1
|
Banning LBD, van Munster BC, van Leeuwen BL, Trzpis M, Zeebregts CJ, Pol RA. Comparison of various functional assessment tools to identify older patients undergoing aortic aneurysm repair at risk for postoperative complications. Ann Vasc Surg 2024:S0890-5096(24)00219-X. [PMID: 38815916 DOI: 10.1016/j.avsg.2024.02.032] [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: 12/28/2023] [Revised: 02/18/2024] [Accepted: 02/28/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND To estimate whether the benefits of aortic aneurysm repair will outweigh the risks, determining individual risks is essential. This single-center prospective cohort study aimed to compare the association of functional tools with postoperative complications in older patients undergoing aortic aneurysm repair. METHODS Ninety-eight patients (≥ 65 years) who underwent aortic aneurysm repair were included. Four functional tools were administered: the Montreal Cognitive Assessment (MoCA); the 4-Meter Walk Test (4-MWT); handgrip strength; and the Groningen Frailty Indicator (GFI). Primary outcome was the association between all tests and 30-day postoperative complications. RESULTS After adjusting for confounders, the OR for MoCA was 1.39 (95% CI 0.450;3.157; P=0.723), for 4-MWT 0.63 (95% CI 0.242;1.650; P=0.348), for GFI 1.82 (95% CI 0.783;4.323, P=0.162), and for weak handgrip strength 4.78 (95% CI 1.338;17.096, P=0.016). CONCLUSION Weak handgrip strength is significantly associated with the development of postoperative complications after aortic aneurysm repair. This study strengthens the idea that implementing a quick screening tool for risk assessment at the outpatient clinic, such as handgrip strength, identifies patients who may benefit from preoperative enhancement with help from, for example, Comprehensive Geriatric Assessment, eventually leading to better outcomes for this patient group.
Collapse
Affiliation(s)
- Louise B D Banning
- Department of Surgery, Divisions of Vascular, Transplantation Surgery and Oncologic Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O.Box 30.001, Groningen, The Netherlands.
| | - Barbara C van Munster
- University of Internal Medicine, Division of Geriatric Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, Groningen, The Netherlands
| | - Barbara L van Leeuwen
- Department of Surgery, Divisions of Vascular, Transplantation Surgery and Oncologic Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O.Box 30.001, Groningen, The Netherlands
| | - Monika Trzpis
- University of Internal Medicine, Division of Geriatric Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, Groningen, The Netherlands
| | - Clark J Zeebregts
- Department of Surgery, Divisions of Vascular, Transplantation Surgery and Oncologic Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O.Box 30.001, Groningen, The Netherlands
| | - Robert A Pol
- Department of Surgery, Divisions of Vascular, Transplantation Surgery and Oncologic Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O.Box 30.001, Groningen, The Netherlands
| |
Collapse
|
2
|
Mohseni A, Di Girolamo A, Cangiano R, Ascione M, di Marzo L, Mansour W. High-Grade Infection after Branched Endovascular Aortic Repair in Patient with Recent COVID-19 Hospitalization. Diagnostics (Basel) 2024; 14:205. [PMID: 38248081 PMCID: PMC10814975 DOI: 10.3390/diagnostics14020205] [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: 11/02/2023] [Revised: 12/29/2023] [Accepted: 01/08/2024] [Indexed: 01/23/2024] Open
Abstract
In the context of the COVID-19 pandemic, the global healthcare landscape has undergone significant transformations, particularly impacting the management of complex medical conditions such as aortic aneurysms. This study focuses on a 76-year-old female patient with a history of extensive cardiovascular surgeries, including aortic valve replacement, Bentall operation, and Frozen Elephant Trunk procedure, who presented with a type II thoracoabdominal aortic aneurysm post-COVID-19 recovery. A comprehensive frailty assessment using the Modified Frailty Index and a two-phase endovascular approach for aneurysm treatment, considering the patient's frailty and complex medical history was performed. Upon successful aneurysm management, the patient's postoperative course was complicated by COVID-19 reinfection and Enterococcus faecalis superinfection, highlighting the increased risk of bacterial superinfections and the challenges posed by antimicrobial resistance in COVID-19 patients. The study underscores the necessity of vigilant postoperative surveillance and a multidisciplinary approach in managing such complex cases, highlighting the importance of personalized care strategies, integrating cardiovascular and infectious disease management, and adapting healthcare practices to the unique challenges of the pandemic. This case contributes to the evolution of knowledge on managing aortic aneurysms in the COVID-19 era, advocating for patient-centric treatment approaches and continuous research into long-term patient outcomes.
