly, mediation analyses were conducted to elucidate the mediating role of surgery/anaesthesia-related factors and the presence of 1-month postoperative psychological symptoms on the studied associations.

RESULTS

We included 1302 (1302/8350, 15.6%) CPSP patients. When analysed separately, all studied preoperative psychological symptoms were associated with increased CPSP risk, with the most pronounced odds ratio noted for anxiety (1.52, 95% confidence interval [CI] 1.23-1.86). Compared with patients clustered in the minor symptom group, excess risk of CPSP and experiencing an increasing pain trajectory was increased among patients with preoperative psychological symptoms featured by sleep disturbances (odds ratio=1.46, 95% CI 1.25-1.70 for CPSP and 1.58, 95% CI 1.20-2.08 for increasing pain trajectory) and multiple psychological symptoms (1.84 [95% CI 1.48-2.28] and 4.34 [95% CI 3.20-5.88]). Mediation analyses revealed acute/subacute postsurgical pain and psychological symptoms existing 1 month after surgery as notable mediators of the observed associations.

CONCLUSIONS

The presence of preoperative psychological symptoms might individually or jointly increase the risk of chronic postsurgical pain or experiencing deterioration in pain trajectory. Interventions for managing acute/subacute postsurgical pain and psychological symptoms at 1 month after surgery might help reduce such risk.

CLINICAL TRIAL REGISTRATION

ChiCTR2000034039.

The pathophysiology and management of depression in cardiac surgery patients

Background

Depression is common in the cardiac surgery population. This contemporary narrative review aims to explore the main pathophysiological disturbances underpinning depression specifically within the cardiac surgery population. The common non-pharmacological and pharmacological management strategies used to manage depression within the cardiac surgery patient population are also explored.

Methods

A total of 1291 articles were identified through Ovid Medline and Embase. The findings from 39 studies were included for qualitative analysis in this narrative review.

Results

Depression is associated with several pathophysiological and behavioral factors which increase the likelihood of developing coronary heart disease which may ultimately require surgical intervention. The main pathophysiological factors contributing to depression are well characterized and include autonomic nervous system dysregulation, excessive inflammation and disruption of the hypothalamic-pituitary-adrenal axis. There are also several behavioral factors in depressed patients associated with the development of coronary heart disease including poor diet, insufficient exercise, poor compliance with medications and reduced adherence to cardiac rehabilitation. The common preventative and management modalities used for depression following cardiac surgery include preoperative and peri-operative education, cardiac rehabilitation, cognitive behavioral therapy, religion/prayer/spirituality, biobehavioral feedback, anti-depressant medications, and statins.

Conclusion

This contemporary review explores the pathophysiological mechanisms leading to depression following cardiac surgery and the current management modalities. Further studies on the preventative and management strategies for postoperative depression in the cardiac surgery patient population are warranted.

Prehabilitation before elective coronary artery bypass grafting surgery: a scoping review

OBJECTIVE

The objective of this scoping review was to identify and map existing preoperative interventions, referred to as prehabilitation, in adult patients at home awaiting elective coronary artery bypass grafting surgery. This review also sought to report feasibility and patient experiences to shape clinical practice and underpin a future systematic review.

INTRODUCTION

As patients age, comorbidities become more common. Strategies to improve postoperative outcomes and to accelerate recovery are required in patients undergoing coronary artery bypass grafting. Prehabilitation refers to a proactive process of increasing functional capacity before surgery to improve the patient's ability to withstand upcoming physiologic stress and, thus, avoid postoperative complications.

INCLUSION CRITERIA

Studies that included adult patients waiting for coronary artery bypass grafting surgery at home and that described interventions optimizing preoperative physical and psychological health in any setting were included.

METHODS

The JBI methodology for conducting scoping reviews was used to identify relevant studies in MEDLINE (PubMed), CINAHL (EBSCOhost), Cochrane Library, Embase (Ovid), Scopus, SweMed+, PsycINFO (EBSCOhost), and PEDro. Gray literature was identified searching Google Scholar, ProQuest Dissertations and Theses, MedNar, OpenGrey, NICE Evidence search, and SIGN. Studies in Danish, English, German, Norwegian, and Swedish were considered for inclusion, with no geographical or cultural limitations, or date restrictions. Two independent reviewers screened titles and abstracts, and studies meeting the inclusion criteria were imported into Covidence. Sixty-seven studies from November 1987 to September 2022 were included. The data extraction tool used for the included papers was developed in accordance with the review questions and tested for adequacy and comprehensiveness with the first 5 studies by the same 2 independent reviewers. The tool was then edited to best reflect the review questions. Extracted findings are described and supported by figures and tables.

RESULTS

Sixty-seven studies were eligible for inclusion, representing 28,553 participants. Analyses of extracted data identified various preoperative interventions for optimizing postoperative and psychological outcomes for adult patients awaiting elective coronary artery bypass grafting surgery. Based on similarities, interventions were grouped into 5 categories. Eighteen studies reported on multimodal interventions, 17 reported on psychological interventions, 14 on physical training interventions, 13 on education interventions, and 5 on oral health interventions.

