Understanding decision making about major surgery: protocol for a qualitative study of shared decision making by high-risk patients and their clinical teams.

INTRODUCTION: Surgical treatments are being offered to more patients than ever before, and increasingly to high-risk patients (typically multimorbid and over 75). Shared decision making is seen as essential practice. However, little is currently known about what 'good' shared decision making involves nor how it applies in the context of surgery for high-risk patients. This new study aims to identify how high-risk patients, their families and clinical teams negotiate decision making for major surgery. METHODS AND ANALYSIS: Focusing on major joint replacement, colorectal and cardiac surgery, we use qualitative methods to explore how patients, their families and clinicians negotiate decision making (including interactional, communicative and informational aspects and the extent to which these are perceived as shared) and reflect back on the decisions they made. Phase 1 involves video recording 15 decision making encounters about major surgery between patients, their carers/families and clinicians; followed by up to 90 interviews (with the same patient, carer and clinician participants) immediately after a decision has been made and again 3-6 months later. Phase 2 involves focus groups with a wider group of (up to 90) patients and (up to 30) clinicians to test out emerging findings and inform development of shared decision making scenarios (3-5 summary descriptions of how decisions are made). ETHICS AND DISSEMINATION: The study forms the first part in a 6-year programme of research, Optimising Shared decision-makIng for high-RIsk major Surgery (OSIRIS). Ethical challenges around involving patients at a challenging time in their lives will be overseen by the programme steering committee, which includes strong patient representation and a lay chair. In addition to academic outputs, we will produce a typology of decision making scenarios for major surgery to feed back to patients, professionals and service providers and inform subsequent work in the OSIRIS programme

Fate of the Aortic Arch Following Surgery on Aortic Root and Ascending Aorta in Bicuspid Aortic Valve.

BACKGROUND: Recent guidelines support more aggressive surgery for aneurysms of the ascending aorta and root in patients with bicuspid aortic valve. However, the fate of the arch after surgery of the root and ascending aorta is unknown. We set out to assess outcomes following root and ascending aortic surgery and subsequent growth of the arch. METHODS: Between 2005 and 2016, 536 consecutive patients underwent surgery for aneurysm of the root and ascending aorta. 168 had bicuspid aortic valve. Patients with dissection were excluded. Arch diameter was measured before and after surgery, at six months and then annually. RESULTS: Of 168 patients, 127 (75.6%) had aortic root replacement and 41 (24.4%) had ascending replacement. Mean age was 57±12.8 years, 82.7% were males and five operations were performed during pregnancy. There was one (0.6%) hospital death. One (0.6%) patient had a stroke and one (0.6%) had re-sternotomy for bleeding. Median ICU and hospital stays were 1 and 6 days respectively. Follow-up was complete for 94% at a median of 5.9 years (1-139 months). Aortic arch diameter was 2.9 cm preoperatively and 3.0 cm at follow-up. There was 97% freedom from reoperation and none of the patients required surgery on the arch. CONCLUSIONS: Prophylactic arch replacement during aortic root and ascending aortic surgery in patients with bicuspid aortic valve is not supported. Our data does not support long term surveillance of the rest of the aorta in this population

Effect of losartan on performance and physiological responses to exercise at high altitude (5035 m)

