Darrell R Schroeder

Mayo Clinic - Scottsdale, Scottsdale, Arizona, United States

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Publications (356)1692.73 Total impact

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    ABSTRACT: Purpose: The immune system plays an important role in tumour progression. Systemic opioids are immunosuppressive; thus, theoretically they may promote tumour spread. Our primary aim was to test the hypothesis that general anesthesia (GA) with spinal analgesia (SA) in patients with bladder cancer undergoing radical cystectomy (RC) will both reduce systemic opioid use and improve oncological outcomes. Since blood transfusions also induce immunosuppression, a secondary aim was to evaluate the effect of perioperative transfusions on oncological outcomes. Methods: One hundred ninety-five patients who underwent RC with GA+SA from 1998-2007 were matched 1:1 to controls who underwent surgery with GA only using propensity scoring and tumour characteristics known to be highly associated with oncological outcomes. Medical records were reviewed for use of opioids and transfusions. Outcomes were tumour recurrence, cancer-specific mortality, and all-cause mortality. Survival was estimated using the Kaplan-Meier method, and associations of anesthetic technique and transfusions with outcomes were analyzed using stratified multivariable proportional hazard regression. Results: Systemic opioid use was reduced with GA+SA relative to GA (P < 0.001). There was no difference between groups with respect to all-cause mortality (hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.77 to 1.53; P = 0.636), bladder cancer mortality (HR, 1.03; 95% CI, 0.66 to 1.61; P = 0.893), or cancer recurrence (HR, 1.32; 95% CI, 0.86 to 2.02; P = 0.205). Nevertheless, patients who were perioperatively transfused had an increased all-cause mortality (HR, 2.21; 95% CI, 1.11 to 4.40; P = 0.025), and cancer-specific mortality (HR, 2.61; 95% CI, 1.05 to 6.48; P = 0.039). Conclusions: In patients undergoing RC, the opioid-sparing effect with SA was not associated with improved oncological outcomes, while blood transfusion was associated with increased mortality.
    No preview · Article · Feb 2016 · Canadian Journal of Anaesthesia
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    Full-text · Article · Feb 2016
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    ABSTRACT: Introduction: Cigarette smoking is a known risk factor for postoperative complications. Quitting or cutting down on cigarettes around the time of surgery may reduce these risks. This study aimed to determine the feasibility of using electronic nicotine delivery systems (ENDS) to help patients achieve this goal, regardless of their intent to attempt long-term abstinence. Methods: An open-label observational study was performed of cigarette smoking adults scheduled for elective surgery at Mayo Clinic Rochester and seen in the pre-operative evaluation clinic between December 2014 and June 2015. Subjects were given a supply of ENDS to use prior to and 2 weeks after surgery. They were encouraged to use them whenever they craved a cigarette. Daily use of ENDS was recorded, and patients were asked about smoking behavior and ENDS use at baseline, 14 days and 30 days. Results: Of the 105 patients approached, 80 (76%) agreed to participate; five of these were later excluded. Among the 75, 67 (87%) tried ENDS during the study period. At 30-day follow-up, 34 (51%) who had used ENDS planned to continue using them. Average cigarette consumption decreased from 15.6 per person/d to 7.6 over the study period (P < .001). At 30 days, 11/67 (17%) reported abstinence from cigarettes. Conclusion: ENDS use is feasible in adult smokers scheduled for elective surgery and is associated with a reduction in perioperative cigarette consumption. These results support further exploration of ENDS as a means to help surgical patients reduce or eliminate their cigarette consumption around the time of surgery. Implications: Smoking in the perioperative period increases patients' risk for surgical complications and healing difficulties, but new strategies are needed to help patients quit or cut down during this stressful time. These pilot data suggest that ENDS use is feasible and well-accepted in surgical patients, and worthy of exploration as a harm reduction strategy in these patients.
