Functional performance after complex endovascular aortic repair: a single-center retrospective cohort study

Purpose Complex endovascular aortic repair (EVAR) procedures provide a treatment option for patients with aortic aneurysms involving visceral branches. Good technical results and short-term outcomes have been reported. Whether complex EVAR provides acceptable functional outcomes is not clear. The current study aims to describe postoperative functional outcomes in complex EVAR patients-an older and relatively frail patient group. Materials and Methods A single-center retrospective cohort study was performed, using data from a computerized database of consecutive patients who underwent complex EVAR in the Leiden University Medical Center (LUMC, The Netherlands) between July 2013 and September 2020. As of May 2017, patients scheduled for complex EVAR were referred to a geriatric care pathway to determine (Instrumental) Activities of Daily Living ((I)ADL) scores at baseline and, if informed consent was given, after 12 months. For the total patient group, adverse functional performance outcomes were: discharge to a nursing home and 12-month mortality. For the patients included in geriatric follow-up, the additional outcome was the incidence of functional decline (defined by a >= 2 point increase in (I)ADL-score) at 12-month follow-up Results Eighty-two patients underwent complex EVAR, of which 68 (82.9%) were male. Mean age was 73.3 years (SD=6.3). Within 30 days postsurgery, 6 patients (7.3%) died. Mortality within 12 months for the total patient group was 14.6% (n=12). After surgery, no patients had to be discharged to a nursing home. Fifteen patients (18.3%) were discharged to a rehabilitation center. Twenty-three patients gave informed consent and were included in geriatric follow-up. Five patients (21.7%) presented functional decline 12 months postsurgery and 4 patients had died (17.4%) by that time. This means that 39.1% of the patients in the care pathway suffered an adverse outcome. Conclusion To our knowledge, this is the only study that examined functional performance after complex EVAR, using a prospectively maintained database. No patients were newly discharged to a nursing home and functional performance results at 12 months are promising. Future multidisciplinary research should focus on determining which patients are most prone to deterioration of function, so that efforts can be directed toward preventing postoperative functional decline.Cardiovascular Aspects of Radiolog

Begeleide web-based interventie voor slaapproblemen (I-Sleep) bij patiënten met een depressie in de ambulante gespecialiseerde ggz: Een pilotstudie

BACKGROUND: Insomnia in depressed patients is usually targeted by medication, while cognitive behavioural treatment for insomnia (CBT-I) is the treatment of first choice. Effective online CBT-I is available but is not frequently offered in regular care. AIM: To determine the feasibility and indications for effectiveness of I-Sleep, an online CBT-I module, for uni- and bipolar depressed patients in specialised mental health care settings. METHOD: In a pilot study I-Sleep (5 sessions) was offered to all 31 patients. Patients who did not (yet) want to participate in the online intervention, and patients who were included after the intended sample size was reached, participated in the control-group. Feasibility was assessed by compliance rates and satisfaction of patients and therapists (CSQ). Effectiveness was assessed within and between groups by the Insomnia Severity Index (ISI) and the Patient Health Questionnaire (PHQ-9) at baseline and after 6 and 12 weeks. RESULTS: In the intervention group 41% completed all treatment sessions and 77% completed 3 or more sessions. Patients rated the intervention positively (CSQ 23.6, range 4-32). Sleep improved in the intervention group (Cohen's d = 1.93), as well as depression (Cohen's d=1.05). In the control group there was no significant improvement. The difference between the two groups washighand significant for sleep problems (Cohen's d = 0.99) but not for depressive symptoms. CONCLUSION: Online CBT-I is a feasible treatment option for depressed patients in mental health care settings. There are indications that CBT-I is also effective in reducing sleep problems in more severely depressed patients

Begeleide web-based interventie voor slaapproblemen (I-Sleep) bij patiënten met een depressie in de ambulante gespecialiseerde ggz: Een pilotstudie

BACKGROUND: Insomnia in depressed patients is usually targeted by medication, while cognitive behavioural treatment for insomnia (CBT-I) is the treatment of first choice. Effective online CBT-I is available but is not frequently offered in regular care. AIM: To determine the feasibility and indications for effectiveness of I-Sleep, an online CBT-I module, for uni- and bipolar depressed patients in specialised mental health care settings. METHOD: In a pilot study I-Sleep (5 sessions) was offered to all 31 patients. Patients who did not (yet) want to participate in the online intervention, and patients who were included after the intended sample size was reached, participated in the control-group. Feasibility was assessed by compliance rates and satisfaction of patients and therapists (CSQ). Effectiveness was assessed within and between groups by the Insomnia Severity Index (ISI) and the Patient Health Questionnaire (PHQ-9) at baseline and after 6 and 12 weeks. RESULTS: In the intervention group 41% completed all treatment sessions and 77% completed 3 or more sessions. Patients rated the intervention positively (CSQ 23.6, range 4-32). Sleep improved in the intervention group (Cohen's d = 1.93), as well as depression (Cohen's d=1.05). In the control group there was no significant improvement. The difference between the two groups washighand significant for sleep problems (Cohen's d = 0.99) but not for depressive symptoms. CONCLUSION: Online CBT-I is a feasible treatment option for depressed patients in mental health care settings. There are indications that CBT-I is also effective in reducing sleep problems in more severely depressed patients

De effectiviteit van psychotherapie in de eerste lijn bij patïnten met een depressieve stoornis een systematisch overzicht

