Delirium after Aortic Valve Therapy. A Prospective Cohort Study of Octogenarian Patients following Surgical Aortic Valve Replacement and Transcatheter Aortic Valve Implantation.

Introduction: Untreated and symptomatic aortic stenosis (AS) is associated with high mortality. Surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) are two treatment options for patients with severe AS. Patients receiving SAVR and TAVI are often 80 years and older. Delirium, an acute state of confusion characterized by temporary and fluctuating decline in attention and cognition, is common in older patients after cardiac surgery. Yet, knowledge about octogenarians undergoing invasive cardiovascular therapy is scarce, and delirium after TAVI remains to be systematically explored. Aims: The overall aim of this study was to investigate delirium in octogenarian patients undergoing SAVR or TAVI by determining its incidence, identifying risk factors, describing its onset and time course, and by determining if delirium can be used to predict physical and cognitive function, self-reported health status, first-time hospital readmissions and mortality 1 and 6 months after aortic valve treatment. Materials and Methods: This is a prospective cohort study of octogenarian patients with AS, scheduled for elective treatment with SAVR or TAVI at a tertiary university hospital in western Norway. Delirium was the main outcome of the study. Inclusion criteria were: age 80 years-old and older and previous acceptance for treatment with SAVR or TAVI. Exclusion criteria were: denied consent to participate in the study and inability to speak Norwegian. Between 2011 and 2013, 143 patients were included in the study. Demographic and clinical information was collected from hospital information system registers, patients’ medical records or by interviewing included patients, as appropriate. Delirium was assessed for 5 postoperative days with the Confusion Assessment Method. Activities of daily living, instrumental activities of daily living and self-reported health status were measured with the Barthel Index, the Nottingham Extended Activities of Daily Living Scale (IADL) and The 12-Item Short Form Health Survey (SF-12), at baseline and at 1 and 6-month follow-up. Cognitive status was assessed at baseline and at 6-month follow-up with the Mini-Mental State Examination (MMSE). Results: The mean age of included patients was 83.5 years (SD 2.7) and TAVI was performed in 46% of them. Patients undergoing SAVR had a higher incidence of delirium than patients treated with TAVI (66% vs 44%, p = 0.01). Multivariate logistic regression analysis revealed that reduced cognitive function at baseline (p = 0.03) and treatment with SAVR (p = 0.02) are risk factors for delirium in octogenarian patients after aorta valve treatment. No differences in the number of days with delirium were found between patient groups (p = 0.20) but the onset and course of delirium in patients treated with SAVR was more unpredictable (p = 0.003) than it was in patients treated with TAVI (Paper I). Patients with and without delirium after SAVR had lower IADL function at 1-month follow-up (scores from 58 to 42 and from 58 to 50 respectively p ≤ 0.02). However, this function returned to baseline levels after 6 months. Improvements in the Physical Component Summary score of SF-12 were found in patients not having delirium and treated with SAVR (from 39 to 48, p < 0.001). No differences between patient groups in other outcomes were identified. Regression models suggest that delirium after SAVR might predict IADL scores1-month after treatment (not significant, p-values ≤ 0.07) but does not predict large differences in ADL, cognitive function or SF-12 scores in octogenarian AS patients. Patients experiencing delirium after TAVI had a lower ADL (from 19 to 16, p < 0.001) and IADL function (from 49 to 40, p = 0.003) 1 month after the procedure. In TAVI patients without delirium, the physical component score of SF-12 increased after 1 and 6 months (30 to 35, p = 0.04 and 30 to 35, p = 0.02 respectively). Regression analyses established that delirium following TAVI predicted lower ADL and IADL function at 1 but not at 6-month follow-up (Paper II). First-time readmissions and death 1 and 6 months after SAVR or TAVI were more common in octogenarian patients who experienced delirium. The effect of delirium was greatest during the first two months after discharge (adjusted hazard ratio 2.9 (95% CI: 1.5 to 5.7).The most common discharge diagnosis at readmission was related to the circulatory system (Paper III). Conclusions: Delirium is often present after aortic valve treatment, especially in patients receiving SAVR. In addition to be a risk factor for delirium in octogenarian patients, SAVR was associated with a more unpredictable onset and course of delirium. Patients who experienced delirium, regardless treatment type, appear to have lower short-term IADL function. Yet, delirium does not seem to confer long-term reductions in physical, mental or self-reported health status in this patient group. Compared to patients without delirium, first-time readmissions and mortality were more common 6 months after hospital discharge in patients who had experienced delirium. Our study provides additional evidence showing that delirium is a serious hospital complication that could be associated with negative outcomes such as lower physical function, morbidity and mortality 1 and 6 months after aortic valve treatment, also when more gentle techniques like TAVI are used. These findings are also relevant when designing future studies and implementing strategies that could lead to the prevention of delirium in other older patient populations

