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Ling RR, Ueno R, Alamgeer M, Sundararajan K, Sundar R, Bailey M, Pilcher D, Subramaniam A. FRailty in Australian patients admitted to Intensive care unit after eLective CANCER-related SURGery: a retrospective multicentre cohort study (FRAIL-CANCER-SURG study). Br J Anaesth 2024; 132:695-706. [PMID: 38378383 DOI: 10.1016/j.bja.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND The association between frailty and short-term and long-term outcomes in patients receiving elective surgery for cancer remains unclear, particularly in those admitted to the ICU. METHODS In this multicentre retrospective cohort study, we included adults ≥16 yr old admitted to 158 ICUs in Australia from January 1, 2018 to March 31, 2022 after elective surgery for cancer. We investigated the association between frailty and survival time up to 4 yr (primary outcome), adjusting for a prespecified set of covariates. We analysed how this association changed in specific subgroups (age categories [<65, 65-80, ≥80 yr], and those who survived hospitalisation), and over time by splitting the survival information at monthly intervals. RESULTS We included 35,848 patients (median follow-up: 18.1 months [inter-quartile range: 8.3-31.1 months], 19,979 [56.1%] male, median age 69.0 yr [inter-quartile range: 58.8-76.0 yr]). Some 3502 (9.8%) patients were frail (defined as clinical frailty scale ≥5). Frailty was associated with lower survival (hazard ratio: 1.72, 95% confidence interval [CI]: 1.59-1.86 compared with clinical frailty scale ≤4); this was concordant across several sensitivity analyses. Frailty was most strongly associated with mortality early on in follow-up, up to 10 months (hazard ratio: 1.39, 95% CI: 1.03-1.86), but this association plateaued, and its predictive capacity subsequently diminished with time up until 4 yr (1.96, 95% CI: 0.73-5.28). Frailty was associated with similar effects when stratified based on age, and in those who survived hospitalisation. CONCLUSIONS Frailty was associated with poorer outcomes after an ICU admission after elective surgery for cancer, particularly in the short term. However, its predictive capacity with time diminished, suggesting a potential need for longitudinal reassessment to ensure appropriate prognostication in this population.
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Affiliation(s)
- Ryan R Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Ryo Ueno
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia
| | - Muhammad Alamgeer
- Department of Medicine/School of Clinical Sciences, Monash University, Clayton, VIC, Australia; Department of Medical Oncology, Monash Health, Clayton, VIC, Australia; Centre for Cancer Research, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Krishnaswamy Sundararajan
- Department of Intensive Care, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Raghav Sundar
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore; Department of Haematology-Oncology, National University Cancer Institute, National University Hospital, Singapore; Cancer and Stem Cell Biology Program, Duke-NUS Medical School, Singapore; The N.1 Institute for Health, National University of Singapore, Singapore; Singapore Gastric Cancer Consortium, Singapore
| | - Michael Bailey
- Department of Intensive Care, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia
| | - David Pilcher
- Department of Intensive Care, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia; Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia; Department of Intensive Care, Peninsula Health, Frankston, VIC, Australia; Department of Intensive Care, Dandenong Hospital, Dandenong, VIC, Australia; Peninsula Clinical School, Monash University, Frankston, VIC, Australia.
