Significant Medical Comorbidities Research Articles

Gallbladder: Role of Interventional Radiology.

Percutaneous cholecystostomy is an established procedure for the management of patients with acute cholecystitis and with significant medical comorbidities that would make laparoscopic cholecystectomy excessively risky. In this review, we will explore the role of percutaneous cholecystostomy in the management of acute cholecystitis as well as other applications in the management of biliary pathology. The indications, grading, technical considerations, and postprocedure management in the setting of acute cholecystitis are discussed. In addition, we will discuss the potential role of percutaneous cholecystostomy in the management of gallstones and biliary strictures, in establishing internal biliary drainage, and in a joint setting with other clinicians such as gastroenterologists in the management of complex biliary pathology.

Patency and perioperative risks of aortofemoral bypass are negatively affected by significant arterial outflow disease

The current practice of vascular surgery requires the clinician to continuously make judgments concerning the risk/benefit ratio of a variety of treatment options available for diseases of the circulatory system. Most of our patients will have significant associated medical comorbidities such that real risks exist for invasive procedures, both surgical and endovascular. Viable options for medical management are often available, typically associated with lower risk but also lower potential to achieve treatment goals.

Biologic Tuberoplasty With an Acellular Dermal Allograft for Massive Rotator Cuff Tears

We present the technique of biologic tuberoplasty, where an acellular dermal allograft is used to cover the tuberosity in patients with massive irreparable cuff tears to prevent bone-to-bone contact between the tuberosity and acromion when active elevation is attempted. This technique can be performed in patients with massive rotator cuff tears who are low-demand and have significant medical comorbidities, poor bone quality, or who are not candidates for a reverse shoulder arthroplasty or who cannot tolerate a lengthy rehabilitation protocol. It is less time-consuming than a superior capsule reconstruction and more bone-sparing than traditional tuberoplasty. Patients with massive rotator cuff tears involving the supraspinatus and a portion of the infraspinatus lose their force couple, leading to superior humeral head migration with abutment of the tuberosity against the acromion upon deltoid activation. The center of rotation moves superiorly with deltoid contraction, developing an acromiohumeral articulation. This results in bone-to-bone contact between the acromion and humerus, leading to pain and acetabularization of the acromion over time. Coverage of the tuberosity with the acellular dermal allograft acts as an interpositional tissue and prevents bone-to-bone contact between the tuberosity and acromion.

1006-P: Progression to Type 2 Diabetes Despite a Baseline Fasting Plasma Glucose ≤ 80 mg/dl in a Population-Based Cohort

Fasting plasma glucose (FPG) concentration is a major predictor of a person’s risk of developing diabetes mellitus (DM). However, we sought to examine characteristics of individuals who develop DM despite a baseline FPG of ≤ 80mg/dL. The Rochester Epidemiology Project (REP) links the medical records of virtually all persons who have resided in Olmsted County, MN, USA between 1966 and present. Electronic laboratory data are available from 2005. Using REP, we identified individuals with ≥ 2 FPG tests from 2005-17, after excluding people who met criteria for DM on/before their first FPG. Those who developed DM (FPG > 125mg/dL) were assigned an event date as the date of their first diagnostic value. Subjects who did not develop DM were censored at their last FPG value on/before Dec 31, 2017. The entire cohort consisted of 44,815 individuals, of whom 3689 (8.2%) developed DM. Although higher baseline FPG was strongly related to development of DM, 2315 had a baseline FPG of ≤ 80mg/dL with 130 (5.6%) developing DM. Within this subset, those who progressed were older at baseline (40 ± 11 vs. 36 ± 12 years, p<0.02) and were more likely to be male (38 vs. 22%, p<0.001). Those who progressed had no difference between BMI at baseline and time of diagnosis (28 ± 8 vs. 29 ± 8 kg/m2, p=0.07). Medical record review suggested that individuals who progressed had high medical complexity. Specifically, 28 (22%) were repeatedly exposed to high dose glucocorticoids during follow up, including 10 (8%) who received a solid organ transplant. Fifteen (12%) had a substance abuse disorder. Nineteen (15%) were treated with insulin at one year following diagnosis, four of whom were diagnosed with type 1 DM. Twenty nine (22%) had a first degree relative with DM. Additional longitudinal follow up revealed that 20 (15%) were deceased at a median time of 2.5 years following the DM diagnosis. While progression to DM in the context of a baseline FPG of ≤ 80mg/dL is uncommon, it typically occurs in the setting of significant medical comorbidity. Disclosure A. M. Egan: None. C. Wood-wentz: None. K. R. Bailey: None. A. Vella: Research Support; Self; Novo Nordisk. Funding National Institutes of Health (DK78646, DK116231, DK126206, K12HD065987)

