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Objective: Evaluate the effects of ketamine versus propofol when used for induction of anesthesia in elderly, high-risk cardiac surgical patients on postoperative complications including cognitive dysfunction, delirium, and acute kidney injury. Methods: Prospective, randomized study performed at a tertiary medical center. A total of 52 patients aged ≥70 and older presenting for complex cardiac surgery were randomized to receive either ketamine or propofol for induction of anesthesia. Patients underwent a battery of cognitive testing preoperatively and postoperatively and the incidence of delirium and acute kidney injury were measured. Norepinephrine (NEE) equivalents following induction were assessed for each group. Results: A total of 49 patients were included, 25 in the ketamine group and 24 in the propofol group with 3 patients excluded from the analysis. No difference was found between groups in either postoperative cognitive dysfunction or delirium incidence. Acute kidney injury occurred in 6 (24%) patients in the ketamine group in 12 (50%) patients in the propofol group, but the difference did not meet statistical significance (P = 0.08; Relative Risk = 2.1, 95% CI 0.9-4.7). NEE equivalents were lower in the ketamine group, 9.6 ± 22.2 versus 32.7 ± 46.0, P < 0.03. Conclusions: The use of ketamine versus propofol for induction of anesthesia did not impact the incidence of postoperative cognitive dysfunction or delirium. Twice as many patients in the propofol group developed acute kidney injury, although not reaching statistical significance and warranting further investigation. In elderly, high-risk patients, ketamine was associated with a significantly reduced need for vasopressor support following induction.

Whole brain radiotherapy (WBRT) is the standard of care to improve intracranial control following resection of brain metastasis. However, stereotactic radiosurgery (SRS) to the surgical cavity is widely used in an attempt to reduce cognitive toxicity, despite the absence of high-level comparative data substantiating efficacy in the postoperative setting. We aimed to establish the effect of SRS on survival and cognitive outcomes compared with WBRT in patients with resected brain metastasis. In this randomised, controlled, phase 3 trial, adult patients (aged 18 years or older) from 48 institutions in the USA and Canada with one resected brain metastasis and a resection cavity less than 5·0 cm in maximal extent were randomly assigned (1:1) to either postoperative SRS (12–20 Gy single fraction with dose determined by surgical cavity volume) or WBRT (30 Gy in ten daily fractions or 37·5 Gy in 15 daily fractions of 2·5 Gy; fractionation schedule predetermined for all patients at treating centre). We randomised patients using a dynamic allocation strategy with stratification factors of age, duration of extracranial disease control, number of brain metastases, histology, maximal resection cavity diameter, and treatment centre. Patients and investigators were not masked to treatment allocation. The co-primary endpoints were cognitive-deterioration-free survival and overall survival, and analyses were done by intention to treat. We report the final analysis. This trial is registered with ClinicalTrials.gov, number NCT01372774. Between Nov 10, 2011, and Nov 16, 2015, 194 patients were enrolled and randomly assigned to SRS (98 patients) or WBRT (96 patients). Median follow-up was 11·1 months (IQR 5·1–18·0). Cognitive-deterioration-free survival was longer in patients assigned to SRS (median 3·7 months [95% CI 3·45–5·06], 93 events) than in patients assigned to WBRT (median 3·0 months [2·86–3·25], 93 events; hazard ratio [HR] 0·47 [95% CI 0·35–0·63]; p<0·0001), and cognitive deterioration at 6 months was less frequent in patients who received SRS than those who received WBRT (28 [52%] of 54 evaluable patients assigned to SRS vs 41 [85%] of 48 evaluable patients assigned to WBRT; difference −33·6% [95% CI −45·3 to −21·8], p<0·00031). Median overall survival was 12·2 months (95% CI 9·7–16·0, 69 deaths) for SRS and 11·6 months (9·9–18·0, 67 deaths) for WBRT (HR 1·07 [95% CI 0·76–1·50]; p=0·70). The most common grade 3 or 4 adverse events reported with a relative frequency greater than 4% were hearing impairment (three [3%] of 93 patients in the SRS group vs eight [9%] of 92 patients in the WBRT group) and cognitive disturbance (three [3%] vs five [5%]). There were no treatment-related deaths. Decline in cognitive function was more frequent with WBRT than with SRS and there was no difference in overall survival between the treatment groups. After resection of a brain metastasis, SRS radiosurgery should be considered one of the standards of care as a less toxic alternative to WBRT for this patient population. National Cancer Institute.