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van Oppen JD, Owen RK, Jones W, Beishon L, Coats TJ. The effect of relative hypotension on 30-day mortality in older people receiving emergency care. Intern Emerg Med 2024; 19:787-795. [PMID: 37940793 DOI: 10.1007/s11739-023-03468-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 10/18/2023] [Indexed: 11/10/2023]
Abstract
Research has observed increased mortality among older people attending the emergency department (ED) who had systolic pressure > 7 mmHg lower than baseline primary care values. This study aimed to (1) assess feasibility of identifying this 'relative hypotension' using readily available ED data, (2) externally validate the 7 mmHg threshold, and (3) refine a threshold for clinically important relative hypotension. A single-centre retrospective cohort study linked year 2019 data for ED attendances by people aged over 64 to hospital discharge vital signs within the previous 18 months. Frailty and comorbidity scores were calculated. Previous discharge ('baseline') vital signs were subtracted from initial ED values to give individuals' relative change. Cox regression analysis compared relative hypotension > 7 mmHg with mean time to mortality censored at 30 days. The relative hypotension threshold was refined using a fully adjusted risk tool formed of logistic regression models. Receiver operating characteristics were compared to NEWS2 models with and without incorporation of relative systolic. 5136 (16%) of 32,548 ED attendances were linkable with recent discharge vital signs. Relative hypotension > 7 mmHg was associated with increased 30-day mortality (HR 1.98; 95% CI 1.66-2.35). The adjusted risk tool (AUC: 0.69; sensitivity: 0.61; specificity: 0.68) estimated each 1 mmHg relative hypotension to increase 30-day mortality by 2% (OR 1.02; 95% CI 1.02-1.02). 30-day mortality prediction was marginally better with NEWS2 (AUC: 0.73; sensitivity: 0.59; specificity: 0.78) and NEWS2 + relative systolic (AUC: 0.74; sensitivity: 0.63; specificity: 0.75). Comparison of ED vital signs with recent discharge observations was feasible for 16% individuals. The association of relative hypotension > 7 mmHg with 30-day mortality was externally validated. Indeed, any relative hypotension appeared to increase risk, but model characteristics were poor. These findings are limited to the context of older people with recent hospital admissions.
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Affiliation(s)
- James David van Oppen
- Department of Population Health Sciences, University of Leicester, Leicester, UK.
- Emergency and Specialist Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK.
| | | | - William Jones
- Emergency and Specialist Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Lucy Beishon
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, UK
| | - Timothy John Coats
- Department of Population Health Sciences, University of Leicester, Leicester, UK
- Emergency and Specialist Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
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Wozniak H, Beckmann TS, Dos Santos Rocha A, Pugin J, Heidegger CP, Cereghetti S. Long-stay ICU patients with frailty: mortality and recovery outcomes at 6 months. Ann Intensive Care 2024; 14:31. [PMID: 38401034 PMCID: PMC10894177 DOI: 10.1186/s13613-024-01261-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/09/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Prolonged intensive care unit (ICU) stay is associated with physical, cognitive, and psychological disabilities. The impact of baseline frailty on long-stay ICU patients remains uncertain. This study aims to investigate how baseline frailty influences mortality and post-ICU disability 6 months after critical illness in long-stay ICU patients. METHODS In this retrospective cohort study, we assessed patients hospitalized for ≥ 7 days in the ICU between May 2018 and May 2021, following them for up to 6 months or until death. Based on the Clinical Frailty Scale (CFS) at ICU admissions, patients were categorized as frail (CFS ≥ 5), pre-frail (CFS 3-4) and non-frail (CFS 1-2). Kaplan-Meier curves and a multivariate Cox model were used to examine the association between frailty and mortality. At the 6 month follow-up, we assessed psychological, physical, cognitive outcomes, and health-related quality of life (QoL) using descriptive statistics and linear regressions. RESULTS We enrolled 531 patients, of which 178 (33.6%) were frail, 200 (37.6%) pre-frail and 153 (28.8%) non-frail. Frail patients were older, had more comorbidities, and greater disease severity at ICU admission. At 6 months, frail patients presented higher mortality rates than pre-frail and non-frail patients (34.3% (61/178) vs. 21% (42/200) vs. 13.1% (20/153) respectively, p < 0.01). The rate of withdrawing or withholding of care did not differ significantly between the groups. Compared with CFS 1-2, the adjusted hazard ratios of death at 6 months were 1.7 (95% CI 0.9-2.9) for CFS 3-4 and 2.9 (95% CI 1.7-4.9) for CFS ≥ 5. At 6 months, 192 patients were seen at a follow-up consultation. In multivariate linear regressions, CFS ≥ 5 was associated with poorer physical health-related QoL, but not with poorer mental health-related QoL, compared with CFS 1-2. CONCLUSION Frailty is associated with increased mortality and poorer physical health-related QoL in long-stay ICU patients at 6 months. The admission CFS can help inform patients and families about the complexities of survivorship during a prolonged ICU stay.
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Affiliation(s)
- Hannah Wozniak
- Division of Critical Care, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland.
- Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
| | - Tal Sarah Beckmann
- Division of Anesthesiology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Andre Dos Santos Rocha
- Division of Anesthesiology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Jérôme Pugin
- Division of Critical Care, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Claudia-Paula Heidegger
- Division of Critical Care, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Sara Cereghetti
- Division of Critical Care, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
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Martínez-Camacho MÁ, Jones-Baro RA, Gómez-González A, Lugo-García DS, Astorga PCG, Melo-Villalobos A, Gonzalez-Rodriguez BK, Pérez-Calatayud ÁA. Prolonged intensive care: muscular functional, and nutritional insights from the COVID-19 pandemic. Acute Crit Care 2024; 39:47-60. [PMID: 38303585 PMCID: PMC11002617 DOI: 10.4266/acc.2023.01284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 10/27/2023] [Accepted: 10/31/2023] [Indexed: 02/03/2024] Open
Abstract
During the coronavirus disease 2019 (COVID-19) pandemic, clinical staff learned how to manage patients enduring extended stays in an intensive care unit (ICU). COVID-19 patients requiring critical care in an ICU face a high risk of experiencing prolonged intensive care (PIC). The use of invasive mechanical ventilation in individuals with severe acute respiratory distress syndrome can cause numerous complications that influence both short-term and long-term morbidity and mortality. Those risks underscore the importance of proactively addressing functional complications. Mitigating secondary complications unrelated to the primary pathology of admission is imperative in minimizing the risk of PIC. Therefore, incorporating strategies to do that into daily ICU practice for both COVID-19 patients and those critically ill from other conditions is significantly important.
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Affiliation(s)
| | - Robert Alexander Jones-Baro
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
| | - Alberto Gómez-González
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
| | - Dalia Sahian Lugo-García
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
| | | | - Andrea Melo-Villalobos
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
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Donnan MT, Bihari S, Subramaniam A, Dabscheck EJ, Riley B, Pilcher DV. The Long-Term Impact of Frailty After an Intensive Care Unit Admission Due to Chronic Obstructive Pulmonary Disease. Chronic Obstr Pulm Dis 2024; 11:83-94. [PMID: 37931590 PMCID: PMC10913924 DOI: 10.15326/jcopdf.2023.0453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 11/08/2023]
Abstract
Rationale Frailty is an increasingly recognized aspect of chronic obstructive pulmonary disease (COPD). The impact of frailty on long-term survival after admission to an intensive care unit (ICU) due to an exacerbation of COPD has not been described. Objective The objective was to quantify the impact of frailty on time to death up to 4 years after admission to the ICU in Australia and New Zealand for an exacerbation of COPD. Methods We performed a multicenter retrospective cohort study of adult patients admitted to 179 ICUs with a primary diagnosis of an exacerbation of COPD using the Australian and New Zealand Intensive Care Society Adult Patient Database from January 1, 2018, through December 31, 2020, in New Zealand, and March 31, 2022, in Australia. Frailty was measured using the clinical frailty scale (CFS). The primary outcome was survival up to 4 years after ICU admission. The secondary outcome was readmission to the ICU due to an exacerbation of COPD. Measurements and Main Results We examined 7126 patients of which 3859 (54.1%) were frail (CFS scores of 5-8). Mortality in not-frail individuals versus frail individuals at 1 and 4 years was 19.8% versus 40.4%, and 56.8% versus 77.3% respectively (both p<0.001). Frailty was independently associated with a shorter time to death (adjusted hazard ratio 1.66; 95% confidence interval 1.54-1.80).There was no difference in the proportion of survivors with or without frailty who were readmitted to the ICU during a subsequent hospitalization. Conclusions Frailty was independently associated with poorer long-term survival in patients admitted to the ICU with an exacerbation of COPD.
