Guohua Li

Long-term Differences in Language and Cognitive Function After Childhood Exposure to Anesthesia

BACKGROUND: Over the past decade, the safety of anesthetic agents in children has been questioned after the discovery that immature animals exposed to anesthesia display apoptotic neurodegeneration and long-term cognitive deficiencies. We examined the association between exposure to anesthesia in children under age 3 and outcomes in language, cognitive function, motor skills, and behavior at age 10. METHODS: We performed an analysis of the Western Australian Pregnancy Cohort (Raine) Study, which includes 2868 children born from 1989 to 1992. Of 2608 children assessed, 321 were exposed to anesthesia before age 3, and 2287 were unexposed. RESULTS: On average, exposed children had lower scores than their unexposed peers in receptive and expressive language (Clinical Evaluation of Language Fundamentals: Receptive [CELF-R] and Expressive [CELF-E]) and cognition (Colored Progressive Matrices [CPM]). After adjustment for demographic characteristics, exposure to anesthesia was associated with increased risk of disability in language (CELF-R: adjusted risk ratio [aRR], 1.87; 95% confidence interval [CI], 1.20–2.93, CELF-E: aRR, 1.72; 95% CI, 1.12–2.64), and cognition (CPM: aRR, 1.69; 95% CI, 1.13–2.53). An increased aRR for disability in language and cognition persisted even with a single exposure to anesthesia (CELF-R aRR, 2.41; 95% CI, 1.40–4.17, and CPM aRR, 1.73; 95% CI, 1.04–2.88). CONCLUSIONS: Our results indicate that the association between anesthesia and neuropsychological outcome may be confined to specific domains. Children in our cohort exposed to anesthesia before age 3 had a higher relative risk of language and abstract reasoning deficits at age 10 than unexposed children.

Comparative analysis of outcome measures used in examining neurodevelopmental effects of early childhood anesthesia exposure

Introduction:Immature animals exposed to anesthesia display apoptotic neurodegeneration and neurobehavioral deficits. The safety of anesthetic agents in children has been evaluated using a variety of neurodevelopmental outcome measures with varied results. Methods:The authors used data from the Western Australian Pregnancy Cohort (Raine) Study to examine the association between exposure to anesthesia in children younger than 3 yr of age and three types of outcomes at age of 10 yr: neuropsychological testing, International Classification of Diseases, 9th Revision, Clinical Modification–coded clinical disorders, and academic achievement. The authors’ primary analysis was restricted to children with data for all outcomes and covariates from the total cohort of 2,868 children born from 1989 to 1992. The authors used a modified multivariable Poisson regression model to determine the adjusted association of anesthesia exposure with outcomes. Results:Of 781 children studied, 112 had anesthesia exposure. The incidence of deficit ranged from 5.1 to 7.8% in neuropsychological tests, 14.6 to 29.5% in International Classification of Diseases, 9th Revision, Clinical Modification–coded outcomes, and 4.2 to 11.8% in academic achievement tests. Compared with unexposed peers, exposed children had an increased risk of deficit in neuropsychological language assessments (Clinical Evaluation of Language Fundamentals Total Score: adjusted risk ratio, 2.47; 95% CI, 1.41 to 4.33, Clinical Evaluation of Language Fundamentals Receptive Language Score: adjusted risk ratio, 2.23; 95% CI, 1.19 to 4.18, and Clinical Evaluation of Language Fundamentals Expressive Language Score: adjusted risk ratio, 2.00; 95% CI, 1.08 to 3.68) and International Classification of Diseases, 9th Revision, Clinical Modification–coded language and cognitive disorders (adjusted risk ratio, 1.57; 95% CI, 1.18 to 2.10), but not academic achievement scores. Conclusions:When assessing cognition in children with early exposure to anesthesia, the results may depend on the outcome measure used. Neuropsychological and International Classification of Diseases, 9th Revision, Clinical Modification–coded clinical outcomes showed an increased risk of deficit in exposed children compared with that in unexposed children, whereas academic achievement scores did not. This may explain some of the variation in the literature and underscores the importance of the outcome measures when interpreting studies of cognitive function.

Substance use and misuse in the aftermath of terrorism: A Bayesian meta-analysis

AIM To conduct a comprehensive analysis of the conflicting evidence on substance use and misuse following mass traumas such as terrorist incidents. METHODS We reviewed and synthesized evidence from 31 population-based studies using Bayesian meta-analysis and meta-regression. RESULTS The majority of the studied were conducted in the aftermath of the terrorist attacks of 11 September 2001. Controlling for exposure, type of incident and time since the event occurred, 7.3% [95% credible interval (CrI) 1.1-32.5%] of a population can be expected to report increased alcohol consumption in the first 2 years following a terrorist event. There is, however, a 20% probability that the prevalence will be as high as 14%. The unadjusted prevalence of increased cigarette smoking following a terrorist event is 6.8% (95% Cr I 2.6-16.5%). Unadjusted reports of mixed drug use (including narcotics and prescription medications) was 16.3% (95% Cr I 1.3-72.5%). CONCLUSIONS These results underscore the potentially pervasive behavioral health effects of mass terrorism, and suggest that public health interventions may usefully consider substance use as an area of focus after such events.