Meningiomas are primary intracranial tumors that are often asymptomatic. To our knowledge, no study has attempted to describe neurocognitive function in patients with incidentally-discovered meningioma. We utilized the Mayo Clinic Study of Aging (MCSA), which is a population-based sample of Olmsted County, Minnesota residents that includes neuropsychological testing and brain MRI approximately every 15 months. Using a text search of radiologists’ notes of 2402 MCSA individuals (mean age 77 years, scanned between 2004 and 2014) we identified 48 eligible subjects (2%) who had at least one meningioma. Most meningiomas were small (90% <3 cm). We matched each of the 48 subjects to 5 non-demented MCSA controls (n = 240) on age, sex, and education. Cognitive domains assessed included memory, attention-executive function, language, and visuospatial. More women (67%) had a meningioma than men (33%). Groups did not differ on prevalence of Mild Cognitive Impairment (Meningioma = 19%, Controls = 13%). Across cognitive domains, we observed similar performance for the two groups ( p ’s ≥ 0.21). Subtle differences emerged in memory and language domains ( p  = 0.05 and p  = 0.11) when we divided the Meningioma group by tumor location, wherein the small group with an infratentorial tumor performed more poorly than controls globally as well as on select memory and language measures. Our findings suggest that small meningiomas are generally cognitively benign, but that may change as the tumor evolves, and might be impacted by other factors such as meningioma location.

To determine the frequency of incidental meningioma and identify associated factors in a population-based sample of participants who systematically underwent brain imaging. We searched the Mayo Clinic Study of Aging, a population-based sample of Olmsted County, Minnesota, residents who underwent longitudinal magnetic resonance imaging of the brain. Using a text search of radiologists’ notes for 2402 individuals (median age, 75.0 years) who underwent imaging between August 10, 2005, and July 31, 2014, we identified 52 patients (2.2%) who had at least one meningioma. We estimated the association of selected risk factors with the presence of meningioma using odds ratios and 95% CIs from logistic regression models adjusted for age and sex. Based on these results, we moved the most significant variables forward to a multivariable model. Controlling for age and sex, significant associations with the presence of meningioma included higher body mass index (odds ratio [OR], 1.06; 95% CI, 1.01-1.12; P=.03), nonsteroidal anti-inflammatory drugs (OR, 2.11; 95% CI, 1.13-3.95; P=.02), aspirin (OR, 1.90; 95% CI, 1.05-3.46; P=.04), and blood pressure–lowering medication (OR, 2.06; 95% CI, 1.06-3.99; P=.03). Lower risk was associated with male sex (OR, 0.51; 95% CI, 0.29-0.90; P=.02), coronary artery disease (OR, 0.46; 95% CI, 0.22-0.97; P=.04), and higher self-reported anxiety (OR, 0.88; 95% CI, 0.78-0.98; P=.02). Simultaneous adjustment for all of these factors except aspirin in a multivariable model did not attenuate these associations (concordance, 0.71). In a population-based sample of 2402 participants, 52 (2.2%) had an incidental meningioma. They were more likely to be female and have higher body mass index. Meningioma was also associated with certain medications (nonsteroidal anti-inflammatory drugs and blood pressure–lowering medications) and inversely with anxiety and coronary artery disease.

Background and ObjectivesDespite widespread use of ultrasound in regional anesthesia, little understanding of the psychomotor and visuospatial skills required to achieve and maintain procedural proficiency exists. Despite its procedural nature, anesthesiology lags behind other fields in assessing technical aptitude among practitioners and trainees. The goals of this study were to measure relevant visuospatial and psychomotor aptitudes of anesthesia residents-in-training and to evaluate the relationship between these skill sets and the performance of ultrasound-guided regional anesthesia.MethodsForty residents from the Mayo Clinic Department of Anesthesiology were enrolled, and 39 (PGY-1 through PGY-4) voluntarily completed a demographic survey, 4 psychomotor and 4 visuospatial aptitude assessments, and an ultrasound-based performance assessment.ResultsThe Block Design Test, a subtest of the Wechsler Adult Intelligent Scale - III, correlated with ultrasound guided skill performance (correlation coefficient, 0.47; P < 0.002). By contrast, psychomotor aptitude assessments did not correlate with ultrasound task performance. Psychomotor skill performance was significantly reduced by indirect hand-eye coordination visual feedback (projected image) compared with direct hand-eye coordination (P < 0.001). A learning effect was observed between the first and second ultrasound skill task attempts and was independent of hand dominance.DiscussionThis study reveals that visuospatial aptitude is a better predictor of ultrasound-based procedural performance than psychomotor ability. The type of real-time visual feedback (indirect versus direct) used for hand-eye coordination significantly impacts procedural performance and has implications for anesthesia and other procedural specialties. The learning effect noted during initial ultrasound skill trials suggests visuospatial assimilation and underscores the importance of early ultrasound instruction.