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Affiliation(s)
- Matthew T. Donnan
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Australia
| | - Shailesh Bihari
- College of Medicine and Public Health, Flinders University, South Australia
- Department of Intensive and Critical Care, Finders Medical Centre, Adelaide, Australia
| | - Ashwin Subramaniam
- Intensive Care Unit, Peninsula Health, Melbourne, Australia
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Eli J. Dabscheck
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Australia
- Central Clinical School, Monash University, The Alfred Hospital, Melbourne, Australia
| | - Brooke Riley
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - David V. Pilcher
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care Society, Centre for Outcome and Resources Evaluation, Melbourne, Victoria, Australia
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Dengler J, Gheewala H, Kraft CN, Hegewald AA, Dörre R, Heese O, Gerlach R, Rosahl S, Maier B, Burger R, Wutzler S, Carl B, Ryang YM, Hau KT, Stein G, Gulow J, Allam A, Abduljawwad N, Rico Gonzalez G, Kuhlen R, Hohenstein S, Bollmann A, Stoffel M. Changes in frailty among patients hospitalized for spine pathologies during the COVID-19 pandemic in Germany-a nationwide observational study. Eur Spine J 2024; 33:19-30. [PMID: 37971536 DOI: 10.1007/s00586-023-08014-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE In spine care, frailty is associated with poor outcomes. The aim of this study was to describe changes in frailty in spine care during the coronavirus disease 2019 (COVID-19) pandemic and their relation to surgical management and outcomes. METHODS Patients hospitalized for spine pathologies between January 1, 2019, and May 17, 2022, within a nationwide network of 76 hospitals in Germany were retrospectively included. Patient frailty, types of surgery, and in-hospital mortality rates were compared between pandemic and pre-pandemic periods. RESULTS Of the 223,418 included patients with spine pathologies, 151,766 were admitted during the pandemic and 71,652 during corresponding pre-pandemic periods in 2019. During the pandemic, the proportion of high-frailty patients increased from a range of 5.1-6.1% to 6.5-8.8% (p < 0.01), while the proportion of low frailty patients decreased from a range of 70.5-71.4% to 65.5-70.1% (p < 0.01). In most phases of the pandemic, the Elixhauser comorbidity index (ECI) showed larger increases among high compared to low frailty patients (by 0.2-1.8 vs. 0.2-0.8 [p < 0.01]). Changes in rates of spine surgery were associated with frailty, most clearly in rates of spine fusion, showing consistent increases among low frailty patients (by 2.2-2.5%) versus decreases (by 0.3-0.8%) among high-frailty patients (p < 0.02). Changes in rates of in-hospital mortality were not associated with frailty. CONCLUSIONS During the COVID-19 pandemic, the proportion of high-frailty patients increased among those hospitalized for spine pathologies in Germany. Low frailty was associated with a rise in rates of spine surgery and high frailty with comparably larger increases in rates of comorbidities.
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Affiliation(s)
- Julius Dengler
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany.
- Department of Neurosurgery, HELIOS Hospital Bad Saarow, Bad Saarow, Germany.
| | - Hussain Gheewala
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany
- Department of Neurosurgery, HELIOS Hospital Bad Saarow, Bad Saarow, Germany
| | - Clayton N Kraft
- Department of Orthopedics, Trauma Surgery and Hand Unit, HELIOS Klinikum Krefeld, Krefeld, Germany
| | - Aldemar A Hegewald
- Department of Neurosurgery, VAMED Ostsee Hospital Damp, Ostseebad Damp, Germany
| | - Ralf Dörre
- Department of Neurosurgery, HELIOS Hospital St. Marienberg, Helmstedt, Germany
| | - Oliver Heese
- Department of Neurosurgery and Spinal Surgery, HELIOS Hospital Schwerin - University Campus of MSH Medical School Hamburg, Schwerin, Germany
| | - Rüdiger Gerlach
- Department of Neurosurgery, HELIOS Hospital Erfurt, Erfurt, Germany
| | - Steffen Rosahl
- Department of Neurosurgery, HELIOS Hospital Erfurt, Erfurt, Germany
| | - Bernd Maier
- Department of Trauma and Orthopedic Surgery, HELIOS Hospital Pforzheim, Pforzheim, Germany
| | - Ralf Burger
- Department of Neurosurgery, HELIOS Hospital Uelzen, Uelzen, Germany
| | - Sebastian Wutzler
- Department of Trauma, Hand and Orthopedic Surgery, HELIOS Dr. Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Germany
| | - Barbara Carl
- Department of Neurosurgery, University of Marburg, Marburg, Germany
- Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
- Department of Neurosurgery, HELIOS Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
