S. A. Loer's research while affiliated with Vrije Universiteit Amsterdam and other places

Background : To better understand physical activity behavior and its health benefits in people living with health conditions, we studied people with and without 20 different self-reported health conditions with regard to (1) their physical activity levels, (2) factors correlated with these physical activity levels, and (3) the association between physical activity and all-cause mortality. Methods : We used a subsample (n = 88,659) of the Lifelines cohort study from the Netherlands. For people living with and without 20 different self-reported health conditions, we studied the aforementioned factors in relation to physical activity. Physical activity was assessed with the Short Questionnaire to Assess Health-Enhancing Physical Activity Questionnaire, and mortality data were obtained from the Dutch death register. Results : People with a reported health condition were less likely to meet physical activity guidelines than people without a reported health condition (odds ratios ranging from 0.55 to 0.89). Higher body mass index and sitting time, and lower self-rated health, physical functioning, and education levels were associated with lower odds of meeting physical activity guidelines across most health conditions. Finally, we found a protective association between physical activity and all-cause mortality in both people living with and without different health conditions. Conclusion : People living with different health conditions are generally less physically active compared with people living without a health condition. Both people living with and without self-reported health conditions share a number of key factors associated with physical activity levels. We also observed the expected protective association between physical activity and all-cause mortality.

Background International guidelines recommend preoperative multidisciplinary team (MDT) assessment for high-risk surgical patients. Preoperative MDT meetings can help to improve surgical care, but there is little evidence on whether they improve patient outcomes. Methods This paper aims to share our experience of MDT meetings for high-risk surgical patients to underline their added value to the current standard of care. An observational study of a retrospective cohort of preoperative high-risk MDT meetings of a tertiary referral hospital between January 2015 and December 2020. For 249 patients the outcomes preoperative data, MDT decisions, and patient outcomes were collected from electronic health records. Main results A total of 249 patients were discussed at high-risk MDT meetings. Most of the patients (97%) were assessed as having an American Society of Anesthesiology score ≥ 3, and 219 (88%) had a European Society of Cardiology and European Society of Anaesthesiology risk score of intermediate or high. After MDT assessment, 154 (62%) were directly approved for surgery, and 39 (16%) were considered ineligible for surgery. The remaining 56 (23%) patients underwent additional assessments before reconsideration at a high-risk MDT meeting. The main reason for patients being discussed at the high-risk MDT meeting was to assess the risk-benefit ratio of surgery. Ultimately, 184 (74%) patients underwent surgery. Of the operated patients, 122 (66%) did not have a major complication in the postoperative period, and 149 patients (81%) were alive after one year. Conclusions This cohort study shows the vulnerability and complexity of high-risk patients but also shows that the use of an MDT assessment contributes too improved peri- and postoperative treatment strategies in high-risk patients. Most patients underwent surgery after careful risk assessment and, if deemed necessary, preoperative and perioperative treatment optimization to reduce their risk.

Objective In cardiac surgery, colloid oncotic pressure (COP) is affected by haemodilution that results from composition and volume of prime fluid of cardiopulmonary bypass (CPB). However, the extent to which different priming strategies alter COP is largely unknown. Therefore, we investigated the effect of different priming strategies on COP in on-pump cardiac surgery. Methods Patients ( n = 60) were divided into 3 groups ( n = 20 each), based on the center in which they were operated and the specific prime fluid strategy used in that center during the inclusion period. CPB prime fluids were either gelofusine-, albumin-, or crystalloid based, the latter two with or without retrograde autologous priming. Results In all groups, COP was lowest after weaning from CPB and one hour after CPB. Between groups, COP was lowest with gelofusine prime fluid (16.4, 16.8 mmHg, respectively) compared with crystalloids (MD: -1.9; 95% CI:-3.6, -0.2; p = .02 and MD: -2.4, 95% CI: -4.2, -0.7; p = .002) and albumin (MD: -1.8, 95% CI: -3.5, -0.50; p = .041 and MD: -2.4, 95% CI: -4.1, -0.7; p = .002). In all groups, the decrease in COP one hour after bypass compared to baseline correlated positively with fluid balance at the end of surgery ( p < .001). Conclusions COP significantly decrease during CPB surgery with the largest decrease in COP at the end of surgery, while at the same time fluid balance increases. We suggest that prime fluid strategy should be carefully selected when maintenance of COP during cardiac surgery is desirable.