Collapse
Affiliation(s)
| | | | | | | | | | - Wassim Mansour
- Department of General Surgery and Surgical Specialties, “Sapienza” University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161 Rome, Italy; (A.M.); (A.D.G.); (R.C.); (M.A.); (L.d.M.)
| |
Collapse
|
3
|
Welsh SA, Pearson RC, Hussey K, Brittenden J, Orr DJ, Quinn T. A systematic review of frailty assessment tools used in vascular surgery research. J Vasc Surg 2023; 78:1567-1579.e14. [PMID: 37343731 DOI: 10.1016/j.jvs.2023.06.010] [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] [Received: 03/15/2023] [Revised: 06/07/2023] [Accepted: 06/10/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVE Frailty is common in vascular patients and is recognized for its prognostic value. In the absence of consensus, a multitude of frailty assessment tools exist. This systematic review aimed to quantify the variety in these tools and describe their content and application to inform future research and clinical practice. METHODS Multiple cross-disciplinary electronic literature databases were searched from inception to August 2022. Studies describing frailty assessment in a vascular surgical population were eligible. Data extraction to a validated template included patient demographics, tool content, and analysis methods. A secondary systematic search for papers describing the psychometric properties of commonly used frailty tools was then performed. RESULTS Screening 5358 records identified 111 eligible studies, with an aggregate population of 5,418,236 patients. Forty-three differing frailty assessment tools were identified. One-third of these failed to assess frailty as a multidomain deficit and there was a reliance on assessing function and presence of comorbidity. Substantial methodological variability in data analysis and lack of methodological description was also identified. Published psychometric assessment was available for only 4 of the 10 most commonly used frailty tools. The Clinical Frailty Scale was the most studied and demonstrates good psychometric properties within a surgical population. CONCLUSIONS Substantial heterogeneity in frailty assessment is demonstrated, precluding meaningful comparisons of services and data pooling. A uniform approach to assessment is required to guide future frailty research. Based on the literature, we make the following recommendations: frailty should be considered a continuous construct and the reporting of frailty tools' application needs standardized. In the absence of consensus, the Clinical Frailty Scale is a validated tool with good psychometric properties that demonstrates usefulness in vascular surgery.
Collapse
Affiliation(s)
- Silje A Welsh
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland.
| | - Rebecca C Pearson
- Department of Medicine for the Elderly, Glasgow Royal Infirmary, Glasgow, Scotland
| | - Keith Hussey
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Julie Brittenden
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Douglas J Orr
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Terry Quinn
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland
| |
Collapse
|
4
|
Kiang SC, Lee MM, Dakour-Aridi H, Hassan M, Afifi RO. Presentation and outcomes of thoracic and thoracoabdominal aortic aneurysms in females, existing gaps, and future directions: A descriptive review. Semin Vasc Surg 2023; 36:501-507. [PMID: 38030324 DOI: 10.1053/j.semvascsurg.2023.10.004] [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] [Received: 08/03/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023]
Abstract
Thoracic and thoracoabdominal aortic aneurysms are more common in men. Yet, females often have worse outcomes, fewer interventions, and lower treatment rates. Females have also benefited less from the research and treatment of those diseases than men. Understanding sex- and sex-specific differences in thoracic and thoracoabdominal aortic aneurysms can improve care delivery, reduce disparities, and optimize outcomes for females with thoracic aortic aneurysms and thoracoabdominal aortic aneurysms. The authors reviewed the literature on the presentation and outcomes of thoracic and thoracoabdominal aortic aneurysms in females, discussing the existing gaps and future directions to address them.
