Additional Medical Comorbidities Research Articles

Associations between depression and diabetic retinopathy in the National Health and Nutrition Examination Survey, 2011 to 2018

Introduction Diabetic retinopathy (DR) is a vision-threatening complication of diabetes mellitus (DM). The relationship between depression and DR is unclear, and prior studies are limited by small sample sizes at single centers. This retrospective, cross-sectional study assessed the prevalence of and associations between depression and DR in the US using the National Health and Nutrition Examination Survey for 2011 to 2018. Methods We collected information on the demographic characteristics, medical conditions, and examination data of NHANES participants with DM. We performed weighted analysis to estimate national prevalence and multivariate analysis to assess the relationship between depression and DR. Results Of the 22,618 participants included, the prevalence of DM and DR were 3146 (13.9%) and 664 (2.9%). The prevalence of depression was 14.2% in DM only and 19.3% in DR (P = 0.006) with greater severity in the DR group (P < 0.001). After adjusting for comorbidities, DR was no longer significantly associated with depression. Depression was not associated with differences in disease management, although participants with depression had poorer self-perceived health status (P < 0.001). Conclusions Depression is more prevalent in individuals with DR than those with DM only. The relationship between depression and DR may be mediated by additional medical comorbidities, but further studies are needed.

Effect of Race and Geography on Patient- and Parent-Reported Quality of Life for Children With Congenital Upper Limb Differences

Patient beliefs about health and disability are shaped by many social factors and are a key determinant in their ultimate outcome. We hypothesized that pediatric and parent-reported outcome measures regarding a child's congenital upper limb difference will be affected by geographic location, parent education, sex, ethnicity, race, age, and presence of additional medical comorbidities. Patients enrolled in the multicenter Congenital Upper Limb Difference registry were included. Age, sex, race, ethnicity, medical comorbidities, highest level of parental education, area deprivation index, and geographic region were recorded. Patient-Reported Outcomes Measurement Information System (PROMIS) in the pediatric and parent-reported domains of upper extremity, anxiety, pain interference, peer relationships, and depressive symptoms were collected. The only difference between geographic regions in the United States in pediatric and parent-reported PROMIS was that parents in the Midwest reported higher upper extremity function scores in children with upper limb differences than the West. Black patients demonstrated higher scores in parent and child-reported domains of depression, pain, and anxiety, and lower scores in upper extremity function than White and Asian peers. Additionally, children with medical comorbidities also demonstrated worse outcomes in multiple PROMIS domains. There was no difference in scores based on sex, parent education, and ethnicity. In children with congenital upper limb differences, race and additional medical comorbidities have an impact on patient- and parent-reported PROMIS outcome measures in multiple domains, with Black children and those with additional medical comorbidities scoring lower than their peers. As we strive to develop a health care system that provides equitable care to all patients, providers who care for children with upper limb differences should be aware that race and additional medical comorbidities can negatively affect patient- and parent-reported PROMIS outcome measures.

52. Patients with additional medical comorbidities failed to maintain MCID+ status at five years following adult spinal deformity surgery

<h3>BACKGROUND CONTEXT</h3> Evidence on long-term maintenance of health status in adult spinal deformity (ASD) patients who improve above MCID threshold (MCID+) at 2 years following surgery is limited. <h3>PURPOSE</h3> This study aims to: (1) evaluate whether patients who reached MCID+ status at two years postoperatively will maintain MCID+ status at 5 years, (2) identify risk factors associated with maintaining MCID+ status, and (3) Assess whether maintaining MCID+ status at 5 years is associated with satisfaction with surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective review. <h3>PATIENT SAMPLE</h3> Patients who underwent adult spinal deformity (ASD) surgery with minimum 5-year follow-up who achieved 2-year MCID in ODI were identified. <h3>OUTCOME MEASURES</h3> Maintenance of MCID+ status at 5 years for Oswestry Diability Index (ODI). <h3>METHODS</h3> Patients who maintained MCID+ status at 5 years and those who did not formed the comparison groups. Multivariable logistic regression, controlling for age, complications after two years and two-year alignment, was used to identify risk factors associated with the inability to maintain MCID+ status. In a separate multivariable logistic regression, whether maintaining MCID+ status was associated with 5-year surgical satisfaction was assessed. <h3>RESULTS</h3> Of 633 eligible patients, 339 had 5-year data. Of 133 with both 2- and 5-year data, 70 who achieved 2-year MCID in ODI were included. 30% (21) failed to maintain MCID+ status at 5 years. Preoperatively, 33% (23) were narcotic users, 47% (33) were frail and mean surgical invasiveness was 96.6±36.02. On multivariable logistic regression, preoperative variables were assessed: CCI > 3 (OR 5.75; p=0.026), ASA grade > 2 (OR 5.25; p=0.015), anemia (OR 19.74; p=0.009), and cancer (OR 6.46; p=0.015) were associated with increased odds of failure to maintain MCID+ status at 5-year follow-up. Patients who failed to maintain MCID+ status at 5 years had a higher odds of being unsatisfied with the surgery (OR 15.66; p=0.001). Frailty and surgical invasiveness had no significant impact on MCID+ status at 5 years. <h3>CONCLUSIONS</h3> Preoperative comorbid conditions significantly impact patient's long-term ability to maintain the positive gains in health-related quality of life measures from the surgery. Surgeons should continue to monitor and treat the chronic conditions to ensure maintenance of long-term recovery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Obesity and other medical comorbidities among NT1 patients after the Norwegian H1N1 influenza epidemic and vaccination campaign.

