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Chang GJ, Gunn HJ, Barber AK, Lowenstein LM, Dohan D, Broering J, Dockter T, Tan AD, Dueck A, Chow S, Neuman H, Finlayson E. Improving Surgical Care and Outcomes in Older Cancer Patients Through Implementation of a Presurgical Toolkit (OPTI-Surg)-Final Results of a Phase III Cluster Randomized Trial (Alliance A231601CD). Ann Surg 2024; 280:623-632. [PMID: 39069901 DOI: 10.1097/sla.0000000000006458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
OBJECTIVE To assess the effect of a practice-level preoperative frailty screening and optimization toolkit (OPTI-Surg) on postoperative functional recovery and complications in elderly cancer patients undergoing major surgery. BACKGROUND Frailty is common in older adults. It increases the risk of poor postoperative functional recovery and complications. The potential for a practice-level screening/optimization intervention to improve outcomes is unknown. METHODS Thoracic, gastrointestinal, and urologic oncological surgery practices within the National Cancer Institute Community Oncology Research Program (NCORP) were randomized 1:1:1 to usual care (UC), OPTI-Surg, or OPTI-Surg with an implementation coach. OPTI-Surg consisted of the Edmonton Frail Scale and guided recommendations for referral interventions. Patients 70 years old or above undergoing curative intent surgery were eligible. The primary outcome was 8 weeks postoperative function (kcal/wk). The key secondary outcome was complications within 90 days. Mixed models were used to compare UC to the 2 OPTI-Surg arms combined. RESULTS From July 2019 to September 2022, 325 patients were enrolled in 29 practices. One hundred ninety-nine (64 UC, 135 OPTI-Surg) and 279 (78 UC, 201 OPTI-Surg) were evaluable for primary and secondary analysis, respectively. UC and OPTI-Surg patients did not significantly differ in total caloric expenditure (2.2 UC, 2.0 OPTI-Surg) after adjusting for baseline function ( P =0.53). UC and OPTI-Surg patients did not significantly differ in postoperative complications (25.6% UC, 35.3% OPTI-Surg, P =0.5). CONCLUSIONS Frailty assessment was successfully performed, but the OPTI-Surg intervention did not improve postoperative function nor reduce postoperative complications compared with UC. Future analysis will explore practice-level factors associated with toolkit implementation and the differences between the coaching and noncoaching arms.
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Affiliation(s)
- George J Chang
- Department of Colon and Rectal Surgery, the University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Health Services Research, the University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Heather J Gunn
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN
| | | | - Lisa M Lowenstein
- Department of Health Services Research, the University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Daniel Dohan
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA
| | | | - Travis Dockter
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN
| | - Angelina D Tan
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN
| | - Amylou Dueck
- Alliance Statistics and Data Management Center, Scottsdale, AZ
| | - Selina Chow
- Alliance Protocol Operations Office, University of Chicago, Chicago, IL
| | - Heather Neuman
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, CA
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Yan E, Butris N, Alhamdah Y, Kapoor P, Lovblom LE, Islam S, Saripella A, Wong J, Tang-Wai DF, Mah L, Alibhai SMH, Tartaglia MC, He D, Chung F. The utility of remote cognitive screening tools in identifying cognitive impairment in older surgical patients: An observational cohort study. J Clin Anesth 2024; 97:111557. [PMID: 39047531 DOI: 10.1016/j.jclinane.2024.111557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/13/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024]
Abstract
STUDY OBJECTIVES To determine the prevalence of suspected cognitive impairment using the Centers for Disease Control and Prevention (CDC) cognitive question, Ascertain Dementia Eight-item Questionnaire (AD8), Modified Telephone Interview for Cognitive Status (TICS-M), and Telephone Montreal Cognitive Assessment (T-MoCA), the agreement between each tool beyond chance, and the risk factors associated with a positive screen. DESIGN Multicenter prospective study. SETTING Remote preoperative assessments. PATIENTS 307 non-cardiac surgical patients aged ≥65 years. MEASUREMENTS Prevalence, Cohen's kappa (κ). MAIN RESULTS The T-MoCA detected the highest prevalence of suspected cognitive impairment (28%), followed by the AD8 (17%), CDC cognitive question (9%), and TICS-M (6%). The four screening tools showed poor agreement beyond chance with one another, with the CDC cognitive question and AD8 approaching the threshold for weak agreement (κ = 0.39). Depression was associated with screening positive on the CDC cognitive question (OR: 2.81; 95% CI: 1.04, 7.68). Obstructive sleep apnea (OSA) (OR: 3.10; 95% CI: 1.26, 7.71) and functional disability (OR: 3.74; 95% CI: 1.34, 11.11) were associated with a positive AD8 screen. Older age (OR: 1.56; 95% CI: 1.01, 2.41), male sex (OR: 3.08; 95% CI: 1.09, 9.40), and higher pain level (OR: 1.21; 95% CI: 1.01, 1.47) were associated with a positive TICS-M screen. Similarly, older age (OR: 1.33; 95% CI: 1.03, 1.73), male sex (OR: 2.02; 95% CI: 1.09, 3.83), and higher pain level (OR: 1.15; 95% CI: 1.02, 1.30) were associated with a positive T-MoCA screen. CONCLUSIONS The CDC cognitive question, AD8, TICS-M, and T-MoCA were easily implemented during preoperative assessment among older surgical patients. OSA, functional disability, and depression were associated with complaints on the CDC cognitive question and AD8. Older age, male sex, and higher pain level were associated with screening positive on the TICS-M and T-MoCA. Early remote cognitive screening may enhance risk stratification of vulnerable patients.
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Affiliation(s)
- Ellene Yan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Nina Butris
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Yasmin Alhamdah
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Paras Kapoor
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Leif Erik Lovblom
- Biostatistics Department, University Health Network, Toronto, ON, Canada
| | - Sazzadul Islam
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Aparna Saripella
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, ON, Canada; Women's College Hospital, Toronto, ON, Canada
| | - David F Tang-Wai
- Temerty Faculty of Medicine, University of Toronto, ON, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Linda Mah
- Temerty Faculty of Medicine, University of Toronto, ON, Canada; Division of Geriatric Psychiatry, Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Rotman Research Institute, Baycrest Health Sciences Centre, Toronto, ON, Canada
| | - Shabbir M H Alibhai
- Temerty Faculty of Medicine, University of Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Maria Carmela Tartaglia
- Temerty Faculty of Medicine, University of Toronto, ON, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - David He
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, ON, Canada.
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Berian JR, Schwarze ML, Werner NE, Mahoney JE, Shah MN. Using Systems Engineering and Implementation Science to Design an Implementation Package for Preoperative Comprehensive Geriatric Assessment Among Older Adults Having Major Abdominal Surgery: Protocol for a 3-Phase Study. JMIR Res Protoc 2024; 13:e59428. [PMID: 39250779 DOI: 10.2196/59428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 06/27/2024] [Accepted: 07/05/2024] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND Older Americans, a growing segment of the population, have an increasing need for surgical services, and they experience a disproportionate burden of postoperative complications compared to their younger counterparts. A preoperative comprehensive geriatric assessment (pCGA) is recommended to reduce risk and improve surgical care delivery for this population, which has been identified as vulnerable. The pCGA optimizes multiple chronic conditions and factors commonly overlooked in routine preoperative planning, including physical function, polypharmacy, nutrition, cognition, mental health, and social and environmental support. The pCGA has been shown to decrease postoperative morbidity, mortality, and length of stay in a variety of surgical specialties. Although national guidelines recommend the use of the pCGA, a paucity of strategic guidance for implementation limits its uptake to a few academic medical centers. By applying implementation science and human factors engineering methods, this study will provide the necessary evidence to optimize the implementation of the pCGA in a variety of health care settings. OBJECTIVE The purpose of this paper is to describe the study protocol to design an adaptable, user-centered pCGA implementation package for use among older adults before major abdominal surgery. METHODS This protocol uses systems engineering methods to develop, tailor, and pilot-test a user-centered pCGA implementation package, which can be adapted to community-based hospitals in preparation for a multisite implementation trial. The protocol is based upon the National Institutes of Health Stage Model for Behavioral Intervention Development and aligns with the goal to develop behavioral interventions with an eye to real-world implementation. In phase 1, we will use observation and interviews to map the pCGA process and identify system-based barriers and facilitators to its use among older adults undergoing major abdominal surgery. In phase 2, we will apply user-centered design methods, engaging health care providers, patients, and caregivers to co-design a pCGA implementation package. This package will be applicable to a diverse population of older patients undergoing major abdominal surgery at a large academic hospital and an affiliate community site. In phase 3, we will pilot-test and refine the pCGA implementation package in preparation for a future randomized controlled implementation-effectiveness trial. We anticipate that this study will take approximately 60 months (April 2023-March 2028). RESULTS This study protocol will generate (1) a detailed process map of the pCGA; (2) an adaptable, user-centered pCGA implementation package ready for feasibility testing in a pilot trial; and (3) preliminary pilot data on the implementation and effectiveness of the package. We anticipate that these data will serve as the basis for future multisite hybrid implementation-effectiveness clinical trials of the pCGA in older adults undergoing major abdominal surgery. CONCLUSIONS The expected results of this study will contribute to improving perioperative care processes for older adults before major abdominal surgery. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/59428.
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Affiliation(s)
- Julia R Berian
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Margaret L Schwarze
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Nicole E Werner
- Department of Health and Wellness Design, School of Public Health, Indiana University-Bloomington, Bloomington, IN, United States
| | - Jane E Mahoney
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Manish N Shah
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
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Agung Y, Hladkowicz E, Boland L, Moloo H, Lavallée LT, Lalu MM, McIsaac DI. Frailty and decisional regret after elective noncardiac surgery: a multicentre prospective cohort study. Br J Anaesth 2024:S0007-0912(24)00464-1. [PMID: 39232909 DOI: 10.1016/j.bja.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/31/2024] [Accepted: 08/01/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Frailty is associated with morbidity and mortality after surgery. The association of frailty with decisional regret is poorly defined. Our objective was to estimate the association of preoperative frailty with decisional regret status in the year after surgery. METHODS We conducted a secondary analysis of a prospective, multicentre cohort study of patients aged ≥65 years who underwent elective noncardiac surgery. Decisional regret about having undergone surgery was ascertained at 30, 90, and 365 (primary time point) days after surgery using a 3-point ordinal scale. Bayesian ordinal logistic regression was used to estimate the association of frailty with decisional regret, adjusted for surgery type, age, sex, and mental health conditions. Subgroup and sensitivity analyses were conducted. RESULTS We identified 669 patients; 293 (43.8%) lived with frailty. At 365 days after surgery, the unadjusted odds ratio (OR) associating frailty with greater decisional regret was 2.21 (95% credible interval [CrI] 0.98-5.09; P(OR>1)=0.97), which was attenuated after confounder adjustment (adjusted OR 1.68, 95% CrI 0.84-3.36; P(OR>1)=0.93). Similar results were estimated at 30 and 90 days. Additional adjustment for baseline comorbidities and disability score substantially altered the OR at 365 days (0.89, 95% CrI 0.37-2.12; P(OR>1)=0.39). There was a high probability that surgery type was an effect modifier (non-orthopaedic: OR 1.90, 95% CrI 1.00-3.59; P(OR>1)=0.98); orthopaedic: OR 0.87, 95% CrI 0.41-1.91; P(OR>1)=0.36). CONCLUSIONS Among older surgical patients, there appears to be a complex association with frailty and decisional regret, with substantial heterogeneity based on assumed causal pathways and surgery type. Future studies are required to untangle the complex interplay between these factors.
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Affiliation(s)
- Yonathan Agung
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Laura Boland
- Centre for Surveillance and Applied Research (CSAR), Public Health Agency of Canada, Ottawa, ON, Canada
| | - Husein Moloo
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Surgery, Division of General Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Luke T Lavallée
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Surgery, Division of Urology, University of Ottawa, Ottawa, ON, Canada
| | - Manoj M Lalu
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; Departments of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Daniel I McIsaac
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; Departments of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
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Chen L, Zong W, Luo M, Yu H. The impact of comprehensive geriatric assessment on postoperative outcomes in elderly surgery: A systematic review and meta-analysis. PLoS One 2024; 19:e0306308. [PMID: 39197016 PMCID: PMC11356442 DOI: 10.1371/journal.pone.0306308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 06/15/2024] [Indexed: 08/30/2024] Open
Abstract
INTRODUCTION The elderly population experiences more postoperative complications. A comprehensive geriatric assessment, which is multidimensional and coordinated, could help reduce these unfavorable outcomes. However, its effectiveness is still uncertain. METHODS We searched multiple online databases, including Medline, PubMed, Web of Science, Cochrane Library, Embase, CINAL, ProQuest, and Wiley, for relevant literature from their inception to October 2023. We included randomized trials of individuals aged 65 and older undergoing surgery. These trials compared comprehensive geriatric assessment with usual surgical care and reported on postoperative outcomes. Two researchers independently screened the literature, extracted data, and assessed the certainty of evidence from the identified articles. We conducted a meta-analysis using RevMan 5.3 to calculate the Odds Ratio (OR) and Mean Difference (MD) of the pooled data. RESULTS The study included 1325 individuals from seven randomized trials. Comprehensive geriatric assessment reduced the rate of postoperative delirium (28.5% vs. 37.0%; OR: 0.63; CI: 0.47-0.85; I2: 54%; P = 0.003) based on pooled data. However, it did not significantly improve other parameters such as length of stay (MD: -0.36; 95% CI: -0.376, 3.05; I2: 96%; P = 0.84), readmission rate (18.6% vs. 15.4%; OR: 1.26; CI: 0.86-1.84; I2: 0%; P = 0.24), and ADL function (MD: -0.24; 95% CI: -1.27, 0.19; I2: 0%; P = 0.64). CONCLUSIONS Apart from reducing delirium, it is still unclear whether comprehensive geriatric assessment improves other postoperative outcomes. More evidence from higher-quality randomized trials is needed.
