Clinical features and long-term outcomes of patients with type 2 autoimmune pancreatitis

OBJECTIVES

Type 2 is a rare form of autoimmune pancreatitis (AIP). Despite being considered a benign disease, only few studies with limited sample size and short follow-up have been published on type 2 AIP. The aim of this observational study was to evaluate long-term outcomes, such as the risk of relapse, pancreatic insufficiency and cancer in a large type 2 AIP cohort with long follow-up.

METHODS

Patients with definitive or probable diagnosis of type 2 AIP by International Consensus Diagnostic Criteria (ICDC) present in our prospectively maintained database since 1995 at 31.12.2021 were identified. All patients were clinically evaluated during the year 2022. Clinical, radiological, serological, and pathological data were evaluated.

RESULTS

Eighty-eight out of 420 patients present in the database (21%) were diagnosed with type 2 AIP (mean age 33.5 ± 13.5 years). According to the ICDC, 21 patients (23.8%) had a definitive and 67 (76.2%) a probable diagnosis of type 2 AIP. The mean follow-up was 9.2 ± 7.1 years (range 1-27 years). No differences were observed when comparing patients with definitive and probable type 2 AIP diagnosis. Concomitant IBD was reported in 77 patients (87.5%). The probability of disease relapse was lower in patients treated with steroids versus surgery (at 5 years 13% vs. 33%; p = 0.038) but this difference was not statistically significant at multivariable analysis. The risk of endocrine or severe exocrine insufficiency was low (5% and 25%). Four extra-pancreatic malignancies (5%) were diagnosed, none pancreatic. One patient died in a car accident.

CONCLUSIONS

Type 2 AIP has benign long-term clinical outcomes. Mortality and cancer rates are low and no specific follow-up is needed after radiological remission.

Predicting de-novo portal vein thrombosis after HCV eradication: A long-term competing risk analysis in the ongoing PITER cohort

BACKGROUND & AIMS

Sustained virological response (SVR) by direct-acting antivirals (DAAs) may reverse the hypercoagulable state of HCV cirrhosis and the portal vein thrombosis (PVT) risk. We evaluated the incidence and predictive factors of de novo, non-tumoral PVT in patients with cirrhosis after HCV eradication.

METHODS

Patients with HCV-related cirrhosis, consecutively enrolled in the multi-center ongoing PITER cohort, who achieved the SVR using DAAs, were prospectively evaluated. Kaplan-Meier and competing risk regression analyses were performed.

RESULTS

During a median time of 38.3 months (IQR: 25.1-48.7 months) after the end of treatment (EOT), among 1609 SVR patients, 32 (2.0%) developed de novo PVT. A platelet count ≤120,000/μL, albumin levels ≤3.5 mg/dL, bilirubin >1.1 mg/dL, a previous liver decompensation, ALBI, Baveno, FIB-4, and RESIST scores were significantly different (p < 0.001), among patients who developed PVT versus those who did not. Considering death and liver transplantation as competing risk events, esophageal varices (subHR: 10.40; CI 95% 4.33-24.99) and pre-treatment ALBI grade ≥2 (subHR: 4.32; CI 95% 1.36-13.74) were independent predictors of PVT. After HCV eradication, a significant variation in PLT count, albumin, and bilirubin (p < 0.001) versus pre-treatment values was observed in patients who did not develop PVT, whereas no significant differences were observed in those who developed PVT (p > 0.05). After the EOT, esophageal varices and ALBI grade ≥2, remained associated with de novo PVT (subHR: 9.32; CI 95% 3.16-27.53 and subHR: 5.50; CI 95% 1.67-18.13, respectively).

CONCLUSIONS

In patients with HCV-related cirrhosis, a more advanced liver disease and significant portal hypertension are independently associated with the de novo PVT risk after SVR.

Trend of Bronchial Hyperresponsiveness to Methacholine as a Cost Predictor of Mild-to-Moderate Asthma: A Twelve-Month Survey in Teenagers

Bronchial asthma is characterized by variable airflow obstruction, airway inflammation, and bronchial hyperresponsiveness (BHR) to non-specific stimuli. The role of underlying airway inflammation and of related long-lasting BHR has been suboptimally investigated in teenagers with mild-to-moderate asthma, as has the corresponding economic impact over time. The aim of the present study was to calculate the cost of mild-to-moderate atopic asthma in teenagers arising from their degree of persisting BHR over a twelve-month period.

METHODS

Patients aged 12-18 years with mild-to-moderate symptoms treated with fluticasone fumarate/vilanterol 92/22 mcg daily were retrospectively followed for 12 months. Usual spirometric parameters, BHR to methacholine (MCh), and resource consumption (visits, hospitalizations, systemic steroids and/or antibiotics courses, school days off) were assessed at recruitment (the index date) and after 6 and 12 months. Adherence to treatment was also calculated. The cost of asthma was calculated based on Italian tariffs and published papers. The trend over time in BHR and the association between response to MCh and total cost were investigated by using regression models adjusted for repeated measures.

RESULTS

106 teenagers (53 males, age 15.9 ± 1.6 years) were investigated. The annual cost of asthma proved significantly related to the BHR trend: every increment of a factor 10 in the response to MCh was associated with a saving of EUR 184.90 (95% CI -305.89 to -63.90). BHR was progressively optimized after 6 and 12 months in relation to the patients' compliance to treatment (≥70% of prescribed inhalation doses).

CONCLUSIONS

the usual spirometric parameters are largely insufficient to reflect the effects of underlying persistent inflammation in milder forms of asthma in teenagers. In terms of clinical governance, the periodic assessment of non-specific BHR is the appropriate procedure from this point of view. Non-specific BHR proves a reliable procedure for predicting and monitoring the economic impact of mild-to-moderate asthma in teenagers over time.

Chronic frontal neurobehavioural symptoms in combat-deployed military personnel with and without a history of blast-related mild traumatic brain injury

OBJECTIVE

This study evaluated frontal behavioural symptoms, via the FrSBe self-report, in military personnel with and without a history of blast-related mild traumatic brain injury (mild TBI).

METHODS

Prospective observational cohort study of combat-deployed service members leveraging 1-year and 5-year demographic and follow up clinical outcome data.

RESULTS

The blast mild TBI group (n = 164) showed greater frontal behavioural symptoms, including clinically elevated apathy, disinhibition, and executive dysfunction, during a 5-year follow-up, compared to a group of combat-deployed controls (n = 107) without mild TBI history or history of blast exposure. We also explored changes inbehaviourall symptoms over a 4-year span, which showed clinically significant increases in disinhibition in the blast mild TBI group, whereas the control group did not show significant increases in symptoms over time.