Objective: Altitude-related and exercise-related elevations in blood pressure (BP) increase the likelihood of developing pulmonary hypertension and high-altitude illness during high-altitude sojourn. This study examined the antihypertensive effect and potential exercise benefit of the angiotensin II receptor antagonist losartan when taken at altitude. Methods: Twenty participants, paired for age and ACE genotype status, completed a double-blinded, randomised study, where participants took either losartan (100 mg/day) or placebo for 21 days prior to arrival at 5035 m (Whymper Hut, Mt Chimborazo, Ecuador). Participants completed a maximal exercise test on a supine cycle ergometer at sea level (4 weeks prior) and within 48 hours of arrival to 5035 m (10-day ascent). Power output, beat-to-beat BP, oxygen saturation (SpO2) and heart rate (HR) were recorded during exercise, with resting BP collected from daily medicals during ascent. Before and immediately following exercise at 5035 m, extravascular lung water prevalence was assessed with ultrasound (quantified via B-line count). Results: At altitude, peak power was reduced relative to sea level (p<0.01) in both groups (losartan vs placebo: down 100±29 vs 91±28 W, p=0.55), while SpO2 (70±6 vs 70±5%, p=0.96) and HR (146±21 vs 149±24 bpm, p=0.78) were similar between groups at peak power, as was the increase in systolic BP from rest to peak power (up 80±37 vs 69±33 mm Hg, p=0.56). Exercise increased B-line count (p<0.05), but not differently between groups (up 5±5 vs 8±10, p=0.44). Conclusion: Losartan had no observable effect on resting or exercising BP, exercise-induced symptomology of pulmonary hypertension or performance at 5035 m

Physiological responses during ascent to high altitude and the incidence of acute mountain sickness.

Acute mountain sickness (AMS) occurs when there is failure of acclimatisation to high altitude. The aim of this study was to describe the relationship between physiological variables and the incidence of AMS during ascent to 5300 m. A total of 332 lowland-dwelling volunteers followed an identical ascent profile on staggered treks. Self-reported symptoms of AMS were recorded daily using the Lake Louise score (mild 3-4; moderate-severe ≥5), alongside measurements of physiological variables (heart rate, respiratory rate (RR), peripheral oxygen saturation (SpO2 ) and blood pressure) before and after a standardised Xtreme Everest Step-Test (XEST). The overall occurrence of AMS among participants was 73.5% (23.2% mild, 50.3% moderate-severe). There was no difference in gender, age, previous AMS, weight or body mass index between participants who developed AMS and those who did not. Participants who had not previously ascended >5000 m were more likely to get moderate-to-severe AMS. Participants who suffered moderate-to-severe AMS had a lower resting SpO2 at 3500 m (88.5 vs. 89.6%, p = 0.02), while participants who suffered mild or moderate-to-severe AMS had a lower end-exercise SpO2 at 3500 m (82.2 vs. 83.8%, p = 0.027; 81.5 vs. 83.8%, p 5000 m (OR 2.740, p-value 0.003) predicted the development of moderate-to-severe AMS. The Xtreme Everest Step-Test offers a simple, reproducible field test to help predict AMS, albeit with relatively limited predictive precision

Caudwell Xtreme Everest: A prospective study of the effects of environmental hypoxia on cognitive functioning.

BACKGROUND: The neuropsychological consequences of exposure to environmental hypobaric hypoxia (EHH) remain unclear. We thus investigated them in a large group of healthy volunteers who trekked to Mount Everest base camp (5,300 m). METHODS: A neuropsychological (NP) test battery assessing memory, language, attention, and executive function was administered to 198 participants (age 44.5±13.7 years; 60% male). These were studied at baseline (sea level), 3,500 m (Namche Bazaar), 5,300 m (Everest Base Camp) and on return to 1,300 m (Kathmandu) (attrition rate 23.7%). A comparable control group (n = 25; age 44.5±14.1 years; 60% male) for comparison with trekkers was tested at/or near sea level over an equivalent timeframe so as to account for learning effects associated with repeat testing. The Reliable Change Index (RCI) was used to calculate changes in cognition and neuropsychological function during and after exposure to EHH relative to controls. RESULTS: Overall, attention, verbal ability and executive function declined in those exposed to EHH when the performance of the control group was taken into account (RCI .05 to -.95) with decline persisting at descent. Memory and psychomotor function showed decline at highest ascent only (RCI -.08 to -.56). However, there was inter-individual variability in response: whilst NP performance declined in most, this improved in some trekkers. Cognitive decline was greater amongst older people (r = .42; p < .0001), but was otherwise not consistently associated with socio-demographic, mood, or physiological variables. CONCLUSIONS: After correcting for learning effects, attention, verbal abilities and executive functioning declined with exposure to EHH. There was considerable individual variability in the response of brain function to sustained hypoxia with some participants not showing any effects of hypoxia. This might have implications for those facing sustained hypoxia as a result of any disease