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Affiliation(s)
- Lin Chen
- Anesthesia and Surgery Department, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Wei Zong
- Department of Critical Care Medicine, First Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jangsu, China
| | - Manyue Luo
- Endocrinology and Metabolism Department, Changsha People’s Hospital, Changsha, Hunan, China
| | - Huiqin Yu
- Anesthesia and Surgery Department, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
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Saetang M, Rewurai N, Oofuvong M, Chanchayanon T, Packawatchai P, Khunpanich P. Preoperative Modified Frailty Index-11 versus EuroSCORE II in Predicting Postoperative Mortality and Complications in Elderly Patients Who Underwent Elective Open Cardiac Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00537-8. [PMID: 39218762 DOI: 10.1053/j.jvca.2024.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 07/10/2024] [Accepted: 08/09/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To compare sensitivity, specificity, receiver operating characteristic (ROC), and area under the curve (AUC) values using the modified Frailty Index 11 (mFI-11), EuroSCORE II, and combined mFI-11 and EuroSCORE II to predict in-hospital mortality and composite morbidities. DESIGN Retrospective cohort study SETTING: Songklanagarind Hospital, a tertiary care center in southern Thailand. PARTICIPANTS Elderly patients age ≥60 years who underwent elective open-heart surgical procedures on a pump between January 2017 and December 2022 were included. INTERVENTIONS ROC curves were constructed to evaluate the discriminatory power of EuroSCORE II and mFI-11 for predicting in-hospital mortality and postoperative complications. MEASUREMENTS AND MAIN RESULTS The actual in-hospital mortality was 2.5% for all patients. The discriminative accuracy of mFI-11, EuroSCORE II, and combined mFI-11 with EuroSCORE II for predicting in-hospital mortality was good, with respective AUC values of 0.733 (95% confidence interval [CI], 0.6157-0.8499), 0.793 (95% CI, 0.6826-0.9026), and 0.78 (95% CI, 0.6686-0.893). The AUC of mFI-11 for predicting postoperative cardiac, respiratory, neurologic, and renal complications was 0.558 (95% CI, 0.5101-0.6063), 0.606 (95% CI, 0.5542-0.6581), 0.543 (95% CI, 0.4533-0.6337), and 0.652 (95% CI, 0.5859-0.7179), respectively, and that of EuroSCORE II was 0.553 (95% CI, 0.5038-0.6013), 0.631 (95% CI, 0.578-0.6836), 0.619 (95% CI, 0.5306-0.7076), and 0.702 (95% CI, 0.6378-0.7657), respectively. CONCLUSIONS The mFI-11 and EuroSCORE II demonstrated good discrimination in ROC analysis, with EuroSCORE II showing superior predictive accuracy for in-hospital mortality in elderly elective cardiac surgery patients. However, neither score independently predicted mortality in multiple logistic regression, nor did combining them enhance predictive power significantly. Furthermore, both scores were less effective in predicting postoperative complications.
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Affiliation(s)
- Mantana Saetang
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat-Yai, Songkhla, Thailand.
| | - Nichakan Rewurai
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat-Yai, Songkhla, Thailand
| | - Maliwan Oofuvong
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat-Yai, Songkhla, Thailand
| | - Thavat Chanchayanon
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat-Yai, Songkhla, Thailand
| | - Patrapon Packawatchai
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat-Yai, Songkhla, Thailand
| | - Ploychanok Khunpanich
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat-Yai, Songkhla, Thailand
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Park CM, Lie JJ, Yang L, Cooper Z, Kim DH. Impact of peri-operative frailty and operative stress on post-discharge mortality, readmission and days at home in Medicare beneficiaries. Anaesthesia 2024; 79:829-838. [PMID: 38775305 PMCID: PMC11246804 DOI: 10.1111/anae.16301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Understanding how patients' frailty and the physiological stress of surgical procedures affect postoperative outcomes may inform risk stratification of older patients undergoing surgery. The objective of the study was to examine the association of peri-operative frailty with mortality, 30-day readmission and days at home after non-cardiac surgical procedures of different physiological stress. METHODS This retrospective study used Medicare claims data from a 7.125% random sample of Medicare fee-for-service beneficiaries from 2015 to 2019 who were aged ≥ 65 years and underwent non-cardiac surgical procedure listed in the Operative Stress Score categories. The exposure of the study was claims-based frailty index (robust, < 0.15; pre-frail, 0.15 to < 0.25; mildly frail, 0.25 to < 0.35; and moderate-to-severely frail, ≥ 0.35) with Operative Stress Score categories being 1, very low stress to 5, very high stress. The primary outcome was all-cause mortality at 30 days and 365 days after the surgical procedure. RESULTS In total, 1,019,938 patients (mean (SD) age of 76.1 (7.3) years; 52.3% female; 16.8% frail) were included. The cumulative incidence of mortality generally increased with Operative Stress Score category, ranging from 5.0% (Operative Stress Score 2) to 24.9% (Operative Stress Score 4) at 365 days. Within each category, increasing frailty was associated with mortality at 30 days (hazard ratio comparing moderate-to-severe frailty vs. robust ranged from 1.59-3.91) and at 365 days (hazard ratio 1.30-4.04). The variation in postoperative outcomes by patients' frailty level was much greater than the variation by the operative stress category. CONCLUSIONS These results emphasise routine frailty screening before major and minor non-cardiac procedures and the need for greater clinician awareness of postoperative outcomes beyond 30 days in shared decision-making with older adults with frailty.
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Affiliation(s)
- Chan Mi Park
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jessica J. Lie
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Laiji Yang
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Zara Cooper
- Harvard Medical School, Boston, MA, USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA
| | - Dae Hyun Kim
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Sugiyama M, Nishijima TF, Kasagi Y, Uehara H, Yoshida D, Nagai T, Koga N, Kimura Y, Morita M, Toh Y. Impact of comprehensive geriatric assessment on treatment strategies and complications in older adults with colorectal cancer considering surgery. J Surg Oncol 2024; 130:329-337. [PMID: 38881197 DOI: 10.1002/jso.27736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 06/01/2024] [Accepted: 06/06/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND AND OBJECTIVES This study aimed to assess the effectiveness of Comprehensive Geriatric Assessment (CGA) in customizing care for elderly cancer patients, specifically focusing on colorectal cancer. The research compared treatment strategies and outcomes in older adults considered for surgery before and after the initiation of a Geriatric Oncology Service (GOS). METHODS Conducting a comparative study, two cohorts of consecutive colorectal cancer patients aged 75 or older were examined: the control group (n = 156) and the GOS group (n = 158). Upon the treating surgeon's GOS consultation request, a geriatrician and an oncologist performed CGA, guiding treatment decisions and perioperative interventions. Postoperative complications were compared using propensity score matching (PSM). RESULTS In the GOS group, 91% (n = 116) underwent CGA consultations, influencing decisions to forego surgery in 12 patients. After PSM for surgical cases (controls n = 146, GOS n = 146), each group comprised 128 patients. Perioperative physical therapy and pharmacist referrals were more frequent in the GOS group. The GOS group exhibited a significantly lower incidence of postoperative complications (22%) compared to the control group (33%) (p = 0.0496). CONCLUSION Patients undergoing colorectal surgery post-GOS implementation experienced a notable reduction in postoperative complications, highlighting the positive impact of personalized geriatric assessment on surgical outcomes in the elderly.
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Affiliation(s)
- Masahiko Sugiyama
- Department of Gastroenterological Surgery, NHO Kyushu Cancer Center, Fukuoka, Japan
| | - Tomohiro F Nishijima
- Geriatric Oncology Service, NHO Kyushu Cancer Center, Fukuoka, Japan
- Department of Gastrointestinal and Medical Oncology, NHO Kyushu Cancer Center, Fukuoka, Japan
| | - Yuta Kasagi
- Department of Gastroenterological Surgery, NHO Kyushu Cancer Center, Fukuoka, Japan
| | - Hideo Uehara
- Department of Gastroenterological Surgery, NHO Kyushu Cancer Center, Fukuoka, Japan
- Department of Gastrointestinal Surgery, NHO Kyushu Medical Center, Fukuoka, Japan
| | - Daisuke Yoshida
- Department of Gastroenterological Surgery, NHO Kyushu Cancer Center, Fukuoka, Japan
- Department of Gastrointestinal Surgery, Oita, Japan
| | - Taichiro Nagai
- Department of Gastroenterological Surgery, NHO Kyushu Cancer Center, Fukuoka, Japan
| | - Naomichi Koga
- Department of Gastroenterological Surgery, NHO Kyushu Cancer Center, Fukuoka, Japan
| | - Yasue Kimura
- Department of Gastroenterological Surgery, NHO Kyushu Cancer Center, Fukuoka, Japan
| | - Masaru Morita
- Department of Gastroenterological Surgery, NHO Kyushu Cancer Center, Fukuoka, Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, NHO Kyushu Cancer Center, Fukuoka, Japan
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Penfold RS, Hunt A. Redefining risk in peri-operative frailty: towards routine frailty assessment and a whole pathway approach. Anaesthesia 2024; 79:797-800. [PMID: 38775328 DOI: 10.1111/anae.16264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2024] [Indexed: 07/16/2024]
Affiliation(s)
- Rose S Penfold
- Department of Ageing and Health, Usher Institute, University of Edinburgh and Advanced Care Research Centre, University of Edinburgh, Scotland, UK
| | - Adam Hunt
- Research Department of Targeted Intervention, University College London, London, UK
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Ron D, Abess AT, Boone MD, Martinez-Camblor P, Deiner SG. Perioperative Primary Care Utilization and Postoperative Readmission, Emergency Department Use, and Mortality in Older Surgical Patients. Anesth Analg 2024; 139:291-299. [PMID: 38848256 DOI: 10.1213/ane.0000000000007036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
BACKGROUND Postdischarge primary care follow-up is associated with lower readmission rates after medical hospitalizations. However, the effect of primary care utilization on readmission has not been studied in surgical patients. METHODS Retrospective cohort study of Medicare beneficiaries aged 65 and older undergoing major inpatient diagnostic or therapeutic procedures (n = 3,552,906) from 2017 through 2018, examining the association between postdischarge primary care visits within 14 days of discharge (primary exposure), and Annual Wellness Visits in the year prior (secondary exposure), with 30-day unplanned readmission (primary outcome), emergency department visits, and mortality (secondary outcomes). RESULTS Overall, 9.5% (n = 336,837) had postdischarge visits within 14 days, 2.9% (n = 104,571) had Annual Wellness Visits in the year preceding the procedure, 9.5% (n = 336,401) were readmitted, 9% (n = 319,054) had emergency department visits, and 0.6% (n = 22,103) of the cohort died within 30 days. Our fully adjusted propensity-matched proportional hazards Cox regression analysis showed that postdischarge visits were associated with a 5% lower risk of readmission (hazard ratio [HR], 0.95, 95% confidence interval [CI], 0.93-0.97), 43% higher risk of emergency department use (HR, 1.43, 95% CI, 1.40-1.46) and no difference in mortality risk (HR, 0.98, 95% CI, 0.90-1.06), compared with not having a visit within 14 days of discharge. In a separate set of regression models, Annual Wellness Visits were associated with a 9% lower risk of readmission (HR, 0.91, 95% CI, 0.88-0.95), 45% higher risk of emergency department utilization (HR, 1.45, 95% CI, 1.40-1.49) and an 18% lower mortality risk (HR, 0.82, 95% CI, 0.75-0.89) compared with no Annual Wellness Visit in the year before the procedure. CONCLUSIONS Both postdischarge visits and the Medicare Annual Wellness Visit appear to be extremely underutilized among the older surgical population. In those patients who do utilize primary care, compared with propensity-matched patients who do not, our study suggests primary care use is associated with modestly lower readmission rates. Prospective studies are needed to determine whether targeted primary care involvement can reduce readmission.
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Affiliation(s)
- Donna Ron
- From the Department of Community and Family Medicine, Dartmouth Hitchcock Medical Center and Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
| | - Alexander T Abess
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center and Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
| | - Myles D Boone
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center and Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
- Department of Neurology, Dartmouth Hitchcock Medical Center and Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
| | - Pablo Martinez-Camblor
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center and Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Stacie G Deiner
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center and Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
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Chang OLB, Pawar N, Whitlock EL, Miller B, Possin KL. Gaps in cognitive care among older patients undergoing spine surgery. J Am Geriatr Soc 2024; 72:2133-2139. [PMID: 38407475 PMCID: PMC11226354 DOI: 10.1111/jgs.18843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/12/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024]
Abstract
INTRODUCTION Among older adults undergoing surgery, postoperative delirium is the most common complication. Cognitive impairment and dementia are major risk factors for postoperative delirium, yet they are frequently under-recognized. It is well established that applying delirium preventive interventions to at-risk individuals can reduce the likelihood of delirium by up to 40%. The aim of this study was to evaluate how often delirium preventive interventions are missing in patients at risk for delirium due to baseline cognitive impairment. METHODS We conducted a retrospective study using data from the observational study Perioperative Anesthesia Neurocognitive Disorder Assessment-Geriatric (PANDA-G) and clinical data from the University of California San Francisco delirium prevention bundle. Patients age 65+ received preoperative multidomain cognitive assessment as part of a research protocol prior to undergoing inpatient spine surgery at a single major academic institution. Results of the cognitive testing were not available to clinical teams. Using electronic medical records, we evaluated if patients who were cognitively impaired at baseline received delirium prevention orders, sleep orders, and avoidance of AGS Beers Criteria® potentially inappropriate medications. RESULTS Of the 245 patients included in the study, 42% were women. The mean [SD] age was 72 [5.2] years. Preoperative cognitive impairment was identified in 40% of participants (N = 98), and of these, 34% had postoperative delirium. Of patients with preoperative cognitive impairment, 45% did not receive delirium preventive orders, 43% received PIMs, and 49% were missing sleep orders. At least one of the three delirium preventive interventions was missing in 70% of the patients. DISCUSSION Undiagnosed preoperative cognitive impairment among older adults undergoing spine surgery is common. When cognitive test results were not available to clinicians, patients with baseline cognitive impairment frequently did not receive evidence-based delirium preventive interventions. These findings highlight an opportunity to improve perioperative brain health care via preoperative cognitive assessment and clinical communication.
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Affiliation(s)
- Odmara L. Barreto Chang
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA
| | - Niti Pawar
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA
| | - Elizabeth L. Whitlock
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA
| | - Bruce Miller
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
| | - Katherine L. Possin
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
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12
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Zhao B, Zhang S, Chen Y, Zhang T, Zhang C. Risk factors for preoperative frailty in older patients with gastric cancer: a systematic review and meta-analysis. Support Care Cancer 2024; 32:450. [PMID: 38904837 DOI: 10.1007/s00520-024-08654-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/12/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE To summarize the available evidence on risk factors for preoperative frailty in older gastric cancer patients. METHODS We comprehensively searched the CNKI, Wanfang, VIP, CBM, PubMed, Embase, The Cochrane Library, Web of Science, and CINAHL databases for preoperative articles on risk factors for frailty in older gastric cancer patients. The search was conducted from the time of construction of the library to January 27, 2024, with no language restrictions. The quality of the included studies was rated by the Newcastle-Ottawa Scale and the Agency for Healthcare Research and Quality tool. RESULTS A total of 20 studies were included, including 16 cohort studies and 4 cross-sectional studies, with a total sample size of 51,717 individuals. The results of the meta-analysis showed that age, albumin, hemoglobin, cancer stage III-IV, Charlson Comorbidity Index score ≥ 3, Eastern Cooperative Oncology Group score > 2, American Society of Anesthesiologists score > 2, smoking, nutritional risk, high school degree or above, and sleep disorders are the main influencing factors for the occurrence of preoperative frailty in older gastric cancer patients. Among them, high school degree or above was a protective factor. CONCLUSIONS Our study provides valid evidence of risk factors for preoperative frailty in older patients with gastric cancer and informs clinical healthcare professionals to make targeted interventions.