CONCLUSION

Our findings add to the growing evidence that a proportion of individuals who sustain mild TBI experience persistent behavioural symptoms. We also offer a demonstration of a novel use of the FrSBe as a tool for longitudinal symptom monitoring in a military mild TBI population.

Neonatal respiratory support strategies-short and long-term respiratory outcomes

Mechanical ventilation (MV), although life-saving, is associated with chronic respiratory morbidity in both preterm and term born infants. New ventilation modes have been developed with the aim of minimising lung injury. These include invasive and non-invasive respiratory support strategies, techniques for less invasive surfactant administration (LISA) and closed-loop automated oxygen control (CLAC) systems. Increasingly, newborn infants with signs of respiratory distress are stabilised on continuous positive airway pressure (CPAP) and receive LISA. Early CPAP when compared to mechanical ventilation reduced the incidence of BPD and respiratory morbidity at 18 to 22 months corrected age. Nasal intermittent positive pressure ventilation reduced treatment failure rates compared to CPAP, but not bronchopulmonary dysplasia (BPD). LISA compared with intubation and surfactant delivery reduced BPD, but there is no evidence from randomised trials regarding long-term respiratory and neurodevelopmental outcomes. Synchronisation of positive pressure inflations with the infant's respiratory efforts used with volume targeting should be applied for infants requiring intubation as this strategy reduces BPD. A large RCT with long term follow up data demonstrated that prophylactic high frequency oscillatory ventilation (HFOV) improved respiratory and functional outcomes at school age, but those effects were not maintained after puberty. CLAC systems appear promising, but their effect on long term clinical outcomes has not yet been explored in randomised trials. Further studies are required to determine the role of newer ventilation modes such as neurally adjusted ventilator assist (NAVA). All such respiratory support strategies should be tested in randomised controlled trials powered to assess long-term outcomes.

Long-term outcomes in refractory status epilepticus

INTRODUCTION

Refractory status epilepticus (RSE) is a diagnosis that can be made when tonic-clonic status epilepticus (SE) and focal SE cannot be stopped by at least two anti-seizure medications after 30 and 60 minutes, respectively, from the time of commencement. It could result in mortality, loss of functionality, neurological deficiency, and other serious short- and long-term effects.

AREAS COVERED

This narrative review covers original clinical studies of any design and case series investigating long-term outcomes of RSE recorded after at least a year from the SE onset.

EXPERT OPINION

The future of a patient with RSE rests mostly on the long-term effects of this severe pathological condition, which may be accompanied with systemic complications like hyperthermia, hyperkalemia, acidosis, and/or stress cardiomyopathy. Younger patients with less severe RSE of shorter duration, particularly of the convulsive kind, are reported to have better long-term outcomes. Previous studies on the factors influencing the long-term outcomes of RSE, however, did not link the outcomes to treatment options for the condition. Such circumstances currently prevent making any definitive recommendations on the treatment of RSE until future research with adequate statistical power is completed.

Purely Off-Clamp Laparoscopic Partial Nephrectomy Stands the Test of Time: 15 Years Functional and Oncologic Outcomes from a Single Center Experience

BACKGROUND

Nephron-sparing surgery represents the gold standard treatment for organ-confined renal tumors. We present 15-years of outcomes after off-clamp laparoscopic partial nephrectomy (ocLPN).

METHODS

a retrospective analysis was performed on patients who underwent ocLPN between May 2001 and December 2005. Baseline demographic, clinical, pathologic, surgical, functional and survival data were collected. The Kaplan-Meier method evaluated group-specific oncologic outcomes at 5, 10 and 15 years and the log rank test assessed differences between groups. The same analysis investigated the probabilities of developing a significant renal function impairment (sRFI) and achieving ROMeS. Cox analyses identified predictors of this latter tricomposite outcome.

RESULTS

We included 63 patients whose median tumor size was 3 cm (IQR:2-4). At 15 years, the chances of developing local recurrence, metachronous renal cancers or distant metastases were 2 ± 2%, 23 ± 6% and 17 ± 5%, respectively. Consequently, disease-free, cancer-specific and overall-survival probabilities were 68 ± 6%, 90 ± 4% and 72 ± 6%. MCRSS and UCISS well predicted oncologic outcomes. Overall, nine (14%) patients experienced an sRFI and 33 (52%) achieved ROMeS. Age (HR: 1.046; p = 0.033) and malignant histology (low-risk cancers HR: 3.233, p = 0.048) (intermediate/high risk cancers HR: 5.721, p = 0.023) were independent predictors of ROMeS non-achievement.

CONCLUSIONS

At 15 years from ocLPN, most of patients will experience both excellent functional and oncologic outcomes.

Living Donor Kidney Transplant in Recipients With Glomerulonephritis: Donor Recipient Biologic Relationship and Allograft Outcomes

Using the Scientific Registry of Transplant Recipients, we examined the association between donor-recipient biologic relationship and long-term recipient and allograft survival among glomerulonephritis (GN) patients. Four GN types were studied: membranous nephropathy, IgA, lupus-associated nephritis, and focal segmental glomerulosclerosis (FSGS). We identified all adult primary living-donor recipients between 2000 and 2018 (n = 19,668): related (n = 10,437); unrelated (n = 9,231). Kaplan-Meier curves were generated for the recipient, death-censored graft survival and death with functioning graft through ten years post-transplant. Multivariable Cox proportional hazard models were used to examine the association between the donor-recipient relationship and outcomes of interest. There was an increased risk for acute rejection by 12 months post-transplant among the unrelated compared to the related group in IgA (10.1% vs. 6.5%, p<0.001), FSGS (12.1% vs. 10%, p-0.016), and lupus nephritis (11.8% vs. 9.2%; p-0.049). The biological donor-recipient relationship was not associated with a worse recipient or graft survival or death with functioning graft in the multivariable models. These findings are consistent with the known benefits of living-related-donor kidney transplants and counter the reports of the potential adverse impact of the donor-recipient biologic relationship on allograft outcomes.

Long term outcomes of occipital nerve stimulation

Background

Occipital nerve stimulation (ONS) has been investigated as a potential treatment for disabling headaches and has shown promise for disorders such as chronic migraine and cluster headache. Long term outcomes stratified by headache subtype have had limited exploration, and literature on outcomes of this neuromodulatory intervention spanning 2 or more years is scarce.