Dynamic Slate Recommendation with Gated Recurrent Units and Thompson Sampling

We consider the problem of recommending relevant content to users of an internet platform in the form of lists of items, called slates. We introduce a variational Bayesian Recurrent Neural Net recommender system that acts on time series of interactions between the internet platform and the user, and which scales to real world industrial situations. The recommender system is tested both online on real users, and on an offline dataset collected from a Norwegian web-based marketplace, FINN.no, that is made public for research. This is one of the first publicly available datasets which includes all the slates that are presented to users as well as which items (if any) in the slates were clicked on. Such a data set allows us to move beyond the common assumption that implicitly assumes that users are considering all possible items at each interaction. Instead we build our likelihood using the items that are actually in the slate, and evaluate the strengths and weaknesses of both approaches theoretically and in experiments. We also introduce a hierarchical prior for the item parameters based on group memberships. Both item parameters and user preferences are learned probabilistically. Furthermore, we combine our model with bandit strategies to ensure learning, and introduce `in-slate Thompson Sampling' which makes use of the slates to maximise explorative opportunities. We show experimentally that explorative recommender strategies perform on par or above their greedy counterparts. Even without making use of exploration to learn more effectively, click rates increase simply because of improved diversity in the recommended slates

Challenges to providing HIV prevention education to youth with disabilities in South Africa

Purpose: In South Africa, little is known how HIV prevention education is implemented in schools for learners with disabilities. This article reports on findings from a study exploring the extent to which HIV education is reached to people with disabilities in South Africa, and the challenges faced by educators providing HIV prevention education to learners with disabilities. Method: A survey questionnaire completed by 34 schools for learners with special education needs in the Western Cape province of South Africa. Additional complimentary data were collected through interviews with a total of 21 members of staff at schools for learners with disabilities. Results: Respondents recognise the importance of providing HIV prevention education for people with disabilities. Staff reports some challenges in providing HIV prevention education: barriers to communication; discomfort about issues of sexuality and disability; disagreements among staff about what is appropriate content for sexual health education; and fears of promoting sexual activity. Conclusions: There is a need for HIV prevention education to be specifically customized to the needs of the specific population. A general programme, which is included as part of a general curriculum and generally tailored to “mainstream” schools, would need to be adapted according to specific needs and disabling barriers faced

Quality of life among cancer inpatients 80 years and older: a systematic review

Objective The aim of this systematic review was to summarize and assess the literature on quality of life (QoL) among cancer patients 80 years and older admitted to hospitals and what QoL instruments have been used. Methods We searched systematically in Medline, Embase and Cinahl. Eligibility criteria included studies with any design measuring QoL among cancer patients 80 years and older hospitalized for treatment (surgery, chemotherapy or radiation therapy). Exclusion criteria: studies not available in English, French, German or Spanish. We screened the titles and abstracts according to a predefined set of inclusion criteria. All the included studies were assessed according to the Critical Appraisal Skills Programme checklists, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement checklist was used to ensure rigor in conducting and reporting. This systematic review was registered in PROSPERO (CRD42017058290). Results We included 17 studies with 2005 participants with various cancer diagnoses and Classification of Malignant Tumors stages (TNM). The included studies used a range of different QoL instruments and had different aims and outcomes. Both cancer-specific and generic instruments were used. Only one of the 17 studies used an age-specific instrument. All the studies included patients 80 years and older in their cohort, but none specifically analyzed QoL outcomes in this particular subgroup. Based on findings in the age-heterogeneous population (age range 20–100 years), QoL seems to be correlated with the type of diagnosed carcinoma, length of stay, depression and severe symptom burden. Conclusion We were unable to find any research directly exploring QoL and its determinants among cancer patients 80 years and older since none of the included studies presented specific analysis of data in this particular age subgroup. This finding represents a major gap in the knowledge base in this patient group. Based on this finding, we strongly recommend future studies that include this increasingly important and challenging patient group to use valid age- and diagnosis-specific QoL instruments.publishedVersio