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Affiliation(s)
- Bingyan Zhao
- Graduate School of Tianjin University of Chinese Medicine, Tianjin, 301617, China
| | - Siai Zhang
- Cardiac Intensive Care Unit, Meizhou People's Hospital, Meizhou, 514031, Guangdong, China
| | - Yu Chen
- Graduate School of Tianjin University of Chinese Medicine, Tianjin, 301617, China
| | - Tongyu Zhang
- Graduate School of Tianjin University of Chinese Medicine, Tianjin, 301617, China
| | - Chunmei Zhang
- School of Nursing, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China.
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13
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Zhang Y, Wu Q, Han M, Yang C, Kang F, Li J, Hu C, Chen X. Frailty is a Risk Factor for Postoperative Complications in Older Adults with Lumbar Degenerative Disease: A Prospective Cohort Study. Clin Interv Aging 2024; 19:1117-1126. [PMID: 38911672 PMCID: PMC11194013 DOI: 10.2147/cia.s462731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 06/07/2024] [Indexed: 06/25/2024] Open
Abstract
Objective Frailty, representing the physiological reserve and tolerance of the body, serves as a crucial evaluation index of the overall status of the older adults. This study aimed to investigate the prevalence of preoperative frailty and its impact on postoperative outcomes among older adults with lumbar degenerative disease in China. Patients and Methods In this prospective study, a total of 280 patients aged 60 and above, diagnosed with lumbar degenerative disease and scheduled for surgical intervention were enrolled. The prevalence of frailty pre-surgery was evaluated using the Tilburg Frailty Indicator (TFI) and the modified Frailty Index 11 (mFI-11). The primary outcome was postoperative complication within 30 days post-surgery. The secondary outcomes were the length of hospital stay, hospital costs, reoperation within 30 days post-surgery and unplanned readmission within 30 days post-discharge. Both univariable and multivariable logistic regression were employed to screen and identify the risk factors predisposing patients to postoperative complications. Results A total of 272 older adults were included in the study ultimately. The frailty detection rates of TFI and mFI-11 were 15.8% (43/272) and 10.7% (29/272) respectively. Thirty-four patients (12.5%) encountered complications. Significantly elevated rates of complications, prolonged hospital stays, increased hospital costs, and heightened readmission rates were observed in the frail group compared to the non-frail group (P<0.05). Univariable analysis showed that the potential factors related to complications are TFI, mFI-11 and albumin. Multivariable logistic regression revealed that TFI was an independent risk factor for postoperative complications (OR=5.371, 95% CI: 2.338-12.341, P < 0.001). Conclusion Frailty was an independent predictor of postoperative complications in older adults undergoing lumbar fusion surgery. Frailty assessment should be performed in such patients to improve preoperative risk stratification and optimize perioperative management strategies.
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Affiliation(s)
- Yan Zhang
- Department of Nursing, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Qixing Wu
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Mingming Han
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Chengwei Yang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Fang Kang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Juan Li
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Chengwen Hu
- Department of Nursing, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
| | - Xia Chen
- Department of Nursing, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People’s Republic of China
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14
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Travers R, Gagliardi G, Ramseyer M. Delirium management in perioperative geriatric services: a narrative review of non-pharmaceutical strategies. Front Psychiatry 2024; 15:1394583. [PMID: 38952635 PMCID: PMC11215170 DOI: 10.3389/fpsyt.2024.1394583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/30/2024] [Indexed: 07/03/2024] Open
Abstract
Delirium, a common complication in elderly surgical patients, poses significant challenges in perioperative care. Perioperative geriatric services (PGS) aim at managing comorbidities, postoperative complications, and initiating early recovery of mobility to enhance elderly patients' prognosis in the perioperative period. Studies have shown that patients with preoperative cognitive disorders are at a significantly increased risk of postoperative delirium. While postoperative delirium affects up to 70% of people over 60 and 90% of people with neurodegenerative diseases, it remains underdiagnosed in many cases. Postoperative delirium can lead to functional decline, prolonged hospitalization, increased healthcare costs, cognitive impairment, and psychological malaise. This article briefly summarizes the literature on delirium, its risk factors, and its non-pharmaceutical management strategies within the perioperative period. It highlights the importance of integrating cognitive and psychological assessments into perioperative care protocols to provide baseline data, improve patient outcomes, reduce hospital stays, and minimize complications associated with delirium. By embracing evidence-based delirium management protocols, healthcare professionals can better identify and manage delirium, ultimately improving the quality of care for elderly surgical patients, which would also benefit healthcare staff and healthcare institutions.
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Affiliation(s)
- Rozenn Travers
- Service de Court Séjour Gériatrique, Pôle Médecines Fortes Consultations, Centre Hospitalier Universitaire d’Orléans, Orléans, France
| | - Geoffroy Gagliardi
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, United States
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Maximilian Ramseyer
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, United States
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15
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Deiner SG, Marcantonio ER, Trivedi S, Inouye SK, Travison TG, Schmitt EM, Hshieh T, Fong TG, Ngo LH, Vasunilashorn SM. Comparison of the frailty index and frailty phenotype and their associations with postoperative delirium incidence and severity. J Am Geriatr Soc 2024; 72:1781-1792. [PMID: 37964474 PMCID: PMC11090994 DOI: 10.1111/jgs.18677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/27/2023] [Accepted: 10/15/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Recent studies have reported an association between presurgical frailty and postoperative delirium. However, it remains unclear whether the frailty-delirium relationship differs by measurement tool (e.g., frailty index vs. frailty phenotype) and whether frailty is associated with delirium, independent of preoperative cognition. METHODS We used the successful aging after elective surgery (SAGES) study, a prospective cohort of older adults age ≥70 undergoing major non-cardiac surgery (N = 505). Preoperative measurement of the modified mini-mental (3MS) test, frailty index and frailty phenotype were obtained. The confusion assessment method (CAM), supplemented by chart review, identified postoperative delirium. Delirium feature severity was measured by the sum of CAM-severity (CAM-S) scores. Generalized linear models were used to determine the relative risk of each frailty measure with delirium incidence and severity. Subsequent models adjusted for age, sex, surgery type, Charlson comorbidity index, and 3MS. RESULTS On average, patients were 76.7 years old (standard deviation 5.22), 58.8% of women. For the frailty index, the incidence of delirium was 14% in robust, 17% in prefrail, and 31% in frail patients (p < 0.001). For the frailty phenotype, delirium incidence was 13% in robust, 21% in prefrail, and 27% in frail patients (p = 0.016). Frailty index, but not phenotype, was independently associated with delirium after adjustment for comorbidities (relative risk [RR] 2.13, 95% confidence interval [CI] 1.23-3.70; RR 1.61, 95% CI 0.77-3.37, respectively). Both frailty measures were associated with delirium feature severity. After adjustment for preoperative cognition, only the frailty index was associated with delirium incidence; neither index nor phenotype was associated with delirium feature severity. CONCLUSION Both the frailty index and phenotype were associated with the development of postoperative delirium. The index showed stronger associations that remained significant after adjusting for baseline comorbidities and preoperative cognition. Measuring frailty prior to surgery can assist in identifying patients at risk for postoperative delirium.
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Affiliation(s)
- Stacie G Deiner
- Department of Anesthesiology, Dartmouth Health, Lebanon, New Hampshire, USA
| | - Edward R Marcantonio
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Shrunjal Trivedi
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Sharon K Inouye
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Thomas G Travison
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Eva M Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Tammy Hshieh
- Harvard Medical School, Boston, Massachusetts, USA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Tamara G Fong
- Harvard Medical School, Boston, Massachusetts, USA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Long H Ngo
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Sarinnapha M Vasunilashorn
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
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16
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Kotani T, Ida M, Naito Y, Kawaguchi M. Comparison of remimazolam-based and propofol-based total intravenous anesthesia on hemodynamics during anesthesia induction in patients undergoing transcatheter aortic valve replacement: a randomized controlled trial. J Anesth 2024; 38:330-338. [PMID: 38347233 DOI: 10.1007/s00540-024-03311-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/10/2024] [Indexed: 05/16/2024]
Abstract
PURPOSE This study aimed to compare the hemodynamic effects of remimazolam- and propofol-based total intravenous anesthesia in patients who underwent transcatheter aortic valve replacement. METHODS This was a single-center, single-blind, randomized controlled trial set at Nara Medical University, Kashihara, Japan. We included 36 patients aged ≥ 20 years scheduled to undergo elective transfemoral transcatheter aortic valve replacement (TAVR) under general anesthesia. The participants were randomly assigned to the remimazolam and propofol groups (n = 18 each). Remimazolam- or propofol-based total intravenous anesthesia was initiated at 12 mg/kg/min or 2.5 mcg/mL via target-controlled infusion, respectively, along with remifentanil. After confirming the loss of consciousness, the administration rate was adjusted using electroencephalographic monitoring. The primary outcome was the rate of arterial hypotension, defined as a mean arterial pressure < 60 mmHg, from anesthesia induction until the beginning of the surgical incision. The total doses of ephedrine and phenylephrine were also assessed. RESULTS During anesthesia induction, the arterial hypotension rates were 11.9% and 21.6% in the remimazolam and propofol groups, respectively (P = 0.01). The total dose of ephedrine was higher in the propofol group (14.4 mg) than in the remimazolam group (1.6 mg) (P < 0.001); however, the total dose of phenylephrine was not significantly different between the two groups (propofol 0.31 mg vs. remimazolam: 0.17 mg, P = 0.10). CONCLUSION Remimazolam-based total intravenous anesthesia resulted in a lower hypotension rate than propofol-based total intravenous anesthesia during induction in patients undergoing TAVR. Remimazolam-based total intravenous anesthesia can be used safely during anesthetic induction in patients with severe aortic stenosis.
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Affiliation(s)
- Taichi Kotani
- Department of Anesthesiology, Nara Medical University Kashihara, Shijo 840, Nara, 634-8522, Japan
| | - Mitsuru Ida
- Department of Anesthesiology, Nara Medical University Kashihara, Shijo 840, Nara, 634-8522, Japan.
| | - Yusuke Naito
- Department of Anesthesiology, Nara Medical University Kashihara, Shijo 840, Nara, 634-8522, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University Kashihara, Shijo 840, Nara, 634-8522, Japan
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17
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Kandula RA, Linquest LA, Kandregula S, Latour M, Ahmed OG, Yim MT. Utility of hospital frailty risk score in predicting postoperative outcomes of sinonasal malignancies. Int Forum Allergy Rhinol 2024; 14:1097-1100. [PMID: 38064283 DOI: 10.1002/alr.23307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 11/02/2023] [Accepted: 11/24/2023] [Indexed: 06/04/2024]
Abstract
KEY POINTS Hospital frailty risk score (HFRS) correlates with complications, length of stay, and non-routine discharge. HFRS is a better predictor of postsurgical sequelae than age and Elixhauser comorbidity index.
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Affiliation(s)
- Rema Anisha Kandula
- Department of Otolaryngology, LSU Health Shreveport, Shreveport, Louisiana, USA
| | | | - Sandeep Kandregula
- Department of Neurosurgery, LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Mackenzie Latour
- Department of Otolaryngology, LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Omar G Ahmed
- Department of Otolaryngology, Houston Methodist Academic Institute, Houston, Texas, USA
| | - Michael T Yim
- Department of Otolaryngology, LSU Health Shreveport, Shreveport, Louisiana, USA
- Department of Neurosurgery, LSU Health Shreveport, Shreveport, Louisiana, USA
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18
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Yuyen T, Muangpaisan W, Pramyothin P, Thanakiattiwibun C, Chaiwat O. The association between sarcopenia, defined by a simplified screening tool, and long-term outcomes. Nutr Clin Pract 2024; 39:599-610. [PMID: 38146781 DOI: 10.1002/ncp.11109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/15/2023] [Accepted: 11/17/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Sarcopenia and frailty are frequently observed in older adult patients and linked to unfavorable postoperative outcomes. Identifying low muscle mass and function is primary for diagnosing sarcopenia. The simpler screening, which excludes muscle mass measurement, exhibited strong predictive capabilities in identifying sarcopenia. This research explored the association between sarcopenia, as defined by the C3 formula, and long-term outcomes in older adult cancer patients who underwent surgery. METHODS Surgical cancer patients aged 60 and older were enrolled. Sarcopenia was identified using the C3 formula, assessing muscle strength through handgrip strength, physical performance via a 6-m walk test, and nutrition status via the Mini Nutritional Assessment-Short Form. Long-term outcomes were evaluated with the Barthel Index for activities of daily living (B-ADL) at 3 months, as well as 1-year mortality rates. RESULTS The study enrolled 251 patients, with 130 classified as sarcopenic according to the C3 formula. Compared with nonsarcopenic patients, patients with sarcopenia exhibited a higher frequency of moderate to severe disability (B-ADL ≤70) 3 months postdischarge (19.5% vs 5.2%; P = 0.001) and elevated 1-year mortality rates (29.5% vs 14.9%; P = 0.006). No significant differences were observed in infection rates, hospital stay duration, or in-hospital mortality. Distant organ metastasis (HR = 3.99; 95% CI = 2.25-7.07) and sarcopenia defined by the C3 formula (HR = 1.78; 95% CI = 1.01-3.15) were identified as independent risk factors for 1-year mortality. CONCLUSION The simplified sarcopenia screening tool was associated with increased rates of moderate to severe disability 3 months postdischarge and higher 1-year mortality rates compared with nonsarcopenic patients.
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Affiliation(s)
- Thassayu Yuyen
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Weerasak Muangpaisan
- Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pornpoj Pramyothin
- Division of Nutrition, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chayanan Thanakiattiwibun
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Onuma Chaiwat
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Sandrucci S. Frailty: How to assess, prognostic role. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:106862. [PMID: 36922252 DOI: 10.1016/j.ejso.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/07/2023]
Abstract
Despite the clear clinical significance of frailty in surgical populations, there is no consensus on how best to define or measure frailty, even within the geriatric literature. A diversity of measures exists to measure some or all these domains, but only research-focused tools have been validated in surgical populations. These tools are too resource-intensive for rapid, cost-effective, preoperative screening of entire populations considering elective surgery. This narrative review deals with the definition of frailty and the different assessment methods of the phenotypic definition and the accumulation of deficits definition. Moreover, as in the area of surgery frailty seems to be an independent risk factor for mortality, morbidity, length of stay, and postoperative complication, different studies reporting the association of preoperative frailty with postoperative outcomes after cancer surgery and the association with postoperative mortality within 30 days are considered. Preoperative care should include a focus on the goals of treatment and care options. Patient-oriented functional and cognitive outcomes as well as the development and implementation of interventions that could potentially improve adverse postoperative effects must be further investigated.