Narcolepsy type 1 (NT1) may be complicated by comorbidities. We aimed to study the extent of obesity and other medical comorbidities in a Norwegian population of NT1 patients with debut of symptoms after the 2009 H1N1 influenza epidemic and vaccination campaign. We also aimed to explore factors associated with obesity. Ninety-one patients (48 children and 43 adults) were included in this cross-sectional study, 80 of whom were H1N1-vaccinated. All participants were hospitalized and underwent sleep investigation and physical examination, and completed a semi-structured clinical interview. In children, 16 females (70%) and 10 males (40%) were classified as overweight or obese. Twenty children (42%) had a co-existing medical disorder. Medical comorbidity was significantly positively associated with BMI in children (p = .032). In adults, 19 females (58%) and 7 males (70%) were classified as overweight or obese. Twenty-six adults (61%) had a co-existing medical disorder. We found no factors significantly associated with BMI in adults. On a fatigue scale from 0 to 100, lower scores indicating more fatigue, we found a mean (SD) total fatigue score of 50 (17) in children and 39 (16) in adults. In a cohort of predominantly H1N1-vaccinated NT1 patients, we found a high prevalence of overweight or obesity. Half of the cohort presented with one or more additional medical comorbidities, and patients reported a clinically relevant degree of fatigue. Our findings highlight the importance of carefully monitoring patients with NT1 with regard to the development of obesity, which is a significant risk factor for cardiovascular disorders.

Regional and Socioeconomic Distribution, Healthcare Utilization, and In-Hospital Mortality of Heart Transplantation

Purpose In 2017, 2817 heart transplants (HT) were performed in the United States, up from 1882 10 years prior. With competing therapies now available, a thorough understanding of the distribution of and resources required for HT is required. Utilizing the National Inpatient Sample (NIS), we examined temporal trends and determinants of short-term outcomes of HT. Methods A retrospective analysis of the NIS from 2001-2011 was performed using SPSS, encompassing N=17426 HT from 2001-2011. Both patient specific and center specific characteristics were characterized with t-test and chi-squared where appropriate. Hospitalizations were grouped according to occurrence before or after the 2006 UNOS allocation policy change. Risk factors were identified using univariate and multivariate analyses. Results Of the N= 17426 HTs included in the analysis, N=6924 and N=10502 occurred 2001-2005 and 2006-2011, respectively. Of these, 76% were male, and 70% were Caucasian, which decreased from 2001 to 2011 (81% v 63%, p Conclusion HT is being performed more frequently in recent years than has occurred previously. Although patients are sicker with additional medical comorbidities and active diagnoses in 2011 than 2001, the average LoS and in-hospital mortality rates are decreasing, likely demonstrating improvement in patient-donor matching and management of HT patients. Elective transplant, hospital region, and teaching status play significant roles in short-term outcomes.

Incidence and Risk Factors for Adverse Outcomes after Open Surgery for Spinal Metastatic Fractures

Introduction Several scoring systems have evolved to estimate life expectancy in the setting of spinal metastases. However, neither overall mortality rate nor risk factors for complications in open surgery for spinal metastatic fractures have been well defined. We hypothesize that the mortality risk for these patients is high, and that additional medical comorbidities add substantially to the risk of early postoperative death. Understanding these risks will help us to choose surgical candidates with more carefully. Methods A national database, the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) files, from 2011–2013 were queried for patients who underwent open surgery for pathologic vertebral fracture in the setting of metastatic cancer. Patients were analyzed for rates of any adverse event (AAE), readmission, reoperation, and mortality. Bivariate and multivariate analyses were performed to determine independent risk factors for these events. Results Of the one hundred and fifty three patients identified, seventy-eight (51%) experienced AAE, fifteen (9.8%) required reoperation, thirty (19.6%) were readmitted, and nineteen (12.4%) died within 30 days. Risk factors for AAE included pulmonary comorbidity ( p = 0.049, OR=3.87) and chronic steroid use ( p = 0.045, OR=2.28). Reoperation risk factors included male gender ( p = 0.038, OR=4.00). No risk factors were identified for readmission. Regarding mortality, identified risk factors included dependent functional status ( p = 0.009, OR=5.75), diabetes ( p = 0.004, OR=5.55), and pulmonary comorbidity ( p = 0.041, OR=4.23). Conclusion Open surgery for spinal metastatic fractures carries significant morbidity and mortality. Greater than half of patients in this cohort experienced an adverse event, nearly 20% were readmitted, and greater than 10% died within 30 days. Patient factors, including pulmonary disease, diabetes, and dependent functional status, were identified as risk factors for poor outcomes. Thorough preoperative counseling should be performed for patients with our proposed risk factors, and the risk of mortality in surgery must be carefully weighed against life expectancy and neurological deficits.