    No preview · Article · Jan 2016 · Nicotine & Tobacco Research
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    ABSTRACT: Objective: To examine whether exposure to general anesthesia for operations and procedures after the age of 40 years is associated with incident mild cognitive impairment (MCI) in elderly patients. Patients and methods: A population-based, prospective cohort of Olmsted County, Minnesota, residents aged 70 to 89 years at enrollment, underwent baseline and 15-month interval evaluations that included the Clinical Dementia Rating scale, a neurologic evaluation, and neuropsychological testing. Anesthesia records after the age of 40 years until last evaluation for MCI were abstracted. Proportional hazards regression, adjusting for other known MCI risk factors, was used to assess whether exposure to surgical general anesthesia after the age of 40 years is associated with the incidence of MCI. Results: Of 1731 participants (mean age, 79 years), 536 (31.0%) developed MCI during a median follow-up of 4.8 years. Anesthesia exposure was not associated with MCI when analyzed as a dichotomous variable (any vs none; adjusted hazard ratio [HR], 1.07; 95% CI, 0.83-1.37; P=.61), the number of exposures (adjusted HR, 1.05; 95% CI, 0.78-1.42; adjusted HR, 1.12; 95% CI, 0.86-1.47; and adjusted HR, 1.02; 95% CI, 0.76-1.34, for 1, 2-3, and ≥4 exposures compared with no exposure as the reference; P=.73), or the total cumulative duration of exposure (adjusted HR, 1.00; 95% CI, 0.98-1.01, per 60-minute increase; P=.83). In secondary sensitivity analyses, anesthesia after 60 years of age was associated with incident MCI (adjusted HR, 1.25; 95% CI, 1.02-1.55; P=.04), as was exposure in the previous 20 and 10 years. Conclusion: We found no significant association between cumulative exposure to surgical anesthesia after 40 years of age and MCI. However, these data do not exclude the possibility that anesthetic exposures occurring later in life may be associated with an increase in the rate of incident MCI.
    Full-text · Article · Jan 2016 · Mayo Clinic Proceedings
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    ABSTRACT: Objective: The aim of the study was to determine whether there is an association between current menopausal symptom bother and a history of abuse (physical, sexual, or emotional/verbal) in the last year. Methods: A cross-sectional survey was completed using the Data Registry on Experiences of Aging, Menopause, and Sexuality and the Menopause Health Questionnaire. Data from the Menopause Health Questionnaire were collected from 4,956 women seen consecutively for menopause consultation in the Women's Health Clinic at Mayo Clinic (Rochester, MN) from January 1, 2006 through October 7, 2014. Data from 3,740 women were included in the analysis. Menopausal symptom ratings were compared between women reporting a history of abuse (physical, sexual, or emotional/verbal) in the last year and those not using a two-sample t test. Analysis of covariance was used to assess whether abuse was associated with menopausal symptom bother after adjusting for baseline participant characteristics. Results: Of the 3,740 women, 253 (6.8%) reported experiencing one or more forms of abuse in the last year, the majority (96%) of which was verbal/emotional abuse. Those reporting abuse in the last year had higher (P < 0.001) mean total menopausal symptom bother scores. Consistent findings were obtained from multivariable analyses adjusting for all demographic and substance use characteristics. Conclusions: In the present study from the Data Registry on Experiences of Aging, Menopause, and Sexuality, menopausal symptom bother scores were directly associated with recent self-reported abuse.
    Full-text · Article · Jan 2016 · Menopause (New York, N.Y.)
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    ABSTRACT: Background: Prior research has provided inconsistent data regarding the risk factors associated with complications from arterial cannulation. The goal of this study was to clearly define the incidence and risks factors associated with arterial cannulation complications. Methods: After obtaining institutional review board approval, all patients requiring arterial line placement with documentation were included in this retrospective study between January 1, 2006, and December 31, 2012. Leveraging two robust data warehouses, the Perioperative DataMart and the Mayo Clinic Life Silences System, the authors cross-matched arterial line cannulation with a documented vascular consult, neurologic consult, infection, or return to surgery within 30 days in order to identify the initial patient population. Results: A total of 62,626 arterial lines were placed in 57,787 patients, and 90.1% of the catheters placed were 20-gauge catheters. The radial artery was cannulated in 94.5% of patients. A total of 21 patients were identified as having experienced vascular complications or nerve injuries, resulting in a complication rate of 3.4 per 10,000 (95% CI, 2.1 to 5.1). Cardiac surgery had the largest number of catheters placed (n = 15,419) with 12 complications (complication rate = 7.8 per 10,000; 95% CI, 4.0 to 13.6). The rate of complications differed significantly (P < 0.001) across the three most common catheter sizes (2.7 per 10,000 [95% CI, 1.5 to 4.4] for 20 gauge, 17.2 per 10,000 [95% CI, 4.7 to 43.9] for 18 gauge, and 9.4 per 10,000 [95% CI, 1.1 to 34.1] for 5 French). Conclusion: In a large retrospective study, the authors document a very low rate of complications with arterial line placement.