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Affiliation(s)
- Sergio Sandrucci
- General Surgery Department, CDSS University of Turin, Torino, Italy.
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20
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Ron D, Gunn CM, Havidich JE, Ballacchino MM, Burdick TE, Deiner SG. Preoperative Communication Between Anesthesia, Surgery, and Primary Care Providers for Older Surgical Patients. Jt Comm J Qual Patient Saf 2024; 50:326-337. [PMID: 38360446 DOI: 10.1016/j.jcjq.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Suboptimal communication between clinicians remains a frequent driver of preventable adverse health care-related events, increased costs, and patient and physician dissatisfaction. METHODS Cross-sectional surveys on preoperative interspecialty communication, tailored by stakeholder type, were administered to (1) primary care providers in northern New England, (2) anesthesia providers working in the perioperative clinic of a tertiary rural academic medical center, (3) surgeons from the same center, and (4) older surgical patients who underwent preoperative assessment at the same center. RESULTS In total, 107/249 (43.0%) providers and 103/265 (39.9%) patients completed the survey. Preoperative communication was perceived as logistically challenging (59.8%), particularly across health systems. More than 77% of anesthesia and surgery providers indicated that they communicate frequently or sometimes, but 92.5% of primary care providers indicated that they rarely or never communicate with anesthesia providers. Some of the most common reasons for preoperative communication were discussion of complex patients, perioperative medication management, and optimization of comorbidities. Although 96.1% of older surgical patients reported that preoperative communication between providers is important, only 40.4% felt that their providers communicate very or extremely well. Many patients emphasized the importance of preoperative communication between providers to ensure transfer of critical clinical information. CONCLUSION Surgeons and anesthesiologists infrequently communicate with primary care providers in one rural tertiary center, in contrast to patient expectations and values. These study results will help identify priorities and potentially resolvable barriers to bridging the gap between the inpatient perioperative and outpatient primary care teams. Future studies should focus on strategies to improve communication between hospital and community providers to prevent complications and readmission.
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Fenton D, Allen A, Kent JR, Nordgren R, Liu A, Rama N, Wang A, Rubin D, Gleason LJ, Justine Landi A, Huisingh-Scheetz M, Ferguson MK, Madariaga MLL. The association between neighborhood disadvantage and frailty: A retrospective case series. J Public Health Res 2024; 13:22799036241258876. [PMID: 38867913 PMCID: PMC11168058 DOI: 10.1177/22799036241258876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 05/16/2024] [Indexed: 06/14/2024] Open
Abstract
Background Frailty predicts poorer outcomes in surgical patients. Recent studies have found socioeconomic status to be an important characteristic for surgical outcomes. We evaluated the association of Area Deprivation Index (ADI) and Social Vulnerability Index (SVI), two geospatial atlases that provide a multidimensional evaluation of neighborhood deprivation, with frailty in a surgery population. Design & methods A retrospective study of patients undergoing routine frailty screening was conducted 12/2020-8/2022. Frailty was measured using Fried's Frailty Phenotype (FFP) and the five-item Modified Frailty Index (mFI-5). ADI and SVI quartiles were determined using patient residence. Logistic regression models were used to evaluated associations of FFP (frail only vs not frail) and mFI-5 (≥2 vs 0-1) with ADI and SVI (α = 0.05). Results Of 372 screened patients, 41% (154) were women, median age was 68% (63-74), and 46% (170) identified as non-White. Across ADI and SVI quartiles, higher number of comorbidities, decreasing median income, and frailty were associated with increasing deprivation (p < 0.01). When controlling for age, sex, comorbidities, and BMI category, frailty by FFP was associated with the most deprived two quartiles of ADI (OR 2.61, CI: [1.35-5.03], p < 0.01) and the most deprived quartile of SVI (OR 2.33, [1.10-4.95], p < 0.05). These trends were also seen with mFI-5 scores ≥2 (ADI: OR 1.64, [1.02-2.63], p < 0.05; SVI: OR 1.71, [1.01-2.91], p < 0.05). Conclusions Surgical patients living in socioeconomically deprived neighborhoods are more likely to be frail. Interventions may include screening of disadvantaged populations and resource allocation to vulnerable neighborhoods.
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Affiliation(s)
- David Fenton
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Amani Allen
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Johnathan R Kent
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Rachel Nordgren
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| | - Allison Liu
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Nihar Rama
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Ally Wang
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Daniel Rubin
- Department of Anesthesia & Critical Care, University of Chicago Medicine, Chicago, IL, USA
| | - Lauren J Gleason
- Department of Medicine, Section of Geriatrics and Palliative Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - A Justine Landi
- Department of Medicine, Section of Geriatrics and Palliative Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Megan Huisingh-Scheetz
- Department of Medicine, Section of Geriatrics and Palliative Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Mark K Ferguson
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
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22
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Sax OC, Douglas SJ, Chen Z, Bains SS, Remily EA, Delanois RE. C. Difficile Infection within 6 Months before TKA Is Associated with Increased Short-Term Complications. J Knee Surg 2024; 37:368-373. [PMID: 37478893 DOI: 10.1055/s-0043-1771163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
A history of Clostridium difficile infection (CDI) before total knee arthroplasty (TKA) may be a marker for poor patient health and could be used to identify patients with higher risks for complications after TKA. We compared the frequency of 90-day postoperative CDI, complications, readmissions, and associated risk factors in (1) patients experiencing CDIs more than 6 months before TKA, (2) patients experiencing CDIs in the 6 months before TKA, and (3) patients without a history of CDI. We identified patients who underwent primary TKAs from 2010 to 2019 and had a history of CDI before TKA (n = 7,195) using a national, all-payer database. Patients were stratified into two groups: those with CDIs > 6 months before TKA (n = 6,027) and those experiencing CDIs ≤ 6 months before TKA (n = 1,168). These patients were compared with the remaining 1.4 million patients without a history of CDI before TKA. Chi-square and unadjusted odds ratios (ORs) with 95% confidence intervals (CI) were used to compare complication frequencies. Prior CDI during either timespan was associated with higher unadjusted odds for postoperative CDI (CDI > 6 months before TKA: OR 8.03 [95% CI 6.68-9.63]; p < 0.001; CDI ≤ 6 months before TKA: OR 59.05 [95% CI 49.66-70.21]; p < 0.001). Patients with a history of CDI before TKA were associated with higher unadjusted odds for 90-day complications and readmission compared with patients without a history of CDI before TKA. Other comorbidities and health metrics were not found to be associated with postoperative CDI (i.e., age, obesity, smoking, antibiotic use, etc.). CONCLUSION: CDI before TKA was associated with higher odds of postoperative CDI compared with patients without a history of CDI. CDI ≤ 6 months before TKA was associated with the highest odds for postoperative complications and readmissions. Providers should consider delaying TKA after CDI, if possible, to allow for patient recovery and eradication of infection.
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Affiliation(s)
- Oliver C Sax
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, LifeBridge Health, Baltimore, Maryland
| | - Scott J Douglas
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, LifeBridge Health, Baltimore, Maryland
| | - Zhongming Chen
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, LifeBridge Health, Baltimore, Maryland
| | - Sandeep S Bains
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, LifeBridge Health, Baltimore, Maryland
| | - Ethan A Remily
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, LifeBridge Health, Baltimore, Maryland
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, LifeBridge Health, Baltimore, Maryland
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Luo L, Fan Y, Wang Y, Wang Z, Zhou J. Prevalence and clinical outcomes of sarcopenia in patients with esophageal, gastric or colorectal cancers receiving preoperative neoadjuvant therapy: A meta-analysis. Asia Pac J Oncol Nurs 2024; 11:100436. [PMID: 38618524 PMCID: PMC11015508 DOI: 10.1016/j.apjon.2024.100436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 03/01/2024] [Indexed: 04/16/2024] Open
Abstract
Objective To investigate the prevalence of sarcopenia and its impact on clinical outcomes in patients with esophageal, gastric, or colorectal cancer (EC, GC, and CRC) receiving neoadjuvant therapy through Meta-analysis. Methods We searched the PubMed, Embase databases, and Cochrane Library for the prevalence of sarcopenia and its impact on clinical outcomes in EC, GC, or CRC patients treated with neoadjuvant therapy (NAT) from inception to November 2022. The primary endpoints were the prevalence of sarcopenia and overall survival in patients with EC, GC, or CRC treated with NAT. Secondary outcomes included recurrence-free survival, total postoperative complications, grade 3-4 chemotherapy toxicity, and 30-day mortality after surgery. Results Thirty-one retrospective studies with 3651 subjects were included. In a fixed-effects model, the prevalence of muscle loss was higher in patients with EC, GC, or CRC at 50% (95% CI = 42% to 58%). The results of the multivariate analysis showed that preoperative patients with sarcopenia had a 1.91 times shorter overall survival (95% CI = 1.61-2.27) and a 1.77 times shorter recurrence-free survival time (95% CI = 1.33-2.35) than patients without sarcopenia, and that patients with sarcopenia had a higher risk of total postoperative complications than patients without sarcopenia OR = 1.27 (95% CI = 1.03-1.57). However, the two groups had no statistical difference in grade 3-4 chemotherapy toxicity (P = 0.84) or 30-d postoperative mortality (P = 0.88). Conclusions The prevalence of sarcopenia in patients with EC, GC, or CRC during NAT is high, and it is associated with poorer clinical outcomes. Clinicians should closely monitor the changes in patients' body composition and guide patients to carry out a reasonable diet and appropriate exercise to improve their poor prognosis and quality of life. Systematic review registration CRD42023387817.
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Affiliation(s)
- Lin Luo
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yidan Fan
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yanan Wang
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhen Wang
- Traumatic Orthopedics, Guangzhou Red Cross Hospital, Guangzhou, China
| | - Jian Zhou
- Mammography, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Brovman EY, Motejunas MW, Bonneval LA, Whang EE, Kaye AD, Urman RD. Relationship Between Newly Established Perioperative DNR Status and Perioperative Outcomes in the Elderly Population: A NSQIP Database Analysis. J Palliat Care 2024; 39:97-104. [PMID: 32718256 DOI: 10.1177/0825859720944746] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Background: Health care practitioners have developed complex algorithms to numerically calculate surgical risk. We examined the association between the initiation of a new do-not-resuscitate (DNR) status during hospitalization and postoperative outcomes, including mortality. We hypothesized that new DNR status would be associated with similar complication rates, even though mortality rates may be higher. Methods: A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Geriatric Surgery Research File. Two cohorts were defined by the presence of a new DNR status during the hospitalization that was not present on hospital admission. Multivariable logistic regression was used to control for differences between the DNR and non-DNR cohorts. The primary outcome was 30-day mortality. Secondary outcomes included rates of postoperative complications, including returning to the operating room, reintubation, failure to wean from ventilation, surgical site infections, dehiscence, pneumonia, acute kidney injury, renal failure, stroke, cardiac arrest, acute myocardial infarction, transfusion requirements, sepsis, urinary tract infections, venous thromboembolisms, total number of complications for each patient, and hospital length of stay. Results: In our geriatric population with a newly established DNR status, the mortality rate was 39.29%, significantly greater than the non-DNR population after multivariable regression. Secondary outcomes also occurred at an increased rate in the DNR cohort including surgical site infections (8.29% vs 4.04%), pneumonia (18% vs 2.26%), renal insufficiency (2.43% vs 0.35%), acute renal failure (5% vs 0.19%), stroke (3% vs 0.36%), acute myocardial infarction (6.29% vs 0.95%), and cardiac arrest (5.86% vs 0.51%). Conclusions: The initiation of a new DNR status during hospitalization is associated with a significantly higher burden of both morbidity and mortality. This contrasts with prior studies that did not show an increased rate of adverse outcomes and suggests that a new DNR status in postoperative patients may reflect a consequence of adverse postoperative events. The informed consent process in older patients at risk for adverse outcomes after surgery should include discussions regarding goals of care and acceptable risk.
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Affiliation(s)
- Ethan Y Brovman
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Mark W Motejunas
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Lauren A Bonneval
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Edward E Whang
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
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25
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Tjeertes EKM, Simoncelli TFW, van den Enden AJM, Mattace-Raso FUS, Stolker RJ, Hoeks SE. Perioperative outcome, long-term mortality and time trends in elderly patients undergoing low-, intermediate- or major non-cardiac surgery. Aging Clin Exp Res 2024; 36:64. [PMID: 38462583 PMCID: PMC10925572 DOI: 10.1007/s40520-024-02717-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/31/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Decision-making whether older patients benefit from surgery can be a difficult task. This report investigates characteristics and outcomes of a large cohort of inpatients, aged 80 years and over, undergoing non-cardiac surgery. METHODS This observational study was performed at a tertiary university medical centre in the Netherlands. Patients of 80 years or older undergoing elective or urgent surgery from January 2004 to June 2017 were included. Outcomes were length of stay, discharge destination, 30-day and long-term mortality. Patients were divided into low-, intermediate and high-risk surgery subgroups. Univariable and multivariable logistic regression were used to evaluate the association of risk factors and outcomes. Secondary outcomes were time trends, assessed with Mantel-Haenszel chi-square test. RESULTS Data of 8251 patients, undergoing 19,027 surgical interventions were collected from the patients' medical record. 7032 primary procedures were suitable for analyses. Median LOS was 3 days in the low-risk group, compared to six in the intermediate- and ten in the high-risk group. Median LOS of the total cohort decreased from 5.8 days (IQR 1.9-14.5) in 2004-2007 to 4.6 days (IQR 1.9-9.0) in 2016-2017. Three quarters of patients were discharged to their home. Postoperative 30-day mortality in the low-risk group was 2.3%. In the overall population 30-day mortality was high and constant during the study period (6.7%, ranging from 4.2 to 8.4%). CONCLUSION Patients should not be withheld surgery solely based on their age. However, even for low-risk surgery, the mortality rate of more than 2% is substantial. Deciding whether older patients benefit from surgery should be based on the understanding of individual risks, patients' wishes and a patient-centred plan.
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Affiliation(s)
- E K M Tjeertes
- Department of Anesthesiology, Erasmus MC University Medical Center, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Anesthesiology, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - T F W Simoncelli
- Department of Anesthesiology, Erasmus MC University Medical Center, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
| | - A J M van den Enden
- Department of Anesthesiology, Erasmus MC University Medical Center, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
| | - F U S Mattace-Raso
- Division of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - R J Stolker
- Department of Anesthesiology, Erasmus MC University Medical Center, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
| | - S E Hoeks
- Department of Anesthesiology, Erasmus MC University Medical Center, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands.
