Faculty Bibliography

STUDY DESIGN/METHODS:Retrospective analysis OBJECTIVE.: To compare long-term outcomes between patients with and without mental health comorbidities who are undergoing surgery for adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA/BACKGROUND:Recent literature reveals that one in three patients admitted for surgical treatment for ASD has comorbid mental health disorder. Currently, impacts of baseline mental health status on long-term outcomes following ASD surgery have not been thoroughly investigated. METHODS:Patients admitted from 2009-2013 with diagnoses of ASD who underwent ≥4-level thoracolumbar fusion with minimum two-year follow-up were retrospectively reviewed using New York State's Statewide Planning and Research Cooperative System (SPARCS). Patients were stratified by fusion length (Short: 4-8-level; Long: ≥9 level). Patients with comorbid mental health disorder (MHD) at time of admission were selected for analysis (MHD) and compared against those without MHD (no-MHD). Univariate analysis compared demographics, complications, readmissions and revisions between cohorts for each fusion length. Multivariate binary logistic regression models identified independent predictors of outcomes (covariates: fusion length, age, female gender, and Deyo score). RESULTS:6,020 patients (MHD: n = 1,631; no-MHD: n = 4,389) met inclusion criteria. Mental health diagnoses included disorders of depression (59.0%), sleep (28.0%), anxiety (24.0%), and stress (2.3%). At two-year follow-up, MHD patients with short fusion had significantly higher complication rates (p = 0.001). MHD patients with short or long fusion also had significantly higher rates of any readmission and revision (all p ≤ 0.002). Regression modeling revealed that comorbid MHD was a significant predictor of any complication (OR: 1.17, p = 0.01) and readmission (OR: 1.32, p < 0.001). MHD was the strongest predictor of any revision (OR: 1.56, p < 0.001). Long fusion most strongly predicted any complication (OR: 1.87, p < 0.001). CONCLUSIONS:ASD patients with comorbid depressive, sleep, anxiety, and stress disorders were more likely to experience surgical complications and revision at minimum of two years following spinal fusion surgery. Proper patient counseling and psychological screening/support is recommended to complement ASD treatment. LEVEL OF EVIDENCE/METHODS:3.

BACKGROUND:Objective of the study is to assess prevalence and survival among end stage renal disease patients with restless legs syndrome (RLS) within a national database (USRDS). METHODS:A case-control, retrospective analysis was performed. Differences in characteristics between the groups, RLS and those with no sleep disorder (NSD), were determined using χ2 tests. Cox proportional hazard regression was used to assess survival between those with RLS and propensity score matched controls. RESULTS:Cases of restless legs syndrome were defined as patients that had received an ICD-9 code of 333.94 at any point during their treatment (n = 372). RLS group demonstrated a significantly higher proportion of patients with major depressive disorder, dysthymic disorder, anxiety, depression, minor depressive disorder, and psychological disorder. The difference between the survival was not statistically significant in those without sleep disorder as compared to those with RLS (HR =1.16±0.14, p = 0.3). CONCLUSIONS:True prevalence of RLS in dialysis patients can only be estimated if knowledge gap for care providers in diagnosis of RLS is addressed. RLS patients also have increased incidence of certain psychological disorders which needs to be addressed.

OBJECTIVE:There is little known about the demands of medical school on students' sleep behavior. The study's main goal was to examine the interplay between medical students' sleep knowledge, personal attitudes towards sleep, and their sleep habits. METHODS:An anonymous online survey was created and emailed to all students enrolled at a large metropolitan medical school. Data on demographics, sleep perception, and habits in addition to self-reported measures of students' sleep knowledge, beliefs, and sleepiness were collected. RESULTS:There were 261, out of a possible 720, responses to the survey. While 71.5% of respondents believed that they needed >7 h of sleep, only 24.9% of respondents stated they average >7 h of sleep. During the week of an examination, only 15.3% of students stated they averaged >7 h of sleep. A comparison of pre-clinical and clinical students revealed that reported median sleep during a school or rotation night was significantly lower in clinical students as compared to pre-clinical students while mean sleep during examination weeks between the two groups was not statistically different. In regard to sleep knowledge, clinical students were more knowledgeable (65.53% correct) than pre-clinical students (39.83% correct) (t(1) = -8.9, p = .00). However, there was no difference in the assessment of dysfunctional beliefs between the two groups (66.0 for preclinical students, 64.7 for clinical students (t(1) = 0.37, p = .71)) while clinical students had a higher score of sleepiness compared to pre-clinical students (9.12 to 7.83, t(1) = -2.3, p = .023). CONCLUSIONS:A majority of medical students are sleeping an inadequate amount of time during their 4 years, and as they progress from the pre-clinical to the clinical years, the amount of time they sleep decreases even though their knowledge about sleep increases. Increased awareness around sleep health is required beyond sleep education, as medical students appear to need help translating knowledge into strategies to improve their own sleep and well-being.