    No preview · Article · Dec 2015 · Anesthesiology
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    ABSTRACT: Obesity is a leading preventable cause of death and disability and is associated with a lower health-related quality of life. We evaluated the impact of telecoaching conducted by a counselor trained in motivational interviewing paired with a portion control plate for obese patients in a primary care setting. We conducted a randomized, clinical trial among patients in a primary care practice in the midwestern United States. Patients were randomized to either usual care or an intervention including telecoaching with a portion control plate. The intervention was provided during a 3-month period with follow-up of all patients through 6 months after randomization. The primary outcomes were weight, body mass index (BMI),waist circumference, and waist to hip ratio measured at baseline, 6, 12, 18, and 24 weeks. Secondary outcomes included measures assessing eating behaviors, self-efficacy, and physical activity at baseline and at 12 and 24 weeks. A total of 1,101 subjects were pre-screened, and 90 were randomly assigned to telecoaching plus portion control plate (n = 45) or usual care (n = 45). Using last-value carried forward without adjustment for baseline demographics, significant reductions in BMI (estimated treatment effect -0.4 kg/m(2), P = .038) and waist to hip ratio (estimated treatment effect -.02, P = .037) at 3 months were observed in the telecoaching plus portion control plate group compared to usual care. These differences were not statistically significant at 6 months. In females, the telecoaching plus portion control plate intervention was associated with significant reductions in weight and BMI at both 3 months (estimated treatment effect -1.6 kg, P = .016 and -0.6 kg/m(2), P = .020) and 6 months (estimated treatment effect -2.3 kg, P = .013 and -0.8 kg/m(2), P = .025). In males, the telecoaching plus portion control intervention was associated with a significant reduction in waist to hip ratio at 3 months (estimated treatment effect -0.04, P = .017), but failed to show a significant difference in weight and BMI. Telecoaching with a portion control plate can produce positive change in body habitus among obese primary care patients; however, changes depend upon sex. ClinicalTrials.gov NCT02373878, 13 February 2015. https://clinicaltrials.gov/ct2/show/NCT02373878 .
    Full-text · Article · Dec 2015 · Trials
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    ABSTRACT: Objective: Smokers with fibromyalgia have greater pain intensity and function impairment compared to nonsmokers. Patients' perceptions of interactions between smoking and fibromyalgia symptoms have not been described. The primary aim of this study was to report the perceptions of female smokers with fibromyalgia on how smoking affects symptoms. Methods: Forty-eight daily smokers with fibromyalgia enrolled in the Mayo Clinic Fibromyalgia Treatment Center completed the Fibromyalgia Impact Questionnaire, Fagerstrom Test for Nicotine Dependence, Patient Health Questionnaire-9, General Anxiety Disorder-7 and a Fibromyalgia Symptoms and Smoking Survey which queried how smoking directly affected fibromyalgia symptoms (eg, pain, tiredness/fatigue, stiffness, nervousness/anxiety, depression/blueness, irritability, concentration, and overall) or indirectly as a coping mechanism. Results: The majority of subjects reported smoking had no direct effect on fibromyalgia physical symptoms (pain [60% reported no effect], fatigue [56%], stiffness [81%]) but direct improvement of emotional symptoms (anxiety [62% reported improvement], irritability [64%]). The majority of subjects used smoking to cope with pain (69%) via distraction (83%) and relaxation (77%), lessening emotional distress by reducing a sense of frustration (83%) or sadness (54%) because of pain, and as a justification for resting vis-à-vis "smoke breaks" (69%). Thirty-one smokers were mildly and 17 moderately/severely dependent on tobacco, and no difference in fibromyalgia impact score (P = 0.70), pain (P = 0.39), depression (P = 0.20), and anxiety (P = 0.64) scores were detected, but more moderately/severely dependent subjects reported smoking improved pain (50% vs. 17%, P = 0.04). Discussion: Smokers with fibromyalgia reported smoking helped to cope with fibromyalgia pain but generally did not directly ameliorate fibromyalgia physical symptoms.