Perceived current needs, psychological distress and functional impairment in a war-affected setting: a cross-sectional study in South Sudan

Objectives To examine the current perceived needs of the general population in a war-affected setting, and to study the influence of perceived needs on the participants’ mental health status and functional impairment across genders. Methods A cross-sectional community survey (n=464) was conducted in war-affected South Sudan. Three regression models were analysed. Perceived needs were assessed with the Humanitarian Emergency Settings Perceived Needs Scale. Psychological distress was measured with the General Health Questionnaire and level of functioning by the Short Form Health Survey (SF-12). Results The most frequently expressed needs were related to drinking water, alcohol and drug use in the community and access to sanitation facilities. No gender differences were found regarding the level of perceived needs or the number of traumatic events. Higher level of perceived needs significantly predicted psychological distress and lower level of functioning even when numbers of experienced trauma events were taken into account. Conclusions The associations of higher level of needs and trauma experiences, on the one hand, and negative health outcomes on the other, necessitate a greater integration of interventions directed towards the population's perceived needs and mental health, particularly for those who have been exposed to trauma

Anxiety and depression in patients aged 80 years and older following aortic valve therapy. A six‑month follow‑up study

Background Little is known about mental health following advanced cardiac procedures in the oldest patients. Aims To study changes in anxiety and depression from baseline to one- and six-month follow-up in older patients following transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR). Methods Prospective cohort study of patients ≥ 80 years undergoing elective TAVI or SAVR in a tertiary university hospital. Anxiety and depression were assessed with the Hospital Anxiety and Depression Scale. Differences between TAVI/SAVR were analyzed using Welch’s t test or chi-squared. Changes over time and group differences were established with longitudinal models using generalized least squares. Results In 143 patients (83.5 ± 2.7 years), 46% (n = 65) received TAVI. Anxiety was identified in 11% of TAVI patients at baseline. One- and six-months later, percentages were 8% and 9%. In SAVR patients, 18% had baseline scores indicating anxiety. One and six-months later, percentages were 11% and 9%. Depression was identified in 15% of TAVI patients. One- and six-months later, percentages were 11% and 17%. At baseline, 11% of SAVR patients had scores indicating depression. One- and six-months after SAVR, percentages were 15% and 12%. Longitudinal analyses showed reductions (P < 0.001) in anxiety from baseline to one-month, and stable scores between one- and six-months for both treatment groups. There was no change over time for depression among treatment groups (P = 0.21). Discussion and conclusions SAVR or TAVI in patients ≥ 80 years was associated with anxiety reduction between baseline and follow-up. For depression, there was no evidence of change over time in either treatment group.publishedVersio

Alcohol use in South Sudan in relation to social factors, mental distress and traumatic events