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Zhang M, Gao X, Liu M, Gao Z, Sun X, Huang L, Zou T, Guo Y, Chen L, Liu Y, Zhang X, Feng H, Wang Y, Sun Y. Correlation of preoperative frailty with postoperative delirium and one-year mortality in Chinese geriatric patients undergoing noncardiac surgery: Study protocol for a prospective observational cohort study. PLoS One 2024; 19:e0295500. [PMID: 38446754 PMCID: PMC10917300 DOI: 10.1371/journal.pone.0295500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 10/23/2023] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND To Frailty is associated with postoperative delirium (POD) but is rarely assessed in patients undergoing noncardiac surgery. In this study, the correlation between preoperative frailty and POD, one-year mortality will be investigated in noncardiac Chinese geriatric surgery patients. METHODS This study is a prospective, observational, cohort study conducted at a single center with Chinese geriatric patients. Patients who undergo noncardiac surgery and are older than 70 years will be included. A total of 536 noncardiac surgery patients will be recruited from the First Affiliated Hospital of Shandong First Medical University for this study. The Barthel Index (BI) rating will be used to assess the patient's ability to carry out everyday activities on the 1st preoperative day. The modified frailty index (mFI) will be used to assess frailty. Patients in the nonfrailty group will have an mFI < 0.21, and patients in the frailty group will have an mFI ≥ 0.21. The primary outcome is the incidence of POD. Three-Minute Diagnostic Interview for CAM-defined Delirium (3D-CAM) will be conducted twice daily during the 1st-7th postoperative days, or just before discharge. The secondary outcomes will include one-year mortality, in-hospital cardiopulmonary events, infections, acute renal injury, and cerebrovascular events. DISCUSSION This study will clarify the correlation of preoperative frailty with POD and one-year all-cause mortality in Chinese geriatric patients undergoing noncardiac surgery. Can preoperative frailty predict POD or one-year mortality? In the face of China's serious aging social problems, this result may have important clinical value for the surgical treatment of geriatric patients. TRIAL REGISTRATION This protocol has been registered with ClinicalTrials. Gov on 12 January 2022 (https://clinicaltrials.gov/ct2/show/NCT05189678).
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Affiliation(s)
- Min Zhang
- Department of Anesthesiology, Shandong Institute of Anesthesia and Respiratory Critical Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Xiaojun Gao
- Department of Anesthesiology, Shandong Institute of Anesthesia and Respiratory Critical Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Mengjie Liu
- Department of Anesthesiology, Shandong Institute of Anesthesia and Respiratory Critical Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Zhongquan Gao
- Department of Anesthesiology, Shandong Institute of Anesthesia and Respiratory Critical Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
- Department of Anesthesiology, Shandong First Medical University, Jinan, China
| | - Xiaxuan Sun
- Department of Anesthesiology, Shandong Institute of Anesthesia and Respiratory Critical Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
- Department of Anesthesiology, Shandong First Medical University, Jinan, China
| | - Linlin Huang
- Department of Nursing, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Ting Zou
- Department of Nursing, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Yongle Guo
- Department of Anesthesiology, Shandong Institute of Anesthesia and Respiratory Critical Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
- Department of Anesthesiology, Shandong First Medical University, Jinan, China
| | - Lina Chen
- Department of Anesthesiology, Shandong Institute of Anesthesia and Respiratory Critical Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Yang Liu
- Department of Anesthesiology, Shandong Institute of Anesthesia and Respiratory Critical Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Xiaoning Zhang
- Department of Anesthesiology, Shandong Institute of Anesthesia and Respiratory Critical Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Hai Feng
- Department of Anesthesiology, Shandong Institute of Anesthesia and Respiratory Critical Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Yuelan Wang
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University (Shandong Provincial Hospital), Jinan, China
| | - Yongtao Sun
- Department of Anesthesiology, Shandong Institute of Anesthesia and Respiratory Critical Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
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Gajdos C, Ryan C, Savulionyte G, Schwaitzberg S, Nader N. Liver resection versus ablation in geriatric populations - Does one method impart improved in-hospital mortality? Turk J Surg 2024; 40:47-53. [PMID: 39035997 PMCID: PMC11257722 DOI: 10.47717/turkjsurg.2024.6358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 03/11/2024] [Indexed: 07/23/2024]
Abstract
Objectives This study aimed to compare surgical resection versus ablation for managing liver malignancies in patients 65 and older. Material and Methods Cases with liver tumors were extracted from the NSQIP database for patients aged ≥65 years. Following propensity score matching, multivariate Cox regression was used for 30-day morbidity and mortality for liver resection and ablation. Results Following a propensity score matching, 1048 patients were 1:1 matched for comorbid conditions. Patients stayed in the hospital three days longer after resection (p<0.001). Mortality was lower after ablation (p= 0.013). This difference was more prominent in patients with primary liver tumors (p= 0.008). Group A had a 10-fold lower risk of developing an abdominal abscess, a fourfold decrease in hospital-associated pneumonia (p= 0.001) and reintubation, a 10-fold reduction in bleeding requiring transfusion (p<0.001), and a three-fold decrease in risk of developing sepsis (p<0.001). Conclusion Despite being a generally sicker patient population with worse underlying liver function, ablative techniques were associated with a lower risk of adverse outcomes when compared to more aggressive resection of primary malignant tumors of the liver.
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Affiliation(s)
- Csaba Gajdos
- Department of Surgery, Buffalo University Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Carrie Ryan
- Department of Surgery, Buffalo University Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Goda Savulionyte
- Department of Surgery, Buffalo University Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Steven Schwaitzberg
- Department of Surgery, Buffalo University Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Nader Nader
- Department of Anesthesiology, Buffalo University Jacobs Faculty of Medicine and Biomedical Scinces, Buffalo, USA
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Tan ZKK, Tang WZ, Jia K, Li DN, Qiu LY, Chen X, Yang L. Relation between frailty and adverse outcomes in elderly patients with gastric cancer: a scoping review. Ann Med Surg (Lond) 2024; 86:1590-1600. [PMID: 38463086 PMCID: PMC10923289 DOI: 10.1097/ms9.0000000000001817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/31/2024] [Indexed: 03/12/2024] Open
Abstract
Background Playing an exemplary role, frailty have crucial effect on the preoperative evaluation of elderly patients. Previous studies have shown that frailty is associated with complications and mortality in patients with gastric cancer (GC). However, with the development of the concept of "patient-centered", the range of health-related outcomes is broad. The differences in relation between frailty and various adverse outcomes will be further explored. Method The PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wan Fang, and Chinese Biomedical Literature databases were searched for keywords, including frailty (such as frail) and gastric cancer (such as stomach neoplasms or stomach cancer or gastrectomy or gastric surgery). The search period is until August 2023. The included studies were observational or cohort studies with postoperative related adverse outcomes as primary or secondary outcome measures. Valid assessment tools were used. The Quality Assessment Tool for Observational Cohort and Cross-sectional Studies was used to assess methodological quality in the included literature. Result Fifteen studies were included, including 4 cross-sectional studies, 8 retrospective cohort studies, and 3 prospective cohort studies. Among them, 6 studies were rated as "Good" and 9 studies were rated as "Fair," indicating that the quality of the literature was high. Then, 10 frailty assessment tools were summarized and classified into two broad categories in accordance with frailty models. Results of the included studies indicated that frailty in elderly patients with GC was associated with postoperative complications, mortality, hospital days, readmissions, quality of life, non-home discharge, and admission to the intensive care unit. Conclusion This scoping review concludes that high levels of preoperative frailty increase the risk of adverse outcomes in elderly patients with GC. Frailty will be widely used in the future clinical evaluation of elderly gastric cancer patients, precise risk stratification should be implemented for patients, and frailty management should be implemented well to reduce the occurrence of adverse treatment outcomes.
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Affiliation(s)
| | | | - Kui Jia
- Gastrointestinal Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, People’s Republic of China
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29
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Popovich SM, Vetter TR. Preoperative Management of the Adult Oncology Patient. Anesthesiol Clin 2024; 42:145-158. [PMID: 38278586 DOI: 10.1016/j.anclin.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
Anesthesiologists are experiencing first-hand the aging population, given older patients more frequently presenting for surgery, often with geriatric syndromes influencing their anesthetic management. The overall incidence and health burden of cancer morbidity and mortality are also rapidly increasing worldwide. This growth in the cancer population, along with the associated risk factors and comorbidities often accompanying a cancer diagnosis, underscores the need for anesthesiologists to become well versed in the preoperative evaluation and management of the adult patient with cancer. This article will focus on the unique challenges and opportunities for the anesthesiologist caring for the adult oncology patient presenting for surgery.
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Affiliation(s)
- Shannon M Popovich
- Department of Anesthesiology and Perioperative Medicine, Division of Anesthesiology, Critical Care Medicine and Pain Medicine, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Thomas R Vetter
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Health Discovery Building, Room 6.812, 1701 Trinity Street, Austin, TX 78712-1875, USA.
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Lindbloom TJ, Corbo JM, Blacksmith HP, Tarnowski A, Frei CR. Evaluation of pharmacists' role in preoperative medication review in a Veterans Affairs Health Care System. Am J Health Syst Pharm 2024; 81:S1-S7. [PMID: 37996069 DOI: 10.1093/ajhp/zxad291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Indexed: 11/25/2023] Open
Abstract
PURPOSE Use of high-risk medications preoperatively may increase the incidence of postoperative complications. Available literature evaluating pharmacists' role in preoperative medication review is limited, and guidance is not currently available on which patients should have a medication review performed by a pharmacist before surgery. A preoperative rehabilitation pilot project in which clinical pharmacists reviewed medication profiles before scheduled surgeries was developed. This review aimed to evaluate pharmacists' role in reviewing medication profiles preoperatively and to identify specific patient factors that suggest a medication review is warranted. METHODS This retrospective review utilized the electronic medical records of nonfrail adults undergoing preplanned surgeries enrolled in the pilot project from August 2021 to April 2022. Endpoints were determined using descriptive statistics and regression models. A multivariate analysis was performed evaluating high-risk medications and VIONE (Vital, Important, Optional, Not indicated, and Every medication has an indication) polypharmacy risk score. RESULTS Forty patients were included, with at least one recommendation made in 83% of chart reviews. Many patients (95%) were taking at least one high-risk medication. Of the high-risk medication classes evaluated independently, only antiplatelets were predictive of pharmacy intervention (P = 0.01). Only high-risk medications were independently predictive of pharmacist intervention (P < 0.01) when multivariate analysis was performed. CONCLUSION Pharmacists made a recommendation in the majority of medication reviews and were most likely to make a recommendation in patients taking high-risk medications. A larger sample size may provide more insight regarding patient-specific factors warranting a preoperative medication review.
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Affiliation(s)
- Tori J Lindbloom
- South Texas Veterans Health Care System, San Antonio, TX
- College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Jason M Corbo
- South Texas Veterans Health Care System, San Antonio, TX
- College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Heather P Blacksmith
- South Texas Veterans Health Care System, San Antonio, TX
- College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Amy Tarnowski
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, Austin, TX, and Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Xue X, Zhao LB, Zhao Z, Xu WH, Cai WM, Chen SH, Li TJ, Nie TY, Rui D, Qian XS, Liu L. Effect of Continuous Positive Airway Pressure on Incident Frailty in Elderly Patients with Obstructive Sleep Apnea: A Study Based on Propensity Score Matching. Clin Interv Aging 2024; 19:255-263. [PMID: 38380228 PMCID: PMC10878137 DOI: 10.2147/cia.s446129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 02/04/2024] [Indexed: 02/22/2024] Open
Abstract
Background The concomitant rise in the prevalence of obstructive sleep apnea (OSA) and frailty among the elderly population has been linked to an increase in mortality rates. Despite continuous positive airway pressure (CPAP) being the gold standard treatment for OSA, its impact on incident frailty remains inadequately explored. Methods In this cohort study, we analyzed data from 1290 patients diagnosed with OSA, aged 60 years and older. A subset of 71 patients who demonstrated high adherence to CPAP therapy were categorized as the CPAP group. Propensity score matching (PSM) was employed at a 1:4 ratio, matching for variables such as age, gender, body mass index (BMI), and sleep apnea-hypopnea index (AHI), to establish a non-CPAP group for comparison. The FRAIL scale was utilized to evaluate the frailty status of participants. Logistic regression analysis examined the relationship between CPAP therapy and incident frailty, as well as its individual components, in elderly patients with OSA. Results During a median follow-up period of 52 months, incident frailty was observed in 70 patients (19.7%). Patients with OSA receiving CPAP therapy exhibited a lower incidence of frailty compared to those not receiving CPAP (11.26% vs 21.83%, P=0.045). In the multivariate model, CPAP therapy was significantly correlated with a reduced risk of incident frailty (OR = 0.36, 95% CI, 0.15-0.88; P = 0.025). Subcomponent analyses revealed that CPAP was associated with a lower risk of fatigue (OR=0.35, 95% CI, 0.19-0.63; P < 0.001), resistance (OR = 0.32, 95% CI, 0.14-0.74; P=0.008), and weight loss (OR = 0.38, 95% CI, 0.19-0.75; P = 0.007). Conclusion CPAP therapy was associated with a reduced risk of incident frailty among elderly patients with OSA.