    No preview · Article · Nov 2015 · Pain Practice

  • No preview · Article · Nov 2015 · Critical care medicine
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    ABSTRACT: Background: Perioperative hemorrhage impacts patient outcomes and health care resource utilization, yet the risks of transfusion therapies are significant. In patients with preoperative thrombocytopenia, the effects of prophylactic preoperative platelet (PLT) transfusion on perioperative bleeding complications remain uncertain. Study design and methods: This is a retrospective cohort study of noncardiac surgical patients between January 1, 2008, and December 31, 2011. Propensity-adjusted analyses were used to evaluate associations between preoperative thrombocytopenia, preoperative PLT transfusion, and the outcomes of interest, with a primary outcome of perioperative red blood cell (RBC) transfusion. Results: A total of 13,978 study participants were included; 860 (6.2%) had a PLT count of not more than 100 × 10(9) /L with 71 (8.3%) receiving PLTs preoperatively. Administration of PLTs was associated with higher rates of perioperative RBC transfusion (66.2% vs. 49.1%, p = 0.0065); however, in propensity-adjusted analysis there was no significant difference between groups (odds ratio [OR] [95% confidence interval {95% CI}], 1.68 [0.95-2.99]; p = 0.0764]. Patients receiving PLTs had higher rates of intensive care unit (ICU) admission (OR [95% CI], 1.95 [1.10-3.46]; p = 0.0224) and longer hospital lengths of stay (estimate [95% bootstrap CI], 7.2 [0.8-13.9] days; p = 0.0006) in propensity-adjusted analyses. Conclusion: Preoperative PLT transfusion did not attenuate RBC requirements in patients with thrombocytopenia undergoing noncardiac surgery. Moreover, preoperative PLT transfusion was associated with increased ICU admission rates and hospital duration. These findings suggest that more conservative management of preoperative thrombocytopenia may be warranted.
    No preview · Article · Nov 2015 · Transfusion
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    ABSTRACT: Objective: To examine association of presenting clinical acuity and Glasgow Aneurysm Score (GAS) with perioperative and 1-year mortality. Design: Retrospective chart review. Setting: Major tertiary care facility. Participants: Patients with ruptured abdominal aortic aneurysm (rAAA) from 2003 through 2013. Interventions: Emergency repair of rAAA. Measurements and main results: The authors reviewed outcomes after stable versus unstable presentation and by GAS. Unstable presentation included hypotension, cardiac arrest, loss of consciousness, and preoperative tracheal intubation. In total, 125 patients (40 stable) underwent repair. Perioperative mortality rates were 41% and 12% in unstable and stable patients, respectively (p<0.001). Unstable status had 88% sensitivity and 41% specificity for predicting perioperative mortality. Using logistic regression, higher GAS was associated with perioperative mortality (p<0.001). Using receiver operating characteristic analysis, the area under the curve was 0.72 (95% CI, 0.62-0.82) and cutoff GAS≥96 had 63% and 72% sensitivity and specificity, respectively. Perioperative mortality for GAS≥96 was 51% (25/49), whereas it was 20% (15/76) for GAS≤95. The estimated 1-year survival (95% CI) was 75% (62%-91%) for stable patients and 48% (38%-60%) for unstable patients. Estimated 1-year survival (95% CI) was 23% (13%-40%) for GAS≥96 and 77% (67%-87%) for GAS≤95. Conclusions: Clinical presentation and GAS identified patients with rAAA who were likely to have a poor surgical outcome. GAS≥96 was associated with poor long-term survival, but>20% of these patients survived 1 year. Thus, neither clinical presentation nor GAS provided reliable guidance for decisions regarding futility of surgery.
