BackgroundAs antiretroviral therapy efficacy improves, HIV is gradually being recognized more as a chronic disease within the aging HIV-infected population. While these individuals are surviving into old age, they may, however, be experiencing “accelerated aging” with greater declines in physical function than that observed among comparably matched individuals free of HIV. This decline is not well understood and it remains unclear if physical decline correlates with the degree of immunosuppression based on CD4 lymphocyte nadir.MethodsIn a cross-sectional study of accelerated aging in the older HIV-infected population on antiretroviral therapy (ART), physical performance evaluations were completed on a cohort of 107 HIV-infected subjects, age 50 years or older (with no HIV-1 RNA >200 copies/mL in the prior 12 months), and compared to reference ranges for age- and gender-matched HIV-uninfected persons. Physical performance testing consisted of four validated assessments: the 2.4-meter walk, 30-second chair stand, grip strength and 6-minute walk test.ResultsWhen compared to age- and gender-matched HIV-uninfected reference controls, older HIV-infected persons had diminished physical function. No correlation was found between physical function and degree of immunosuppression as determined by pre-ART CD4 nadir.ConclusionsDespite improved survival, HIV–infected adults on suppressive ART have diminished physical function compared to HIV-uninfected persons. The degree of HIV-associated immunosuppression does not correlate with the observed degree of physical function decline in older HIV-infected persons, suggesting the decline is mediated by other mechanisms.

The enhanced recovery after thoracic surgery (ERATS) protocol has been shown to reduce complications and hospital length of stay (LOS). [1][2][3] In thoracic surgery, the prototypical ERATS pathway involves a preoperative phase, which focuses on patient education and smoking cessation; the intraoperative phase incorporates multimodal anesthesia along with minimally invasive surgery (video-assisted thoracoscopic surgery [VATS]); and the postoperative phase emphasizes the use of incentive spirometry, early mobilization, early chest tube and urinary catheter removal. Goal-directed fluid therapy and minimization of opioids is encouraged. [2][3][4] Most of the evidence for ERATS has been published in small, retrospective, single-center studies and case-series reports, all of which are prone to bias. [5][6][7] In 2016, Fiore and colleagues 8 published a systematic review (SR) of 6 studies on ERATS in lung resections; however, the authors determined their results were inconclusive due to high risk of bias. Li and colleagues 9 also published a SR of 7 randomized-controlled trials (RCTs), but all study participants were from China, Europe, and the Middle East. In 2019, Batchelor and colleagues 3 formulated ERATS guidelines for the Enhanced Recovery After Surgery (ERAS) Society and the European Society of Thoracic Surgeons with an SR. Recently, a few retrospective cohort studies of ERATS in lung resections have been conducted in the United States and Canada, demonstrating that ERATS improves patient outcomes after lung resections and provides more cost-effective care. [10][11][12] In this updated SR and metaanalysis, we aimed to synthesize the evidence regarding the effect of ERATS, in comparison to conventional care, on surgical outcomes of adult patients undergoing lung resections. We hypothesized that ERATS would improve surgical outcomes by decreasing hospital LOS, postoperative complications, and readmission rates. METHODS Eligibility CriteriaThis SR was conducted in compliance with the preferred reporting items for systematic reviews and meta-analyses statement. 13 We developed inclusion and exclusion criteria with respect to populations, interventions, comparators, outcomes, timing, setting, and study designs (Table E1). Studies