Critical care of obese patients during and after spine surgery.

Obesity is one of the most prevalent health problems facing the United States today, with a recent JAMA article published in 2014 estimating the prevalence of one third of all adults in the United States being obese. Also, due to technological advancements, the incidence of spine surgeries is growing. Considering these overall increases in both obesity and the performance of spinal surgeries, it can be inferred that more spinal surgery candidates will be obese. Due to this, certain factors must be taken into consideration when dealing with spine surgeries in the obese. Obesity is closely correlated with additional medical comorbidities, including hypertension, coronary artery disease, congestive heart failure, and diabetes mellitus. The pre-operative evaluation may be more difficult, as a more extensive medical evaluation may be needed. Also, adequate radiographic images can be difficult to obtain due to patient size and equipment limitations. Administering anesthesia becomes more difficult, as does proper patient positioning. Post-operatively, the obese patient is at greater risk for reintubation, difficulty with pain control, wound infection and deep vein thrombosis. However, despite these concerns, appropriate clinical outcomes can still be achieved in the obese spine surgical candidate. Obesity, therefore, is not a contraindication to spine surgery, and appropriate patient selection remains the key to obtaining favorable clinical outcomes.

Clinically significant psychotropic drug-drug interactions in the primary care setting.

In recent years, the growing numbers of patients seeking care for a wide range of psychiatric illnesses in the primary care setting has resulted in an increase in the number of psychotropic medications prescribed. Along with the increased utilization of psychotropic medications, considerable variability is noted in the prescribing patterns of primary care providers and psychiatrists. Because psychiatric patients also suffer from a number of additional medical comorbidities, the increased utilization of psychotropic medications presents an elevated risk of clinically significant drug interactions in these patients. While life-threatening drug interactions are rare, clinically significant drug interactions impacting drug response or appearance of serious adverse drug reactions have been documented and can impact long-term outcomes. Additionally, the impact of genetic variability on the psychotropic drug's pharmacodynamics and/or pharmacokinetics may further complicate drug therapy. Increased awareness of clinically relevant psychotropic drug interactions can aid clinicians to achieve optimal therapeutic outcomes in patients in the primary care setting.

Feeding Outcomes in Infants after Supraglottoplasty

Review the impact of bilateral supraglottoplasty on feeding and compare the risk of postoperative feeding difficulties between infants with and without additional comorbidities. Case series with chart review. Children's hospital. The medical records of all patients between birth and 12 months of age treated for laryngomalacia with bilateral supraglottoplasty by a single surgeon (GPD) between December 2005 and September 2009 and followed for a minimum of 1 month were reviewed. Infants with significant comorbidities were evaluated separately. Nutritional intake before and after surgery, as well as speech and language pathology reports, was reviewed to qualify any feeding difficulties. Age at the time of surgery, additional surgical interventions, medical comorbidities, and length of follow-up were also noted during chart review. Of 81 infants who underwent bilateral supraglottoplasty, 75 were eligible for this review. In the cohort of infants without comorbidities, 46 of 48 (96%) had no change or an improvement in their oral intake after surgery. Of the 2 patients with initial worsening of feeding, all resumed oral intake within 2 months. In the group of patients with additional medical comorbidities, 22% required further interventions such as nasogastric tube, dietary modification, or gastrostomy tube placement. Supraglottoplasty in infants has a low incidence of persistent postoperative dysphagia. Infants with additional comorbidities are at a higher risk of feeding difficulty than otherwise healthy infants.