    No preview · Article · Nov 2015 · Journal of cardiothoracic and vascular anesthesia

  • No preview · Article · Nov 2015 · Medicine
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    ABSTRACT: Background: Surgical site infection (SSI) is one of the most challenging and costly complications associated with total joint arthroplasty. Our primary aim in this case-controlled trial was to compare the risk of SSI within a year of surgery for patients undergoing primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) and revision TKA or THA under general anesthesia versus neuraxial anesthesia. Our secondary aim was to determine which patient, anesthetic, and surgical variables influence the risk of SSI. We hypothesized that patients who undergo neuraxial anesthesia may have a lesser risk of SSI compared with those who had a general anesthetic. Methods: We conducted a retrospective, case-control study of patients undergoing primary or revision TKA and THA between January 1, 1998, and December 31, 2008, who subsequently were diagnosed with an SSI. The cases were matched 1:2 with controls based on type of joint replacement (TKA versus THA), type of procedure (primary, bilateral, revision), sex, date of surgery (within 1 year), ASA physical status (I and II versus III, IV, and V), and operative time (<3 vs >3 hours). Results: During the 11-year period, 202 SSIs were identified. Of the infections identified, 115 (57%) occurred within the first 30 days and 87 (43%) occurred between 31 and 365 days. From both univariate and multivariable analyses, no significant association was found between the use of central neuraxial anesthesia and the postoperative infection (univariate odds ratio [OR] = 0.92; 95% confidence interval [CI], 0.63-1.34; P = 0.651; multivariable OR = 1.10; 95% CI, 0.72-1.69; P = 0.664). The use of peripheral nerve block also was not found to influence the risk of postoperative infection (univariate OR = 1.41; 95% CI, 0.84-2.37; P = 0.193; multivariable OR = 1.35; 95% CI, 0.75-2.44; P = 0.312). The factors that were found to be associated with postoperative infection in multivariable analysis included current smoking (OR = 5.10; 95% CI, 2.30-11.33) and higher body mass index (BMI) (OR = 2.68; 95% CI, 1.42-5.06 for BMI ≥ 35 kg/m compared with those with BMI < 25 kg/m). Conclusions: Recent studies using large databases have concluded that the use of neuraxial compared with general anesthesia is associated with a decreased incidence of SSI in patients undergoing total joint arthroplasty. In this retrospective, case-controlled study, we found no difference in the incidence of SSI in patients undergoing total joint arthroplasty under general versus neuraxial anesthesia. We also concluded that the use of peripheral nerve blocks does not influence the incidence of SSI. Increasing BMI and current smoking were found to significantly increase the incidence of SSI in patients undergoing lower extremity total joint arthroplasty.
    No preview · Article · Oct 2015 · Anesthesia and analgesia
  • Toby N Weingarten · Elisa Y Chong · Darrell R Schroeder · Juraj Sprung
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    ABSTRACT: Purpose: To identify characteristics associated with postoperative respiratory depression that required naloxone intervention during Phase I recovery following general anesthesia. A secondary aim is to compare postoperative outcomes between patients who received naloxone and those who did not. Methods: Patients who received naloxone to reverse opioid-induced respiratory depression or sedation during Phase I postanesthesia recovery from January 1, 2010 to December 31, 2013 were identified and matched to 2 controls based on age, sex, and surgical procedure during the same year. A chart review was performed to identify factors associated with risk for intervention requiring naloxone as well as to note the occurrence of adverse postoperative outcomes. Analyses to assess characteristics potentially associated with naloxone use were performed using conditional logistic regression taking into account the 1:2 matched set case-control study design. Results: Naloxone was administered to 413 patients, with an incidence of 2.5 per 1000 anesthetics [95 % confidence interval (CI) 0.7-6.5]. Presence of obstructive sleep apnea [odds ratio (OR) = 1.74, 95 % CI 1.22-2.48, P = 0.002], ASA Physical Status (PS) ≥III (OR 1.44, 95 % CI 1.08-1.92, P = 0.013), and greater opioid administration (OR 1.22, 95 % CI 1.12-1.33, per 10 intravenous morphine equivalents mg, P < 0.001) were associated with naloxone administration. Naloxone administration was associated with increased adverse events (OR 3.39, 95 % CI 2.22-5.23, P < 0.001). Conclusions: Obstructive sleep apnea, higher ASA-PS scores and greater doses of intraoperative opioids were associated with naloxone administration during Phase I recovery. Patients administered naloxone had increased adverse events after discharge from the recovery room and may benefit from a higher level of postoperative care.