CONCLUSION

This scoping review provides a comprehensive summary of strategies that can be applied when developing a prehabilitation program for patients awaiting elective coronary artery bypass surgery. Although prehabilitation has been tested extensively and appears to be feasible, available evidence is mostly based on small studies. For patients undergoing elective coronary artery bypass grafting to derive benefit from prehabilitation, methodologically robust clinical trials and knowledge synthesis are required to identify optimal strategies for patient selection, intervention design, adherence, and intervention duration. Future research should also consider the cost-effectiveness of prehabilitation interventions before surgery. Finally, there is a need for more qualitative studies examining whether individual interventions are meaningful and appropriate to patients, which is an important factor if interventions are to be effective.

Pre-Habilitation of Cardiac Surgical Patients, Part 2: Frailty, Malnutrition, Respiratory disease, Alcohol/Smoking cessation and Depression

The concept of "pre-habilitation" comprises screening for and identification of pre-existing disorders followed by medical optimization. This is performed for many types of surgeries, but may have profound impacts on outcomes, particularly in cardiac surgery given the multiple comorbidities typically carried by these patients. Components of pre-habilitation include direct medical intervention by preoperative specialists as well as significant care coordination and shared decision-making. In this second part of a two-part review, the authors describe existing evidence to support the optimization of various preoperative problems and present a few institutional protocols utilized at out center for cardiac presurgical care. This second installment will focus on alcohol and smoking cessation and the management of frailty, malnutrition, respiratory disease, and depression.

Psychological and pharmacological interventions for depression in patients with coronary artery disease

BACKGROUND

Depression occurs frequently in individuals with coronary artery disease (CAD) and is associated with a poor prognosis.

OBJECTIVES

To determine the effects of psychological and pharmacological interventions for depression in CAD patients with comorbid depression.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL databases up to August 2020. We also searched three clinical trials registers in September 2021. We examined reference lists of included randomised controlled trials (RCTs) and contacted primary authors. We applied no language restrictions.

SELECTION CRITERIA

We included RCTs investigating psychological and pharmacological interventions for depression in adults with CAD and comorbid depression. Our primary outcomes included depression, mortality, and cardiac events. Secondary outcomes were healthcare costs and utilisation, health-related quality of life, cardiovascular vital signs, biomarkers of platelet activation, electrocardiogram wave parameters, non-cardiac adverse events, and pharmacological side effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently examined the identified papers for inclusion and extracted data from the included studies. We performed random-effects model meta-analyses to compute overall estimates of treatment outcomes.

MAIN RESULTS

Thirty-seven trials fulfilled our inclusion criteria. Psychological interventions may result in a reduction in end-of-treatment depression symptoms compared to controls (standardised mean difference (SMD) -0.55, 95% confidence interval (CI) -0.92 to -0.19, I² = 88%; low certainty evidence; 10 trials; n = 1226). No effect was evident on medium-term depression symptoms one to six months after the end of treatment (SMD -0.20, 95% CI -0.42 to 0.01, I² = 69%; 7 trials; n = 2654). The evidence for long-term depression symptoms and depression response was sparse for this comparison. There is low certainty evidence that psychological interventions may result in little to no difference in end-of-treatment depression remission (odds ratio (OR) 2.02, 95% CI 0.78 to 5.19, I² = 87%; low certainty evidence; 3 trials; n = 862). Based on one to two trials per outcome, no beneficial effects on mortality and cardiac events of psychological interventions versus control were consistently found. The evidence was very uncertain for end-of-treatment effects on all-cause mortality, and data were not reported for end-of-treatment cardiovascular mortality and occurrence of myocardial infarction for this comparison. In the trials examining a head-to-head comparison of varying psychological interventions or clinical management, the evidence regarding the effect on end-of-treatment depression symptoms is very uncertain for: cognitive behavioural therapy compared to supportive stress management; behaviour therapy compared to person-centred therapy; cognitive behavioural therapy and well-being therapy compared to clinical management. There is low certainty evidence from one trial that cognitive behavioural therapy may result in little to no difference in end-of-treatment depression remission compared to supportive stress management (OR 1.81, 95% CI 0.73 to 4.50; low certainty evidence; n = 83). Based on one to two trials per outcome, no beneficial effects on depression remission, depression response, mortality rates, and cardiac events were consistently found in head-to-head comparisons between psychological interventions or clinical management. The review suggests that pharmacological intervention may have a large effect on end-of-treatment depression symptoms (SMD -0.83, 95% CI -1.33 to -0.32, I² = 90%; low certainty evidence; 8 trials; n = 750). Pharmacological interventions probably result in a moderate to large increase in depression remission (OR 2.06, 95% CI 1.47 to 2.89, I² = 0%; moderate certainty evidence; 4 trials; n = 646). We found an effect favouring pharmacological intervention versus placebo on depression response at the end of treatment, though strength of evidence was not rated (OR 2.73, 95% CI 1.65 to 4.54, I² = 62%; 5 trials; n = 891). Based on one to four trials per outcome, no beneficial effects regarding mortality and cardiac events were consistently found for pharmacological versus placebo trials, and the evidence was very uncertain for end-of-treatment effects on all-cause mortality and myocardial infarction. In the trials examining a head-to-head comparison of varying pharmacological agents, the evidence was very uncertain for end-of-treatment effects on depression symptoms. The evidence regarding the effects of different pharmacological agents on depression symptoms at end of treatment is very uncertain for: simvastatin versus atorvastatin; paroxetine versus fluoxetine; and escitalopram versus Bu Xin Qi. No trials were eligible for the comparison of a psychological intervention with a pharmacological intervention.