Hugh L. Cooper & Company to Horace Kephart, March 13, 1923

In a letter to Horace Kephart on March 13, 1923, Hugh L. Cooper and Company receive “Our Southern Highlanders” and express interest in a water power device Kephart mentions in his book. They send a photograph of a similar contraption used in Brazil and request a location of this device in the Appalachian mountain region.£*>*_ cable address "Coopower New York" Hugh L. cooper & Co. lOt PARK AVENUE New York March 13, 1923. Mr. Horace Kephart, c/o MacMillan Company, 64 Fifth Avenue, New York City. Dear Sir: We had great pleasure in reading recently a copy of your book entitled "Our Southern Highlanders". We were especially interested in the contrivance described on page 365, the last paragraph, and are sending you a photograph of a similar device which we found some years ago in Brazil, used there up to this day by the Portugese, and would greatly appreciate your telling us whether the crude water power you have found in the southern mountains is of the same construction. At the same time, it would be much appreciated if you would tell us the exact location of at least one of these outfits, as we would like to have the local photographer, if possible, get us some actual pictures of it. Yours very truly, HUGH L. .COOPER & CO., R.D. Edsell RDE-WGS. Enclosure

Squalor in Hoarded Homes

Domestic squalor is a difficult topic to study; residents of squalid homes are unlikely to volunteer for research due to factors such as stigma or poor insight. Although squalor and hoarding are distinct constructs, extant research suggests squalor occurs more commonly in hoarding than in the general population, but little is known about the circumstances under which squalor develops in hoarded homes. The current study aimed to identify correlates and unique predictors of squalor in the context of hoarded homes based on archival data (N = 381) collected in 2010-2014 from three North American community agencies who help clients with hoarding symptoms and squalor. As part of their routine services, each agency completed in-home assessments to evaluate client characteristics (poor insight, social isolation) and conditions of the home (clutter accumulation, poor access to kitchen or bathroom, number of pets). Across sites, degree of clutter accumulation and poor access to the kitchen or bathroom were consistent unique predictors of squalor presence. This research provides a window into the homes of people who struggle with problematic living conditions and suggests that specific conditions of the home are potential risk factors for squalor in the context of hoarding symptoms.Arts, Faculty ofNon UBCPsychology, Department ofSocial Work, School ofSociology, Department ofReviewedFacultyGraduat

Corrigendum to: 'Analysis of aortic area/height ratio in patients with thoracic aortic aneurysm and Type A dissection' [Eur J Cardiothorac Surg 2018; doi:10.1093/ejcts/ezy110].

OBJECTIVES: Significant proportions of aortic dissections occur at aortic diameters 10 cm2/m, are at increased risk of aortic complications. METHODS: IAAs were calculated at 3 aortic locations in 187 aneurysm and 66 dissection patients operated on between 2010 and 2016 at our tertiary aortic centre. Proportions of patients with IAA >10 cm2/m, mean IAAs corresponding to aortic diameters 5.5 cm, and mean aortic diameters corresponding to IAAs 10-12 cm2/m, 12-14 cm2/m and >14 cm2/m were determined. RESULTS: Proportions of patients with abnormal IAAs were similar in both groups. In all, 49.1% of aneurysm patients with aortic diameters 4.5-5.0 cm, and 98.5% with aortic diameters 5.0-5.5 cm had abnormal IAAs. Out of 207 separate aneurysms with IAAs >10 cm2/m between the mid-sinus and mid-ascending aorta, only 139 (69.5%) would warrant surgery according to existing guidelines. CONCLUSIONS: Using the IAA, we identified a significant proportion of patients with thoracic aortic aneurysms who are at increased risk of aortic complications, despite current aortic guidelines not endorsing surgical intervention in this group. Our data suggests the IAA may be useful in preoperative risk evaluation and as a criterion for surgery