Collapse
Affiliation(s)
- Sharon C Kiang
- Vascular Division, Department of Surgery, Loma Linda Veterans Healthcare System, Loma Linda, CA
| | - Mary M Lee
- Vascular Division, Department of Surgery, Loma Linda Veterans Healthcare System, Loma Linda, CA
| | - Hanaa Dakour-Aridi
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Madiha Hassan
- McGovern Medical School at UTHealth Houston, 6400 Fannin Street, Suite 2850, Houston, TX, 77030
| | - Rana O Afifi
- McGovern Medical School at UTHealth Houston, 6400 Fannin Street, Suite 2850, Houston, TX, 77030.
| |
Collapse
|
5
|
Pearl A, Ismail A, Alsadi T, Crespi Z, Daher M, Saleh K. Frailty and Pre-Frailty in the Setting of Total Joint Arthroplasty: A Narrative Review. Geriatr Orthop Surg Rehabil 2023; 14:21514593231188864. [PMID: 37456105 PMCID: PMC10338663 DOI: 10.1177/21514593231188864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Background Total joint arthroplasties are among the most common surgical procedures performed in the United States. Although numerous safeguards are in place to optimize patient health and safety pre-, intra-, and postoperatively, patient frailty is often incompletely assessed or not assessed at all. Frailty has been shown to increase rates of adverse events and length of stay. We discuss the impact of frailty on patient outcomes and healthcare economics as well as provide widely accepted models to assess frailty and their optimal usage. Methods Several databases were searched using the keywords "frailty," "TJA," "THA," "frailty index," "frailty assessment," and "frailty risk." A total of 45 articles were used in this literature review. Results It is estimated that nearly half of patients over the age of 85 meet criteria for frailty. Frailty in surgical patients has been shown to increase total costs as well as length of stay. Additionally, increased rates of numerous adverse events are associated with increased frailty. Conclusions The literature demonstrates that frailty poses increased risk of adverse events, increased length of stay, and increased cost. There are several models that accurately assess frailty and can feasibly be implemented into preoperative screening.
Collapse
Affiliation(s)
- Adam Pearl
- HCA Healthcare Aventura Hospital, Department of Emergency Medicine, FL, USA
| | - Aya Ismail
- University of Michigan, Dearborn, MI, USA
| | - Tariq Alsadi
- Michigan State University, East Lansing, MI, USA
| | - Zachary Crespi
- Central Michigan University College of Medicine, Mount Pleasant, MI, USA
| | | | - Khaled Saleh
- Michigan State University College of Osteopathic Medicine, Detroit, MI, USA
| |
Collapse
|
6
|
Zil-E-Ali A, Ahmadzada M, Calisi O, Holcomb RM, Patel A, Aziz F. A Systematic Review and Meta-Analysis to Assess the Impact of Pre-existing Comorbidities on the 30-Day Readmission after Lower Extremity Bypass Surgery for Peripheral Artery Occlusive Disease. Ann Vasc Surg 2023; 91:10-19. [PMID: 36549476 DOI: 10.1016/j.avsg.2022.12.072] [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: 07/19/2022] [Revised: 11/18/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Unplanned hospital readmissions after surgical operations are considered a marker for suboptimal care during index hospitalizations and are associated with poor patient outcomes and increased healthcare resource utilization. Patients undergoing lower extremity bypass (LEB) operations for severe peripheral arterial disease (PAD) have one of the highest readmission rates, among all the vascular and nonvascular surgical operations. This review is meant to evaluate the impact of pre-existing comorbidities (diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension (HTN), and coronary artery disease (CAD))-on the 30-day readmission rates among patients who underwent LEB for severe PAD. METHODS The review protocol was registered to the PROSPERO database (CRD42021261067). A systematic review of the English literature was performed using PubMed, Scopus, and the Cochrane Library databases from inception till April 2022. The review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and included only studies reporting on 30-day readmission following LEB for occlusive PAD. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach and was reported as high, moderate, or low. The risk of bias was evaluated utilizing the Risk of Bias in Nonrandomized Studies - of Interventions (ROBINS-I) tool. A pooled odds ratio (OR) for each study was computed, and a P-value of <0.05 was designated as statistically significant. Interstudy heterogeneity was evaluated by Q-metric and quantified using Higgins I2 statistics. RESULTS Five studies reported data on 30-day readmission after LEB for occlusive PAD. A total of 19,739 patients were included. Readmission occurred among 3,559 (18%) patients. DM and COPD were reported by all 5 selected studies, and CHF and HTN were reported by 4 studies. CAD was least reported among the selected 5 pre-existing conditions, with only 2 studies mentioning it. HTN (OR, 1.35; 95% confidence interval (CI), 1.10-1.64; P ≤ 0.001; I2 = 52.20%), DM (OR, 1.52; 95% CI, 1.30-1.79; P ≤ 0.001; I2 = 74.51%), and CHF (OR, 1.85; 95% CI, 1.51-2.25; P ≤ 0.001; I2 = 50.48%) were all found to be associated with an increased risk of 30-day readmission, while the presence of COPD (OR, 1.16; 95% CI, 0.98-1.36; P = 0.09; I2 = 61.93%) and CAD (OR, 1.30; 95% CI, 0.94-1.78; P = 0.11; I2 = 51.01%) was not associated with early readmission on meta-analysis of the available studies. CONCLUSIONS The pre-existing comorbidities HTN, DM, and CHF increase the risk of 30-day readmission after LEB for occlusive PAD. The identification of these risk factors can help stratify the patients and further guide in understanding the variety of factors that contribute in hospital readmissions.
Collapse
Affiliation(s)
- Ahsan Zil-E-Ali
- Division of Vascular Surgery, Heart and Vascular Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA.
| | | | - Olivia Calisi
- Office of Medical Education, Pennsylvania State University College of Medicine, Hershey, PA
| | - Ryan M Holcomb
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Akshilkumar Patel
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Faisal Aziz
- Division of Vascular Surgery, Heart and Vascular Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| |
Collapse
|
7
|
Frailty in emergency general surgery: Low-risk procedures pose similar risk as high-risk procedures for frail patients. Surgery 2023; 173:485-491. [PMID: 36435653 DOI: 10.1016/j.surg.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/21/2022] [Accepted: 10/03/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The association of frailty on postoperative outcomes after elective and emergency general surgery procedures has been widely studied. However, this association has not been examined in the geriatric population stratified by emergency general surgery procedural risk. METHODS A retrospective cohort study was performed using the 2012 to 2017 American College of Surgeons-National Surgical Quality Improvement Program database. We identified geriatric patients (age ≥65 years) undergoing an emergency general surgery procedure within 48 hours of admission stratified by the procedural risk. Frailty was accessed using Modified 5-item Frailty Index, and the patients were divided into 4 groups Modified 5-item Frailty Index = 0, 1, 2, and ≥3. Multivariable logistic regression was used to assess the impact of increasing Modified 5-item Frailty Index score on postoperative