Maryanne Bailey

Delirium after coronary artery bypass graft surgery and late mortality

Delirium is common after cardiac surgery, although under‐recognized, and its long‐term consequences are likely underestimated. The primary goal of this study was to determine whether patients with delirium after coronary artery bypass graft (CABG) surgery have higher long‐term out‐of‐hospital mortality when compared with CABG patients without delirium.

Is there cognitive decline 1 year after CABG?: Comparison with surgical and nonsurgical controls

Background: It is widely assumed that decline in cognition after coronary artery bypass grafting (CABG) is related to use of the cardiopulmonary bypass pump. Because most studies have not included comparable control groups, it remains unclear whether postoperative cognitive changes are specific to cardiopulmonary bypass, general aspects of surgery, or vascular pathologies of the aging brain. Methods: This nonrandomized study included four groups: CABG patients (n = 140); off-pump coronary surgery (n = 72); nonsurgical cardiac controls (NSCC) with diagnosed coronary artery disease but no surgery (n = 99); and heart healthy controls (HHC) with no cardiac risk factors (n = 69). Subjects were evaluated at baseline (preoperatively), 3 months, and 12 months. Eight cognitive domains and a global cognitive score, as well as depressive and subjective symptoms were analyzed. Results: At baseline, patients with coronary artery disease (CABG, off-pump, and NSCC) had lower performance than the HHC group in several cognitive domains. By 3 months, all groups had improved. From 3 to 12 months, there were minimal intrasubject changes for all groups. No consistent differences between the CABG and off-pump patients were observed. Conclusions: Compared with heart healthy controls (HHC), the groups with coronary artery disease had lower cognitive test scores at baseline. There was no evidence that the cognitive test performance of coronary artery bypass grafting (CABG) patients differed from that of control groups with coronary artery disease over a 1-year period. This study emphasizes the need for appropriate control groups for interpreting longitudinal changes in cognitive performance after CABG.

Statin use and neurologic morbidity after coronary artery bypass grafting A cohort study

Background: Statin use before surgery has been associated with reduced morbidity and mortality after vascular surgery. The effect of preoperative statin use on stroke and encephalopathy after coronary artery bypass grafting (CABG) is unclear. Methods: A post hoc analysis was undertaken of a prospectively collected cohort of isolated CABG patients over a 10-year period at a single institution. Primary outcomes were stroke and encephalopathy. Univariable analyses identified risk factors for statin use, which were applied to a propensity score model using logistic regression and patients were divided into quintiles of propensity for statin use. Controlling for propensity score quintile, the odds ratio (OR) of combined stroke and encephalopathy (primary endpoint), cardiovascular mortality, myocardial infarction, and length of stay were compared between statin users and nonusers. Results: There were 5,121 CABG patients, of whom 2,788 (54%) were taking statin medications preoperatively. Stroke occurred in 166 (3.2%) and encephalopathy in 438 (8.6%), contributing to 604 patients (11.8%) who met the primary endpoint. The unadjusted OR of stroke/encephalopathy in statin users was 1.053 (95% confidence interval [CI] 0.888-1.248, p = 0.582). Adjustment based on propensity score resulted in balance of stroke risk factors among quintiles. The propensity score-adjusted OR of stroke/encephalopathy in statin users was 0.958 (95% CI 0.784-1.170, p = 0.674). There were no significant differences in cardiovascular mortality, myocardial infarction, or length of stay between statin users and otherwise similar nonusers. Conclusions: In this large data cohort study, preoperative statin use was not associated with a decreased incidence of stroke and encephalopathy after coronary artery bypass grafting.