The surgical Apgar score is strongly associated with intensive care unit admission after high-risk intraabdominal surgery.

BACKGROUND: Understanding intensive care unit (ICU) triage decisions for high-risk surgical patients may ultimately facilitate resource allocation and improve outcomes. The surgical Apgar score (SAS) is a simple score that uses intraoperative information on hemodynamics and blood loss to predict postoperative morbidity and mortality, with lower scores associated with worse outcomes. We hypothesized that the SAS would be associated with the decision to admit a patient to the ICU postoperatively. METHODS: We performed a retrospective cohort study of adults undergoing major intraabdominal surgery from 2003 to 2010 at an academic medical center. We calculated the SAS (0–10) for each patient based on intraoperative heart rate, mean arterial blood pressure, and estimated blood loss. Using logistic regression, we assessed the association of the SAS with the decision to admit a patient directly to the ICU after surgery. RESULTS: The cohort consisted of 8501 patients, with 72.7% having an SAS of 7 to 10 and <5% an SAS of 0 to 4. A total of 8.7% of patients were transferred immediately to the ICU postoperatively. After multivariate adjustment, there was a strong association between the SAS and the decision to admit a patient to the ICU (adjusted odds ratio 14.41 [95% confidence interval {CI}, 6.88–30.19, P < 0.001] for SAS 0–2, 4.42 [95% CI, 3.19–6.13, P < 0.001] for SAS 3–4, and 2.60 [95% CI, 2.08–3.24, P < 0.001] for SAS 5–6 compared with SAS 7–8). CONCLUSIONS: The SAS is strongly associated with clinical decisions regarding immediate ICU admission after high-risk intraabdominal surgery. These results provide an initial step toward understanding whether intraoperative hemodynamics and blood loss influence ICU triage for postsurgical patients.

Neurodevelopmental outcomes after initial childhood anesthetic exposure between ages 3 and 10 years

Introduction: Epidemiologic studies examining the association between anesthetic exposure and neurodevelopmental outcomes have primarily focused on exposures occurring under 3 years of age. In this study, we assess outcomes associated with initial anesthetic exposure occurring between 3 and 10 years of age. Methods: We used data from the Western Australian Pregnancy Cohort (Raine) Study to examine the risk of cognitive deficit at age 10 in children with initial anesthetic exposure between 3 and 5 years and between 5 and 10 years of age compared with children unexposed at those ages. The cohort included 2868 children born from 1989 to 1992 evaluated using a range of neuropsychological tests. A modified multivariable Poisson regression model was used to determine the adjusted association of initial anesthetic exposure in each age group with outcomes. Results: Exposed and unexposed children were found to have similar neuropsychological test results except for the McCarron Assessment of Neuromuscular Development (MAND) motor function scores. Even after adjusting for demographic and comorbidity differences, children exposed to anesthesia had a higher risk of motor deficit after initial exposure between ages 3 and 5 years (adjusted risk ratio, 2.32; 95% confidence interval, 1.42-3.79) and between 5 and 10 years (adjusted risk ratio, 2.33; 95% confidence interval, 1.21-4.48) compared with unexposed children. Conclusions: Initial exposure to anesthesia after age 3 had no measurable effects on language or cognitive function. Decreased motor function was found in children initially exposed after age 3 even after accounting for comorbid illness and injury history. These results suggest that there may be distinct windows of vulnerability for different neurodevelopmental domains in children.

Temporal trends in anesthesia-related adverse events in cesarean deliveries, New York State, 2003-2012

Background: Cesarean delivery (CD) is associated with significantly increased risks of anesthesia-related adverse events (ARAEs) and nonanesthetic perioperative morbidity compared with vaginal delivery. Temporal trends in these adverse outcomes remain unknown despite efforts to improve maternal safety. This study examines temporal trends in ARAEs and nonanesthetic perioperative complications in CDs in New York hospitals. Methods: Data are from the State Inpatient Database for New York, 2003–2012. ARAEs, including minor and major ARAEs, and nonanesthetic perioperative complications were identified through International Classification of Diseases, Ninth Revision, Clinical Modification codes. Statistical significance in time trends was assessed using the Cochran–Armitage test and multivariable logistic regression. Results: Of the 785,854 CDs studied, 5,715 (730 per 100,000; 95% CI, 710 to 750) had at least one ARAE and 7,040 had at least one perioperative complication (890 per 100,000; 95% CI, 870 to 920). The overall annual rate of ARAEs decreased from 890 per 100,000 in 2003 to 660 in 2012 (25% decrease; 95% CI, 16 to 34; P < 0.0001). The rate of minor ARAEs decreased 23% (95% CI, 13 to 32) and of major ARAEs decreased 43% (95% CI, 23 to 63). No decrease was observed in the rate of ARAEs for CDs performed under general anesthesia. The rate of nonanesthetic complications increased 47% (95% CI, 31 to 63; P < 0.0001). Conclusions: Anesthesia-related outcomes in cesarean deliveries appear to have improved significantly across hospitals in New York in the past decade. Perioperative nonanesthetic complications remain a serious healthcare issue.