BACKGROUND: Psychotherapy may be an alternative to drug treatment for depressive disorder in primary care. AIM: To give a systematic review about the effectiveness of psychotherapy for depressive disorder in primary care. METHOD: Randomised controlled trials were selected in which the effectiveness of psycho therapy was studied in primary care patients with depressive disorder, using Medline, Psychinfo, the Cochrane library and Embase. Effect differences were estimated according to the standardized mean difference. RESULTS: Ten studies met the selection criteria. Overall (based upon five studies), psychotherapy applied in a primary care setting was slightly more effective than usual care by a primary care physician for patients with depressive disorder. In seven studies psychotherapy was as effective as farmacotherapy for primary care patients with a depressive disorder. In one study, psychotherapy was more effective than placebo therapy for primary care patients with major depression. In patients with minor depression or dysthymia there was no difference between psychotherapy and placebo (two studies). CONCLUSION: Psychotherapy is a good alternative to drug treatment, also in primary care patients with depressive disorder. Further research is needed to show to what extent psychotherapy is a feasible option in primary care

Prevalence and predictors of violent victimization in remitted patients with recurrent depression

Background: Depressed patients are at increased risk to fall victim to a violent crime compared to the general population. It remains unknown whether their increased risk persists after remission. This study compared victimization rates of remitted patients with both a random general population sample and a group of currently depressed patients. Furthermore, this study aimed to identify predictors of future violent victimization. Methods: In this longitudinal study conducted in the Netherlands, 12-month prevalence rates of sexual assaults, physical assaults, and threats were assessed with the Safety Monitor in 140 currently remitted patients with recurrent depression, and compared to those of a weighted general population sample (N = 9.175) and a weighted sample of currently depressed outpatients (N = 102) using Chi-square tests. Logistic regression analyses were performed to identify baseline predictors of future victimization. Results: The prevalence of violent victimization did not differ between remitted patients and the general population (12.1 vs. 11.7%). Remitted patients were significantly less likely to have been victimized over the past 12 months than currently depressed patients (12.1 vs. 35.5%). In remitted patients, living alone and low sense of mastery at baseline predicted future violent victimization. However, when combined in a multiple model, only living alone was independently associated with violent victimization (χ2 = 16.725, df = 2, p <.001, R2 = 0.221). Limitations: Our comparison of victimization rates across samples was cross-sectional. Conclusions: Since the increased risk of victimization appears to be specific for the acute depressive state, preventive interventions should target victimization in currently depressed patients. Trial registration: Netherlands Trial Register (NTR): 2599

Werkwijze en eerste resultaten van multidisciplinaire afbouwpoli anti-depressiva

BACKGROUND: Discontinuation of antidepressant medication can be difficult due to withdrawal symptoms and relapse risk. Scientific evidence on the questions of who, when, and how to stop antidepressants is limited. In Amsterdam a multidisciplinary outpatient clinic was started to provide advice and guidance. AIM: To substantiate the design of the clinic. Central questions relate to knowing which patients are referred, the background of their request, and their experiences with the outpatient clinic. METHOD: The first 51 patients of the clinic were described on the basis of file research, in addition a survey was conducted into patient experiences. RESULTS: Half of the patients (55%) actually started discontinuation, 39% were advised not to do so (yet). Patients at the clinic had used antidepressants for an average of 10 years, and 76% had previously attempted to stop. 21% had now successfully stopped and 25% were satisfied with a lower dose. One patient relapsed during tapering. CONCLUSION: So far, patients with long-term antidepressant use and multiple quit attempts have been referred. Our experiences are aimed at helping individual patients but can also result in more knowledge about who can stop at what moment, and how this should be done

Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines for CYP3A5 genotype and tacrolimus dosing

Tacrolimus is the mainstay immunosuppressant drug used after solid organ and hematopoietic stem cell transplantation. Individuals who express CYP3A5 (extensive and intermediate metabolizers) generally have decreased doseâ djusted trough concentrations of tacrolimus as compared with those who are CYP3A5 nonexpressers (poor metabolizers), possibly delaying achievement of target blood concentrations. We summarize evidence from the published literature supporting this association and provide dosing recommendations for tacrolimus based on CYP3A5 genotype when known (updates at www.pharmgkb.org)

Genotypes associated with reduced activity of VKORC1 and CYP2C9 and their modification of acenocoumarol anticoagulation during the initial treatment period.

Item does not contain fulltextThe objective of this study was to investigate the influence of genotypes associated with reduced activity of vitamin K epoxide reductase complex subunit 1 (VKORC1) and cytochrome P450 2C9 (CYP2C9) on anticoagulation with acenocoumarol during the first 6 weeks of treatment. In 1,525 patients from the Rotterdam Study who were started on anticoagulation therapy with acenocoumarol, the presence of VKORC1 1173C>T and CYP2C9*2 and *3 allele variants was determined. The first international normalized ratio (INR) after initial standard dose, risk of overanticoagulation, and mean dosage at the end of the initiation period were compared between genotypes. The initial standard dosage significantly increased the risk of severe overanticoagulation by 85% for each additional VKORC1 T-allele present. At the end of the initiation period, each VKORC1 T-allele present was shown to decrease the required acenocoumarol dosage by 5.1 mg/week, while each CYP2C9 variant allele present reduced the required dosage by 1.8 mg/week. Our conclusion was that an initial standard dosing regimen with acenocoumarol increases the risk of severe overanticoagulation in patients with variant alleles of the VKORC1 and CYP2C9 genes