#90: Outcomes of Gram-negative Bacteremia Managed According to a Risk-based Algorithm

Abstract Background Management of gram-negative bacteremia (GNB) in children with cancer (CWC) is complicated by increasing rates of antimicrobial resistance. Guidelines for the management of CWC with suspected serious bacterial infections at St. Jude Children’s Research Hospital (SJ) recommend cefepime (CEF) monotherapy for empirical therapy for most patients. Children with evidence of sepsis, recent treatment with CEF or known colonization with a CEF-resistant (CEF-R) organism are initially treated with meropenem and/or amikacin. We compared outcomes of CWC with infections caused by CEF susceptible (CEF-S) and CEF-R bacteria treated according to this algorithm. Methods Demographic information on patients, and clinical and microbiological characteristics of 100 episodes of GNB treated from May 2018 to April 2019 at SJ were retrospectively reviewed. Results Patients’ median age was 8 years; 48% were female. Overall, 46% of patients had leukemia or lymphoma, 40% solid tumors, and 14% were HSCT recipients. Patients were neutropenic [absolute neutrophil count (ANC) <1000] during 70% of episodes and severely neutropenic (ANC <100) in 59%. The most common bacteria identified included E. coli (42%), Ps. aeruginosa (17%), and Klebsiella spp. (10%); 26% of episodes were polymicrobial and 24% of patients had focal infections complicating their bacteremia. Overall, 52% of episodes were caused by CEF-R organisms, including 57% of infections caused by E. coli. Demographic characteristics of CWC with infections caused by CEF-R organisms were similar to those with CEF-S organisms, except that these patients were more likely to have leukemia (adjusted OR 3.6, 95% CI 1.3–9.8) and to have had previous colonization or infection caused by a CEF-R organism (adjusted OR 14.4, 95% CI 2.7–76.0). CWC with infectious caused by CEF-R organisms were more likely to receive intensive care at admission and in the first 3 days of hospitalization than those with CEF-S isolates, but these differences were not statistically significant. The median time to administration of effective antimicrobial therapy was 0.53 hours for episodes caused by CEF-S bacteria and 12.05 hours for episodes caused by CEF-R organisms (P < 0.001), and CEF-R bacteremia was associated with increased time to microbiological resolution (P = 0.002) and a greater likelihood of early modification of treatment because of poor clinical response (5% vs. 14%, P = 0.043). CWC with CEF-R bacteremia had a longer median duration of fever (1 day vs. 2 days, P = 0.015), time to resolution of other signs and symptoms of infection (2 days vs. 4 days, P = 0.005), and median duration of hospitalization (6 vs. 11.5 days, P < 0.001) relative to CEF-S infections. All-cause mortality at hospital discharge and at 30 days was 8% in both CEF-S and CEF-R infections and was associated with the presence of relapsed or refractory malignancy and other significant medical comorbidities. Conclusion Over half of the episodes of GNB in this study were caused by CEF-R organisms. Infection with CEF-R organisms was associated with a delay in the administration of effective therapy and greater morbidity, but not greater mortality. Further studies are warranted to clarify the relationship between antimicrobial resistance, disease severity, treatment, and infection outcomes.