Intraoperative reported adverse events in children

Background:  Significant intraprocedural adverse events (AE) are reported in children who receive anesthesia for procedures outside the Operating Rooms (NORA). No study, so far, has characterized AE in children who receive anesthesia in the operating rooms (ORA) and NORA when anesthesia care is provided by the same team in a consistent manner.

Age at Exposure to Surgery and Anesthesia in Children and Association With Mental Disorder Diagnosis

BACKGROUND: Animals exposed to anesthetics during specific age periods of brain development experience neurotoxicity, with neurodevelopmental changes subsequently observed during adulthood. The corresponding vulnerable age in children, however, is unknown. METHODS: An observational cohort study was performed using a longitudinal dataset constructed by linking individual-level Medicaid claims from Texas and New York from 1999 to 2010. This dataset was evaluated to determine whether the timing of exposure to anesthesia ⩽5 years of age for a single common procedure (pyloromyotomy, inguinal hernia, circumcision outside the perinatal period, or tonsillectomy and/or adenoidectomy) is associated with increased subsequent risk of diagnoses for any mental disorder, or specifically developmental delay (DD) such as reading and language disorders, and attention deficit hyperactivity disorder (ADHD). Exposure to anesthesia and surgery was evaluated in 11 separate age at exposure categories: ⩽28 days old, >28 days and ⩽6 months, >6 months and ⩽1 year, and 6-month age intervals between >1 year old and ⩽5 years old. For each exposed child, 5 children matched on propensity score calculated using sociodemographic and clinical covariates were selected for comparison. Cox proportional hazards models were used to measure the hazard ratio of a mental disorder diagnosis associated with exposure to surgery and anesthesia. RESULTS: A total of 38,493 children with a single exposure and 192,465 propensity score-matched children unexposed before 5 years of age were included in the analysis. Increased risk of mental disorder diagnosis was observed at all ages at exposure with an overall hazard ratio of 1.26 (95% confidence interval [CI], 1.22–1.30), which did not vary significantly with the timing of exposure. Analysis of DD and ADHD showed similar results, with elevated hazard ratios distributed evenly across all ages, and overall hazard ratios of 1.26 (95% CI, 1.20–1.32) for DD and 1.31 (95% CI, 1.25–1.37) for ADHD. CONCLUSIONS: Children who undergo minor surgery requiring anesthesia under age 5 have a small but statistically significant increased risk of mental disorder diagnoses and DD and ADHD diagnoses, but the timing of the surgical procedure does not alter the elevated risks. Based on these findings, there is little support for the concept of delaying a minor procedure to reduce long-term neurodevelopmental risks of anesthesia in children. In evaluating the influence of age at exposure, the types of procedures included may need to be considered, as some procedures are associated with specific comorbid conditions and are only performed at certain ages.

Patient-, Hospital-, and Neighborhood-Level Factors Associated with Severe Maternal Morbidity During Childbirth: A Cross-Sectional Study in New York State 2013–2014

Background The incidence of severe maternal morbidity (SMM) during childbirth is increasing in the United States. A better characterization of risk factors for SMM may identify targets for improving maternal outcomes. This study aims to characterize patient-, hospital-, and neighborhood-level factors associated with SMM during childbirth. Methods SMM during childbirth was identified in the 2013–2014 State Inpatients Database for New York. Hospital and neighborhood characteristics were abstracted from the American Hospital Association and the Area Health Resources files. Multilevel modeling was used to identify factors associated with SMM, with and without blood transfusion, and its between-hospital variation. Results 403,116 delivery-related discharges from 139 hospitals were analyzed; 1557 (0.39%) recorded SMM without blood transfusion. In the final multilevel model, 7 patient-level factors were associated with a greater than fourfold increase in the risk of SMM: pulmonary hypertension, postpartum hemorrhage, placenta accreta, chronic kidney disease, cardiac conduction disorders, emergent cesarean delivery, and preeclampsia. Three hospital-level factors were associated with SMM: proportion of non-White patients, proportion of Medicaid beneficiaries, and coding intensity. No neighborhood-level factors were predictive of SMM. The proportion of variation in SMM explained by the model was 23.5 with 23.2% related to patient-level factors. The model explained 55% of the between-hospital variation, primarily related to patient-level factors. Similar results were observed for SMM with blood transfusion. Conclusions This study confirms the association between patient-level factors and SMM. It identifies patient-level factors as the major driver of between-hospital variation in SMM. Efforts to improve maternal outcomes should target patient-level factors.

Epidemiologic Patterns of In-Hospital Anaphylaxis in Pediatric Surgical Patients

The incidence of in-hospital anaphylaxis in pediatric surgical patients has more than doubled between 2003 and 2012. Patients with hematological and myeloproliferative disorders, particularly when admitted for bone marrow transplant, are at especially heightened risk.