Association between Hypotension, Low Ejection Fraction and Cognitive Performance in Cardiac Patients

Background and Purpose: Impaired cardiac function can adversely affect the brain via decreased perfusion. The purpose of this study was to determine if cardiac ejection fraction (EF) is associated with cognitive performance, and whether this is modified by low blood pressure. Methods: Neuropsychological testing evaluating multiple cognitive domains, measurement of mean arterial pressure (MAP), and measurement of EF were performed in 234 individuals with coronary artery disease. The association between level of EF and performance within each cognitive domain was explored, as was the interaction between low MAP and EF. Results: Adjusted global cognitive performance, as well as performance in visuoconstruction and motor speed, was significantly directly associated with cardiac EF. This relationship was not entirely linear, with a steeper association between EF and cognition at lower levels of EF than at higher levels. Patients with low EF and low MAP at the time of testing had worse cognitive performance than either of these alone, particularly for the global and motor speed cognitive scores. Conclusions: Low EF may be associated with worse cognitive performance, particularly among individuals with low MAP and for cognitive domains typically associated with vascular cognitive impairment. Further care should be paid to hypotension in the setting of heart failure, as this may exacerbate cerebral hypoperfusion.

Translating community-based participatory research principles into practice

Background: Although academics are trained in research methods, few receive formal training in strategies for implementing equitable community engaged research. Academics and their community partners can benefit from such direction and assistance as they establish and maintain community-based participatory research (CBPR) partnerships. Research partners from the University of Pittsburgh, the Johns Hopkins Center for Injury Research and Policy, and the House of Ruth Maryland, one of the nations leading domestic violence centers serving Baltimore and the surrounding areas, joined together to design, implement, and evaluate a series of activities to increase local CPBR capacity.Objectives: This article provides an overview of process and findings from two CBPR workshops jointly held for academic and community members and explores specific suggestions from the workshop participants about how to put the CBPR principles into practice to promote community engaged research to address intimate partner violence (IPV).Methods: Twenty-four academic and community partners with experience addressing IPV participated in the two workshops. Facilitators led discussions based on the core CPBR principles. Participants were asked to interpret those principles, identify actions that could help to put the principles into practice, and discuss challenges related to CBPR approaches for IPV research. Observational notes and transcripts of the discussions and workshop evaluations are summarized.Results: The CBPR principles were interpreted and revised through consensus into common language that reflected the group discussion of the core CBPR principles. Workshop participants provided a range of actions for putting the principles into practice and identified the need for sensitivity in relation to IPV research. A majority of participants felt that the workshop generated novel ideas about how they could use CPBR in their own work.Conclusions: Translating CBPR principles into common, action-oriented language is a useful first step when building a new academic-community research partnership.

Working Inside the Firehouse Developing a Participant-Driven Intervention to Enhance Health-Promoting Behaviors

Cardiovascular disease (CVD) is the most common cause of on-duty death among U.S. firefighters among whom volunteers comprise 71% of the fire service. We sought to understand CVD risk among volunteer firefighters and to develop a CVD intervention based on their input. To accomplish these aims, we conducted a series of focus groups with volunteer firefighters and firefighters who serve with volunteers in Maryland. We conducted two additional focus groups with fire service leaders. Ninety-eight people participated in 15 focus groups. Participants discussed health and wellness, stress and the demanding nature of the volunteer fire service, and the challenges associated with healthy eating. They talked about food in the firehouse and the lack of quick, healthy, satisfying, and affordable food. Several suggestions for interventions to improve the food environment and firefighters’ ability to choose and prepare healthy meals and snacks emerged. An intervention reflecting the participants’ recommendations resulted. The way volunteer firefighters understand health and wellness and the specific factors that influence their food intake are valuable insights for addressing CVD risks in this population. To our knowledge, this is the first study that systematically brings firefighters into the process of developing an intervention to reduce CVD risk among this high-risk population.

Fighting fires and fat: an intervention to address obesity in the fire service

An estimated 80% of paid and volunteer firefighters are overweight or obese. In addition to obesityrelated health concerns, firefighters must also contend with an increased risk of cardiovascular stress because of the nature of their jobs. It is therefore not surprising that the primary cause of on-duty death among both career and volunteer firefighters between 1994 and 2004 was heart attacks, accounting for over 45% of deaths. This suggests that poor cardiovascular health endangers individual firefighters and the communities they serve. Although the primary factors contributing to excess weight are 2fold (poor nutrition and insufficient physical activity), previous programs designed to improve the health of firefighters focused on physical activity. The goal of this study was to design, implement, and evaluate a pilot nutrition intervention to reduce obesity and risk of heart attack in firefighters.