Measures

We performed a narrative review on long term outcomes with ONS for treatment of headache disorders. We surveyed the available literature for studies that have outcomes for 24 months or greater to see if there is a habituation in response over time. Review of the literature revealed evidence in treatment of occipital neuralgia, chronic migraine, cluster headache, cervicogenic headache, short lasting unilateral neuralgiform headache attacks (SUNHA) and paroxysmal hemicrania. While the term "response" varied per individual study, a total of 17 studies showed outcomes in ONS with long term sustained responses (as defined per this review) in the majority of patients with specific headache types 177/311 (56%). Only 7 studies in total (3 cluster, 1 occipital neuralgia, 1 cervicogenic headache, 1 SUNHA, 1 paroxysmal hemicrania) provided both short-term and long-term responses up to 24 months to ONS. In cluster headache, the majority of patients (64%) were long term responders (as defined per this review) and only a minority of patients 12/62 (19%) had loss of efficacy (e.g., habituation). There was a high number 313/439 (71%) of adverse events per total number of patients in the studies including lead migration, requirements of revision surgery, allergy to surgical materials, infection and intolerable paresthesias.

Conclusions

With the evidence available, the response to ONS was sustained in the majority of patients with cluster headache with low rates of loss of efficacy in this patient population. There was a high percent of adverse events per number of patients in long term follow-up and likely related to the off-label use of leads typically used for spinal cord stimulation. Further longitudinal assessments of outcomes in occipital nerve stimulation with devices labelled for use in peripheral nerve stimulation are needed to evaluate the extent of habituation to treatment in headache.

High Plasma Oxalate Levels Early After Kidney Transplantation Are Associated With Impaired Long-Term Outcomes

Background: Elevated levels of oxalate are common in renal failure patients and non-hyperoxaluria disease, and may cause damage after transplantation. We examined outcomes after 15 years for 167 kidney transplant recipients who had plasma oxalate measured early after transplantation. Analyses included plasma oxalate, recipient age, donor age, live donor, HLA-DR mismatch, mGFR, and smoking. Results: Median age was 52 years (range 18-81), 63% were male and 38% had live donors. Median plasma oxalate concentration 10 weeks after transplantation was 9.0 μmol/L (range 2.7-53.0), one third above the upper reference limit (11.0 μmol/L). Multivariable analysis revealed upper quartile plasma oxalate (>13.0 μmol/L, p = 0.008), recipient age (p < 0.001), deceased donor (p = 0.003), and current smoking (p < 0.001) as significant factors associated with patient survival. Upper quartile plasma oxalate (p = 0.021), recipient age (p = 0.001), deceased donor kidney (p = 0.001), HLA-DR mismatch (p = 0.015), and current smoking (p = 0.014) were also associated with graft loss. Factors associated with death censored graft losses were donor age (p = 0.012), deceased donor (p = 0.032), and HLA-DR mis-matched kidneys (p = 0.005) but plasma oxalate was not (p = 0.188). Conclusions: Plasma oxalate in the upper quartile early after transplantation was significantly associated with impaired long-term patient survival and graft losses, but not when censored for death.

"Timing to carotid endarterectomy affects early and long term outcomes of symptomatic carotid stenosis."

OBJECTIVE

The aim of this study is to evaluate early and long-term outcomes according to the timing to carotid endarterectomy (CEA) of symptomatic carotid stenosis.

METHODS

Consecutive CEAs with selective shunting for symptomatic carotid stenosis ≥50% performed between 2009 and 2020. Patients had acute neurological impairment on presentation, defined as <5 points on the National Institutes of Health Stroke Scale(NIHSS). We grouped patients according to time between index event and CEA: the first group was operated between 0-2 days, the second group between 3 and 7 days, the third group between 8 and 14 days and the last group after 15 days. Thirty-day neurological status improvement was defined as a decrease (≥1) in the 30-day NIHSS score vs. NIHSS score immediately before surgery.

RESULTS

500 CEAs were performed. The perioperative combined stroke and mortality rate was 3.6% (18/500), representing a perioperative mortality rate of .2 (n=1) and stroke rate of 3.4% (n=17). Overall freedom from stroke was 95% at 1 year, 89 % at 6 years, and 88% at 10 years. Annual stroke rate was 0.6% after the 30-day period. Thirty-day improvement in neurologic status occurred in 103 patients (20.6%), while in 380 (76%) neurologic status was unchanged, and 17 (3.4%) experienced worsening of their neurologic status. Patients treated within 7 days from the index event had significant benefit (OR=2.6) in the 30-day neurological improvement vs. those treated after 7 days from the index event. Timing to CEA <2 days increased significantly the risk of late stroke (OR=9.7).

CONCLUSIONS

The ideal timing for performing CEA is between 3 and 7 days from the index event if NIHSS <5 as it is associated with the best rates of improvement in neurological status and durability in the long term. Very early CEA (<48 hours) was associated with increased late stroke occurrence.

Gender Dysphoria in children and young people: The implications for clinical staff of the Bell V's Tavistock Judicial Review and Appeal Ruling

In the past few years, there has been a very significant rise in the number of children and young people seeking treatment for gender dysphoria This area is the subject of much discussion, as evidenced in a recent court case in the UK which examined competence and capacity of young people to consent to potentially irreversible interventions. Clinicians involved in gaining consent to puberty blockers for gender dysphoric young people, must understand the evidence in this area and be aware of the heavy burden of accountability placed upon them.

Early and Long-Term Follow-Up for Chronic Type B and Type Non-A Non-B Aortic Dissection Using the Frozen Elephant Trunk Technique

Background: This study aimed to evaluate the early and long-term outcomes of a single center using a frozen elephant trunk (FET) procedure for chronic type B or non-A non-B aortic dissection.

Methods: From February 2009 to December 2019, 79 patients diagnosed with chronic type B or non-A non-B aortic dissection who underwent the FET procedure were included in the present study. We analyzed operation mortality and early and long-term outcomes, including complications, survival and interventions.

Results: The operation mortality rate was 5.1% (4/79). Spinal cord injury occurred in 3.8% (3/79), stroke in 2.5% (2/79), and acute renal failure in 5.1% (4/79). The median follow-up time was 53 months. The overall survival rates were 96.2, 92.3, 88.0, 79.8, and 76.2% at 1/2, 1, 3, 5 and 7 years, respectively. Moreover, 79.3% of patients did not require distal aortic reintervention at 7 years. The overall survival in the subacute group was superior to that in the chronic group (P = 0.047).