Modifying the psychiatric evaluation for older adults: at tool for medical learners

<h3>Introduction</h3> The population of the United States is aging rapidly. The most recent estimate from 2019 data is that 16.3% of the US population is over 65, totaling over 52 million people. In parallel, cases of dementia are increasing, with an expected increase to 13.8 million US citizens affected by 2050. At the same time, there exists a serious shortage of geriatric psychiatrists, thus necessitating that non-psychiatrist physicians possess some basic skills in the assessment of their older patients' mental health needs. Standard medical school curriculum includes limited training on mental health needs of older adults and those with cognitive disorders. A general psychiatric interview as taught to most medical learners may not be adequate for many older adults, particularly if there is an element of cognitive impairment. Also, the addition of family members or other collateral sources may be necessary when interviewing older adults which is distinctly different from the psychiatric interview of younger adults. Because of these needs, we set about to develop an educational tool for students and residents to use when performing a psychiatric evaluation on an older adult. <h3>Methods</h3> We contrasted the elements of the standard psychiatric interview of adult patients with that used by a panel of experienced geriatric psychiatrists to identify unique aspects of the interview that are age specific. Then, we developed an interview guide for older adults with the target audience being a learner, student or resident. While this would likely be used primarily in a psychiatry clerkship or residency, it has broader applicability to any provider addressing mental health needs in an older adult. <h3>Results</h3> After reviewing the interview elements that need to be emphasized when performing a psychiatric evaluation in a geriatric patient, we identified the following areas most likely needing to be adapted in this population. Introductions and identifying the chief complaint – Patients, especially if they have a cognitive concern, may lack insight about the purpose of the appointment. Clarifying roles and the purpose of the visit is appropriate to set the tone. Collaboration with collateral sources (CS) – Patients may present to clinic with a friend or family member who is eager to share their concerns about the patient. Setting ground rules for how these sources will be asked to contribute that information at the beginning of the interview is helpful, to allow for the addition of this vital information while respecting the dignity and autonomy of the patient. Screening for common psychiatric illness – Depression and anxiety, two of the most common psychiatric syndromes experienced by older patients, may present with a different symptom profile in the older adult, particularly in the presence of cognitive impairment. Focusing mood questions on dysphoria, sleep and appetite changes, feelings of guilt and suicidality may increase the depression screening specificity given that loss of interest, decreased attention and low energy are frequently seen in persons with dementia without depression. Likewise, symptoms of generalized anxiety disorder are much more common than OCD or panic disorder in this population. Psychotic symptom screening needs to occur with the recognition that specific delusions are common in dementia, and that visual hallucinations are a core symptom of dementia with Lewy bodies. Cognitive screening with a standardized test, such as the MOCA or MMSE, as well as assessing for functional impairment, is important to evaluate for dementia. Medication and medical history review – While this is an important part of any psychiatric interview, it takes on increased importance in older adults who are at greater risk for adverse events and are more likely to be prescribed inappropriate medications as outlined by the Beers Criteria. Social history – Because older adults are more likely to have significant medical co-morbidities and disabilities, clarification of sources of social support becomes more important. Physical exam – A focused neurologic exam can be exceptionally helpful in the differential diagnosis of dementia sub-types as well as medical etiologies of psychiatric syndromes. Wrap up discussion – Due to the breadth of the geriatric psychiatric evaluation, the effective interview concludes with an interim summary and plan that is shared with the patient and family members. Depending on the initial impression, laboratory testing and neuroimaging may be necessary to refine the differential diagnosis and provide a treatment plan. <h3>Conclusions</h3> The psychiatric evaluation in older adults, particularly those with cognitive disorders, needs to be modified to recognize the specific needs and common disorders of late life. Use of an interview guide that recognizes these differences can help students and residents focus on the specific issues which concern this patient population and better prepare them to assist their future older adult patients. <h3>Funding</h3> Not applicable.

Racial Disparities in Maternal Critical Care: Are There Racial Differences in Level of Care?