AUTHORS' CONCLUSIONS

In individuals with CAD and depression, there is low certainty evidence that psychological intervention may result in a reduction in depression symptoms at the end of treatment. There was also low certainty evidence that pharmacological interventions may result in a large reduction of depression symptoms at the end of treatment. Moderate certainty evidence suggests that pharmacological intervention probably results in a moderate to large increase in depression remission at the end of treatment. Evidence on maintenance effects and the durability of these short-term findings is still missing. The evidence for our primary and secondary outcomes, apart from depression symptoms at end of treatment, is still sparse due to the low number of trials per outcome and the heterogeneity of examined populations and interventions. As psychological and pharmacological interventions can seemingly have a large to only a small or no effect on depression, there is a need for research focusing on extracting those approaches able to substantially improve depression in individuals with CAD and depression.

Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors as adjuncts for postoperative pain management: systematic review and meta-analysis of randomised controlled trials

BACKGROUND

We conducted a systematic review and meta-analysis to assess effects of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) as adjuncts for postoperative pain management.

METHODS

We searched seven databases and two trial registers from inception to February 2021 for RCTs that compared SSRIs or SNRIs with placebo or an active control for postoperative pain management.

RESULTS

We included 24 RCTs with 2197 surgical patients (21 trials for SNRIs and three trials for SSRIs). Moderate-quality evidence found that, compared with placebo, SSRIs/SNRIs (majority SNRIs) significantly reduced postoperative pain within 6 h {weighted mean difference (WMD) -0.73 cm on a 10 cm VAS (95% confidence interval [CI]: -1.04 to -0.42)}, 12 h (-0.68 cm [-1.28 to -0.07]), 24 h (-0.68 cm [-1.16 to -0.20]), 48 h (-0.73 cm [-1.22 to -0.23]), 10 days to 1 month (-0.71 cm [-1.11 to -0.31]), 3 months (-0.64 cm [-1.05 to -0.22]), and 6 months (-0.95 cm [-1.64 to -0.25]), and opioid consumption within 24 h (WMD -12 mg [95% CI: -16 to -8]) and 48 h (-10 mg [-15 to -5]), and improved patient satisfaction (WMD 0.49 point on a 1-4 Likert scale [95% CI: 0.09 to 0.89]) without significant increase in adverse events. Selective serotonin reuptake inhibitors tended to be less effective despite non-significant subgroup effects.

CONCLUSIONS

Serotonin-norepinephrine reuptake inhibitors as an adjunct to standard perioperative care probably provide small reduction in both acute and chronic postoperative pain and opioid consumption, and small improvement in patient satisfaction without increases in adverse events. The effects of SSRIs are inconclusive because of very limited evidence.

Research design considerations for chronic pain prevention clinical trials: IMMPACT recommendations

Although certain risk factors can identify individuals who are most likely to develop chronic pain, few interventions to prevent chronic pain have been identified. To facilitate the identification of preventive interventions, an IMMPACT meeting was convened to discuss research design considerations for clinical trials investigating the prevention of chronic pain. We present general design considerations for prevention trials in populations that are at relatively high risk for developing chronic pain. Specific design considerations included subject identification, timing and duration of treatment, outcomes, timing of assessment, and adjusting for risk factors in the analyses. We provide a detailed examination of 4 models of chronic pain prevention (ie, chronic postsurgical pain, postherpetic neuralgia, chronic low back pain, and painful chemotherapy-induced peripheral neuropathy). The issues discussed can, in many instances, be extrapolated to other chronic pain conditions. These examples were selected because they are representative models of primary and secondary prevention, reflect persistent pain resulting from multiple insults (ie, surgery, viral infection, injury, and toxic or noxious element exposure), and are chronically painful conditions that are treated with a range of interventions. Improvements in the design of chronic pain prevention trials could improve assay sensitivity and thus accelerate the identification of efficacious interventions. Such interventions would have the potential to reduce the prevalence of chronic pain in the population. Additionally, standardization of outcomes in prevention clinical trials will facilitate meta-analyses and systematic reviews and improve detection of preventive strategies emerging from clinical trials.

Use of serotonin reuptake inhibitors is not associated with increased bleeding after CABG

OBJECTIVES

Selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors (SNRIs) are the most commonly prescribed antidepressants worldwide. Studies suggest that SSRI/SNRIs can increase bleeding following different surgical procedures, including open heart surgery, but results are conflicting. The objective of this study was to analyse their effects on bleeding after coronary artery bypass grafting (CABG).

METHODS

Of 1237 patients that underwent CABG in Iceland in 2007-2016, 97 (7.8%) used SSRIs/SNRIs preoperatively and were compared to a reference group (n = 1140). Bleeding was assessed using 24-h chest-tube output, number of RBC units transfused and reoperation for bleeding. Thirty-day mortality rates and incidence of complications were also compared.