Conclusion: The FET technique is a safe and feasible approach for treating chronic type B and non-A non-B aortic dissection in patients who have contraindications for primary endovascular aortic repair. The technique combines the advantages of both open surgical repair and endovascular intervention, providing comparable early and long-term follow-up outcomes and freedom from reintervention.

Atypical Food protein-induced enterocolitis syndrome in children: Is IgE sensitization an issue longitudinally?

BACKGROUND

Food Protein-Induced Enterocolitis Syndrome (FPIES) is a clinically well-characterized, non-IgE mediated, food allergy syndrome yet its rare atypical presentation remain poorly understood.

OBJECTIVE

Aim of this study was to present the 10-year experience of a referral center highlighting the atypical FPIES cases and their long-term outcome.

METHODS

FPIES cases were prospectively, longitudinally evaluated in respect of food outgrowth and developing other allergic diseases with or without concomitant IgE sensitization later on in life.

RESULTS

Out of a total of 14,188 referrals (0.7%), 100 cases were identified. At presentation, 15 cases were found sensitized to the offending food. Fish was the most frequent eliciting food, followed by cow's milk and egg. Tolerance acquisition was earlier for cow's milk, followed by egg and fish, while found not protracted in atypical cases. Resolution was not achieved in half of the fish cases during the 10-year follow up time. Sensitization to food was not related to infantile eczema or culprit food but was related to sensitization to aeroallergens. In the long-term evaluation, persistence of the FPIES or aeroallergen's sensitization was significantly associated with an increased hazard risk of developing early asthma symptoms.

CONCLUSION

Sensitization to food was neither related to eczema, culprit food, nor to tolerance acquisition but rather to the development of allergic asthma through aero sensitization. In addition to an IgE profile in an early age, FPIES persistence may also trigger mechanisms switching FPIES cases to a Th2 immune response later in life, predisposing to atopic respiratory symptoms; albeit further research is required.

Maternal Iron Status in Pregnancy and Child Health Outcomes after Birth: A Systematic Review and Meta-Analysis

In pregnancy, iron deficiency and iron overload increase the risk for adverse pregnancy outcomes, but the effects of maternal iron status on long-term child health are poorly understood. The aim of the study was to systematically review and analyze the literature on maternal iron status in pregnancy and long-term outcomes in the offspring after birth. We report a systematic review on maternal iron status during pregnancy in relation to child health outcomes after birth, from database inception until 21 January 2021, with methodological quality rating (Newcastle-Ottawa tool) and random-effect meta-analysis. (PROSPERO, CRD42020162202). The search identified 8139 studies, of which 44 were included, describing 12,7849 mother–child pairs. Heterogeneity amongst the studies was strong. Methodological quality was predominantly moderate to high. Iron status was measured usually late in pregnancy. The majority of studies compared categories based on maternal ferritin, however, definitions of iron deficiency differed across studies. The follow-up period was predominantly limited to infancy. Fifteen studies reported outcomes on child iron status or hemoglobin, 20 on neurodevelopmental outcomes, and the remainder on a variety of other outcomes. In half of the studies, low maternal iron status or iron deficiency was associated with adverse outcomes in children. Meta-analyses showed an association of maternal ferritin with child soluble transferrin receptor concentrations, though child ferritin, transferrin saturation, or hemoglobin values showed no consistent association. Studies on maternal iron status above normal, or iron excess, suggest deleterious effects on infant growth, cognition, and childhood Type 1 diabetes. Maternal iron status in pregnancy was not consistently associated with child iron status after birth. The very heterogeneous set of studies suggests detrimental effects of iron deficiency, and possibly also of overload, on other outcomes including child neurodevelopment. Studies are needed to determine clinically meaningful definitions of iron deficiency and overload in pregnancy.

Post-Transplant Cyclophosphamide and Tacrolimus-Mycophenolate Mofetil Combination Governs GVHD and Immunosuppression Need, Reducing Late Toxicities in Allogeneic Peripheral Blood Hematopoietic Cell Transplantation from HLA-Matched Donors

Combined direct antineoplastic activity and the long-lasting immunological effects of allogeneic hematopoietic cell transplant (HCT) can cure many hematological malignancies, but broad adoption requires non-relapse mortality (NRM) rates and graft-versus-host disease (GVHD) control. Recently, posttransplant cyclophosphamide (PTCy) given after a bone marrow transplant significantly reduced GVHD-incidence, while PTCy given with tacrolimus/mofetil mycophenolate (T/MMF) showed activity following allogeneic peripheral blood stem cell transplantation (alloPBSCT). Here, we report the experience of a larger cohort (85 consecutive patients) and expanded follow-up period (03/2011-12/2019) with high-risk hematological malignancies who received alloPBSCT from Human-Leukocyte-Antigens HLA-matched unrelated/related donors. GVHD-prophylaxis was PTCy 50 mg/kg (days+3 and +4) combined with T/MMF (day+5 forward). All patients stopped MMF on day+28 with day+110 = median tacrolimus discontinuation. Cumulative incidences were 12% for acute and 7% for chronic GVHD- and no GVHD-attributed deaths. For surviving patients, the 12, 24, and 36-month probabilities of being off immunosuppression were 92, 96, and 96%, respectively. After a 36-month median follow-up, NRM was 4%; median event-free survival (EFS) and overall survival (OS) had yet to occur. One- and two-year chronic GVHD-EFS results were 57% (95% CI, 46-68%) and 53% (95% CI, 45-61%), respectively, with limited late infections and long-term organ toxicities. Disease relapse caused the most treatment failures (38% at 2 years), but low transplant toxicity allowed many patients (14/37, 38%) to receive donor lymphocyte infusions as a post-relapse strategy. We confirmed that PTCy+T/MMF treatment effectively prevented acute and chronic GVHD and limited NRM to unprecedented low rates without loss of disease control efficacy in an expanded patient cohort. This trial is registered at U.S. National Library of Medicine as #NCT02300571.

Long-Term Outcomes of Biotechnology Student Participation in Undergraduate Research Experiences at Delaware Technical Community College

Engagement in undergraduate research experiences (UREs) positively impacts student skill development, scientific identity, and retention in STEM. Incorporating UREs into 2-year programs would greatly benefit the diverse, nontraditional student populations enrolled at community colleges. This article describes the infusion of the Bioscience/Biotechnology program at Delaware Technical Community College with course-based and mentored research experiences that could serve as a model for other institutions. Studies done with the Office of Institutional Research revealed a concurrent increase in enrollment and graduation rates. Retrospective interviews with graduates from the program highlight the critical influence of research, the mentor/student relationship, and a sense of community on the development of transferable skills, self-efficacy, and subsequent successes in pursuing higher education and employment.