Study objective Rising patient numbers, with increasing complexity, challenge the sustainability of the current preoperative process. We evaluated whether an electronic screening application can distinguish patients that need a preoperative consultation from low-risk patients that can be first seen on the day of surgery. Design Prospective cohort study. Setting Preoperative clinic of a tertiary academic hospital. Patients 1395 adult patients scheduled for surgery or procedural sedation. Interventions We assessed a novel electronic preoperative screening application which consists of a questionnaire with a maximum of 185 questions regarding the patient's medical history and current state of health. The application provides an extensive health report, including an American Society of Anesthesiologists physical status (ASA-PS) classification and a recommendation for either consultation by an anesthesiologist at the preoperative clinic or approval for screening on the day of surgery. Measurements The recommendation of the electronic screening system was compared with the regular preoperative assessment using measures of diagnostic accuracy and agreement. Secondary outcomes included ASA-PS classification, patient satisfaction, and the anesthesiologists' opinion on the completeness and quality of the screening report. Results Sensitivity to detect patients who needed additional consultation was 97.5% (95%CI 91.2–99.7) and the negative likelihood ratio was 0.08 (95%CI 0.02–0.32). 407 (29.2%) patients were approved for surgery by both electronic screening and anesthesiologist. In 909 (65.2%) cases, the electronic screening system recommended further consultation while the anesthesiologist approved the patient (specificity 30.9% (95%CI 28.4–33.5); poor level of agreement (ĸ = 0.04)). Agreement regarding ASA-PS classification scores was weak (ĸ = 0.48). The majority of patients (78.0%) felt positive about electronic screening replacing the regular preoperative assessment. Conclusions Electronic screening can reliably identify patients who can have their first contact with an anesthesiologist on the day of surgery, potentially allowing a major proportion of patients to safely bypass the preoperative clinic.

Purpose Regulation of spontaneous breathing is highly complex and may be influenced by drugs administered during the perioperative period. Because of their different pharmacological properties we hypothesized that midazolam and s-ketamine exert different effects on the variability of minute ventilation (MV), tidal volume (TV) and respiratory rate (RR). Methods Patients undergoing procedural sedation (PSA) with propofol and remifentanil received a single dose of midazolam (1–3 mg, n = 10) or s-ketamine (10–25 mg, n = 10). We used non-invasive impedance-based respiratory volume monitoring to record RR as well as changes in TV and MV. Variability of these three parameters was calculated as coefficients of variation. Results TV and MV decreased during PSA to a comparable extent in both groups, whereas there was no significant change in RR. In line with our hypothesis we observed marked differences in breathing variability. The variability of MV (– 47.5% ± 24.8%, p = 0.011), TV (– 42.1% ± 30.2%, p = 0.003), and RR (– 28.5% ± 29.3%, p = 0.011) was significantly reduced in patients receiving midazolam. In contrast, variability remained unchanged in patients receiving s-ketamine (MV + 16% ± 45.2%, p = 0.182; TV +12% ± 47.7%, p = 0.390; RR +39% ± 65.2%, p = 0.129). After termination of PSA breathing variables returned to baseline values. Conclusions While midazolam reduces respiratory variability in spontaneously breathing patients undergoing procedural sedation, s-ketamine preserves variability suggesting different effects on the regulation of spontaneous breathing.