Background. Enhanced recovery after surgery (ERAS) is an evidence-based, multidisciplinary perioperative care model shown to reduce complications and hospital length of stay (LOS). While some thoracic ERAS studies were inconclusive, others demonstrated that ERAS improves patient outcomes after lung resections and provides more cost-effective care. We aimed to investigate the effects of preliminary implementation of an ERAS protocol, in comparison with conventional care, on lung resection outcomes at a single academic institution.Methods. In this observational study, adult patients undergoing lung resections during the pre-ERAS (April 2014 to September 2015) and post-ERAS (January 2016 to May 2017) periods were identified. Relevant demographic, preoperative, anesthesia, and surgical variables were collected. Pre-ERAS and post-ERAS cohorts were compared in terms of hospital LOS, postoperative complications, and 30-day outcomes.Results. We identified 264 patients, half in each cohort. Pre-ERAS and post-ERAS groups were similar with respect to age, race, and comorbidities. There were no significant differences in LOS, complications, 30-day readmission and mortality rates, or patient-reported outcomes. Of the patients with prolonged LOS, 31% had pulmonary complications, almost half of which were prolonged air leaks. ERAS adherence rate was approximately 60%.Conclusions. In the first year of implementation, median LOS, complications, and 30-day outcomes did not differ significantly between the pre-ERAS and post-ERAS groups. Prolonged air leaks commonly led to prolonged LOS; therefore, thoracic ERAS protocols could include interventions to reduce air leak and consideration for discharging patients with chest tubes placed to Heimlich valves. Buy-in and adherence to a new protocol are necessary for implementation to be effective.

Antiretroviral therapy (ART) has prolonged lives of persons living with HIV/AIDS (PLWHA), resulting in greater incidence of aging-related diseases and disability. Physical activity (PA) is recommended for healthy aging, but little is known about PA in older PLWHA. The purpose of this study was to objectively assess PA levels in older PLWHA and the associations with physical function. Twenty-one PLWHA, ≥50 years old, on ART with undetectable HIV-1 viral loads, wore an accelerometer to assess PA, including number of steps, activity intensity, and energy expenditure over 7 days. A physical function performance battery assessing aerobic capacity, strength, and gait speed was also completed. Average age was 66, and 67% were male. An average of 3,442 (interquartile range: 4,613) steps were walked daily, with 254.9 kcals expended. Participants spent most waking hours (75%) sedentary, with minimal hours (24%) in light-intensity activity. Only 5 min per day (35 min per week), on average, were spent in moderate-to-vigorous physical activity (MVPA). Maximal gait speed and 6-min walk test significantly correlated (p < .05) with all PA outcomes. Usual gait speed significantly correlated with all PA outcomes, except for daily kcals and light-intensity activity. Greater PA was associated with better physical performance, while high sedentary time was associated with poorer performance. To our knowledge, this is the first study to objectively measure PA in older PLWHA. Our findings indicate that older PLWHA accumulate substantial sedentary time. Most (86%) do not achieve recommended MVPA levels. This activity profile was associated with poor physical function. Providers should promote PA among PLWHA.

Background. Since transcatheter aortic valve replacement (TAVR) first became approved for inoperable patients followed by high, intermediate-, and low-risk patients, referrals to TAVR centers have rapidly increased. The purpose of this study was to investigate referral patterns to a large academic TAVR center in the state of North Carolina and evaluate differences between externally and internally referred patients. Methods. Data for all patients who underwent TAVR at our institution between November 2014 and March 2020 were pulled from the Transcatheter Valve Therapy Registry. The electronic medical record was used to determine the referral source. The descriptive statistical analysis was performed using Excel (Microsoft, Redmond, Washington). Results. 491 patients underwent TAVR at our institution between November 2014 and March 2020. Half of the patients were referred by a cardiologist within the same health system (N = 250, 50.9%). Other referral sources included a cardiologist external to the health system (N = 210, N = 42.8%) and a surgeon or proceduralist (such as urologist, surgeon, or gastroenterologist) during the workup for another procedure (N = 26, 5.3%). Over time, there was a trend toward an increasing proportion of patients referred by a cardiologist external to our system, but this trend did not reach statistical significance (20.0% in 2014, 29.2% in 2015, 30.7% in 2016, 53.0% in 2017, 36% in 2018, 48.4% in 2019, and 56.8% in 2020, p = 0.06 using the Mann–Kendall trend test). Externally referred patients were less likely to have private insurance and were more likely to have a reduced ejection fraction and had a higher mean gradient across the valve. Postprocedure, externally referred patients were more likely to have the procedure under moderate sedation and less likely to be discharged home. Conclusions. This study presents the referral pattern to a large TAVR center in North Carolina. Over time, there was an increase in external referrals suggesting that TAVR is increasingly adopted as an important component of the management of aortic valve stenosis. Internally and externally referred patients have differences in baseline demographic and clinical characteristics which may have an impact on clinical outcomes.