This is an Open Access article licensed under the Creative Commons Attribution License 3.0 (CC BY 3.0) and originally published in BMC Public Health. You can access the article by following this link: http://dx.doi.org/10.1186/s12889-016-3605-9Dette er en vitenskapelig, fagfellevurdert artikkel som opprinnelig ble publisert i BMC Public Health. Artikkelen er publisert under lisensen Creative Commons Attribution License 3.0 (CC BY 3.0). Du kan også få tilgang til artikkelen ved å følge denne lenken: http://dx.doi.org/10.1186/s12889-016-3605-9Background Alcohol use is a major public health problem with vast implications for poor, war-torn countries. The objective of this study was to describe prevalence of alcohol use and risky drinking across socio-demographic factors in South Sudan, and to determine the association between risky drinking, traumatic events and mental distress. Methods This is a randomized, population based, cross-sectional study from the north-western part of South Sudan with nearly 500 participants. We used the Alcohol Use Disorders Identification Test (AUDIT) as main outcome variable, the General Health Questionnaire (GHQ-28) for mental distress and five questions to assess traumatic events. Results The mean AUDIT score was 2.7 (SD 0.3) with 14,2 % in the high risk problem drinking category. Being male, lack of a regular income and psychological distress were significantly associated with higher AUDIT score. Traumatic events, however, was not associated with higher score on AUDIT. Conclusion Despite decades of civil war and great poverty the alcohol use in this population was at the same level as other countries in Southern Africa. Traumatic events were not related to risk of problem drinking

Baseline frailty status and outcomes important for shared decision-making in older adults receiving transcatheter aortic valve implantation, a prospective observational study.

AIMS The objective of this study was to examine baseline frailty status (including cognitive deficits) and important clinical outcomes, to inform shared decision-making in older adults receiving transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS We conducted a prospective, observational study of 82 TAVI patients, recruited 2013 to 2015, with 2-year follow-up. Mean age was 83 years (standard deviation (SD) 4.7). Eighteen percent of the patients were frail, as assessed with an 8-item frailty scale. Fifteen patients (18%) had a Mini-Mental Status Examination (MMSE) score below 24 points at baseline, indicating cognitive impairment or dementia and five patients had an MMSE below 20 points. Mean New York Heart Association (NYHA) class at baseline and 6 months was 2.5 (SD 0.6) and 1.4 (SD 0.6), (p < 0.001). There was no change in mean Nottingham Extended Activities of Daily Living (NEADL) scale between baseline and 6 months, 54.2 (SD 11.5) and 54.5 (SD 10.3) points, respectively, mean difference 0.3 (p = 0.7). At 2 years, six patients (7%) had died, four (5%, n = 79) lived in a nursing home, four (5%) suffered from disabling stroke, and six (7%) contracted infective endocarditis. CONCLUSIONS TAVI patients had improvement in symptoms and maintenance of activity of daily living at 6 months. They had low mortality and most patients lived in their own home 2 years after TAVI. Complications like death, stroke, and endocarditis occurred. Some patients had cognitive impairment before the procedure which might influence decision-making. Our findings may be used to develop pre-TAVI decision aids

Relationship of Treatment Delay with Surgical Defect Size from Keratinocyte Carcinoma (Basal Cell Carcinoma and Squamous Cell Carcinoma of the Skin)

Larger keratinocyte carcinoma (KC) lesions are associated with higher morbidity. This study examined the association of potentially modifiable characteristics, including treatment delay, with KC defect size after Mohs micrographic surgery (MMS). A stratified random sample of patients treated for KC with MMS were selected for telephone interview. Two hundred and nineteen interviews were completed (refusal rate 24%). Regression models were used to examine the predictors to defect size and delay. Anatomic site, age, histology, and gender predicted defect size (R2=0.39) and were used as control variables. Self-reported delay between initial physician examination and MMS predicted defect size (p=0.0004), with greater than 1 y delay being associated with a doubling of defect size (adjusted odds ratio (OR) 2.0; 95% confidence interval (CI) 1.3–3.1). Delays of this duration were associated with initial examination by a primary provider (unadjusted OR 3.9; 95% CI 1.7–8.8), misdiagnosis (unadjusted OR 6.8; 95% CI 2.5–18.7), being treated without biopsy (unadjusted OR 23.3; 95% CI 6.5–83.7), and multiple surgical removals (unadjusted OR 6.2; 95% CI 2.5–15.5). All but provider specialty were independent predictors of delay. Attention to processes of care delivery for KC may have a greater impact on morbidity than efforts are earlier detection by the public