Obstetric care in the US is complicated by marked racial and ethnic disparities in maternal obstetric outcomes, including severe morbidity and mortality, which are not explained by underlying differences in patient characteristics. Understanding differences in care delivery related to clinical acuity across different racial groups may help elucidate the source of these disparities. This study examined the association of maternal race with utilization of critical care interventions. This is a retrospective cohort study conducted as a secondary analysis of a large, multicenter observational study of women undergoing cesarean delivery. All women with a known delivery date were included. The primary outcome measure, a composite of critical care interventions (CCI) at delivery or postpartum that included mechanical ventilation, central and arterial line placement, and intensive care unit (ICU) admission were compared by racial/ethnic group-non-Hispanic white, non-Hispanic black, Hispanic, Asian, and Native American. We evaluated differences in utilization of critical care with a multivariable regression model accounting for selected characteristics present at admission for delivery, including maternal age, BMI, co-morbidities, parity, and plurality. Maternal mortality was also evaluated as a secondary outcome and the frequency of CCI by significant maternal co-morbidity, specifically heart disease, renal disease, and chronic hypertension was assessed to ascertain the level of care provided to women of different race/ethnicity with specific baseline co-morbidities. 73,096 of 73,257 women in the parent trial met inclusion criteria, of whom 505 (0.7%) received a CCI and 3337 (4.6%) had a significant medical co-morbidity (1.2% heart disease, 0.8% renal disease, 2.5% chronic hypertension). The mortality rate was significantly higher among non-Hispanic black women, compared to non-Hispanic white and Hispanic women. In the adjusted model, there was no significant association between CCI and race/ethnicity. This study suggests that differences in maternal morbidity by race may be accounted for by differential escalation to higher intensity care. Further investigation into processes for care intensification may continue to clarify sources of racial and ethnic disparities in maternal morbidity and potential for improvement.

Increased perioperative complication rates in patients with solid organ transplants following rotator cuff repair.

Rotator cuff repair is the second most common soft tissue procedure performed in orthopedics. Additionally, an increasing percentage of the population has received a solid organ transplant (SOT). The chronic use of immunosuppressants as well as a high prevalence of medical comorbidities in this population are both important risk factors when considering surgical intervention. The purpose of this study is to determine the demographic profile, comorbidity profile, and perioperative complication rate of SOT patients undergoing inpatient rotator cuff repair surgery compared to nontransplanted patients. The Nationwide Inpatient Sample (NIS) database was queried from years 2002-2017 to identify all patients who underwent inpatient rotator cuff repair (n = 144,528 weighted). This group was further divided into SOT (n = 286 weighted) and nontransplant (n = 144,242 weighted) cohorts. Demographic and comorbidity analyses were performed between these groups. Additionally, a matched cohort of nontransplanted patients controlled for the year of procedure, age, sex, race, income, and hospital region was created in a 1:1 ratio to the SOT group (n = 286 each) for perioperative complication rate analysis. Compared to nontransplanted patients, SOT patients were more likely to have at least 1 significant medical comorbidity (98% vs. 69%, P < .001), had a higher number of total comorbidities (3.1 vs. 1.4, P < .001), and had a higher Charlson-Deyo Comorbidity Index (2.6 vs. 0.54, P < .001). Compared to the matched cohort, SOT patients experienced longer hospital stays (2.9 vs. 1.8 days, P < .001), higher surgery costs ($12,031 vs. $8476, P < .001), and were more likely to experience a perioperative complication (24% vs. 3%, P < .001) with an odds ratio of 7.7 (95% confidence interval: 3.9-15.1). Compared with nontransplanted patients, SOT patients undergoing rotator cuff repair had a significantly higher comorbidity index, longer hospital stays, costlier surgeries, and were >7 times more likely to experience a perioperative complication. With nearly a quarter of all SOT patients experiencing a perioperative complication following rotator cuff repair, careful consideration for surgery as well as increased postoperative surveillance should be considered in this unique population.