RESULTS

The two groups were comparable with respect to preoperative and operative variables, with the exception of BMI being significantly higher in the SSRI/SNRI group (30.2 vs. 28.3 kg/m², p < 0.001). No significant differences were observed between groups in 24-h chest-tube output [815 (SSRI/SNRI) vs. 877 ml (reference), p = 0.26], number of RBC units transfused (2.2 vs. 2.2, p = 0.99) or the rate of reoperation for bleeding (4.1% vs. 6.0%, p = 0.61). The incidences of complications and 30-day mortality rate were also similar.

CONCLUSIONS

Using three different criteria, preoperative use of SSRIs/SNRIs was not shown to increase bleeding after CABG. Furthermore, short-term complications as well as 30-day mortality rates did not differ from those of controls. Thus, temporary cessation of SSRI/SNRI treatment prior to CABG to decrease the risk of bleeding is unwarranted.

Prevalence of Depression in Coronary Artery Bypass Surgery: A Systematic Review and Meta-Analysis

Coronary artery bypass graft surgery (CABG) might adversely affect the health status of the patients, producing cognitive deterioration, with depression being the most common symptom. The aim of this study is to analyse the prevalence of depression in patients before and after coronary artery bypass surgery. A systematic review and meta-analysis was carried out, involving a study of the past 10 years of the following databases: CINAHL, LILACS, MEDLINE, PsycINFO, SciELO, Scopus, and Web of Science. The total sample comprised n = 16,501 patients. The total number of items was n = 65, with n = 29 included in the meta-analysis. Based on the different measurement tools used, the prevalence of depression pre-CABG ranges from 19-37%, and post-CABG from 15-33%. There is a considerable presence of depression in this type of patient, but this varies according to the measurement tool used and the quality of the study. Systematically detecting depression prior to cardiac surgery could identify patients at potential risk.

Screening and Management of Depression in Patients With Cardiovascular Disease: JACC State-of-the-Art Review

Depression is a common problem in patients with cardiovascular disease (CVD) and is associated with increased mortality, excess disability, greater health care expenditures, and reduced quality of life. Depression is present in 1 of 5 patients with coronary artery disease, peripheral artery disease, and heart failure. Depression complicates the optimal management of CVD by worsening cardiovascular risk factors and decreasing adherence to healthy lifestyles and evidence-based medical therapies. As such, standardized screening pathways for depression in patients with CVD offer the potential for early identification and optimal management of depression to improve health outcomes. Unfortunately, the burden of depression in patients with CVD is under-recognized; as a result, screening and management strategies targeting depression have been poorly implemented in patients with CVD. In this review, the authors discuss a practical approach for the screening and management of depression in patients with CVD.

Efficacy and acceptability of antidepressants in patients with ischemic heart disease: systematic review and meta-analysis

To assess the efficacy and acceptability of antidepressants in adults with ischemic heart disease (IHD). We gathered all available randomized-controlled trials comparing antidepressants versus placebo or other antidepressants in adults with IHD. The primary outcome was depressive symptoms at the study endpoint, as measured by validated rating scales. We pooled data in a meta-analysis using a random-effects model. The confidence in the estimates (or certainty of the evidence) was assessed using the GRADE approach. Antidepressants appeared to be more effective than placebo in reducing depressive symptoms (11 comparisons; 1685 participants; standardized mean difference -0.71, 95% confidence interval: -1.11 to -0.30; GRADE quality: moderate). This result was confirmed in the subgroup of serotonin selective reuptake inhibitors, and for the single drugs sertraline and citalopram, with a greater magnitude of effect and a higher quality of evidence for the former. No differences between antidepressants and placebo emerged in terms of acceptability and tolerability, quality of life, mortality, and cardiovascular events. Only two small head-to-head studies were identified. Sertraline is a reasonable first-line choice in patients with IHD and depression, whereas the role of citalopram as the first-line agent should be reconsidered.

Selective serotonin reuptake inhibitor use and outcomes following cardiac surgery-a systematic review

A high prevalence of depression is observed in patients undergoing cardiac surgery, and depression has been shown to be an independent predictor of morbidity and mortality in this patient population. Selective serotonin re-uptake inhibitors (SSRIs) are the first-line recommended therapy for depressive disorders, however due to their platelet inhibitory actions they have been associated with increased incidences of post-operative bleeding. This review has sought to address whether the use of SSRIs is associated with a higher rate of mortality, major adverse events or bleeding events following cardiac surgery. A retrospective literature search selected studies comparing the use of SSRIs with no SSRI use in patients undergoing cardiac surgery. Seven of the ten studies analysed reported no significant difference in mortality in SSRI users. Five of the seven studies reporting bleeding events demonstrated no significant difference in SSRI users. Three of the five studies reporting other significant morbidity demonstrated no significant difference in SSRI users. Our study demonstrates the safety of the use of SSRIs for the treatment of depressive disorders in patients undergoing cardiac surgery.

Do selective serotonin reuptake inhibitors increase the risk of bleeding or mortality following coronary artery bypass graft surgery? A meta-analysis of observational studies

INTRODUCTION

Depressive illness has a high prevalence in patients undergoing coronary artery bypass graft surgery (CABG). The first line treatment for depression are selective serotonin reuptake inhibitors (SSRIs) which inhibit serotonin reuptake in the presynaptic neuronal membrane and uptake by platelets, inhibiting subsequent serotonin-mediated platelet activation. This presents a theoretically increased risk of bleeding and subsequent postoperative mortality. This review aims to investigate the effects of SSRIs on postoperative bleeding, defined as the need for transfusions and re-operation for bleeding, as well as 30-day mortality in patients undergoing CABG.