    No preview · Article · Oct 2015 · Journal of Anesthesia
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    ABSTRACT: Background: Congenital diaphragmatic hernia (CDH) is a congenital malformation associated with life-threatening pulmonary dysfunction and high neonatal mortality. Outcomes are improved with protective ventilation, less severe pulmonary pathology, and the proximity of the treating center to the site of delivery. The major CDH treatment center in Croatia lacks a maternity ward, thus all CDH patients are transferred from local Zagreb hospitals or remote areas (outborns). In 2000 this center adopted protective ventilation for CDH management. In the present study we assess the roles of protective ventilation, transport distance, and severity of pulmonary pathology on survival of neonates with CDH. Methods: The study was divided into Epoch I, (1990–1999, traditional ventilation to achieve normocapnia), and Epoch II, (2000–2014, protective ventilation with permissive hypercapnia). Patients were categorized by transfer distance (local hospital or remote locations) and by acuity of respiratory distress after delivery (early presentation-occurring at birth, or late presentation, ≥6 h after delivery). Survival between epochs, types of transfers, and acuity of presentation were assessed. An additional analysis was assessed for the potential association between survival and end-capillary blood CO2 (PcCO2), an indirect measure of pulmonary pathology. Results: There were 83 neonates, 26 in Epoch I, and 57 in Epoch II. In Epoch I 11 patients (42 %) survived, and in Epoch II 38 (67 %) (P = 0.039). Survival with early presentation (N = 63) was 48 % and with late presentation 95 % (P <0.001). Among early presentation, survival was higher in Epoch II vs. Epoch I (57 % vs. 26 %, P = 0.031). From multiple logistic regression analysis restricted to neonates with early presentation and adjusting for severity of disease, survival was improved in Epoch II (OR 4.8, 95%CI 1.3–18.0, P = 0.019). Survival was unrelated to distance of transfer but improved with lower partial pressure of PcCO2 on admission (OR 1.16, 95%CI 1.01–1.33 per 5 mmHg decrease, P = 0.031). Conclusions: The introduction of protective ventilation was associated with improved survival in neonates with early presentation. Survival did not differ between local and remote transfers, but primarily depended on severity of pulmonary pathology as inferred from admission capillary PcCO2. Keywords: Acute lung injury, Comorbidity, Hernia, Diaphragmatic/epidemiology/mortality, Infant: newborn/ outborn status, Mechanical ventilation: pressure controlled/volume controlled, Risk assessment, Severity of illness index: probability of survival score
    Full-text · Article · Oct 2015 · BMC Pediatrics
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    Megan M Dulohery · Darrell R Schroeder · Roberto P Benzo
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    ABSTRACT: Background: Cognitive impairment is increasingly being found to be a common comorbidity in chronic obstructive pulmonary disease (COPD). This study sought to understand the relationship of comprehensively measured cognitive function with COPD severity, quality of life, living situation, health care utilization, and self-management abilities. Methods: Subjects with COPD were recruited from the outpatient pulmonary clinic. Cognitive function was assessed using the Montreal Cognitive Assessment (MOCA). Self-management abilities were measured using the Self Management Ability Score 30. Quality of life was measured using the Chronic Respiratory Disease Questionnaire. Pearson correlation was used to assess the bivariate association of the MOCA with other study measures. Multivariate analysis was completed to understand the interaction of the MOCA and living situation on COPD outcomes of hospitalization, quality of life, and self-management ability. Results: This study included 100 participants of mean age 70±9.4 years (63% male, 37% female) with COPD (mean FEV1 [forced expiratory volume in 1 second] percentage predicted 40.4±16.7). Mean MOCA score was 23.8±3.9 with 63% of patients having mild cognitive impairment. The MOCA was negatively correlated with age (r=-0.28, P=0.005) and positively correlated with education (r=+0.24, P=0.012). There was no significant correlation between cognitive function and exacerbations, emergency room (ER) visits, or hospitalizations. There was no association between the MOCA score and self-management abilities or quality of life. We tested the interaction of living situation and the MOCA with self-management abilities and found statistical significance (P=0.017), indicating that individuals living alone with higher cognitive function report lower self-management abilities. Conclusion: Cognitive impairment in COPD does not appear to be meaningfully associated with COPD severity, health outcomes, or self-management abilities. The routine screening for cognitive impairment due to a diagnosis of COPD may not be indicated. Living alone significantly affects the interaction between self-management abilities and cognitive function.