Building safety into active living initiatives

OBJECTIVE Efforts to promote environmental designs that facilitate opportunities for physical activity should consider the fact that injuries are the leading cause of death for Americans ages 1 to 44, with transportation-related injuries the most common cause. Drawing on the latest research and best practices in the field of injury prevention, the purpose of this article is to provide those working to promote physical activity with evidence-based recommendations on building in safety while designing active environments. METHOD A systematic review of the peer-reviewed and grey literature published from 1995 to 2012 was conducted to identify injury prevention strategies applicable to objectives in the Active Design Guidelines (ADG), which present design strategies for active living. Injury prevention strategies were rated according to the strength of the research evidence. RESULTS We identified 18 urban design strategies and 9 building design strategies that promote safety. Evidence was strong or emerging for 14/18 urban design strategies and 7/9 building design strategies. CONCLUSION ADG strategies are often wholly compatible with well-accepted injury prevention principles. By partnering with architects and planners, injury prevention and public health professionals can help ensure that new and renovated spaces maximize both active living and safety.

One of my fears is that physically or mentally, the time will come where I'll be unable to drive anymore. and I'm not looking forward to that: a mixed methods feasibility study to assess older driver's risk impairment.

Sixty-seven older adults were assessed using multiple validated tools. The current study aimed to identify high-, medium-, and low-risk impairment among older drivers and to explore high-risk drivers’ reactions to being told their results. Of 67 adults screened from a convenience sample of older drivers, nine high-risk participants, four completed in-depth follow-up qualitative interviews. The quantitative assessment algorithm identified 13% as high risk, 30% as medium risk, and 57% as low risk, and only Trails B distinguished the medium- and high-risk impairment groups. Although the assessment tests did not predict future crash involvement over a 7-month period, four participants in the medium- and high-risk impairment categories had been involved in a crash during the 5 years prior to the study compared with none of those who screened low risk. Only three participants (1 high risk) voluntarily surrendered their driver’s licenses after the assessment, and one participant in the in-depth interviews reported that the assessment influenced the decision to stop driving. There may be some benefit in using driving record history and assessment results to determine driving risk impairment level. However, more research is needed to determine the best combination of tools to predict risk level. How to best communicate risk levels remains to be determined, although results from the older drivers in this study underscore the need for great sensitivity when identifying areas of concern about driving ability.

Developing role models for health in the fire service: a pilot case study

Summary Objectives The objectives of this case study were to develop role models for health in the fire service through knowledge and behaviour change, to improve the role models’ own health, and to facilitate behaviour change in other firefighters through their example. Design Volunteers interested in improving their own health and serving as role models to others in the fire service were identified at a statewide Maryland fire service leadership meeting. Setting Participants worked with the Johns Hopkins Weight Management Center to learn how to improve their own health and shared that knowledge with others in their fire departments. Participants Three Maryland fire service leaders were recruited at a leadership meeting with the goal of improving their own health and becoming role models. One participant dropped out shortly after beginning, while two male participants, aged 57 and 61, completed the study. Main outcome measures Quantitative measures were collected at baseline and 12 months, and included weight, blood pressure and fasting glucose and cholesterol. Semi-structured interviews were conducted approximately 14 months postintervention to determine the participants’ perceptions of their own health and impact on others in the fire service. Results Each participant had biweekly to monthly visits over a one-year period to learn the knowledge and skills that would assist him with improving dietary behaviours, increasing fitness and achieving a healthy weight. Case study participants experienced reductions in body weight (−13% and −11% of total body weight), glucose and blood pressure. Qualitative one-on-one interviews conducted postintervention with the participants revealed that they embraced their status as role models and felt their success inspired other firefighters. Their experiences suggest that role models can play an important role in helping firefighters increase self-efficacy, self-regulation and social support in the workplace environment. Conclusions These findings provide promising evidence for the use of role models to improve health, especially in the workplace.