The Mid- to Long-Term Outcomes of the Lateral Domed Oxford Unicompartmental Knee Replacement: An Analysis From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man

BACKGROUND

Lateral unicompartmental knee replacement (UKR) is an alternative to total knee replacement for isolated lateral unicompartmental knee arthritis. The geometry and mechanics of the lateral compartment differ to the medial compartment with the Lateral Domed Oxford UKR designed to address this. We used the National Joint Registry (NJR) data to report the mid- to long-term outcomes of this device.

METHODS

We performed a retrospective observational study using NJR data on 992 Lateral Domed Oxford UKRs implanted between 1st January 2005 and 31st December 2017. Outcomes of interest were implant survival and revision indications.

RESULTS

The 10 year cumulative implant survival rates were 88.6% (CI 85.3-91.2). When compared with <55 year age group, the 55-64, 65-74 and ≥75 groups had significantly lower revision rates (hazard ratio (HR) = 0.56 (CI 0.32-0.98, P = .04), HR 0.40 (CI 0.22-0.72, P = .003), and HR 0.27 (CI 0.12-0.58, P = .001), respectively). The obese group had significantly (P = .04) increased revision risk compared with normal BMI (HR 2.33, CI 1.06-5.12). The commonest reasons for revision surgery were dislocation (n = 23, 2.3%), pain (n = 15, 1.5%), and aseptic loosening (n = 14, 1.4%).

CONCLUSION

The Lateral Domed Oxford UKR provides a good option for isolated lateral compartment osteoarthritis. However, dislocation of the mobile bearing remains a problem, occurring in 2.3% of the patients and accounting for 30% of the revisions. To help prevent dislocation, it is now possible to assess bearing stability intraoperatively and if very unstable to implant a compatible fixed bearing tibial component, without the need for further bone preparation.

Predictive Values of Location and Volumetric MRI Injury Patterns for Neurodevelopmental Outcomes in Hypoxic-Ischemic Encephalopathy Neonates

Hypoxic-ischemic encephalopathy (HIE) is a severe neonatal complication with up to 40–60% long-term morbidity. This study evaluates the distribution and burden of MRI changes as a prognostic indicator of neurodevelopmental (ND) outcomes at 18–24 months in HIE infants who were treated with therapeutic hypothermia (TH). Term or late preterm infants who were treated with TH for HIE were analyzed between June 2012 and March 2016. Brain MRI scans were obtained from 107 TH treated infants. For each infant, diffusion weighted brain image (DWI) sequences from a 3T Siemens scanner were obtained for analysis. Of the 107 infants, 36 of the 107 infants (33.6%) had normal brain MR images, and 71 of the 107 infants (66.4%) had abnormal MRI findings. The number of clinical seizures was significantly higher in the abnormal MRI group (p < 0.001) than in the normal MRI group. At 18–24 months, 76 of the 107 infants (70.0%) showed normal ND stages, and 31 of the 107 infants (29.0%) exhibited abnormal ND stages. A lesion size count >500 was significantly associated with abnormal ND. Similarly, the total lesion count was larger in the abnormal ND group (14.16 vs. 5.29). More lesions in the basal ganglia (BG) and thalamus areas and a trend towards more abnormal MRI scans were significantly associated with abnormal ND at 18–24 months. In addition to clinical seizure, a larger total lesion count and lesion size as well as lesion involvement of the basal ganglia and thalamus were significantly associated with abnormal neurodevelopment at 18–24 months.

The prognosis of brain magnetic resonance imaging injury pattern for outcomes of hypothermia-treated infants

Magnetic resonance imaging (MRI) can be a tool that allows the observation of structural injury patterns after cooling. The aim of this study was to determine the early pattern of brain injury in the MRIs of infants with hypoxic ischemic encephalopathy (HIE) after cooling and to search for any clinical factors related to abnormal MRI findings.The study retrospectively recruited 118 infants who were treated with therapeutic hypothermia (TH) between 2013 and 2016.Forty-three patients had normal brain MRI, and 75 had abnormal brain MRI findings. The TH-treated infants with abnormal brain MRI readings showed significantly more clinical seizures and the use of additional antiepileptic drugs (AEDs) than the normal MRI group. As a long-term outcome, more lesions in the basal ganglia and thalamus, posterior limb of internal capsule, or severe white matter lesions were associated with abnormal neurodevelopmental outcomes at 18 to 24 months of age.A higher frequency of clinical seizures and AED use were related to abnormal brain injury on MRI. A significant risk for poor long-term outcomes was found in the abnormal brain MRI group.

Laser-assisted in situ keratomileusis long term outcomes in late adolescence

PURPOSE

Evaluate the long term outcomes of myopic-LASIK in a late adolescent population (age ⩾17 and <20 at the time of surgery).

METHODS

Monocentric retrospective case series study. Eyes with at least 3 years of follow-up time were included. Primary outcome measures were long term efficacy, safety and stability of the refractive error. Secondary outcome measure was the evaluation of the relation between the postoperative spherical aberration and the long term stability of the refractive error.

RESULTS

Forty-seven eyes of 25 patients were included. Mean follow-up was 9.23 ± 3.16 years. Mean age at the time of surgery was 18.74 ± 0.44 years. With time, postoperative UDVA showed a mild but significant deterioration of 1-2 Snellen lines (p = 0.012), in connection with a mild but significant myopization of the SE (mean increase of -0.43 D; p < 0.001), sphere (mean increase of -0.29 D; p = 0.004) and cylinder (mean increase of -0.16 D; p = 0.013). CDVA remained stable over time (p > 0.05). Efficacy index decreased from 1.01 to 0.87 in the long term (77% UDVA ⩾ 20/32). Safety remained at 1.06. 66% and 74% of eyes presented a SE within ±0.50 D and ±1.00 D respectively. SE changed over 0.50D in 33% of eyes. No correlation could be detected between the SE and the postoperative spherical aberration. No cases of corneal ectasia were detected.

CONCLUSIONS

Myopic-LASIK in late adolescence is safe and effective, but a mild myopic progression occurs. Despite presence of refractive stability is preferable, if necessary, myopic LASIK provides relatively good outcomes in the long term in this young population.