METHOD

Four hundred and thirty-seven papers were screened with seven meeting the full inclusion criteria.

RESULTS

Meta-analysis demonstrated that SSRI use increased the risk of red blood cell transfusion (odds ratio (OR) = 1.15; 95% confidence interval (CI): 1.06-1.26), but resulted in no difference in the rate of re-operation for bleeding (OR = 1.07; 95% CI: 0.66-1.74). SSRI use had no effect on the rates of platelet (OR = 0.93; 95% CI: 0.79-1.09) or fresh frozen plasma (OR = 0.96; 95% CI: 0.74-1.24) transfusion nor on the mortality rate (OR =1.03; 95 CI: 0.90-1.17).

CONCLUSION

This review demonstrates that SSRIs are largely safe in cardiac surgery as no increase in mortality was observed. However, there is a significantly raised chance of red blood cell transfusion. The heterogeneous nature of the current evidence base highlights the need for further research into SSRIs and whether any effect on patient outcomes in cardiac surgery occurs.

A comparison of early and late treatments on allodynia and its chronification in experimental neuropathic pain

Background Surgeries causing nerve injury can result in chronic neuropathic pain, which is clinically managed by using antidepressant or anticonvulsant drugs. Currently, there is a growing interest for investigating preemptive treatments that would prevent this long-term development of neuropathic pain. Our aim was to compare analgesic drugs using two distinct treatment modalities: either treatment onset at surgery time or following a couple of weeks of neuropathic pain. Methods In male C57BL/6J mice, neuropathic pain was induced by cuffing the sciatic nerve, and allodynia was assessed using von Frey filaments. We tested the effect of anticonvulsants (gabapentin 10 mg/kg and carbamazepine 40 mg/kg), antidepressants (desipramine 5 mg/kg, duloxetine 10 mg/kg, and fluoxetine 10 mg/kg), dexamethasone (2 mg/kg), and ketamine (15 mg/kg). Drugs were injected daily or twice a day, starting either at surgery time or on day 25 postsurgery (15 days of treatment for antidepressants and 10 days for other drugs). Results Ketamine was the only effective treatment during the early postsurgical period. Although early anticonvulsant treatment was not immediately effective, it prevented chronification of allodynia. When treatments started at day 25 postsurgery, desipramine, duloxetine, and anticonvulsants suppressed the mechanical allodynia. Conclusions Our data show that allodynia measured in experimental neuropathic pain model likely results from a combination of different processes (early vs. late allodynia) that display different sensitivity to treatments. We also propose that early anticonvulsant treatment with gabapentin or carbamazepine may have a prophylactic effect on the chronification of allodynia following nerve injury.

Poorly controlled postoperative pain: prevalence, consequences, and prevention

This review provides an overview of the clinical issue of poorly controlled postoperative pain and therapeutic approaches that may help to address this common unresolved health-care challenge. Postoperative pain is not adequately managed in greater than 80% of patients in the US, although rates vary depending on such factors as type of surgery performed, analgesic/anesthetic intervention used, and time elapsed after surgery. Poorly controlled acute postoperative pain is associated with increased morbidity, functional and quality-of-life impairment, delayed recovery time, prolonged duration of opioid use, and higher health-care costs. In addition, the presence and intensity of acute pain during or after surgery is predictive of the development of chronic pain. More effective analgesic/anesthetic measures in the perioperative period are needed to prevent the progression to persistent pain. Although clinical findings are inconsistent, some studies of local anesthetics and nonopioid analgesics have suggested potential benefits as preventive interventions. Conventional opioids remain the standard of care for the management of acute postoperative pain; however, the risk of opioid-related adverse events can limit optimal dosing for analgesia, leading to poorly controlled acute postoperative pain. Several new opioids have been developed that modulate μ-receptor activity by selectively engaging intracellular pathways associated with analgesia and not those associated with adverse events, creating a wider therapeutic window than unselective conventional opioids. In clinical studies, oliceridine (TRV130), a novel μ-receptor G-protein pathway-selective modulator, produced rapid postoperative analgesia with reduced prevalence of adverse events versus morphine.

Antidepressant Drugs for Postsurgical Pain: Current Status and Future Directions

Current treatments for postsurgical pain are often inadequate and adverse effects are substantial such that residual pain and/or side effects impair recovery. The recognition of analgesic efficacy with antidepressant drugs for chronic pain suggests the potential for efficacy in acute postsurgical pain. As reviewed here, current evidence suggests that approximately half of previous trials suggest efficacy of various antidepressants for acute postoperative pain. However, most trials are older with deficiencies including: lack of designation of a primary outcome, no assessment of movement-evoked pain, small size and limited safety assessment. Only one of three trials addressing prevention of chronic postsurgical pain suggested any efficacy; however, the evidence base for this indication is limited. Thus, current evidence does not yet support routine use of any one specific antidepressant for treatment of acute, or prevention of chronic, postsurgical pain. However, limitations in available trials are such that one cannot yet rule out the possibility that one or more antidepressant drugs may provide benefit in specific populations. Therefore, future larger trials should explore optimal dosing and duration of antidepressant treatment, procedure specificity, safety evaluation, and assessment of movement-evoked pain.