    Full-text · Article · Sep 2015 · International Journal of COPD
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    ABSTRACT: To determine the demographic characteristics of patients undergoing primary total knee arthroplasty during the years 1989, 1999, and 2009 at our institution and determine whether their characteristics mirror the changing US demographic characteristics. Retrospective chart review of patients and prospective survey of experienced anesthesia providers in total knee arthroplasty. Tertiary care academic medical center. All patients 18 years and older who underwent unilateral primary total knee arthroplasty in 1989, 1999, and 2009 were identified through the Mayo Clinic Total Joint Registry. For each year, 200 patients were randomly selected. The demographic characteristics, comorbidities, perioperative care, and postoperative outcomes of patients, as well as survey responses from experienced anesthesia providers. During the 3 study years, a total of 591 patients were included for analysis. A statistically significant increase in body mass index (BMI) was observed over time in patients undergoing primary total knee arthroplasty (average BMI, 29.01 in 1989, 31.32 in 1999, and 32.32 in 2009 [P < .001]). Despite the increase in patient comorbidities, the percentage of patients who had postoperative complications decreased over time (P = .003), and postoperative disposition (general medicine ward vs intensive care unit) did not change. Our provider survey received a 76% response rate. In total, 82% of anesthesia providers who responded to the survey perceived that both BMI and the number of comorbidities had increased. Of survey respondents, 67% state that they have modified their perioperative anesthesia care because of changes in body habitus and patient comorbidities. The number of obese patients with comorbidities who present for total knee arthroplasty at our institution has increased over the past 20 years. Despite this fact, a reduction was detected in postoperative complications. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Aug 2015 · Journal of clinical anesthesia
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    ABSTRACT: Poliomyelitis is a viral infectious disease caused by 1 of the 3 strains of poliovirus. The World Health Organization launched an eradication campaign in 1988. Although the number of cases of poliomyelitis has drastically declined, eradication has not yet been achieved, and there are a substantial number of survivors of the disease. Survivors of poliomyelitis present a unique set of challenges to the anesthesiologist. The scientific literature regarding the anesthetic management of survivors of poliomyelitis, however, is limited and primarily experiential in nature. Using a retrospective, matched cohort study, we sought to more precisely characterize the anesthetic implications of poliomyelitis and to determine what risks, if any, may be present for patients with a history of the disease. Using the Mayo Clinic Life Sciences System Data Discovery and Query Builder, study subjects were identified as those with a history of paralytic poliomyelitis who had undergone major surgery at Mayo Clinic Rochester between 2005 and 2009. For each case, 2 sex- and age-matched controls that underwent the same surgical procedure during the study period were randomly selected from a pool of possible controls. Medical records were manually interrogated with respect to demographic variables, comorbid conditions, operative and anesthetic course, and postoperative course. We analyzed 100 cases with 2:1 matched controls and found that the peri- and postoperative courses were very similar for both groups of patients. Pain scores, postanesthesia care unit admission, length of postanesthesia care unit stay, intensive care unit admission, length of intensive care unit stay, and initial extubation location were not significantly different between the 2 groups. Looking at pulmonary complications in our primary outcome, there was no significant difference between the 2 groups (17% vs 14% for polio versus control, respectively; conditional logistic regression odds ratio = 1.5; 95% confidence interval, 0.7-3.3; P = 0.33). In addition, no difference was noted in those requiring a code or rapid response team intervention (4% vs 3% for polio versus control; P = 0.46) and the 30-day mortality rate was also not significantly different, with 2% of polio patients dying compared with 3% of controls (P = 0.79). The analysis of the primary outcome was repeated for the subset of patients with a history of poliomyelitis who had persistent neurologic deficits preoperatively (n = 36) and their matched controls (n = 72). In this subset analysis, there were 4 (11%) polio patients and 8 (11%) control patients who experienced pulmonary complications (conditional logistic regression odds ratio = 1.00; 95% confidence interval, 0.27-3.72; P = 1.00). The percentage of patients experiencing specific pulmonary complications of interest was similar between groups (postoperative mechanical ventilation: 6% vs 8% for polio and control patients, respectively; prolonged mechanical ventilation: 0% vs 1%; reintubation: 8% vs 4%; pulmonary infection: 6% vs 6%; and aspiration: 0% vs 1%). This study suggests that patients with a history of poliomyelitis do not seem to have an increased risk of pulmonary complications in the perioperative period. However, an odds ratio as great as 3.3-fold may be present.