Getting back on the bike: Participation in cycling after a hospitalisation crash

This study firstly aimed to describe bicyclists' return to cycling after a hospitalisation crash. Secondly, it aimed to determine factors associated with reduced cycling post-crash. A study of 83 cyclists hospitalised due to an on-road crash was undertaken in Perth, Western Australia. Participants completed a questionnaire shortly following the crash and were followed up approximately 12 months after the crash. Injury information was obtained from the WA State Trauma Registry. A binary logistic regression model was used to examine factors associated with 'reduced cycling exposure' at follow-up. Sixty percent of participants had 'reduced cycling exposure' and 40% had 'no reduction in cycling exposure' at follow up. Twenty-two percent of participants had not cycled at all since the crash. Despite 46% reporting fear of crashing/ lack of confidence as a reason for 'reduced cycling exposure', only 7% of all participants had received any counselling. After controlling for confounding factors, those who participated in group riding before the crash (OR: 0.24, 95% CI: 0.08-0.66, p = 0.006) and those who had a 'complete functional recovery' (OR: 0.15, 95% CI: 0.04-0.64, p = 0.011), had lower odds of 'reduced cycling exposure' at follow-up. In addition, those who were not employed full time at baseline had higher odds of 'reduced cycling exposure' at follow up (OR: 3.72, 95% CI: 1.22-11.33, p = 0.021). Provision of psychological services following a bicycle crash may be an important intervention for improving levels of fear and confidence surrounding cycling and assisting cyclists in returning to their pre-crash level of participation. In addition, interventions promoting return to cycling, should be targeted towards non-group riders who cycle for either commuting or recreational purposes.

Neurodevelopmental Outcomes Among Children With Congenital Heart Disease: At-Risk Populations and Modifiable Risk Factors

As survivable outcomes among patients with complex congenital heart disease (cCHD) have continued to improve over the last several decades, more attention is being dedicated to interventions that impact not just survival but quality of life among patients with cCHD. In particular, patients with cCHD are at risk for impaired neurodevelopmental outcomes. In this review summarizing select presentations given at the 14th Annual Pediatric Cardiac Intensive Care Society's Annual Meeting in 2019, we discuss the neurodevelopmental phenotype of patients with cCHD, patients at greatest risk of impaired development, and three specific modifiable risk factors impacting development.

Assessing the Long-term Patency and Clinical Outcomes of Venous and Arterial Grafts Used in Coronary Artery Bypass Grafting: A Meta-analysis

Introduction

The long-term patency of the grafts used during the coronary artery bypass grafting (CABG) is one of the most significant predictors of the clinical outcomes. The gold standard graft used during CABG with the best long-term patency rate and the better clinical outcomes is left internal thoracic artery (LITA) grafted to the left coronary artery (LCA). The controversy lies in choosing the second-best conduit for the non-left coronary artery (NLCA) with similar patency rate as LITA. This meta-analysis examines the long-term patency and clinical outcomes of all arterial grafts versus all venous grafts used during the CABG.

Methods

A comprehensive literature search of all published randomized control trials (RCTs) assessing long-term patency and clinical outcomes of grafts used in CABG was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2018). Keywords searched included combinations of “CABG”, “venous grafts in CABG”, “arterial grafts in CABG”, “radial artery grafts in CABG”, “gastroepiploic artery grafts in CABG”, “patency and clinical outcomes”. Inclusion criteria included: RCTs comparing the long-term patency, and clinical outcomes of radial artery, right internal thoracic artery, gastroduodenal artery, and saphenous vein grafts used in CABG. Long-term patency of the grafts and clinical outcomes were analyzed.

Results

Eight RCTs involving 2,091 patients with 1,164 patients receiving arterial grafts and 927 patients receiving venous grafts were included. There was no difference between the long-term patency rate (relative risk (RR) = 1.050, 95% confidence interval (CI) = 0.949 to 1.162, and p = 0.344), overall mortality rate (RR = 1.095, 95% CI = 0.561 to 2.136, and p = 0.790), rate of myocardial infarction (MI) (RR = 0.860, 95% CI = 0.409 to 1.812, and P = 0.692), and re-intervention rate (RR = 0.0768, 95% CI = 0.419 to 1.406, and P = 0.392) between arterial and venous grafts.

Conclusion

The use of arterial conduits over the venous conduits has no significant superiority regarding the long-term graft patency, the rate of MI, overall mortality, and the rate of revascularization following CABG. Additional adequately powered studies are needed to further evaluate the long-term outcomes of arterial and venous grafts following the CABG.

Bicuspid aortic valve repair: systematic review on long-term outcomes

Background

Many patients with bicuspid aortic valve (BAV) develop aortic regurgitation but are not considered for valve repair. This is partly due to limited long term data regarding repair durability. The purpose of the review is to summarize the long-term (1 year) outcomes of BAV repair.

Methods

A systematic review was performed to evaluate durability and survival following BAV repair. OVID SP versions of MEDLINE and Embase were searched using 'aortic valve', 'bicuspid', 'repair', 'David' 'Yacoub', 'reimplantation' and 'remodeling'.

Results

Initial search produced 770 abstracts, reduced to 92 full papers for review after excluding duplications and abstract review for relevance. Twenty-six studies met full inclusion criteria. BAV repair revealed low operative mortality, with excellent 5-year survival, and low freedom from reoperation. Differences in surgical technique between reimplantation and remodeling do not appear to confer protection against reintervention. Systematic assessment of cusp height and annular stabilization in some form do appear to favor improved long term durability. Leaflet calcification is associated with higher rates of reintervention.

Conclusions

BAV repair is associated with acceptable long term survival. Ongoing standardized outcome assessments will further refine surgical techniques associated with excellent repair durability.

Models of Peer Support to Remediate Post-Intensive Care Syndrome: A Report Developed by the Society of Critical Care Medicine Thrive International Peer Support Collaborative

OBJECTIVES

Patients and caregivers can experience a range of physical, psychologic, and cognitive problems following critical care discharge. The use of peer support has been proposed as an innovative support mechanism.

DESIGN

We sought to identify technical, safety, and procedural aspects of existing operational models of peer support, among the Society of Critical Care Medicine Thrive Peer Support Collaborative. We also sought to categorize key distinctions between these models and elucidate barriers and facilitators to implementation.

SUBJECTS AND SETTING

Seventeen Thrive sites from the United States, United Kingdom, and Australia were represented by a range of healthcare professionals.