Research design considerations for chronic pain prevention clinical trials: IMMPACT recommendations

Although certain risk factors can identify individuals who are most likely to develop chronic pain, few interventions to prevent chronic pain have been identified. To facilitate the identification of preventive interventions, an IMMPACT meeting was convened to discuss research design considerations for clinical trials investigating the prevention of chronic pain. We present general design considerations for prevention trials in populations that are at relatively high risk for developing chronic pain. Specific design considerations included subject identification, timing and duration of treatment, outcomes, timing of assessment, and adjusting for risk factors in the analyses. We provide a detailed examination of 4 models of chronic pain prevention (ie, chronic postsurgical pain, postherpetic neuralgia, chronic low back pain, and painful chemotherapy-induced peripheral neuropathy). The issues discussed can, in many instances, be extrapolated to other chronic pain conditions. These examples were selected because they are representative models of primary and secondary prevention, reflect persistent pain resulting from multiple insults (ie, surgery, viral infection, injury, and toxic or noxious element exposure), and are chronically painful conditions that are treated with a range of interventions. Improvements in the design of chronic pain prevention trials could improve assay sensitivity and thus accelerate the identification of efficacious interventions. Such interventions would have the potential to reduce the prevalence of chronic pain in the population. Additionally, standardization of outcomes in prevention clinical trials will facilitate meta-analyses and systematic reviews and improve detection of preventive strategies emerging from clinical trials.

Psychiatric Disorders and Psychopharmacologic Treatment as Risk Factors in Elective Fast-track Total Hip and Knee Arthroplasty

BACKGROUND

Psychiatric disorder (PsD) is rarely considered when evaluating perioperative risk factors. Studies on PsD are often limited by use of administrative coding, incomplete follow-up, and lack of preoperative data on psychopharmacological treatment.

METHODS

A multicenter study with prospective registration on preoperative comorbidity, complete 90-day follow-up, and information on dispensed prescriptions on psychopharmacological treatment (excluding benzodiazepines). All departments used similar fast-track approaches and discharge to home. Evaluation of postoperative morbidity was based on discharge records. Odds ratios for length of stay (LOS) more than 4 days and surgery-related readmissions were calculated using multiple logistic regression adjusting for potential confounders.

RESULTS

Of 8,757 procedures, 1,001 (11.4%) were in PsD patients. Of these, 43.4% used selective serotonin inhibitors (SSRIs), 31.6% used other antidepressants, 8.5% used a combination, and 16.5% used antipsychotics. PsD was associated with increased risk of LOS more than 4 days (16.5 vs. 7.3%; odds ratio, 1.90; 95% CI, 1.52 to 2.37), regardless of treatment with SSRIs (2.19; 1.62 to 2.97), other antidepressants (1.81; 1.25 to 2.61), or antipsychotics (1.90; 1.62 to 3.16). PsD was associated with increased 30- (9.9 vs. 5.1%; 1.93; 1.49 to 2.49) and 90-day surgery-related readmissions (12.8 vs. 7.4%; 1.68; 1.34 to 2.10), significant for SSRIs (1.97; 1.38 to 2.82 and 1.77; 1.29 to 2.43), other antidepressants (2.24; 1.51 to 3.32 and 1.82; 1.27 to 2.61), and antipsychotics (1.85; 1.03 to 3.31, 30 days only). In PsD patients, pain (1.4%), postoperative anemia (1.1%), and pulmonary complications (1.1%) were the most frequent causes of LOS more than 4 days. Hip displacements (2.8%) and falls (1.9%) were the most frequent readmissions, and 90-day surgery-related mortality was 0.7% with and 0.2% without PsD.

CONCLUSIONS

Psychopharmacologically treated PsD is a risk factor for postoperative morbidity after fast-track arthroplasty, regardless of treatment type. This may be due to PsD per se and/or drug-related side effects.

Depression and Anxiety following Coronary Artery Bypass Graft: Current Indian Scenario

Epidemiological studies have shown a high prevalence of coronary artery disease among the Indian Population. Due to increasing availability and affordability of tertiary care in many parts of India, carefully selected patients undergo coronary artery bypass surgery to improve cardiac function. However, the procedure is commonly associated with depression and anxiety which can adversely affect overall prognosis. The objective of this review is to highlight early identifiable symptoms of depression and anxiety following coronary artery bypass graft (CABG) in Indian context so as to facilitate prompt intervention for better outcome. The current review was able to establish firm evidence in support of screening for depression and anxiety following CABG. Management of depression and anxiety following CABG is briefly reviewed.

Hyponatremia Due to Escitalopram and Thiazide Use After Cardiac Surgery

Depression and mood disorders occur commonly following emergent cardiac surgery. Selective serotonin reuptake inhibitors are commonly used antidepressants. We report the development of severe hyponatremia leading to adverse clinical effects due to escitalopram and thiazide diuretic use concomitantly in a patient with depression after emergency coronary artery bypass grafting.