532 Comparison of N-terminal pro-brain natriuretic peptide levels in healthy obese and non-obese pregnant women

NT-proBNP, a marker of ventricular dysfunction, varies by BMI outside of pregnancy with a lower threshold proposed for obesity. We sought to compare NT-proBNP levels between healthy obese and non-obese pregnant women. Prospective observational study of healthy pregnant women in the 3rd and 4th trimesters. Subjects were excluded if they had significant medical comorbidities or if their fetus had anomalies, growth restriction or aneuploidy. NT-proBNP was measured at 28 weeks(3TM), prior to delivery(PD), 1-2 days postpartum(IP), and 4-6 weeks postpartum(PP). LogNT-proBNP at these time points was analyzed using linear mixed effects models, including BMI< or ≥30, time, and time-by-BMI interactions with adjustment for hypertensive disorders of pregnancy (PIH) and race. 55 pregnant women (28 BMI≥30 and 27 BMI<30) enrolled. Obese women were more likely to develop PIH (50% vs 15%, p=0.010), be black (75% vs 29.6%, p=0.002), and have higher systolic blood pressure at all time points (p <0.05). Median NT-proBNP in pg/mL was 18 vs 26 at 3TM, 16 vs 43 at PD, 58 vs 63 at IP, and 33 vs 23 at PP for obese vs non-obese women (Figure 1). In linear mixed effects models, logNT-proBNP was significantly lower in obese women at 3TM (β=-0.89, 95%CI -1.51, -0.26) and PD (β=-1.05, 95%CI -1.72, -0.38) and trended lower IP (β=-0.52, 95%CI -1.16, 0.13; Table 1). The logNT-proBNP trends over time differed by BMI category, with higher values in obese women at both postpartum time points compared to the 3TM (IP β=1.24, 95% CI 0.75, 1.73); PP β=1.08, 95%CI 0.52, 1.63), but only IP for non-obese women (β=0.87, 95%CI 0.36, 1.38). Obese women have significantly lower NT-proBNP than non-obese women during pregnancy, but not postpartum. While NT-proBNP increases in the immediate postpartum period in obese and non-obese women, this increase persists to 4-6 weeks postpartum for obese women. These findings suggest that healthy obese pregnant women have lower baseline NT-proBNP levels than non-obese women, but that their cardiac recovery postpartum may be more prolonged.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Sepsis in the urgent care setting

Sepsis, in particular severe sepsis, is a major cause of morbidity and mortality in pediatrics. It is most likely to affect very young children and children with significant medical comorbidities. The definition of sepsis in pediatrics is currently rapidly evolving but the best treatment for children with severe sepsis remains early goal directed therapy with intravenous fluids and antibiotics. It is therefore important for any pediatric urgent care providers to be able to recognize and treat patients with severe sepsis. It is also important for pediatric urgent care providers to be aware of certain groups of patients who have an increased risk of mortality when they develop sepsis. This article summarizes the current understanding of pediatric sepsis and then focuses on the management of these patients in the pediatric urgent care setting, with special attention paid to groups at higher risks of negative outcomes.

Medium-term outcomes of multi-disciplinary surgical management of non-ischemic diabetic heel ulcers

BackgroundHeel ulcers in patients with peripheral neuropathy and diabetes pose a significant challenge to treating physicians. Infection spreading to the os calcis is associated with a poor prognosis. There is no consensus on which method of surgical treatments results in better outcomes. The aim of this study was to assess patients’ survival, rate of ulcer healing following surgical treatment, along with limb salvage rate, time taken for healing, ulcer recurrence and patients’ functional outcome after healing. MethodsWe studied 29 patients (20 men, 9 women) presenting with diabetic neuropathic heel ulcers (30 feet) and no critical limb ischemia, were managed surgically in our unit and followed-up for a minimum of 12 months. We assessed their clinical and functional outcomes within a mean follow-up period of 28 months (12–83). Results11 out of 29 patients died (38%) with mean duration of post op survival being 31months (range 4–70). 14 ulcers (50%) healed fully within a mean of 360 days (131–1676). Limb salvage was achieved in 29 feet (97%). Only 5 out of 17 patients with diabetic nephropathy (p value 0.016) and 9 out of 24 ulcers with calcaneal osteomyelitis (p value 0.044) achieved full ulcer healing. Ulcer recurrence rate was 36% (5/14) within 12 months of achieving ulcer healing. Six patients were able to return to independent walking in surgical shoes while 11 patients were mobilising using either a crutch or frame. ConclusionWhile excellent limb salvage can be anticipated from the outcome of surgically managed infected heel ulcers in patients with diabetes, complete healing can still be slow and unpredictable. Significant medical co-morbidities in these patients make them vulnerable to medium-term post-operative complication and survival.