Background Cognitive side-effects are an important reason for the limited use of electroconvulsive therapy (ECT). Cognitive side-effects are heterogeneous and occur frequently in older persons. To date, insight into these side-effects is hampered due to inconsistencies in study designs and small sample sizes. Among all cognitive side-effects, confusion and delirious states are especially troublesome for patients, relatives and clinicians. In particular inter-ictal delirium-like states are worrisome, since they may lead to premature treatment discontinuation. Besides a need for further insight into determinants of cognitive side-effects of ECT, there is a great need for treatment options. Methods and design The Rivastigmine for ECT-induced Cognitive Adverse effects in Late Life depression (RECALL) study combines a multicenter, prospective cohort study on older patients with depression, treated with ECT, with an embedded randomized, placebo-controlled cross-over trial to examine the effect of rivastigmine on inter-ictal delirium. Patients are recruited in four centers across the Netherlands and Belgium. We aim to include 150 patients into the cohort study, in order to be able to subsequently include 30 patients into the trial. Patients are included in the trial when inter-ictal delirium, assessed by the Confusion Assessment method (CAM), or a drop in Mini Mental State Examination (MMSE) score of ≥4 during ECT, develops. In the cohort study, comprehensive measurements of ECT-related cognitive side-effects—and their putative determinants—are done at baseline and during the ECT-course. The primary outcome of the clinical trial is the effectiveness of rivastigmine on inter-ictal delirium-severity, assessed with a change in the Delirium Rating Scale-Revised-98. Secondary outcomes of the clinical trial are several ECT-characteristics and side-effects of rivastigmine. Discussion This study is the first clinical trial with a focus on ECT-induced, inter-ictal delirium. The cohort provides the basis for recruitment of patients for the cross-over trial and additionally provides an excellent opportunity to unravel cognitive side-effects of ECT and identify putative determinants. This paper describes the rationale and study protocol. Clinical trial registration EudraCT 2014-003385-24.

Objectives Colloid oncotic pressure is an important factor in cardiac surgery, owing to its role in haemodilution. The effect of cardiopulmonary bypass prime fluids on the colloid oncotic pressure are unknown. In this study, the effect of crystalloid and colloid prime fluids, with or without retrograde autologous priming on the colloid oncotic pressure during elective cardiac surgery were evaluated. Methods Randomized controlled trials and prospective clinical trials comparing crystalloid and colloid priming fluids or with retrograde autologous priming were selected. Primary outcome was the colloid oncotic pressure; secondary outcomes were fluid balance, fluid requirements, weight gain, blood loss, platelet count, and transfusion requirements. Results From 1582 records, 29 eligible studies were identified. Colloid oncotic pressures were comparable between gelofusine and hydroxyethyl starch during bypass (mean difference [MD]: 0.69; 95% confidence interval [CI]: -2.05, 3.43; P = 0.621), after bypass (MD: -0.11; 95% CI: -2.54, 2.32; P = 0.930), and postoperative (MD: -0.61; 95% CI: -1.60, 0.38; P = 0.228). Fluid balance was lower with hydroxyethyl starch than with crystalloids. Retrograde autologous priming reduced transfusion requirements compared with crystalloids. Blood loss was comparable between groups. Conclusions Colloid oncotic pressures did not differ between crystalloids and colloids. As a result of increased transcapillary fluid movement, fluid balance was lower with hydroxyethyl starch than with crystalloids. Haematocrit and transfusion requirements were comparable between groups. However, the latter was lower when retrograde autologous priming was applied to crystalloid priming compared with crystalloids alone. Finally, no differences in blood loss were observed between the groups.

Objectives : Accurate preoperative transfusion risk stratification may serve to better manage our elderly cardiac surgery patients. Therefore, the aim of the present study was to externally validate the existing ACTA-PORT transfusion risk score in a population ≥ 70 year of age, scheduled for cardiac surgery. Furthermore, we investigated the additional prognostic value of individual frailty variables to this transfusion risk score. Design : Retrospective analysis Setting : Tertiary-care hospital. Participants : 507 patients aged ≥ 70 years undergoing elective cardiac surgery from July 2015 to August 2017. Interventions : None Measurements and Main Results : The primary outcome was administration of perioperative blood transfusion. Frailty domains were assessed in a preoperative anesthesia geriatric assessment and a priori selection of biomarkers derived from blood were determined. The original ACTA-PORT score resulted in a c-statistics of 0.78 (95% CI 0.74-0.82) with moderate calibration in predicting perioperative allogeneic transfusion in elderly cardiac surgery patients. Model updating using the closed testing procedure resulted in model revision with a higher discriminatory performance (c-statistic of 0.83, 95% CI 0.79-0.86) and corrected calibration slope. Iron deficiency, impaired nutritional status, and physical impairment were associated with perioperative transfusions. Addition of individual frailty variables to the updated ACTA-PORT model did not result in improved predictive performance. Conclusions : External validation of the original ACTA-PORT score showed good discrimination and moderate calibration in elderly cardiac surgery patients at risk of frailty. Updating the original ACTA-PORT improved predictive performance. Careful evaluation of additional frailty domains did not add prognostic value to ACTA-PORT score.