Sleep Quality and Emotional Correlates in Taiwanese Coronary Artery Bypass Graft Patients 1 Week and 1 Month after Hospital Discharge: A Repeated Descriptive Correlational Study

Background

Poor sleep quality is a common health problem for coronary artery bypass graft patients, however few studies have evaluated sleep quality during the period immediately following hospital discharge.

Purpose

The aim of this study was to investigate changes in sleep quality and emotional correlates in coronary artery bypass graft patients in Taiwan at 1 week and 1 month after hospital discharge.

Methods

We used a descriptive correlational design for this study. One week after discharge, 87 patients who had undergone coronary artery bypass surgery completed two structured questionnaires: the Pittsburgh Sleep Quality Index and the Hospital Anxiety and Depression Scale. Three weeks later (1 month after discharge) the patients completed the surveys again. Pearson correlations, t-tests, ANOVA and linear multiple regression analysis were used to analyze the data.

Results

A majority of the participants had poor sleep quality at 1 week (82.8%) and 1 month (66.7%) post-hospitalization, based on the global score of the Pittsburgh Sleep Quality Index. Despite poor sleep quality at both time-points the sleep quality at 1 month was significantly better than at 1-week post hospitalization. Poorer sleep quality correlated with older age, poorer heart function, anxiety and depression. The majority of participants had normal levels of anxiety at 1 week (69.0%) and 1 month (88.5%) as measured by the Hospital Anxiety and Depression Scale. However, some level of depression was seen at 1 week (78.1%) and 1 month (59.7%). Depression was a significant predictor of sleep quality at 1 week; at 1 month after hospital discharge both anxiety and depression were significant predictors of sleep quality.

Conclusion

Sleep quality, anxiety and depression all significantly improved 1 month after hospital discharge. However, more than half of the participants continued to have poor sleep quality and some level of depression. Health care personnel should be encouraged to assess sleep and emotional status in patients after coronary artery bypass surgery and offer them appropriate management strategies to improve sleep and reduce anxiety and depression.

Outcome Reporting in Cardiac Surgery Trials: Systematic Review and Critical Appraisal

BACKGROUND

There is currently no accepted standard for reporting outcomes following cardiac surgery. The objective of this paper was to systematically review the literature to evaluate the current use and definition of perioperative outcomes reported in cardiac surgery trials.

METHODS AND RESULTS

We reviewed 5 prominent medical and surgical journals on Medline from January 1, 2010, to June 30, 2014, for randomized controlled trials involving coronary artery bypass grafting and/or valve surgery. We identified 34 trials meeting inclusion criteria. Sample sizes ranged from 57 to 4752 participants (median 351). Composite end points were used as a primary outcome in 56% (n=19) of the randomized controlled trials and as a secondary outcome in 12% (n=4). There were 14 different composite end points. Mortality at any time (all-cause and/or cardiovascular) was reported as an individual end point or as part of a combined end point in 82% (n=28), myocardial infarction was reported in 68% (n=23), and bleeding was reported in 24% (n=8). Patient-centered outcomes, such as quality of life and functional classification, were reported in 29% (n=10). Definition of clinical events such as myocardial infarction, stroke, renal failure, and bleeding varied considerably among trials, particularly for postoperative myocardial infarction and bleeding, for which 8 different definitions were used for each.

CONCLUSIONS

Outcome reporting in the cardiac surgery literature is heterogeneous, and efforts should be made to standardize the outcomes reported and the definitions used to ascertain them. The development of standardizing outcome reporting is an essential step toward strengthening the process of evidence-based care in cardiac surgery.

Analgesic Effect of Perioperative Escitalopram in High Pain Catastrophizing Patients after Total Knee Arthroplasty

Background:

Sufficient pain treatment remains a challenge after total knee arthroplasty (TKA), especially in high pain catastrophizing patients. Serotonergic signaling may be involved in pain processing, but the effect of selective serotonin reuptake inhibitors on well-defined postoperative pain has not previously been investigated. The authors hypothesized that perioperative escitalopram would reduce pain after TKA in high pain catastrophizing patients.

Methods:

A total of 120 pain catastrophizing patients (selected using the pain catastrophizing scale as preoperative screening tool) scheduled for TKA were randomized in a double-blind manner to either 10 mg escitalopram or placebo daily from preanesthesia to postoperative day 6 in addition to a standardized analgesic regime. The primary outcome was pain upon ambulation 24 h after surgery. Secondary outcomes were overall pain during well-defined mobilizations and at rest from 2 to 48 h and from days 2 to 6, morphine equivalents, anxiety, depression, and side effects.

Results:

Pain upon ambulation (mean [95% CI]) 24 h after surgery in the escitalopram versus placebo group was 58 (53 to 64) versus 64 (58 to 69), the mean difference being −5 (−13 to 3), P = 0.20. Overall pain upon ambulation and at rest from days 2 to 6 was lower in the escitalopram versus placebo group, as was depression score at day 6 (all P ≤ 0.01 in analyses uncorrected for multiple tests). Side effects were nonsignificant except for reduced tendency to sweat and prolonged sleep in the escitalopram group. No other between-group differences were observed.

Conclusions:

Escitalopram did not reduce pain upon ambulation 24 h after TKA in high pain catastrophizing patients. Future studies on optimal timing, dose, and duration of selective serotonin reuptake inhibitor treatment might be warranted.