BACKGROUND:Nonadherence to immunosuppressant medication is a prevalent practice among kidney transplant recipients and has been associated with increased risk for graft failure and economic burden. The aim of this pilot study was to test whether a culturally sensitive cognitive-behavioral adherence promotion program could significantly improve medication adherence to tacrolimus prescription as measured by telephone pill counts among kidney transplant recipients. METHODS:Thirty-three adult transplant recipients were less than 98% adherent to tacrolimus prescription based on 3 telephone pill counts and were randomized either to the 2-session cognitive-behavioral adherence promotion program or to standard care. The curriculum was developed from an iterative process with transplant recipients into a 2-session group program that provided psychoeducation, addressed barriers to adherence, fostered motivation to improve adherence behavior, and discussed cultural messages on adherence behavior. RESULTS:The intervention group displayed significantly higher levels of adherence when compared to the control group (t = 2.2, p = 0.04) and. similarly, when the amount of change was compared between the groups, the intervention group showed more change than the control condition (F (22,1) = 12.005, p = 0.003). Tacrolimus trough concentration levels were used as a secondary measure of adherence and, while there were no significant between-group differences for mean trough concentration levels, the variability in the trough levels did significantly decrease over time indicating more consistent pill-taking behavior in the intervention group. CONCLUSIONS:There is preliminary support for the pilot program as a successful intervention in helping patients with their immunosuppressant medication.

BACKGROUND:Sleep disorders and depression are prevalent conditions in patients with end-stage kidney disease. These co-morbidities have significant overlap and compounded morbidity and mortality burden. This overlap presents challenges to optimal clinical assessment and treatment. The goal of this study was to assess the prevalence of sleep disturbance in patients on maintenance haemodialysis, and to assess the impact of depressive affect. OBJECTIVES/OBJECTIVE:This was a single-site, single group, cross-sectional study of 69 English-speaking patients undergoing maintenance haemodialysis. Self-reported assessments included those of sleep quality (Pittsburgh Sleep Quality Index), depression (Beck Depression Inventory), daytime sleepiness (Epworth's Sleepiness Scale), a dialysis-specific sleep questionnaire, and standard laboratory values. No objective sleep information was collected. METHOD/METHODS:All participants were well dialysed, and represented all four daily shifts. Fifty-eight per cent reported clinically significant sleep difficulty, with elevated yet sub-threshold daytime sleepiness. Mean depressive affect was also elevated, yet sub-diagnostic and was positively correlated with increased age. RESULTS:Participants scoring above the diagnostic threshold for depression had significantly more disturbed sleep quality, more daytime sleepiness and had more problems sleeping due to restless leg syndrome than people with minimal depressive affect. CONCLUSION/CONCLUSIONS:Poor sleep quality is prevalent in patients on maintenance haemodialysis, and is associated with increased daytime sleepiness. Depression further compounds this relationship, and is significantly associated with increased daytime sleepiness and restless leg syndrome.

Major Depressive Disorder (MDD) is highly prevalent in patients with End Stage Renal Disease (ESRD) treated with maintenance hemodialysis (HD). Despite the high prevalence and robust data demonstrating an independent association between depression and poor clinical and patient-reported outcomes, MDD is under-treated when identified in such patients. This may in part be due to the paucity of evidence confirming the safety and efficacy of treatments for depression in this population. It is also unclear whether HD patients are interested in receiving treatment for depression. ASCEND (Clinical Trials Identifier Number NCT02358343), A Trial of Sertraline vs. Cognitive Behavioral Therapy (CBT) for End-stage Renal Disease Patients with Depression, was designed as a multi-center, 12-week, open-label, randomized, controlled trial of prevalent HD patients with comorbid MDD or dysthymia. It will compare (1) a single Engagement Interview vs. a control visit for the probability of initiating treatment for comorbid depression in up to 400 patients; and (2) individual chair-side CBT vs. flexible-dose treatment with a selective serotonin reuptake inhibitor, sertraline, for improvement of depressive symptoms in 180 of the up to 400 patients. The evolution of depressive symptoms will also be examined in a prospective longitudinal cohort of 90 HD patients who choose not to be treated for depression. We discuss the rationale and design of ASCEND, the first large-scale randomized controlled trial evaluating efficacy of non-pharmacologic vs. pharmacologic treatment of depression in HD patients for patient-centered outcomes.

Anxiety is a common yet frequently overlooked psychiatric symptom in patients with ESRD treated with hemodialysis (HD). Anxiety is characterized by disruptive feelings of uncertainty, dread, and fearfulness. A variety of common medical complaints may be manifestations of an anxiety disorder, including palpitations, tremors, indigestion, numbness/tingling, nervousness, shortness of breath, diaphoresis, and fear. It is essential for the clinician to rule out specific medical conditions, including cardiovascular, pulmonary, and neurologic diseases, before ascribing these symptoms to an anxiety disorder. In addition, there is considerable overlap between the symptoms of anxiety and those of depression and uremia. This psychiatric condition has a significant adverse impact on patients' perception of quality of life. Little is known regarding the prevalence and impact of anxiety disorders in patients with ESRD treated with HD; however, many of the seemingly irrational behaviors of patients, or behaviors which place them in conflict with staff and physicians, such as behavioral noncompliance, may be the expression of an underlying anxiety disorder. In this review, we present three clinical vignettes, highlighting the impact of anxiety disorders in patients with ESRD treated with HD.