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Affiliation(s)
- Xin Xue
- Department of Pulmonary and Critical Care Medicine, Second Medical Center of Chinese PLA General Hospital, Beijing, People’s Republic of China
- National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Li-Bo Zhao
- Department of Vasculocardiology, Second Medical Center of Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Zhe Zhao
- Department of Vasculocardiology, Second Medical Center of Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Wei-Hao Xu
- Department of Geriatrics, Guangdong Provincial Geriatrics Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, People’s Republic of China
| | - Wei-Meng Cai
- Department of Pulmonary and Critical Care Medicine, Second Medical Center of Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Shao-Hua Chen
- Department of Pulmonary and Critical Care Medicine, Second Medical Center of Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Tian-Jiao Li
- Medical College, Yan’ an University, Yan’ an, People’s Republic of China
| | - Ting-Yu Nie
- Medical College, Yan’ an University, Yan’ an, People’s Republic of China
| | - Dong Rui
- Department of Pulmonary and Critical Care Medicine, Second Medical Center of Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Xiao-Shun Qian
- Department of Pulmonary and Critical Care Medicine, Second Medical Center of Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Lin Liu
- Department of Pulmonary and Critical Care Medicine, Second Medical Center of Chinese PLA General Hospital, Beijing, People’s Republic of China
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Patel J, Martinchek M, Mills D, Hussain S, Kyeso Y, Huisingh-Scheetz M, Rubin D, Landi AJ, Cimeno A, Madariaga MLL. Comprehensive geriatric assessment predicts listing for kidney transplant in patients with end-stage renal disease: a retrospective cohort study. BMC Geriatr 2024; 24:148. [PMID: 38350846 PMCID: PMC10865555 DOI: 10.1186/s12877-024-04734-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 01/22/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Comprehensive geriatric assessment (CGA) involves a formal broad approach to assess frailty and creating a plan for management. However, the impact of CGA and its components on listing for kidney transplant in older adults has not been investigated. METHODS We performed a single-center retrospective study of patients with end-stage renal disease who underwent CGA during kidney transplant candidacy evaluation between 2017 and 2021. All patients ≥ 65 years old and those under 65 with any team member concern for frailty were referred for CGA, which included measurements of healthcare utilization, comorbidities, social support, short physical performance battery, Montreal Cognitive Assessment (MoCA), and Physical Frailty Phenotype (FPP), and estimate of surgical risk by the geriatrician. RESULTS Two hundred and thirty patients underwent baseline CGA evaluation; 58.7% (135) had high CGA ("Excellent" or "Good" rating for transplant candidacy) and 41.3% (95) had low CGA ratings ("Borderline," "Fair," or "Poor"). High CGA rating (OR 8.46; p < 0.05), greater number of CGA visits (OR 4.93; p = 0.05), younger age (OR 0.88; p < 0.05), higher MoCA scores (OR 1.17; p < 0.05), and high physical activity (OR 4.41; p < 0.05) were all associated with listing on transplant waitlist. CONCLUSIONS The CGA is a useful, comprehensive tool to help select older adults for kidney transplantation. Further study is needed to better understand the predictive value of CGA in predicting post-operative outcomes.
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Affiliation(s)
- Jay Patel
- Pritzker School of Medicine, University of Chicago, 5841 S. Maryland Ave. MC5047, 60637, Chicago, IL, USA.
| | - Michelle Martinchek
- Geriatrics and Extended Care and New England Geriatrics Research Education and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Dawson Mills
- Pritzker School of Medicine, University of Chicago, 5841 S. Maryland Ave. MC5047, 60637, Chicago, IL, USA
| | - Sheraz Hussain
- Department of Medicine, University of Chicago Medicine & Biological Sciences, Chicago, USA
| | - Yousef Kyeso
- Department of Medicine, University of Chicago Medicine & Biological Sciences, Chicago, USA
| | - Megan Huisingh-Scheetz
- Department of Medicine, University of Chicago Medicine & Biological Sciences, Chicago, USA
| | - Daniel Rubin
- Department of Anesthesia, University of Chicago Medicine & Biological Sciences, Chicago, USA
| | - Andrea J Landi
- Department of Medicine, University of Chicago Medicine & Biological Sciences, Chicago, USA
| | - Arielle Cimeno
- Department of Surgery, University of Chicago Medicine & Biological Sciences, Chicago, USA
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Canales C, Ramirez C, Yang SC, Feinberg S, Grogan T, Whittington R, Sarkisian C, Cannesson M. A Prospective Observational Cohort Study of Language Preference and Preoperative Cognitive Screening in Older Adults: Do Language Disparities Exist in Cognitive Screening and Does the Association Between Test Results and Postoperative Delirium Differ Based on Language Preference? Anesth Analg 2024:00000539-990000000-00735. [PMID: 38324340 PMCID: PMC11303592 DOI: 10.1213/ane.0000000000006780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND A greater percentage of surgical procedures are being performed each year on patients 65 years of age or older. Concurrently, a growing proportion of patients in English-speaking countries such as the United States, United Kingdom, Australia, and Canada have a language other than English (LOE) preference. We aimed to measure whether patients with LOE underwent cognitive screening at the same rates as their English-speaking counterparts when routine screening was instituted. We also aimed to measure the association between preoperative Mini-Cog and postoperative delirium (POD) in both English-speaking and LOE patients. METHODS We conducted a single-center, observational cohort study in patients 65 years old or older, scheduled for surgery and evaluated in the preoperative clinic. Cognitive screening of older adults was recommended as an institutional program for all patients 65 and older presenting to the preoperative clinic. We measured program adherence for cognitive screening. We also assessed the association of preoperative impairment on Mini-Cog and POD in both English-speaking and LOE patients, and whether the association differed for the 2 groups. A Mini-Cog score ≤2 was considered impaired. Postoperatively, patients were assessed for POD using the Confusion Assessment Method (CAM) and by systematic chart review. RESULTS Over a 3-year period (February 2019-January 2022), 2446 patients 65 years old or older were assessed in the preoperative clinic prior. Of those 1956 patients underwent cognitive screening. Eighty-nine percent of English-speaking patients underwent preoperative cognitive screening, compared to 58% of LOE patients. The odds of having a Mini-Cog assessment were 5.6 times higher (95% confidence interval [CI], 4.6-7.0) P < .001 for English-speaking patients compared to LOE patients. In English-speaking patients with a positive Mini-Cog screen, the odds of having postop delirium were 3.5 times higher (95% CI, 2.6-4.8) P < .001 when compared to negative Mini-Cog. In LOE patients, the odds of having postop delirium were 3.9 times higher (95% CI, 2.1-7.3) P < .001 for those with a positive Mini-Cog compared to a negative Mini-Cog. The difference between these 2 odds ratios was not significant (P = .753). CONCLUSIONS We observed a disparity in the rates LOE patients were cognitively screened before surgery, despite the Mini-Cog being associated with POD in both English-speaking and LOE patients. Efforts should be made to identify barriers to cognitive screening in limited English-proficient older adults.
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Affiliation(s)
- Cecilia Canales
- Department of Anesthesiology and Perioperative Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Cecilia Ramirez
- Department of Anesthesiology and Perioperative Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | | | - Sharon Feinberg
- Preoperative Evaluation and Planning Center (PEP-C), UCLA Health
| | - Tristan Grogan
- Department of Medicine Statistics Core, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Robert Whittington
- Department of Anesthesiology and Perioperative Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Catherine Sarkisian
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System Geriatrics Research Education and Clinical Center (GRECC)
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Guidet B, Vallet H, Flaatten H, Joynt G, Bagshaw SM, Leaver SK, Beil M, Du B, Forte DN, Angus DC, Sviri S, de Lange D, Herridge MS, Jung C. The trajectory of very old critically ill patients. Intensive Care Med 2024; 50:181-194. [PMID: 38236292 DOI: 10.1007/s00134-023-07298-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/27/2023] [Indexed: 01/19/2024]
Abstract
The demographic shift, together with financial constraint, justify a re-evaluation of the trajectory of care of very old critically ill patients (VIP), defined as older than 80 years. We must avoid over- as well as under-utilisation of critical care interventions in this patient group and ensure the inclusion of health care professionals, the patient and their caregivers in the decision process. This new integrative approach mobilises expertise at each step of the process beginning prior to intensive care unit (ICU) admission and extending to long-term follow-up. In this review, several international experts have contributed to provide recommendations that can be universally applied. Our aim is to define a minimum core dataset of information to be shared and discussed prior to ICU admission and to facilitate the shared-decision-making process with the patient and their caregivers, throughout the patient journey. Documentation of uncertainty may contribute to a tailored level of care and ultimately to discussions around possible limitations of life sustaining treatments. The goal of ICU care is not only to avoid death, but more importantly to maintain an acceptable quality of life and functional autonomy after hospital discharge. Societal consideration is important to highlight, together with alternatives to ICU admission. We discuss challenges for the future and potential areas of research. In summary, this review provides a state-of-the-art current overview and aims to outline future directions to address the challenges in the treatment of VIP.
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Affiliation(s)
- Bertrand Guidet
- Medical ICU, Assistance Publique, Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Réanimation Médicale, 75012, Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, 75013, Paris, France.
| | - Helene Vallet
- Department of Geriatrics, Sorbonne Université, Institut National de la Santé Et de la Recherche Médicale (INSERM), UMRS 1135, Centre d'immunologie et de Maladies Infectieuses (CIMI), Saint Antoine, Assistance Publique Hôpitaux de Paris (AP-HP), 75012, Paris, France
| | - Hans Flaatten
- Department of Clinical Medicine, Haukeland University Hospital, University of Bergen, Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| | - Gavin Joynt
- Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | | | - Michael Beil
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Bin Du
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Daniel N Forte
- Departament of Emergency Medicine, Faculdade de Medicina, Universidade de São Paulo, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Derek C Angus
- Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, USA
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Christian Jung
- Department of Cardiology, Pulmonology and Angiology, University Hospital, Düsseldorf, Germany
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Bates A, West MA, Jack S, Grocott MPW. Preparing for and Not Waiting for Surgery. Curr Oncol 2024; 31:629-648. [PMID: 38392040 PMCID: PMC10887937 DOI: 10.3390/curroncol31020046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Cancer surgery is an essential treatment strategy but can disrupt patients' physical and psychological health. With worldwide demand for surgery expected to increase, this review aims to raise awareness of this global public health concern, present a stepwise framework for preoperative risk evaluation, and propose the adoption of personalised prehabilitation to mitigate risk. Perioperative medicine is a growing speciality that aims to improve clinical outcome by preparing patients for the stress associated with surgery. Preparation should begin at contemplation of surgery, with universal screening for established risk factors, physical fitness, nutritional status, psychological health, and, where applicable, frailty and cognitive function. Patients at risk should undergo a formal assessment with a qualified healthcare professional which informs meaningful shared decision-making discussion and personalised prehabilitation prescription incorporating, where indicated, exercise, nutrition, psychological support, 'surgery schools', and referral to existing local services. The foundational principles of prehabilitation can be adapted to local context, culture, and population. Clinical services should be co-designed with all stakeholders, including patient representatives, and require careful mapping of patient pathways and use of multi-disciplinary professional input. Future research should optimise prehabilitation interventions, adopting standardised outcome measures and robust health economic evaluation.
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Affiliation(s)
- Andrew Bates
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Malcolm A. West
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Sandy Jack
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Michael P. W. Grocott
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
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Hassan AM, Paidisetty P, Ray N, Govande JG, Nelson JA, Mehrara BJ, Butler CE, Mericli AF, Selber JC. Frail but Resilient: Frailty in Autologous Breast Reconstruction is Associated with Worse Surgical Outcomes but Equivalent Long-Term Patient-Reported Outcomes. Ann Surg Oncol 2024; 31:659-671. [PMID: 37864119 DOI: 10.1245/s10434-023-14412-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 09/19/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Frailty is associated with higher risk of complications following breast reconstruction, but its impact on long-term surgical and patient-reported outcomes has not been investigated. We examined the association of the five-item modified frailty index (MFI) score with long-term surgical and patient-reported outcomes in autologous breast reconstruction. PATIENTS AND METHODS We conducted a retrospective cohort study of consecutive patients who underwent mastectomy and autologous breast reconstruction between January 2016 and April 2022. Primary outcome was any flap-related complication. Secondary outcomes were patient-reported outcomes and predictors of complications in the frail cohort. RESULTS We identified 1640 reconstructions (mean follow-up 24.2 ± 19.2 months). In patients with MFI ≥ 2, the odds of surgical [odds ratio (OR) 2.13, p = 0.023] and medical (OR 17.02, p < 0.001) complications were higher than in nonfrail patients. We found no significant difference in satisfaction with the breast (p = 0.287), psychosocial well-being (p = 0.119), or sexual well-being (p = 0.314) according to MFI score. Chronic obstructive pulmonary disease was an independent predictor of infection (OR 3.70, p = 0.002). Tobacco use (OR 7.13, p = 0.002) and contralateral prophylactic mastectomy (OR 2.36, p = 0.014) were independent predictors of wound dehiscence. Dependent functional status (OR 2.36, p = 0.007) and immediate reconstruction (compared with delayed reconstruction; OR 3.16, p = 0.026) were independent predictors of skin flap necrosis. Dependent functional status was also independently associated with higher odds of reoperation (OR 2.64, p = 0.011). CONCLUSION Frailty is associated with higher risk of complications in breast reconstruction, but there is no significant difference in long-term patient-reported outcomes. MFI should be considered in breast reconstruction to improve outcomes in high-risk frail patients.
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Affiliation(s)
- Abbas M Hassan
- Division of Plastic and Reconstructive Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Praneet Paidisetty
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Nicholas Ray
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Janhavi G Govande
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jonas A Nelson
- Department of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak J Mehrara
- Department of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles E Butler
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexander F Mericli
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Kunz V, Wichmann G, Wald T, Dietz A, Wiegand S. Frailty and Increased Levels of Symptom Burden Can Predict the Presence of Each Other in HNSCC Patients. J Clin Med 2023; 13:212. [PMID: 38202219 PMCID: PMC10779894 DOI: 10.3390/jcm13010212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/22/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
Frailty is an important risk factor for adverse events (AEs), especially in elderly patients. Therefore, assessing frailty before therapy is recommended. In head and neck squamous cell carcinoma (HNSCC) patients, frailty is prognostic for severe postoperative complications and declining quality of life (QoL) after HNSCC treatment. Thus, assessment of frailty may help to identify individuals at risk for AE caused by oncologic therapy. We investigated the relationship between frailty and symptom burden to better understand their interaction and impact on HNSCC patients. In this prospectively designed cross-sectional study, the presence of frailty and symptom burden was assessed by using the Geriatric 8 (G8) and Minimal Documentation System (MIDOS2) questionnaires. A total of 59 consecutively accrued patients with a first diagnosis of HNSCC before therapy were evaluated. Patients were considered frail at a total G8 score ≤ 14. The MIDOS2 symptom burden score was considered pathological with a total score ≥ 4 or any severe symptom (=3). Statistical correlations were analyzed using Spearman and Pearson correlation. Receiver operator characteristic (ROC) curves were used to analyze the potential of predicting frailty and MIDOS2. p-values < 0.05 were considered significant. A total of 41 patients (69.5%) were considered frail, and 27 patients (45.8%) had increased symptom burden. "Tiredness" was the most common (overall rate 57.8%) and "Pain" was the most often stated "severe" symptom (5 patients, 8.5%). G8 and MIDOS2 correlated significantly (ρ = -0.487, p < 0.001; r = -0.423, p < 0.001). Frailty can be predicted by MIDOS2 symptom score (AUC = 0.808, 95% CI 0.698-0.917, p < 0.001). Vice versa, the G8 score can predict pathological symptom burden according to MIDOS2 (AUC = 0.750, 95% CI 0.622-0.878, p < 0.001). Conclusions: The strong link between frailty and increased symptom burden assessed by G8 or MIDOS2 indicates a coherence of both risk factors in HNSCC patients. Considering at least one of both scores might improve the identification of individuals at risk and achieve higher QoL and reduced complication rates by decision making for appropriate therapy regimens.