Real-world assessment of response to anti-programmed cell death 1 therapy in advanced cutaneous squamous cell carcinoma

Real-world assessment of response to anti-programmed cell death 1 therapy in advanced cutaneous squamous cell carcinoma

An Assessment of Patient Satisfaction and Decisional Regret in Patients Undergoing Staged Free-Flap Breast Reconstruction.

In the setting of radiation therapy or significant medical comorbidities, free-flap breast reconstruction may be intentionally delayed or staged with tissue expander placement ("delayed-immediate" approach). The effect of a staged approach on patient satisfaction and decisional regret remains unclear. All patients undergoing free-flap breast reconstruction (n = 334) between 2014 and 2019 were identified. Complication rates, patient satisfaction using the BREAST-Q, and decisional regret using the Decision Regret Scale were compared between patients undergoing immediate, delayed, and staged approaches. Overall, 100 patients completed the BREAST-Q and Decision Regret Scale. BREAST-Q scores for psychosocial well-being (P = 0.19), sexual well-being (P = 0.26), satisfaction with breast (P = 0.28), physical well-being (chest, P = 0.49), and physical well-being (abdomen, P = 0.42) did not significantly vary between patients undergoing delayed, staged, or immediate reconstruction. Overall, patients experienced low regret after reconstruction (mean score, 11.5 ± 17.1), and there was no significant difference in regret scores by reconstruction timing (P = 0.09). Compared with normative BREAST-Q data, unlike immediate and delayed approaches, staged reconstruction was associated with lower sexual well-being (P = 0.006). Furthermore, a significantly higher infection rate was seen among staged patients (immediate 0%, delayed 5%, staged 20%, P = 0.01). Staged free-flap breast reconstruction confers similar long-term satisfaction and decisional regret as immediate and delayed reconstruction but may be associated with worsened sexual well-being, when compared with normative data, and an increased risk of surgical site infection. When counseling patients regarding the timing of reconstruction, it is important to weigh these risks in the context of equivalent long-term satisfaction and decisional regret between immediate, delayed, and staged approaches.

Awake Laser Laryngeal Stenosis Surgery.

Awake Laser Laryngeal Stenosis Surgery.

Which surgical patients require shared care?

Most hospitalized surgical patients have significant medical comorbidity and are treated with a considerable number of drugs and/or experience significant complications. Shared care (SC) is the shared responsibility and authority in managing hospitalized patients. In this article, we discuss whether patients should be selected for SC or not. The various selection criteria are not an exact science nor are they easy to apply. Furthermore, they may leave out many patients who may be good candidates for SC. Perioperative management is essential for preventing postoperative mortality. Failure to rescue (in-hospital mortality secondary to postoperative complications) is the main factor linked to in-hospital surgical mortality and can affect any patient regardless of age, comorbidity, or type of surgery. The component that most reduces failure to rescue is the presence of internists in surgical wards. We believe that all patients hospitalized in surgery departments should receive SC.

Perioperative shared decision-making in the Bay of Plenty, New Zealand: Audit results from a complex decision pathway quality improvement initiative using a structured communication tool.

Patients presenting for elective surgery in the Bay of Plenty area in New Zealand are increasingly elderly with significant medical comorbidities. For these patients the risk-benefit balance of undergoing surgery can be complex. We recognised the need for a robust shared decision-making pathway within our perioperative medicine service. We describe the setup of a complex decision pathway within our district health board and report on the audit data from our first 49 patients. The complex decision pathway encourages surgeons to identify high-risk patients who will benefit from shared decision-making, manages input from multiple specialists as needed with excellent communication between those specialists, and provides a patient-centred approach to decision-making using a structured communication tool.

Orthodontics in patients with significant medical co-morbidities.

A wide variety of patients with medical co-morbidities may present to general orthodontic practice. It is important for the treating clinician to have a general understanding of key medical conditions that may impact upon the treatment and management options. This clinical supplement provides a treatment-focused summative update for the orthodontist regarding significant medical co-morbidities, their general prevalence and an exploration of potential impacts upon orthodontic treatment. This review also discusses the significance of key medications and provides suggestions for the safe provision of orthodontic treatment.

The Known Unknowns of Obesity and Extracorporeal Membrane Oxygenation.