complications, failure-to-rescue, and readmissions. RESULTS In the study, 16,911 low risk procedure emergency general surgery patients were grouped as (33.3%) Modified 5-item Frailty Index = 0, (45.1%) Modified 5-item Frailty Index = 1, (18.7%) Modified 5-item Frailty Index = 2, and (2.9%) Modified 5-item Frailty Index ≥3 respectively. After multivariable analyses, increasing Modified 5-item Frailty Index score (versus Modified 5-item Frailty Index = 0) was associated with complications (odds ratio [95% confidence interval]; Modified 5-item Frailty Index = 2: 2.1 [1.3-3.5], Modified 5-item Frailty Index ≥ 3: 2.2 [1.2-4.2]), failure-to-rescue (Modified 5-item Frailty Index = 2: 2.3 [1.3-4.0], Modified 5-item Frailty Index ≥ 3: 2.3 [1.2-4.6]), readmission (Modified 5-item Frailty Index = 2: 1.4 [1.2-1.7], Modified 5-item Frailty Index ≥ 3: 1.5 [1.1-2.1]). In addition, 30,305 high-risk patients undergoing procedure emergency general surgery were grouped as (24.1%) Modified 5-item Frailty Index = 0, (44.9%) Modified 5-item Frailty Index = 1, (24.0%) Modified 5-item Frailty Index = 2, and (7.0%) Modified 5-item Frailty Index ≥3, respectively. After multivariable analyses, increasing Modified 5-item Frailty Index score (versus Modified 5-item Frailty Index = 0) was associated with complications (odds ratio [95% confidence interval]; Modified 5-item Frailty Index = 2: 1.2 [1.2-1.3], Modified 5-item Frailty Index ≥3: 1.7 [1.5-2.0]), failure-to-rescue (Modified 5-item Frailty Index = 2: 1.3 [1.2-1.5], Modified 5-item Frailty Index ≥3: 1.5 [1.3-1.7]), readmission (Modified 5-item Frailty Index = 2: 1.3 [1.2-1.4], Modified 5-item Frailty Index ≥3: 1.6 [1.4-1.9]). CONCLUSION Increasing levels of frailty in geriatric emergency general surgery patients are associated with higher levels of postoperative complications, failure-to-rescue, and readmission. Clinicians should consider frailty in assessing the risk of even low-risk surgeries in this population.
Collapse
|
8
|
Association between Masseter Muscle Area and Thickness and Outcome after Carotid Endarterectomy: A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11113087. [PMID: 35683474 PMCID: PMC9181694 DOI: 10.3390/jcm11113087] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/23/2022] [Accepted: 05/27/2022] [Indexed: 02/01/2023] Open
Abstract
Low muscle mass is associated with adverse outcomes after surgery. This study examined whether facial muscles, such as the masseter muscle, could be used as a proxy for generalized low muscle mass and could be associated with deviant outcomes after carotid endarterectomy (CEA). As a part of the Vascular Ageing study, patients with an available preoperative CT-scan, who underwent an elective CEA between December 2009 and May 2018, were included. Bilateral masseter muscle area and thickness were measured on preoperative CT scans. A masseter muscle area or thickness of one standard deviation below the sex-based mean was considered low masseter muscle area (LMA) or low masseter muscle thickness (LMT). Of the 123 included patients (73.3% men; mean age 68 (9.7) years), 22 (17.9%) patients had LMA, and 18 (14.6%) patients had LMT. A total of 41 (33.3%) patients had a complicated postoperative course and median length of hospital stay was four (4–5) days. Recurrent stroke within 5 years occurred in eight (6.6%) patients. Univariable analysis showed an association between LMA, complications and prolonged hospital stay. LMT was associated with a prolonged hospital stay (OR 8.78 [1.15–66.85]; p = 0.036) and recurrent stroke within 5 years (HR 12.40 [1.83–84.09]; p = 0.010) in multivariable logistic regression analysis. Masseter muscle might be useful in preoperative risk assessment for adverse short- and long-term postoperative outcomes.