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Affiliation(s)
- Viktor Kunz
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Leipzig, 04103 Leipzig, Germany; (G.W.); (A.D.); (S.W.)
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Wadhwa A, Balbale SN, Palleti SK, Samra M, Lopez-Soler RI, Stroupe KT, Markossian TW, Huisingh-Scheetz M. Prevalence and feasibility of assessing the frailty phenotype among hemodialysis patients in a dialysis unit. BMC Nephrol 2023; 24:371. [PMID: 38093284 PMCID: PMC10720194 DOI: 10.1186/s12882-023-03413-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/28/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Frailty increases risk of morbidity and mortality in hemodialysis patients. Frailty assessments could trigger risk reduction interventions if broadly adopted in clinical practice. We aimed to assess the clinical feasibility of frailty assessment among Veteran hemodialysis patients. METHODS Hemodialysis patients' ≥50 years were recruited from a single dialysis unit between 9/1/2021 and 3/31/2022.Patients who consented underwent a frailty phenotype assessment by clinical staff. Five criteria were assessed: unintentional weight loss, low grip strength, self-reported exhaustion, slow gait speed, and low physical activity. Participants were classified as frail (3-5 points), pre-frail (1-2 points) or non-frail (0 points). Feasibility was determined by the number of eligible participants completing the assessment. RESULTS Among 82 unique dialysis patients, 45 (52%) completed the assessment, 13 (16%) refused, 18 (23%) were not offered the assessment due to death, transfers, or switch to transplant or peritoneal dialysis, and 6 patients were excluded because they did not meet mobility criteria. Among assessed patients, 40(88%) patients were identified as pre-frail (46.6%) or frail (42.2%). Low grip strength was most common (90%). Those who refused were more likely to have peripheral vascular disease (p = 0.001), low albumin (p = 0.0187), low sodium (p = 0.0422), and ineligible for kidney transplant (p = 0.005). CONCLUSIONS Just over half of eligible hemodialysis patients completed the frailty assessment suggesting difficulty with broad clinical adoption expectations. Among those assessed, frailty and pre-frailty prevalence was high. Given patients who were not tested were clinically high risk, our reported prevalence likely underestimates true frailty prevalence. Providing frailty reduction interventions to all hemodialysis patients could have high impact for this group.
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Affiliation(s)
- Anuradha Wadhwa
- Department of Medicine/ Nephrology, Edward Hines Jr. Veterans Administration Hospital, Hines, IL, USA.
- Department of Medicine/ Nephrology, Loyola University Chicago, Maywood, IL, USA.
| | - Salva N Balbale
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines, Jr. VA Hospital, Hines, IL, USA
| | - Sujith K Palleti
- Department of Medicine/ Nephrology, Edward Hines Jr. Veterans Administration Hospital, Hines, IL, USA
- Department of Medicine/ Nephrology, Loyola University Chicago, Maywood, IL, USA
| | - Manpreet Samra
- Department of Medicine/ Nephrology, Edward Hines Jr. Veterans Administration Hospital, Hines, IL, USA
- Department of Medicine/ Nephrology, Loyola University Chicago, Maywood, IL, USA
| | - Reynold I Lopez-Soler
- Department of Surgery and Renal Transplant, Edward Hines Jr. Veterans Administration Hospital, Hines, IL, USA
- Department of Surgery and Renal Transplant, Loyola University Chicago, Maywood, IL, USA
| | - Kevin T Stroupe
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Department of Public Health Sciences, Parkinson School of Health Science and Public Health, Loyola University Chicago, Maywood, IL, USA
| | - Talar W Markossian
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Department of Public Health Sciences, Parkinson School of Health Science and Public Health, Loyola University Chicago, Maywood, IL, USA
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Shi LL, Pudney J, Brangman S, Parham K, Nuara M. Head & Neck Trauma in the Geriatric Population. Otolaryngol Clin North Am 2023; 56:1183-1201. [PMID: 37385861 DOI: 10.1016/j.otc.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Craniofacial trauma in the geriatric population is increasing as our population ages. Due to loss of bone quality and medical comorbidities, injuries for minor trauma can be severe. A more extensive medical evaluation is usually warranted in this population before proceeding with surgery. In addition, unique surgical considerations exist in the repair of atrophic and edentulous bony fractures. Some quality improvement measures have already been undertaken but more is needed to help standardize care in this vulnerable population.
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Affiliation(s)
- Lucy L Shi
- Division of Facial Plastic & Reconstructive Surgery, Virginia Mason Franciscan Health, 1201 Terry Avenue 9th Floor, Seattle, WA 98101, USA
| | - Jacey Pudney
- Department of Geriatrics, SUNY Upstate University Hospital, 750 East Adams Street, Syracuse, NY 13210, USA
| | - Sharon Brangman
- Department of Geriatrics, SUNY Upstate University Hospital, 750 East Adams Street, Syracuse, NY 13210, USA
| | - Kourosh Parham
- Department of Otolaryngology-Head & Neck Surgery, University of Connecticut, 263 Farmington Avenue, Farmington, CT 06030, USA
| | - Michael Nuara
- Division of Facial Plastic & Reconstructive Surgery, Virginia Mason Franciscan Health, 1201 Terry Avenue 9th Floor, Seattle, WA 98101, USA.
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Persaud E, Nissley C, Piasecki E, Quinn C. Transition of Care for Older Adults Undergoing General Surgery. Crit Care Nurs Clin North Am 2023; 35:453-467. [PMID: 37838418 DOI: 10.1016/j.cnc.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
The demand for surgical intervention and hospitalization is expected to increase with the growth of the older adult population. Despite advances in technology and minimally invasive surgical procedures, the needs of the older adult in the perioperative period are unique. Transitions of care from the decision to support surgery through surgical intervention, subsequent hospitalization, and postacute discharge must be supported to achieve optimal patient outcomes. The clinical nurse specialist is well suited to address care delivery and assure implementation of best practices across the continuum.
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Affiliation(s)
- Elissa Persaud
- Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5866, USA.
| | - Courtney Nissley
- Penn Medicine Lancaster General Hospital, 555 North Duke Street, Lancaster, PA 17602, USA
| | - Eric Piasecki
- Penn Medicine Lancaster General Hospital, 555 North Duke Street, Lancaster, PA 17602, USA
| | - Carrie Quinn
- Penn Medicine Lancaster General Hospital, 555 North Duke Street, Lancaster, PA 17602, USA
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Owodunni OP, Yocky AG, Courville EN, Peter-Okaka U, Alare KP, Schmidt M, Alunday R, Greene-Chandos D, Bowers CA. A comprehensive analysis of the triad of frailty, aging, and obesity in spine surgery: the risk analysis index predicted 30-day mortality with superior discrimination. Spine J 2023; 23:1778-1789. [PMID: 37625550 DOI: 10.1016/j.spinee.2023.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/09/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND CONTEXT The United States has experienced substantial shifts in its population dynamics due to an aging population and increasing obesity rates. Nonetheless, there is limited data about the interplay between the triad of frailty, aging, and obesity. PURPOSE To investigate discriminative thresholds and independent associations of the Risk Analysis Index (RAI), Modified Frailty Index-5 (mFI-5), and greater patient age. STUDY DESIGN An observational retrospective cohort study. PATIENT SAMPLE We analyzed 49,754 spine surgery patients from the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2020. OUTCOME MEASURE A total of 30-day postoperative mortality. METHODS Using receiver operating characteristic (ROC) and multivariable (odds ratios [OR] and 95% confidence intervals [CI]) analyses, we compared the discriminative thresholds and independent associations of RAI, mFI-5, and greater patient age in elderly obese patients who underwent spine surgery. RESULTS There were 49,754 spine surgery patients, with a median age of 71 years (IQR: 68-75), largely white (82.6%) and male (51.9%). The ROC analysis for 30-day postoperative mortality demonstrated superior discrimination for RAI (C-statistic 0.779, 95%CI 0.54-0.805) compared to mFI-5 (C-statistic 0.623, 95% CI 0.594-0.651) and greater patient age (C-statistic 0.627, 95% CI 0.598-0.656). Multivariable analyses revealed a dose-dependent association and a larger effect magnitude for RAI: frail patients OR: 19.52 (95% CI 18.29-20.82) and very frail patients OR: 65.81 (95% CI 62.32-69.50). A similar trend was observed in the interaction evaluating RAI-age-obesity (p<.001). CONCLUSION Our study highlights a strong association between frailty and 30-day postoperative mortality in elderly obese spine patients, revealing a dose-dependent relationship. The RAI has superior discrimination than the mFI-5 and greater patient age in predicting 30-day postoperative mortality after spine surgery. Using the RAI in preoperative assessments may improve outcomes and help healthcare providers effectively communicate accurate surgical risks and potential benefits, set realistic recovery expectations, and enhances patient satisfaction.
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Affiliation(s)
- Oluwafemi P Owodunni
- Department of Emergency Medicine, University of New Mexico Hospital, MSC11 6025, 1 University of New Mexico, Albuquerque, NM 87131, USA; Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA.
| | - Alyssa G Yocky
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA; University of New Mexico School of Medicine, 2501 Frontier Ave NE, Albuquerque, NM 87106, USA
| | - Evan N Courville
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA; Department of Neurosurgical Surgery, University of New Mexico Hospital, MSC08 4720 1 UNM, Albuquerque, NM 87131, USA
| | - Uchenna Peter-Okaka
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA; West Virginia University School of Medicine, 64 Medical Center Dr, Morgantown, WV 26506, USA
| | - Kehinde P Alare
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
| | - Meic Schmidt
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA; Department of Neurosurgical Surgery, University of New Mexico Hospital, MSC08 4720 1 UNM, Albuquerque, NM 87131, USA
| | - Robert Alunday
- Department of Emergency Medicine, University of New Mexico Hospital, MSC11 6025, 1 University of New Mexico, Albuquerque, NM 87131, USA; Department of Neurosurgical Surgery, University of New Mexico Hospital, MSC08 4720 1 UNM, Albuquerque, NM 87131, USA; Center for Adult Critical Care, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM 8710, USA
| | - Diana Greene-Chandos
- Center for Adult Critical Care, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM 8710, USA; Department of Neurology, University of New Mexico Hospital, MSC08 4720 1 UNM, Albuquerque, NM 87131, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
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Estock JL, Pandalai PK, Johanning JM, Youk AO, Varley PR, Arya S, Massarweh NN, Hall DE. A Retrospective Cohort Study to Evaluate Adding Biomarkers to the Risk Analysis Index of Frailty. J Surg Res 2023; 292:130-136. [PMID: 37619497 DOI: 10.1016/j.jss.2023.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/13/2023] [Accepted: 07/12/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION The Risk Analysis Index (RAI) is a frailty assessment tool associated with adverse postoperative outcomes including 180 and 365-d mortality. However, the RAI has been criticized for only containing subjective inputs rather than including more objective components such as biomarkers. METHODS We conducted a retrospective cohort study to assess the benefit of adding common biomarkers to the RAI using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. RAI plus body mass index (BMI), creatinine, hematocrit, and albumin were evaluated as individual and composite variables on 180-d postoperative mortality. RESULTS Among 480,731 noncardiac cases in VASQIP from 2010 to 2014, 324,320 (67%) met our inclusion criteria. Frail patients (RAI ≥30) made up to 13.0% of the sample. RAI demonstrated strong discrimination for 180-d mortality (c = 0.839 [0.836-0.843]). Discrimination significantly improved with the addition of Hematocrit (c = 0.862 [0.859-0.865]) and albumin (c = 0.870 [0.866-0.873]), but not for body mass index (BMI) or creatinine. However, calibration plots demonstrate that the improvement was primarily at high RAI values where the model overpredicts observed mortality. CONCLUSIONS While RAI's ability to predict the risk of 180-d postoperative mortality improves with the addition of certain biomarkers, this only observed in patients classified as very frail (RAI >49). Because very frail patients have significantly elevated observed and predicted mortality, the improved discrimination is likely of limited clinical utility for a frailty screening tool.
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Affiliation(s)
- Jamie L Estock
- Center for Health Equity Research and Promotion, VA Pittsburg Healthcare System, University Drive C, Pittsburgh, Pennsylvania.
| | | | - Jason M Johanning
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ada O Youk
- Center for Health Equity Research and Promotion, VA Pittsburg Healthcare System, University Drive C, Pittsburgh, Pennsylvania; Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick R Varley
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | | | - Daniel E Hall
- Center for Health Equity Research and Promotion, VA Pittsburg Healthcare System, University Drive C, Pittsburgh, Pennsylvania; Department of Surgery, University of Pittsburgh, Pittsburg, Pennsylvania; Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Osaki T, Tatebe S, Orihara J, Uchinaka E, Ashida K, Hirooka Y, Fujiwara Y. Impact of Frailty and Sarcopenia on Short- and Long-Term Outcomes in Elderly Patients Undergoing Radical Gastrectomy for Gastric Cancer. World J Surg 2023; 47:3250-3261. [PMID: 37777671 DOI: 10.1007/s00268-023-07200-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND The impact of frailty and sarcopenia in patients with gastric cancer is unclear. This study aimed to comprehensively examine the impact of frailty and sarcopenia on the short- and long-term outcomes in elderly patients undergoing radical gastrectomy for gastric cancer. METHODS We retrospectively assessed 246 patients aged ≥ 65 years who underwent radical gastrectomy. Frailty and sarcopenia were assessed using the modified frailty index (mFI) and psoas muscle mass index (PMI), respectively. RESULTS There were 30 (12.2%) and 60 (24.4%) patients with High-mFI and Low-PMI, respectively. As the age increased, both sexes showed significant correlations with PMI and mFI (r = - 0.238, 0.322, P = 0.003 and 0.002, respectively). High-mFI and Low-PMI did not affect the short-term outcomes. However, High-mFI was an independent risk factor for non-home discharge (P = 0.004) and was a significant predictor of 3- and 5-year overall survival (OS) (HR = 2.76 and 2.26; P = 0.002 and 0.005, respectively) and 1-, 3- and 5-year non-cancer-specific survival (non-CSS) (HR = 4.88, 8.05, and 4.01; P = 0.017, < 0.001, < 0.001, respectively). Low-PMI was a significant predictor of only 5-year OS (HR = 2.03, P = 0.003) and non-CSS (HR = 2.10, P = 0.020). CONCLUSIONS Frailty is significant predictor of non-home discharge and 1-, 3-, 5-year OS and 3- and 5-year non-CSS. Sarcopenia is a significant predictor of 5-year OS and non-CSS. Preoperative assessment of both frailty and sarcopenia can help surgeons to select adequate treatment strategies for the elderly population.