Cardiopulmonary Bypass During Pregnancy

Cardiac surgery during pregnancy carries significant maternal and fetal risk and is typically considered after failure of medical therapy. We sought to determine the maternal and neonatal outcomes of cardiopulmonary bypass during pregnancy. Twenty-one pregnant patients undergoing cardiothoracic surgery were identified from the Mayo Clinic surgical database (1976 to 2009). Maternal and neonatal outcomes were reviewed. Operations included 8 aortic valve replacements, 6 mitral valve repair-replacements, 2 myxoma excisions, 1 patent foramen ovale closure, 1 myectomy, 2 aortic aneurysm repairs, and 1 prosthetic aortic valve thrombectomy. Median cardiopulmonary bypass time was 53 minutes (range 16 to 185). Twelve patients (57%) required emergent surgery with a median gestational age (GA) of 25 weeks (range 7 to 35.5). Seven patients underwent cesarean section immediately prior to sternotomy delivering viable infants (median GA 31 weeks). In the remaining patients, three additional preterm births occurred, all in operations performed at an early GA (13 to 15 weeks). Median follow-up was 16 months (range 3 to 305). All patients improved to New York Heart Association functional class I or II. One early maternal death occurred 2 days after emergent mechanical aortic valve thrombectomy and 3 late maternal deaths occurred 2, 10, and 19 years postoperatively. Three fetal deaths occurred in mothers with additional medical comorbidities. In the current era, cardiothoracic surgery can be performed with relative safety during pregnancy. Fetal complications (prematurity and death) are associated with urgent, high-risk surgery, maternal comorbidity, and early GA. Emergent surgery appears to confer a higher risk of maternal death.

The role of continuous monitoring in a 24/7 telecardiology consultation service—a feasibility study

Today's coronary care unit patients include those with complicated and uncomplicated myocardial infarction, decompensated heart failure and frank cardiogenic shock, severe valvular heart disease, high-grade conduction disturbances, and incessant ventricular arrhythmias. Increasingly in modern medicine, these conditions are not seen in isolation but rather in connection with a series of additional medical comorbidities. Increased life expectancy results in an increase in the prevalence of chronic cardiovascular diseases and an increased demand for health care services. Telemedicine is the provision of health care services, through the use of information and communication technology, in situations where the health care professional and the patient, or 2 health care professionals, are not in the same location. It involves the secure transmission of medical data and information, through text, sound, images, or other forms needed for the prevention, diagnosis, treatment, and follow-up of a patient. Telecardiology is one of the oldest applications in telemedicine and has been largely applied during the last 10 to 20 years. This study evaluated the feasibility of remote surveillance of coronary care unit and cardiology ward patient monitoring data by a “telecardiologist” with access to electronic health care record data and digitally stored 12-lead electrocardiograms. The remote access to the hospital intranet proved to be technically feasible. Also, the server applications used over the remote connection proved to be reliable and showed robustness against network performance variations. Extending remote patient surveillance to other hospitals is possible, provided that similar electrocardiogram and electronic health care record applications are available and a remote access can be arranged to them. However, the usability from cardiologist's perspective may be degraded if connecting with multiple applications and hospital networks is needed. The study indicated potential for speeding up the diagnostic and therapeutic processes in the hospital, although the study was limited in that the telecardiologist played a passive role and did not acutely impact patient care. In the future, the system could be expanded to surveillance of smaller hospitals. Telemedicine has the potential to aid in solving the conflict between aging of population, rise in the demand for critical care services, and shortage of professional personnel. This might, however, require a more active remote surveillance than the one tested in this study. Privacy- and security-related aspects are major components of building trust and confidence in telemedicine systems. In telecardiology, the real-time interactive telemedicine model with 24/7 service has potential superior performance compared with a store-and-forward telemedicine model.

Transcatheter Closure of Secundum Atrial Septal Defects with the Amplatzer Septal Occluder in Adults and Children—Follow-up Closure Rates, Degree of Mitral Regurgitation and Evolution of Arrhythmias

To report the results of transcatheter atrial septal defect (ASD) closure with the Amplatzer septal occluder (ASO) from the single centre providing interventions for congenital heart disease in New Zealand. A single centre retrospective review of all patients 1997-2004 inclusive, undergoing planned transcatheter ASD closure was undertaken. Implantation success, complications and latest patient follow-up are described. Percutaneous ASD closure was planned in 227 adults and children. (55% had additional medical co-morbidities.) The mean ASD size was 22+/-6 mm, and device size ranged from 5 to 40 mm. Closure was successful in 93%, unsuccessful in 5% and not attempted in 2%. There were two device embolisations, one immediately post-release and one within 24h. Minor procedural complications occurred in 5% of patients. There were no cases of suspected or proven device erosion. Ninety-two percent had documented follow-up beyond 6 months. At latest follow-up the closure rate was 98.5%. There was no significant change in the degree of mitral regurgitation. Sixteen of 24 with pre-closure arrhythmias resolved while 10 remained in atrial fibrillation. Six patients developed new arrhythmias but these were well controlled medically. There is a high implantation and closure rate using transcatheter ASD closure with the Amplatzer septal occluder in children and adults avoiding the need for cardiac surgery. Follow-up at one year shows there is no progression of mitral regurgitation, and supraventricular arrhythmias have usually resolved.

Psychiatric Sequelae of Traumatic Brain Injury: A Case Report

Psychiatric Sequelae of Traumatic Brain Injury: A Case Report