Collapse
|
9
|
Elevated Risk Analysis Index (RAI) Frailty Scores Are Independently Associated with Adverse Outcomes in Lower Extremity Surgical Revascularizations Similarly Across Genders. Ann Vasc Surg 2022; 87:47-56. [PMID: 35460856 DOI: 10.1016/j.avsg.2022.04.004] [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: 02/14/2022] [Revised: 04/11/2022] [Accepted: 04/11/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The Risk Analysis Index (RAI) frailty scoring system, developed in a predominantly male Veteran sample, has recently undergone revision and external validation to become the RAI-rev using a general surgical sample from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database. We set forth to evaluate the application of RAI-rev scoring to lower extremity surgical revascularization outcomes in the NSQIP database while verifying that similar associations with outcomes persist in this subset across genders. METHODS All elective cases in the NSQIP Targeted Lower Extremity Open (LEO) database recorded from 2015-2019 were paired with the NSQIP Participant User File using Case IDs. Groups were defined by EMR-recorded gender. Extended length of stay was defined as top quartile postoperative stays. Aggregate demographics, perioperative factors, and 30-day outcomes were compared between groups using unpaired t-test and Fisher's exact test. Adjusted odds-ratios (aOR) for each outcome were generated by applying a multivariate binary logistic regression model in IBM SPSSTM for five-point RAI-rev score increments from 25-45 and a most-frail group with scores >45. Covariates included surgical indication, prior ipsilateral surgical revascularization versus percutaneous intervention, graft utilization, presence of dirty/infected wound, smoking, hypertension, diabetes, and steroid use. A non-frail group with RAI-rev scores <25 was utilized as the reference for generating adjusted odds ratios. RESULTS 8,155 cases were recorded in the NSQIP LEO database from 2015-2019, including 2,498 (31%) performed in women who had slightly lower RAI-rev scores on average (22.1±5.8 vs 24.2±5.1; p=0.0001). Univariate trends demonstrated dose-dependent increases in frequency of most outcomes with rising frailty score ranges, with the most substantial changes over mortality (0.4% of non-frail to 14.7% most-frail), disposition to a skilled nursing facility (8% of non-frail to 27% most-frail), and extended length of stay (16% of non-frail to 44% most-frail). After adjusting for co-variates, patients with RAI-rev scores of 26-30 had aOR of 1.4 (95% CI: 1.2-1.6; p<0.001), 1.9 (95% CI: 1.6-2.2; p<0.001), and 2.4 (95% CI: 1.3-4.4; p<0.001) for extended stay, disposition to skilled nursing, and mortality respectively as compared to those with RAI-rev scores <25. Despite more non-significant aOR for women than men, trends were similar across genders in both univariate and multivariate analyses. CONCLUSION Our study is the first to find that outcomes other than mortality are significantly predicted by RAI-rev score ranges in lower extremity surgical revascularizations with similar associations regardless of gender. RAI-rev frailty scores >30 may help to identify frail patients at a higher risk of mortality, extended stay, and increased rehabilitation needs prior to lower extremity surgical revascularization to inform risk assessment and optimize patient recovery.
Collapse
|
10
|
Management of Advanced Urothelial Carcinoma in Older and Frail Patients: Have Novel Treatment Approaches Improved Their Care? Drugs Aging 2022; 39:271-284. [PMID: 35344197 DOI: 10.1007/s40266-022-00933-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 11/03/2022]
Abstract
Patients with urothelial carcinoma tend to be older and frailer with a large number of chronic medical conditions. This is particularly pronounced in those with unresectable locally advanced and metastatic urothelial carcinoma. Prior to 2016, treatment options in advanced urothelial carcinoma were limited to chemotherapy, and as a result, a large number of patients were not receiving disease-directed management. Over the last 6 years, multiple alternative modalities including immune checkpoint inhibitors and targeted therapies have been introduced. They are being utilized clinically in older and frail patients, but there are limited studies investigating outcomes in these specific populations. Based upon current evidence, age does not impact the efficacy and tolerance of immune checkpoint inhibitors if patients are fit enough to receive therapy. In frailer patients, immune checkpoint inhibitors appear to be safe, but outcomes from largely retrospective studies demonstrate mixed data regarding their efficacy. Although there are indications from clinical trials that enfortumab vedotin, sacituzumab govitecan, and erdafitinib are also efficacious irrespective of age, there is still not enough evidence to draw definitive conclusions about their use in older and frail patients. Regardless, in all older patients with advanced urothelial carcinoma, it is critical to evaluate for frailty through geriatric screening tools and comprehensive assessments. Combining these evaluations with consideration of an individual patient's goals should be the foundation upon which therapeutic decisions are made in this population of patients.