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Affiliation(s)
- Tomohiro Osaki
- Tottori Prefectural Central Hospital, Department of Surgery, Tottori, Japan.
| | - Shigeru Tatebe
- Tottori Prefectural Central Hospital, Department of Surgery, Tottori, Japan
| | - Junpei Orihara
- Tottori Prefectural Central Hospital, Department of Surgery, Tottori, Japan
| | - Ei Uchinaka
- Tottori Prefectural Central Hospital, Department of Surgery, Tottori, Japan
| | - Keigo Ashida
- Tottori Prefectural Central Hospital, Department of Surgery, Tottori, Japan
| | - Yasuaki Hirooka
- Tottori Prefectural Central Hospital, Department of Surgery, Tottori, Japan
| | - Yoshiyuki Fujiwara
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine Graduate, Tottori, Japan
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Zhang HP, Zhang HL, Zhou XM, Chen GJ, Zhou QF, Tang J, Zhu ZY, Wang W. Predictive value of frailty assessment tools in patients undergoing surgery for gastrointestinal cancer: An observational cohort study. World J Gastrointest Surg 2023; 15:2525-2536. [PMID: 38111763 PMCID: PMC10725547 DOI: 10.4240/wjgs.v15.i11.2525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/09/2023] [Accepted: 09/26/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Few studies have simultaneously compared the predictive value of various frailty assessment tools for outcome measures in patients undergoing gastrointestinal cancer surgery. Therefore, it is difficult to determine which assessment tool is most relevant to the prognosis of this population. AIM To investigate the predictive value of three frailty assessment tools for patient prognosis in patients undergoing gastrointestinal cancer surgery. METHODS This single-centre, observational, prospective cohort study was conducted at the Affiliated Lianyungang Hospital of Xuzhou Medical University from August 2021 to July 2022. A total of 229 patients aged ≥ 18 years who underwent surgery for gastrointestinal cancer were included in this study. We collected baseline data on the participants and administered three scales to assess frailty: The comprehensive geriatric assessment (CGA), Fried phenotype and FRAIL scale. The outcome measures were the postoperative severe complications and increased hospital costs. RESULTS The prevalence of frailty when assessed with the CGA was 65.9%, 47.6% when assessed with the Fried phenotype, and 34.9% when assessed with the FRAIL scale. Using the CGA as a reference, kappa coefficients were 0.398 for the Fried phenotype and 0.291 for the FRAIL scale (both P < 0.001). Postoperative severe complications and increased hospital costs were observed in 29 (12.7%) and 57 (24.9%) patients, respectively. Multivariate logistic analysis confirmed that the CGA was independently associated with increased hospital costs (odds ratio = 2.298, 95% confidence interval: 1.044-5.057; P = 0.039). None of the frailty assessment tools were associated with postoperative severe complications. CONCLUSION The CGA was an independent predictor of increased hospital costs in patients undergoing surgery for gastrointestinal cancer.
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Affiliation(s)
- Hui-Pin Zhang
- Department of Gastrointestinal Surgery, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang 222061, Jiangsu Province, China
- Department of Gastrointestinal Surgery, The First People’s Hospital of Changzhou, Changzhou 213000, Jiangsu Province, China
| | - Hai-Lin Zhang
- Department of Nursing, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang 222061, Jiangsu Province, China
| | - Xiao-Min Zhou
- Department of Nursing, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang 222061, Jiangsu Province, China
| | - Guan-Jie Chen
- Department of Invasive Technology, Zhongda Hospital Southeast University, Nanjing 210003, Jiangsu Province, China
| | - Qi-Fan Zhou
- Department of Hemopurification Center, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222061, Jiangsu Province, China
| | - Jie Tang
- Department of Hemopurification Center, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222061, Jiangsu Province, China
| | - Zi-Ye Zhu
- Department of Nursing, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang 222061, Jiangsu Province, China
| | - Wei Wang
- Department of Gastrointestinal Surgery, The First People’s Hospital of Changzhou, Changzhou 213000, Jiangsu Province, China
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Baldasseroni S, Bari MD, Pratesi A, Rivasi G, Stefàno P, Olivo G, Meo MLD, Orso F, Pace SD, Ungar A, Marchionni N. Prediction of worsening postoperative renal function in older candidates to elective cardiac surgery: Choosing the best eGFR formula may not be enough. Heart Lung 2023; 62:28-34. [PMID: 37295187 DOI: 10.1016/j.hrtlng.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Though renal impairment is highly prevalent in older patients and influence post-operative outcomes in cardiac surgery; its prognostic relevance is debated and not fully assessed by surgical risk scores. OBJECTIVE We investigated the predictive role of estimated glomerular filtration rate formulas for in-hospital worsening renal function (WRF) after cardiac surgery. METHODS We prospectively enrolled in single-center cohort study, patients aged ≥ 75 years candidate to elective cardiac surgery. Four creatinine-based equations were used to calculate estimated glomerular filtration rate (eGFR) formulas: Cockroft-Gault, Modification of Diet in Renal Disease, Chronic Kidney Disease Epidemiology, and Berlin Initiative Study 1 formulas. Each patient underwent geriatric and clinical evaluation before surgery with calculation of the Society of Thoracic Surgeons scores. In-hospital WRF was defined as a composite of an increase in SCr ≥0.5 mg/dl or the occurrence of grade III KDIGO acute kidney injury. The association between each eGFR equation, alone and in models including clinical variables, and WRF was analyzed using logistic regressions and ROC analysis. RESULTS WRF occurred in 69 patients (19.8%), and the predictors of WRF were previous acute myocardial infarction, hypertension, 4-mt gait speed performance, and preoperative eGFR, irrespective of the equation used. With all equations, inclusion of these additional variables in the logistic regression models improved the prediction of WRF (AUCs 0.798-0.810). CONCLUSIONS An accurate assessment of renal function and of physical performance should be incorporated into cardiac surgery risk scores to improve prediction of in-hospital WRF and, hence, risk stratification in older adults undergoing elective cardiac surgery.
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Affiliation(s)
- Samuele Baldasseroni
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Mauro Di Bari
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Alessandra Pratesi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Pierluigi Stefàno
- Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Giuseppe Olivo
- Division of Cardiac Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Maria Laura Di Meo
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Francesco Orso
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Stefano Del Pace
- Division of General Cardiology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Niccolò Marchionni
- Division of Cardiac Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
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Reilly J, Ajitsaria P, Buckley L, Magnusson M, Darvall J. Interrater reliability of the Clinical Frailty Scale in the anesthesia preadmission clinic. Can J Anaesth 2023; 70:1726-1734. [PMID: 37934359 PMCID: PMC10656316 DOI: 10.1007/s12630-023-02590-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 02/12/2023] [Accepted: 02/21/2023] [Indexed: 11/08/2023] Open
Abstract
PURPOSE As many as 30% of patients with frailty die, are discharged to a nursing home, or have a new disability after surgery. The 2010 United Kingdom National Confidential Enquiry into Patient Outcome and Death recommended that frailty assessment be developed and included in the routine risk assessment of older surgical patients. The Clinical Frailty Scale (CFS) is a simple, clinically-assessed frailty measure; however, few studies have investigated interrater reliability of the CFS in the surgical setting. The objective of this study was to determine the interrater reliability of frailty classification between anesthesiologists and perioperative nurses. METHODS We conducted a cohort study assessing interrater reliability of the CFS between perioperative nurses and anesthesiologists for elective surgical patients aged ≥ 65 yr, admitted to a large regional university-affiliated hospital in Australia between July 2020 and February 2021. Agreement was measured via Cohen's kappa. RESULTS Frailty assessment was conducted on 238 patients with a median [interquartile range] age of 74 [70-80] yr. Agreement was perfect between nursing and medical staff for CFS scores in 112 (47%) patients, with a further 99 (42%) differing by only one point. Interrater kappa was 0.70 (95% confidence interval, 0.63 to 0.77; P < 0.001), suggesting good agreement between anesthesiologists and perioperative nurses. CONCLUSION This study suggests that CFS assessment by either anesthesiologists or nursing staff is reliable across a population of patients from a range of surgical specialities, with an acceptable degree of agreement. The CFS measurement should be included in the normal preanesthesia clinic workflow.
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Affiliation(s)
- Jennifer Reilly
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3004, Australia.
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, VIC, Australia.
| | - Pragya Ajitsaria
- Department of Anaesthesia, John Hunter Hospital, Newcastle, NSW, Australia
- Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Louise Buckley
- Department of Anaesthesia, John Hunter Hospital, Newcastle, NSW, Australia
- Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Monique Magnusson
- Department of Anaesthesia, John Hunter Hospital, Newcastle, NSW, Australia
| | - Jai Darvall
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
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McIsaac DI, Grudzinski AL, Aucoin SD. Preoperative frailty assessment: just do it! Can J Anaesth 2023; 70:1713-1718. [PMID: 37814118 DOI: 10.1007/s12630-023-02589-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 05/30/2023] [Accepted: 07/21/2023] [Indexed: 10/11/2023] Open
Affiliation(s)
- Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada.
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Civic Campus, 1053 Carling Ave, Room B311, Ottawa, ON, K1Y 4E9, Canada.
| | - Alexa L Grudzinski
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Sylvie D Aucoin
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Pu J, Zhou W, Zeng W, Shang S. Long-term trajectories of frailty phenotype in older cancer survivors: a nationally representative longitudinal cohort study. Age Ageing 2023; 52:afad190. [PMID: 37897808 DOI: 10.1093/ageing/afad190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Frailty is a dynamic process associated with adverse health outcomes. However, little is known about the long-term trajectories of frailty in older cancer survivors. OBJECTIVES To describe the trajectories of frailty phenotype over time amongst older cancer survivors and examine the socio-demographic and health-related predictors of different trajectories. DESIGN Population-based longitudinal cohort study. SETTING Community-dwelling older adults in the United States. SUBJECTS 1,763 older adults who were diagnosed with cancer from the National Health and Ageing Trends Study. METHODS Frailty was assessed by the Fried Frailty Phenotype. The group-based trajectory model was used to identify the trajectories of frailty. Multinomial logistic regression analyses were used to examine the socio-demographic and health-related predictors of different trajectories. RESULTS Three frailty trajectories were identified; 52.8% of older cancer survivors had a sustained low risk of frailty over time, 25.0% had a low frailty risk at baseline but the risk increased steadily, and 22.3% had a high frailty risk with a slight change in the observed period. Older cancer survivors were at a high-risk frailty trajectory if they were older, female, African American, had lower education status, had lower annual income, were underweight or obese, self-rated poorer health, had more chronic conditions and difficulties with activities of daily living (ADL), and had worse cognitive functions (P < 0.05). CONCLUSIONS Long-term frailty trajectories in older cancer survivors are heterogeneous. This study helps identify patients at high risk of sustained or deteriorating frailty and has the potential to inform targeted frailty management strategies addressing modifiable factors identified (e.g. body mass index, ADL).
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Affiliation(s)
- Junlan Pu
- School of Nursing, Peking University, Beijing 100191, China
| | - Weijiao Zhou
- School of Nursing, Peking University, Beijing 100191, China
| | - Wen Zeng
- School of Nursing, Peking University, Beijing 100191, China
- Neurology Department, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Shaomei Shang
- School of Nursing, Peking University, Beijing 100191, China
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Verma A, Branche C, Chervu NL, Sakowitz S, Bakhtiyar SS, Hadaya J, Benharash P. Dementia is Associated With Inferior Outcomes Following Emergency General Surgery. Am Surg 2023; 89:3994-3999. [PMID: 37132661 DOI: 10.1177/00031348231175447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Given the steadily aging United States population, we used a national database to examine the association of dementia with clinical and financial outcomes following emergency general surgery. METHODS All adults undergoing non-elective appendectomy, cholecystectomy, small bowel resection, large bowel resection, repair of perforated ulcer, or lysis of adhesions were identified within the 2016-2019 Nationwide Readmissions Database. Entropy balancing and multivariable regressions were used to assess the risk-adjusted association between dementia and in-hospital mortality, complications, length of stay, costs, non-home discharge, and 30-day unplanned readmissions. RESULTS Of an estimated 1,332,922 patients, 2.7% had dementia. Compared to those without, patients with dementia were older, more commonly male, and had a greater burden of chronic conditions. Following entropy balancing and multivariable risk-adjustment, dementia was associated with increased odds of mortality and sepsis across all operations except perforated ulcer repair. Dementia was also linked to greater likelihood of pneumonia across all operative categories. Moreover, dementia was associated with increased length of stay for patients in all operative categories except perforated ulcer repair, while costs were only increased for those undergoing appendectomy, cholecystectomy, and lysis of adhesions. Dementia was also linked to higher odds of non-home discharge following all operations, while non-elective readmissions were only increased for patients undergoing cholecystectomy. CONCLUSIONS The present study found dementia to be associated with a significant clinical and financial burden. Our findings may help inform shared decision making with patients and their families.
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Affiliation(s)
- Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Corynn Branche
- Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Nikhil L Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
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Dunlop RAN, Van Zundert A. A systematic review of predictive accuracy via c-statistic of preoperative frailty tests for extended length of stay, post-operative complications, and mortality. Saudi J Anaesth 2023; 17:575-580. [PMID: 37779562 PMCID: PMC10540983 DOI: 10.4103/sja.sja_358_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 10/03/2023] Open
Abstract
Frailty, as an age-related syndrome of reduced physiological reserve, contributes significantly to post-operative outcomes. With the aging population, frailty poses a significant threat to patients and health systems. Since 2012, preoperative frailty assessment has been recommended, yet its implementation has been inhibited by the vast number of frailty tests and lack of consensus. Since the anesthesiologist is the best placed for perioperative care, an anesthesia-tailored preoperative frailty test must be simple, quick, universally applicable to all surgeries, accurate, and ideally available in an app or online form. This systematic review attempted to rank frailty tests by predictive accuracy using the c-statistic in the outcomes of extended length of stay, 3-month post-operative complications, and 3-month mortality, as well as feasibility outcomes including time to completion, equipment and training requirements, cost, and database compatibility. Presenting findings of all frailty tests as a future reference for anesthesiologists, Clinical Frailty Scale was found to have the best combination of accuracy and feasibility for mortality with speed of completion and phone app availability; Edmonton Frailty Scale had the best accuracy for post-operative complications with opportunity for self-reporting. Finally, extended length of stay had too little data for recommendation of a frailty test. This review also demonstrated the need for changing research emphasis from odds ratios to metrics that measure the accuracy of a test itself, such as the c-statistic.
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Affiliation(s)
- Richard A. N. Dunlop
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital and The University of Queensland, Brisbane, QLD, Australia
| | - André Van Zundert
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital and The University of Queensland, Brisbane, QLD, Australia
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