MEASUREMENTS AND MAIN RESULTS

Via an iterative process of in-person and email/conference calls, members of the Collaborative defined the key areas on which peer support models could be defined and compared, collected detailed self-reports from all sites, reviewed the information, and identified clusters of models. Barriers and challenges to implementation of peer support models were also documented. Within the Thrive Collaborative, six general models of peer support were identified: community based, psychologist-led outpatient, models-based within ICU follow-up clinics, online, groups based within ICU, and peer mentor models. The most common barriers to implementation were recruitment to groups, personnel input and training, sustainability and funding, risk management, and measuring success.

CONCLUSIONS

A number of different models of peer support are currently being developed to help patients and families recover and grow in the postcritical care setting.

Incidence of Adverse Reactions to Metal Debris From 28-mm Metal-on-Metal Total Hip Arthroplasties With Minimum 10 Years of Follow-Up: Clinical, Laboratory, and Ultrasound Assessment of 44 Cases

BACKGROUND

Total hip arthroplasty with metal-on-metal (MoM) bearings has been suspected to cause adverse reactions to metal debris (ARMD), with the incidence varying greatly by implant type and patient gender. The prevalence of ARMD from small-diameter MoM bearings in women is unknown, especially after 10 years of follow-up (FU).

METHODS

Cementless 28-mm MoM total hip arthroplasty bearings (Metasul) were implanted consecutively in 42 active women between 1996 and 2002. They were reviewed after a minimum of 10 years' FU with clinical, laboratory, radiological, and ultrasound assessments.

RESULTS

Mean FU was 15.9 years (range, 13-18). The mean Postel-Merle d'Aubigné and Oxford scores were 16.9 (range, 13-18) and 15.1 (range, 12-24), respectively, at FU. Mean cup inclination angle was 46.3° (range, 35°-57°). No femoral osteolysis was detected, but limited acetabular osteolysis (11%) over the screw holes occurred in 5 cases. No liquid or solid synovial reactions or ARMD were apparent on ultrasound, even in the 5 cases of pelvic osteolysis. Mean chromium levels were 1.32 μg/L (range, 0.1-7.9) and cobalt levels were 1.85 μg/L (range, 0.35-13.6). Cobalt was >3 μg/L in only 3 cases. The 15.9-year survivorship was 95% (range, 94.1%-98.9%).

CONCLUSION

Reliable results were obtained with 28-mm MoM bearings, notably in young, active patients. This implant configuration requires very accurate positioning. No ARMD was seen in this group at 16 years' FU.

First-line antiretroviral therapy durability in a 10-year cohort of naïve adults started on treatment in Uganda

INTRODUCTION

The majority of studies from resource-limited settings only report short-term virological outcomes of patients on antiretroviral treatment (ART). We aim to describe the long-term durability of first-line ART and identify factors associated with long-term virological outcomes.

METHODS

At the Infectious Diseases Institute in Kampala, Uganda, 559 adult patients starting ART in 2004 were enrolled into a research cohort and monitored with viral load (VL) testing every six months for 10 years. We report the proportion and cumulative probability of 1) achieving virologic suppression (at least one VL <400 copies/ml); 2) experiencing virologic failure in patients who achieved suppression (two consecutive VLs >1000 copies/ml or one VL >5000, for those without a subsequent one); 3) treatment failure (not attaining virologic suppression or experiencing virologic failure). We used Cox regression methods to determine the characteristics associated with treatment failure. We included gender, baseline age, WHO stage, body mass index, CD4 count, propensity score for initial ART regimen, VL, time-dependent CD4 count and adherence.

RESULTS

Of the 559 patients enrolled, 472 (84.8%) had at least one VL (67 died, 13 were lost to follow-up, 4 transferred, 2 had no VL available); 73.6% started on d4T/3TC/nevirapine and 26.4% on AZT/3TC/efavirenz. Patients in the two groups had similar characteristics, except for the higher proportion of patients in WHO Stage 3/4 and higher VL in the efavirenz-based group. Four hundred thirty-nine (93%) patients achieved virologic suppression with a cumulative probability of 0.94 (confidence interval (CI): 0.92-0.96); 74/439 (16.9%) experienced virologic failure with a cumulative probability of 0.18 (CI: 0.15-0.22). In the multivariate analysis, initial d4T/3TC/nevirapine regimen (hazard ratio (HR): 3.02; CI: 3.02 (1.66-5.44, p<0.001)) and baseline VL ≥5 log10 copies/ml (HR: 2.29; CI: 1.29-4.04) were associated with treatment failures; patients of older age (HR: 0.87 per five-year increase; CI: 0.77-0.99), with adherence >95% (HR: 0.04; CI: 0.02-0.11) and with higher time-dependent CD4 count (HR: 0.94 per 50 cells/µl increase; CI: 0.92-0.99, p<0.001) were less likely to experience treatment failure.

CONCLUSIONS

The long-term virological outcomes from this cohort are promising and comparable to those from research-rich settings. Our results provide further evidence that efavirenz is associated with better virological outcomes.

Long Term Outcomes of a Curriculum on Care for the Underserved

ACKNOWLEDGEMENTS

This work was funded by HRSA grants D16HP00067 and D08PE50097.

BACKGROUND

Evaluations of curricula to enhance ability to care for the underserved are often limited to short-term medical student outcomes.

PURPOSE

This study evaluates retention of short-term improvements in outcomes from post-curriculum to graduation.

METHODS

Third-year students on 2003-2004 pediatric clerkships were randomized to a curriculum on caring for the underserved in one of three formats: established "readings only", faculty-led, or web-based. Outcomes (knowledge, attitudes, self-efficacy and clinical skills) were assessed at three timepoints-pre- and post-curriculum and at graduation. Analyses, from 2009-2010, included Fisher's exact test to assess the relationship of curriculum group with response patterns, demographics, and outcomes at graduation. Multivariate regression was used to model the longitudinal relationship between outcomes and curriculum groups, adjusting for prior clerkship experiences, baseline scores, and clustering by student.

RESULTS

Of 137 students, 135 (99%) completed the pre-curriculum survey, 128 (93%) completed the post-curriculum survey and 88 (64%) completed the graduation survey. Post-curriculum improvements in self-efficacy and clinical skills seen among students receiving the faculty-led or web-based curricula were retained at graduation. At graduation, web-based curriculum students' self-efficacy was significantly greater for "establishing achievable goals with underserved families" compared to established curriculum students. With regard to skills relevant to caring for the underserved, few graduates had facilitated a referral to Women, Infants and Children (33%) or followed up to ensure a patient accessed a needed resource (56%).