Antidepressant drugs for prevention of acute and chronic postsurgical pain: early evidence and recommended future directions

BACKGROUND

This review evaluates trials of antidepressants for acute and chronic postsurgical pain.

METHODS

Trials were systematically identified using predefined inclusion and exclusion criteria. Extracted data included the following: pain at rest and with movement, adverse effects, and other outcomes.

RESULTS

Fifteen studies (985 participants) of early postoperative pain evaluated amitriptyline (three trials), bicifadine (two trials), desipramine (three trials), duloxetine (one trial), fluoxetine (one trial), fluradoline (one trial), tryptophan (four trials), and venlafaxine (one trial). Three studies (565 participants) of chronic postoperative pain prevention evaluated duloxetine (one trial), escitalopram (one trial), and venlafaxine (one trial). Heterogeneity because of differences in drug, dosing regimen, outcomes, and/or surgical procedure precluded any meta-analyses. Superiority to placebo was reported in 8 of 15 trials for early pain reduction and 1 of 3 trials for chronic pain reduction. The majority of positive trials did not report sufficient data to estimate treatment effect sizes. Many studies had inadequate size, safety evaluation/reporting, procedure specificity, and movement-evoked pain assessment.

CONCLUSIONS

There is currently insufficient evidence to support the clinical use of antidepressants-beyond controlled investigations-for treatment of acute, or prevention of chronic, postoperative pain. Multiple positive trials suggest the therapeutic potential of antidepressants, which need to be replicated. Other nontrial evidence suggests potential safety concerns of perioperative antidepressant use. Future studies are needed to better define the risk-benefit ratio of antidepressants in postoperative pain management. Higher-quality trials should optimize dosing, timing and duration of antidepressant treatment, trial size, patient selection, safety evaluation and reporting, procedure specificity, and assessment of movement-evoked pain relevant to postoperative functional recovery.

Differences in quality of life outcomes among depressed spinal cord injury trial participants

OBJECTIVE

To assess the role that treatment response plays in a randomized controlled trial of an antidepressant among people with spinal cord injury (SCI) diagnosed with major depressive disorder (MDD) in explaining quality of life (QOL), assessed both globally as life satisfaction and in terms of physical and mental health-related QOL.

DESIGN

Multivariable analyses were conducted, controlling for demographic, neurologic, and participatory factors and perceived functional limitations.

SETTING

Rehabilitation centers.

PARTICIPANTS

Of the 133 persons who were randomized into the Project to Improve Symptoms and Mood after Spinal Cord Injury randomized controlled trial, 124 participated in this study. All participants were between the ages of 18 and 64 years, at least 1 month post-SCI, met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for MDD, and completed the core measures used in this study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Satisfaction with Life Scale and the physical and mental component summary scores of the Medical Outcomes Study 12-Item Short-Form Health Survey.

RESULTS

Reduction in depressive symptoms over the course of a 12-week trial was predictive of increased QOL, which was measured as life satisfaction and mental well-being, within the context of other explanatory factors. However, reduction in symptoms did not explain differences in physical well-being among those with MDD. Perceived functional disability explained all 3 indices of QOL.

CONCLUSIONS

Greater recognition has been given to QOL outcomes as endpoints of clinical trials because these often reflect participants' reported outcomes. Our findings support the association of QOL to the reduction of depression symptoms among trial participants. This association differs depending on how QOL is defined and measured, with stronger relations observed with life satisfaction and mental well-being among those diagnosed with MDD. The lack of association between depression and physical well-being may be explained by participants' subjective interpretation of physical well-being after SCI and their expectations and perceptions of improved physical health-related QOL based on the use of assistive technology. Consistent with our findings, pain is likely to play a role in decreasing physical QOL among those with incomplete injuries. Practicing caution is suggested in using physical well-being as an endpoint in trials among people with SCI.

Surgical resilience: a review of resilience biomarkers and surgical recovery

BACKGROUND

Two distinct and large bodies of literature exist on resilience that are of potential interest for surgical outcomes. First is the literature on the impact of resilience on surgical recovery and wound-healing. Second is the literature on biomarkers for resilience, which largely focuses on neuropeptide Y (NPY), testosterone and dehydroepiandrosterone (DHEA). Despite this activity, there is a dearth of literature linking these two bodies of research by investigating biomarkers for surgical resilience and its impact on surgical recovery. This paper reviews both bodies of literature within the context of surgical recovery.

METHOD

Literature searches within Medline and Embase were conducted for studies and previous reviews of resilience biomarkers and for the impact of individual resilience on surgical recovery. Reference lists of the reviews were searched for additional papers. No systematic review is yet possible due to the novelty of the use of resilience biomarkers within a surgical context.

RESULTS

This is the first review to explore a potential link between resilience biomarkers and surgical recovery. There are a number of biomarkers that correlate with individual resilience levels and resilient individuals exhibit better recovery trajectories following surgery, suggesting a novel use of such biomarkers for the identification of "surgical resilience".

CONCLUSION

By identifying surgical resilience, there is potential for utilising these biomarkers as prognostic indicators of likely recovery trajectories from surgery, which in turn complement individualised peri-operative management.