    No preview · Article · Aug 2015 · Anesthesia and analgesia
  • David O Warner · Keith Berge · Huaping Sun · Ann Harman · Andrew Hanson · Darrell R Schroeder
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    ABSTRACT: The goal of this work is to evaluate selected risk factors and outcomes for substance use disorder (SUD) in physicians enrolled in anesthesiology residencies approved by the Accreditation Council for Graduate Medical Education. For each of 384 individuals with evidence of SUD while in primary residency training in anesthesiology from 1975 to 2009, two controls (n = 768) who did not develop SUD were identified and matched for sex, age, primary residency program, and program start date. Risk factors evaluated included location of medical school training (United States vs. other) and anesthesia knowledge as assessed by In-Training Examination performance. Outcomes (assessed to December 31, 2013, with a median follow-up time of 12.2 and 15.1 yr for cases and controls, respectively) included mortality and profession-related outcomes. Receiving medical education within the United States, but not performance on the first in-training examination, was associated with an increased risk of developing SUD as a resident. Cases demonstrated a marked increase in the risk of death after training (hazard ratio, 7.9; 95% CI, 3.1 to 20.5), adverse training outcomes including failure to complete residency (odds ratio, 14.9; 95% CI, 9.0 to 24.6) or become board certified (odds ratio, 10.4; 95% CI, 7.0 to 15.5), and adverse medical licensure actions subsequent to residency (hazard ratio, 6.8; 95% CI, 3.8 to 12.2). As of the end of follow-up, 54 cases (14.1%) were deceased compared with 10 controls (1.3%); 28 cases and no controls died during residency. The attributable risk of SUD to several adverse outcomes during and after residency training, including death and adverse medical license actions, is substantial. (Anesthesiology 2015; 123:00-00).
    No preview · Article · Aug 2015 · Anesthesiology
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    ABSTRACT: Background: Transfusion-associated circulatory overload (TACO) is a leading cause of transfusion-related fatalities, but its incidence and associated patient and transfusion characteristics are poorly understood. To inform surgical transfusion practice and to begin mitigating perioperative TACO, the authors aimed to define its epidemiology. Methods: In this retrospective cohort study, the medical records of adult patients undergoing noncardiac surgery with general anesthesia during 2004 or 2011 and receiving intraoperative transfusions were screened using an electronic algorithm for identification of TACO. Those patients who were screened as high probability for TACO underwent rigorous manual review. Univariate and multivariate analyses evaluated associations between patient and transfusion characteristics with TACO rates in a before-and-after study design. Results: A total of 2,162 and 1,908 patients met study criteria for 2004 and 2011, respectively. The incidence of TACO was 5.5% (119 of 2,162) in 2004 versus 3.0% (57 of 1,908) in 2011 (P < 0.001), with comparable rates for men (4.8% [98 of 2,023]) and women (3.8% [78 of 2,047]) (P = 0.09). Overall, vascular (12.1% [60 of 497]), transplant (8.8% [17 of 193]), and thoracic surgeries (7.2% [10 of 138]) carried the highest TACO rates. Obstetric and gynecologic patients had the lowest rate (1.4% [4 of 295]). The incidence of TACO increased with volume transfused, advancing age, and total intraoperative fluid balance (all P < 0.001). Conclusions: The incidence of perioperative TACO is similar to previous estimates in nonsurgical populations. There was a reduction in TACO rate between 2004 and 2011, with incidence patterns remaining comparable in subgroup analyses. Future efforts exploring risk factors for TACO may guide preventive or therapeutic interventions, helping to further mitigate this transfusion complication.
    No preview · Article · Aug 2015 · Anesthesiology

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  • 2015
    • Mayo Clinic - Scottsdale
      Scottsdale, Arizona, United States
  • 1995-2015
    • Mayo Clinic - Rochester
      • • Department of Anesthesiology
      • • Department of Health Science Research
      • • Department of Psychiatry & Psychology
      Рочестер, Minnesota, United States
  • 2000-2008
    • Mayo Foundation for Medical Education and Research
      • • Division of Hematology
      • • Department of Anesthesiology
      Scottsdale, AZ, United States
  • 2007
    • University of Texas at Austin
      Austin, Texas, United States
    • Oregon Research Institute
      Eugene, Oregon, United States
    • University of Montana
      • Department of Psychology
      Missoula, MT, United States
  • 2004
    • University of Minnesota Rochester
      Rochester, Minnesota, United States
  • 2002
    • Toranomon Hospital
      Edo, Tōkyō, Japan
  • 1999
    • West Virginia University
      • Department of Psychology
      MGW, West Virginia, United States