Collapse
|
11
|
Edman NI, Zettervall SL, Dematteis MN, Ghaffarian A, Shalhub S, Sweet MP. Women with Thoracoabdominal Aortic Aneurysms Have Increased Frailty and More Complex Aortic Anatomy Compared with Men. J Vasc Surg 2022; 76:61-69.e3. [DOI: 10.1016/j.jvs.2022.01.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
|
12
|
Lin F, Hong G, Kwon F, Pirani F, Makhani S, Henry M, Cooke I, Nabavizadeh R, Midenberg E, Mehta A, Ritenour C, Master VA, Ogan K. Low free testosterone is associated with increased mortality in frail surgical patients. Surg Open Sci 2022; 7:36-41. [PMID: 35036888 PMCID: PMC8743202 DOI: 10.1016/j.sopen.2021.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/18/2021] [Accepted: 11/02/2021] [Indexed: 11/07/2022] Open
Abstract
Background Preoperative frailty has been associated with adverse postoperative outcomes. Additionally, low testosterone has been associated with physical frailty and cognitive decline. However, the impact of simultaneous frailty and low testosterone on surgical outcomes is understudied. Methods Preoperative frailty status and testosterone levels were obtained in patients undergoing a diverse range of surgical procedures. Preoperative frailty was evaluated independently and in combination with testosterone through the creation of composite risk groups. Relationships between preoperative frailty and composite risk groups with overall survival were determined using Kaplan–Meier and logistic regression analyses. Bivariate analysis was used to determine the associations between frailty and testosterone status on postoperative complications, length of hospital stay, and readmission rates. Results Median age of the cohort was 63 years, and the median follow-up time was 105 weeks. Thirty-one patients (23%) were frail, and 36 (27%) had low free testosterone. Bivariate analysis demonstrated a statistically significant relationship between preoperative frailty and overall survival (P = .044). In multivariate analysis, coexisting frailty and low free testosterone were significantly associated with decreased overall survival (hazard ratio 4.93, 95% confidence interval, 1.68–14.46, P = .004). Conclusion We observed preoperative frailty, both independently and in combination with low free testosterone levels, to be significantly associated with decreased overall survival across various surgical procedures. Personalizing the surgical risk assessment through the incorporation of preoperative frailty and testosterone status may serve to improve the prognostication of patients undergoing major surgery. Both frailty (P = .015) and low free testosterone (P = .005) were independently associated with 1-year mortality. After stratifying our cohort into 4 composite groups based on frailty and testosterone status, frail patients with low free T had the shortest overall survival when compared to the reference group, with nearly a 5-fold higher risk of death.
Collapse
Key Words
- ASA, American Society of Anesthesiologists
- BMI, body mass index
- CCI, Charlson Comorbidity Index
- CI, confidence interval
- ECOG, Eastern COoperative Oncology Group
- HR, hazard ratio
- IQR, interquartile range
- OS, overall survival
- T, testosterone
- eGFR, estimated Glomerular Filtration Rate
Collapse
Affiliation(s)
- Fangyi Lin
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Gordon Hong
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Frances Kwon
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Mark Henry
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Ian Cooke
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Reza Nabavizadeh
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Eric Midenberg
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Akanksha Mehta
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Chad Ritenour
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Viraj A Master
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Kenneth Ogan
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
13
|
Changes in frailty after parathyroid and thyroid surgery. Surgery 2021; 171:718-724. [PMID: 34972594 DOI: 10.1016/j.surg.2021.10.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 09/13/2021] [Accepted: 10/27/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Frailty tools assess symptoms and comorbidities that may coincide with those of primary hyperparathyroidism. To test the hypothesis that parathyroidectomy improves frailty, we conducted a prospective cohort comparison of frailty after parathyroid or thyroid surgery. METHODS The Risk Analysis Index measuring frailty was prospectively administered to patients undergoing curative parathyroid exploration or total thyroidectomy. Risk Analysis Index results at the preoperative, postoperative, and last follow-up visits were assessed longitudinally. RESULTS Compared to total thyroidectomy patients (n = 142), parathyroid exploration patients (n = 187) were older (P = .001), more often male (P = .05) and had longer surgical follow-up (P < .001). Mean preoperative Risk Analysis Index scores were higher in parathyroid exploration patients (24 ± 9 vs total thyroidectomy 17 ± 8, P < .001). Parathyroid exploration patients demonstrated a significant decrease in Risk Analysis Index score from preoperative to last follow-up (P < .01); total thyroidectomy patients did not (P = .44). Parathyroid exploration patients were also less likely to exhibit a 20% increase in Risk Analysis Index over time, suggesting that parathyroidectomy slowed progression of frailty (2% vs 19%, P = .003). CONCLUSION In this prospective study of frailty using a validated assessment tool, Risk Analysis Index scores decreased after parathyroid exploration surgery. When compared to total thyroidectomy patients, parathyroid exploration patients were also less likely to suffer a clinically meaningful ≥20% increase in Risk Analysis Index scores after surgery, suggesting that parathyroid exploration patients better maintained baseline health at final follow-up.