Purpose A primary brain tumor patient and caregiver survey was completed to investigate interest in brief support opportunities, focused on education, memory training, and healthy coping, during a routine clinical visit and at 3-month follow-up. Methods Patients with primary brain tumors receiving care in the Radiation Oncology Department at Mayo Clinic Rochester and their caregivers were recruited to complete the survey between June 2008 and September 2009. Results Both patients and their caregivers expressed greatest interest in education about brain tumors and cognitive effects of treatment. Interest in support opportunities targeting education, memory training, or healthy coping was low to modest. Bimodal distributions were found for almost all the support opportunities, revealing subgroups of patients and caregivers with high interest in such sessions. Overall, ratings of interest did not differ over time. Conclusions Patients with primary brain tumors and their caregivers expressed most interest in education about their disease and potential cognitive effects of treatment. It appears that subgroups of patients and caregivers have very high interest in brief support opportunities. Identifying these subgroups of patients and families will allow targeted interventions focused on their needs and make the best use of limited resources.

Neuropsychological tests are increasingly being used as outcome measures in clinical trials of brain tumor therapies. This study informs development of brief neurocognitive batteries for clinical trials by identifying cognitive tasks that detect effects on a group level in a mixed brain tumor population. This is a retrospective study of brain tumor patients who completed a standardized battery sampling multiple cognitive domains using twelve subtests with widely-used task formats (the Repeatable Battery for the Assessment of Neuropsychological Status). Sixty-eight patients with brain tumors were studied (60% high-grade glioma). Forty patients (58.8%) were impaired (>2 standard deviations below published means) on at least one subtest. A combination of four subtests (Figure Copy, Coding, List Recognition, and Story Recall) captured 90% of the impaired subgroup. These results suggest visuoconstruction, processing speed, and verbal memory measures may be the most important domains to assess when evaluating cognitive change in brain tumor clinical trials.

To examine the effectiveness of motivational interviewing training on improving medical students’ knowledge of and confidence in their ability to counsel patients regarding health behavior change. In the spring of 2002, 42 first-year medical students participated in a counseling course on health behavior change. Three small groups focused on learning and practicing motivational interviewing techniques using brief lectures, interactive class activities, student role-plays, and simulated patients. Students completed an identical precourse and postcourse questionnaire that measured their confidence and knowledge regarding counseling skills in health behavior change. The medical students reported improved confidence in their understanding of motivational interviewing after participation in the course (very confident, 77%) compared with before the course (very confident, 2%). Each of the 8 confidence items were compared before and after the course using a signed rank test. All comparisons indicated a significant improvement ( P<.001) in confidence. Regarding knowledge-based questions, students showed significant improvement; 31% of students answered all the questions correctly before the course, and 56% answered all the questions correctly after the course ( P=.004). These results show that teaching motivational interviewing techniques to first-year medical students can enhance student confidence in and knowledge of providing counseling to patients regarding health behavior change.

Objective: Evaluate the effects of ketamine versus propofol when used for induction of anesthesia in elderly, high-risk cardiac surgical patients on postoperative complications including cognitive dysfunction, delirium, and acute kidney injury. Methods: Prospective, randomized study performed at a tertiary medical center. A total of 52 patients aged ≥70 and older presenting for complex cardiac surgery were randomized to receive either ketamine or propofol for induction of anesthesia. Patients underwent a battery of cognitive testing preoperatively and postoperatively and the incidence of delirium and acute kidney injury were measured. Norepinephrine (NEE) equivalents following induction were assessed for each group. Results: A total of 49 patients were included, 25 in the ketamine group and 24 in the propofol group with 3 patients excluded from the analysis. No difference was found between groups in either postoperative cognitive dysfunction or delirium incidence. Acute kidney injury occurred in 6 (24%) patients in the ketamine group in 12 (50%) patients in the propofol group, but the difference did not meet statistical significance (P = 0.08; Relative Risk = 2.1, 95% CI 0.9-4.7). NEE equivalents were lower in the ketamine group, 9.6 ± 22.2 versus 32.7 ± 46.0, P < 0.03. Conclusions: The use of ketamine versus propofol for induction of anesthesia did not impact the incidence of postoperative cognitive dysfunction or delirium. Twice as many patients in the propofol group developed acute kidney injury, although not reaching statistical significance and warranting further investigation. In elderly, high-risk patients, ketamine was associated with a significantly reduced need for vasopressor support following induction.