The Known Unknowns of Obesity and Extracorporeal Membrane Oxygenation.

Efficacy outcomes in the MDD-1 India study: First episode major depressive disorder outcomes in antidepressant-treated real-world patients in India

Little is known about the outcome of major depressive disorder in India, especially in primary care contexts not usually associated with research. This large, prospective, naturalistic observational study examined the feasibility of studying first-episode major depressive disorder outcomes in such contexts, and examined outcomes after antidepressant drug treatment. A convenience sample of 205 psychiatrists across India each recruited five adults with first-episode major depressive disorder. No patient had clinically significant suicidal ideation, psychotic symptoms, or significant medical or psychiatric comorbidity. Patients were naturalistically treated with antidepressant medication and rated using the Montgomery-Asberg Depression Rating Scale and other instruments, including patient-reported outcome measures. Assessments were obtained at baseline and at a 6-week follow-up. Of 900 patients recruited, 92 did not meet selection criteria, and there were 10 dropouts, leaving 798 evaluable patients. The most common antidepressants received were desvenlafaxine, vilazodone, and escitalopram. The primary outcome, response (50% attenuation of Montgomery-Asberg Depression Rating Scale score), was identified in 66.1% of the sample. The patient-reported outcome measures-defined response rate was 53.1%. Remission (endpoint Montgomery-Asberg Depression Rating Scale score of 10 or less) was observed in 36.7% of the sample. Response (but not remission) was very slightly but significantly better in women than in men on some but not all measures. It is feasible to conduct simple but meaningful observational studies in primary care contexts that are not usually associated with research. About two-thirds of real-world adults in primary care in India diagnosed with uncomplicated first-episode major depressive disorder respond to 6 weeks of antidepressant medications; about one-third of the adults remit.

Long-Term Results of Revision Total Hip Arthroplasty Using a Modern Extensively Porous-Coated Femoral Stem

BackgroundThe use of an extensively porous-coated uncemented cobalt-chrome monoblock femoral stem for revision total hip arthroplasty (THA) is well established with excellent mid-term results. The aim of this study is to report the long-term survivorship of these implants in femoral stem revisions. MethodsThis is a long-term retrospective review of prospectively collected data of 55 femoral stem revisions in 55 patients using a contemporary, cementless extensively porous-coated cobalt-chrome monoblock stem. All patients between 2001 and 2006 who underwent first time femoral stem revision with a contemporary, cementless extensively porous-coated cobalt-chrome monoblock stem were included. Harris Hip Score, Western Ontario and McMaster Universities Index, and University of California Los Angeles activity scores were recorded preoperatively and at latest follow-up. Radiographs were analyzed for evidence of loosening, subsidence, osteolysis, and bony union. This study included 55 patients, comprising of 36 females (66%) and 19 males (34%) with a mean age of 66.4 ± 9.3 years at the time of surgery. The mean time interval from index procedure was 9.8 ± 2.9 years. Mean time from revision THA to final follow-up was 13.2 ± 2.17 years with a minimum of 10 years of follow-up. ResultsIndications for revision included aseptic loosening (33), prosthetic joint infection (13), and periprosthetic fracture (10). Significant improvement in Harris Hip Score (85.1 ± 1.77 vs 51.8 ± 2.3, P < .001), Western Ontario and McMaster Universities Index (17.6 ± 0.77 vs 33.3 ± 0.8, P < .001), and University of California Los Angeles (5.25 ± 0.2 vs 2.7 ± 0.36, P < .001) scores were found at latest follow-up compared to preoperative. Fifty-four patients (98%) achieved stable bony ingrowth on radiographic analysis. All 10 patients treated for periprosthetic fractures achieved bony union of their fractures. Two patients suffered intraoperative periprosthetic fractures and were treated with a cable-plating system. There were no mechanical failures and no femoral stem re-revisions. One patient was diagnosed with a deep infection and was treated with chronic suppressive antibiotic therapy due to significant medical comorbidities. ConclusionRevision of the femoral component with a contemporary extensively porous-coated cobalt-chrome femoral stem has excellent functional outcomes, radiographic outcomes, and long-term survivorship with minimal complications.