Collapse
|
14
|
Takauji S, Hifumi T, Saijo Y, Yokobori S, Kanda J, Kondo Y, Hayashida K, Shimazaki J, Moriya T, Yagi M, Yamaguchi J, Okada Y, Okano Y, Kaneko H, Kobayashi T, Fujita M, Shimizu K, Yokota H, Yaguchi A. Association between frailty and mortality among patients with accidental hypothermia: a nationwide observational study in Japan. BMC Geriatr 2021; 21:507. [PMID: 34563118 PMCID: PMC8466946 DOI: 10.1186/s12877-021-02459-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 09/10/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Frailty has been associated with a risk of adverse outcomes, and mortality in patients with various conditions. However, there have been few studies on whether or not frailty is associated with mortality in patients with accidental hypothermia (AH). In this study, we aim to determine this association in patients with AH using Japan's nationwide registry data. METHODS The data from the Hypothermia STUDY 2018&19, which included patients of ≥18 years of age with a body temperature of ≤35 °C, were obtained from a multicenter registry for AH conducted at 120 institutions throughout Japan, collected from December 2018 to February 2019 and December 2019 to February 2020. The clinical frailty scale (CFS) score was used to determine the presence and degree of frailty. The primary outcome was the comparison of mortality between the frail and non-frail patient groups. RESULTS In total, 1363 patients were included in the study, of which 920 were eligible for the analysis. The 920 patients were divided into the frail patient group (N = 221) and non-frail patient group (N = 699). After 30-days of hospitalization, 32.6% of frail patients and 20.6% of non-frail patients had died (p < 0.001). Frail patients had a significantly higher risk of 90-day mortality (Hazard ratio [HR], 1.64; 95% confidence interval [CI], 1.25-2.17; p < 0.001). Based on the Cox proportional hazards analysis using multiple imputation, after adjustment for age, potassium level, lactate level, pH value, sex, CPK level, heart rate, platelet count, location of hypothermia incidence, and rate of tracheal intubation, the HR was 1.69 (95% CI, 1.25-2.29; p < 0.001). CONCLUSIONS This study showed that frailty was associated with mortality in patients with AH. Preventive interventions for frailty may help to avoid death caused by AH.
Collapse
Affiliation(s)
- Shuhei Takauji
- Department of Emergency Medicine, Asahikawa Medical University Hospital, 2-1, Midorigaoka higashi, Asahikawa, 078-8510, Japan. .,Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.
| | - Toru Hifumi
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasuaki Saijo
- Department of Social Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Shoji Yokobori
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Jun Kanda
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Department of Emergency Medicine, Teikyo University Hospital, Tokyo, Japan
| | - Yutaka Kondo
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Kei Hayashida
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, USA
| | - Junya Shimazaki
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School, Osaka, Japan
| | - Takashi Moriya
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masaharu Yagi
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Department of Emergency, Disaster and Critical Care Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Junko Yamaguchi
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yohei Okada
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Department of Primary care and Emergency medicine, Graduate school of medicine, Kyoto University, Kyoto, Japan
| | - Yuichi Okano
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Department of Emergency Medicine, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Hitoshi Kaneko
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Tatsuho Kobayashi
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Motoki Fujita
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Keiki Shimizu
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Hiroyuki Yokota
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Arino Yaguchi
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee, Tokyo, Japan.,Department of Critical Care and Emergency Medicine, Tokyo Women's Medical University, Tokyo, Japan
| |
Collapse
|
15
|
Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
Collapse
Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| |
Collapse
|