CONCLUSIONS

Self-efficacy and skills gained through web-based and faculty-led curricula were retained at graduation. Data from items at graduation support targeted curricular improvement.

Long Term Treatment Results for Deep Infections of Total Knee Arthroplasty

This study aims to identify the long-term outcomes of total knee arthroplasty (TKA) treated for deep infection. 3270 consecutive primary and 175 revision TKAs were followed prospectively. There were 39 deep infections (1.16%): 29 primary (0.9%) and 10 revision (5.7%) cases. Two-stage resection and re-implantation procedure was performed in 13 primary cases with 10/13 (77%) successfully resolved. Early (<1 month) Irrigation and Debridement (I&D) was performed in 16 primary cases with 100% success. Late (>4 months) I&D was performed in 6 cases with 5/6 (83.3%) successful. Infection following revision TKA resulted in poor outcomes with both two-stage (2/4 successful) and I&D (2/6 successful). Deep infection after primary TKA can be successfully resolved with I&D and appropriate antibiotic treatment in the early postoperative course.

Ten year outcomes of participants in the REACT (Randomised Evaluation of Assertive Community Treatment in North London) study

BACKGROUND

A previous randomised controlled trial that investigated Assertive Community Treatment (ACT) in the UK (the REACT Study) found no clinical advantage over usual care delivered by Community Mental Health Teams (CMHTs) at 18 and 36 month follow-ups. No studies have investigated long term clinical and social outcomes for patients receiving ACT.

METHOD

We investigated inpatient service use, social outcomes, service contact and adverse events for the 251 REACT study participants 10 years after randomisation through case note review. Data were analysed using regression models adjusted for original treatment group allocation and changes in treatment group.

RESULTS

We found no statistically significant differences in outcomes by original treatment group over the 10 years. Those whose care remained with ACT, or transferred to ACT or forensic services, had more inpatient days over the 10 years (coefficient 223, 95% CI 83 to 363, p = 0.002) than those whose care remained with the CMHTs or were discharged to primary care. Being subject to a Community Treatment Order was associated with a greater chance of being under ACT at 10 year follow-up (OR 6.39, 95% CI 2.98 to 13.70, p <0.001).

CONCLUSIONS

The ACT teams in this study showed no clinical advantage over usual care provided by CMHTs at 10 year follow-up. We also found that the ACT teams accrued patients from the original study sample who had more complex needs than those who remained with or transferred to the CMHTs or primary care during this period. Further well conducted trials are needed to identify the most cost-effective approaches to supporting successful community living and optimum long term outcomes for this group.

Long term outcomes of pharmacological treatments for opioid dependence: does methadone still lead the pack?

The aim of this review was to update and summarize the scientific knowledge on the long term outcomes of the different pharmacological treatment options for opioid dependence currently available and to provide a critical discussion on the different treatment options based on these results. We performed a literature search using the PubMed databases and the reference lists of the identified articles. Data from research show that the three pharmacological options reviewed are effective treatments for opioid dependence with positive long term outcomes. However, each one has its specific target population and setting. While methadone and buprenorphine are first line options, heroin-assisted treatment is a second line option for those patients refractory to treatment with methadone with concomitant severe physical, mental, social and/or functional problems. Buprenorphine seems to be the best option for use in primary care offices. The field of opioid dependence treatment is poised to undergo a process of reinforcement and transformation. Further efforts from researchers, clinicians and authorities should be made to turn new pharmacological options into clinical reality and to overcome the structural and functional obstacles that maintenance programmes face in combatting opioid dependence.

Long-term outcomes of a new model of anatomical hydroxyapatite-coated hip prosthesis

This prospective study was designed to evaluate 196 Anatomique Benoist Giraud (ABG II) total hip arthroplasties which were implanted between September 1999 and December 2000. A minimum 11 years follow up was completed in 183 cases. The bearing surfaces were polyethylene-zirconia in 84 cases, polyethylene-metal in 42 and ceramic-ceramic in 57. Changes in the femoral stem design, in relation to the previous ABG I model, have led to a significant improvement in stress-shielding. Polyethylene wear rate was lower by more than 50% compared with non-crosslinked polyethylene. Excellent and good results were obtained in 90.32% of cases, and implant survival was 98.39% at the end of follow-up.

Novel risk markers and long-term outcomes of delirium: the successful aging after elective surgery (SAGES) study design and methods

OBJECTIVES

Delirium, a costly, life-threatening, and potentially preventable condition, is a common complication for older adults following major surgery. Although the basic epidemiology of delirium after surgery has been defined, the contribution of delirium to long term outcomes remains uncertain, and novel biomarkers from plasma and neuroimaging have yet to be examined. This program project was designed to contribute to our understanding of the complex multifactorial syndrome of delirium.

DESIGN

Long term prospective cohort study.

SETTING

Three academic medical centers (2 hospitals and 1 coordinating center).

PARTICIPANTS

Patients without recognized dementia (targeted cohort= 550 patients) age 70 and older scheduled to undergo elective major surgery are assessed at baseline before surgery, daily during their hospital stay, and for 18 to 36 months after discharge.

MEASUREMENTS

The Successful Aging after Elective Surgery (SAGES) study is an innovative, interdisciplinary study that includes biomarkers, neuroimaging, cognitive reserve markers, and serial neuropsychological testing to examine the contribution of delirium to long term cognitive and functional decline. The primary goal is to examine the contribution of delirium to long term cognitive and functional decline. In addition, novel risk markers for delirium are being examined, including plasma biomarkers (eg, cytokines, proteomics), advanced neuroimaging markers (eg, volumetric, white matter hyperintensity, noncontrast blood flow, and diffusion tensor measures), and cognitive reserve markers (eg, education, occupation, lifetime activities).

CONCLUSION

Results from this study will contribute to a fuller understanding of the etiology and prognosis of delirium. Ultimately, we hope this project will provide the groundwork for future development of prevention and treatment strategies for delirium, designed to minimize the long term negative impact of delirium in older adults.

Long-term outcomes in elderly surgical patients

Anesthesia has developed to the point where long-term outcomes are important endpoints. Elderly patients are becoming an increasingly large part of most surgical practices, consistent with demographic shifts. Long-term outcomes are particularly important for this group. In this review, we discuss functional outcomes in the elderly. We describe the areas of cognitive change and frailty, both of which are specific to the elderly. We also discuss prevention of surgical infections and emerging evidence around hemodynamic alterations in the operating room and their impact on long-term outcomes.