| | - Yu-Mi Ryang
- Department of Neurosurgery and Spine Center, HELIOS Hospital Berlin Buch, Berlin, Germany
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Munich, Germany
| | - Khanh Toan Hau
- Department of Spine Surgery, HELIOS Hospital Duisburg, Duisburg, Germany
| | - Gregor Stein
- Department of Orthopaedic, Trauma and Spine Surgery, HELIOS Hospital Siegburg, Siegburg, Germany
| | - Jens Gulow
- Department of Spine Surgery, HELIOS Park-Klinikum Leipzig, Leipzig, Germany
| | - Ali Allam
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany
- Department of Anesthesiology and Intensive Care Medicine, HELIOS Hospital Bad Saarow, Bad Saarow, Germany
| | - Nehad Abduljawwad
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany
- Department of Neurosurgery, HELIOS Hospital Bad Saarow, Bad Saarow, Germany
| | - Gerardo Rico Gonzalez
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany
- Department of Neurosurgery, HELIOS Hospital Bad Saarow, Bad Saarow, Germany
| | | | - Sven Hohenstein
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
| | - Andreas Bollmann
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
- Department of Electrophysiology, Heart Center Leipzig at Leipzig University, Leipzig, Germany
| | - Michael Stoffel
- Department of Neurosurgery, HELIOS Hospital Krefeld, Krefeld, Germany
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Alamgeer M, Ling RR, Ueno R, Sundararajan K, Sundar R, Pilcher D, Subramaniam A. Frailty and long-term survival among patients in Australian intensive care units with metastatic cancer (FRAIL-CANCER study): a retrospective registry-based cohort study. Lancet Healthy Longev 2023; 4:e675-e684. [PMID: 38042160 DOI: 10.1016/s2666-7568(23)00209-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/28/2023] [Accepted: 09/28/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND Recent advances in cancer therapeutics have improved outcomes, resulting in increasing candidacy of patients with metastatic cancer being admitted to intensive care units (ICUs). A large proportion of patients also have frailty, predisposing them to poor outcomes, yet the literature reporting on this is scarce. We aimed to assess the impact of frailty on survival in patients with metastatic cancer admitted to the ICU. METHODS In this retrospective registry-based cohort study, we used data from the Australia and New Zealand Intensive Care Society Adult Patient (age ≥16 years) database to identify patients with advanced (solid and haematological cancer) and a documented Clinical Frailty scale (CFS) admitted to 166 Australian ICUs. Patients without metastatic cancer were excluded. We analysed the effect of frailty (CFS 5-8) on long-term survival, and how this effect changed in specific subgroups (cancer subtypes, age [<65 years or ≥65 years], and those who survived hospitalisation). Because estimates tend to cluster within centres and vary between them, we used Cox proportional hazards regression models with robust sandwich variance estimators to assess the effect of frailty on survival time up to 4 years after ICU admission between groups. FINDINGS Between Jan 1, 2018, and March 31, 2022, 30 026 patients were eligible, and after exclusions 21 174 patients were included in the analysis; of these, 6806 (32·1%) had frailty, and 11 662 (55·1%) were male, 9489 (44·8%) were female, and 23 (0·1%) were intersex or self-reported indeterminate sex. The overall survival was lower for patients with frailty at 4 years compared with patients without frailty (29·5% vs 10·9%; p<0·0001). Frailty was associated with shorter 4-year survival times (adjusted hazard ratio 1·52 [95% CI 1·43-1·60]), and this effect was seen across all cancer subtypes. Frailty was associated with shorter survival times in patients younger than 65 years (1·66 [1·51-1·83]) and aged 65 years or older (1·40 [1·38-1·56]), but its effects were larger in patients younger than 65 years (pinteraction<0·0001). Frailty was also associated with shorter survival times in patients who survived hospitalisation (1·49 [1·40-1·59]). INTERPRETATION In patients with metastatic cancer admitted to the ICU, frailty was associated with poorer long-term survival. Patients with frailty might benefit from a goal-concordant time-limited trial in the ICU and will need suitable post-intensive care supportive management. FUNDING None.
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Affiliation(s)
- Muhammad Alamgeer
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia; Department of Medical Oncology, Monash Health, Clayton, VIC, Australia.
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ryo Ueno
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Eastern Health, Box Hill, VIC, Australia
| | - Krishnaswamy Sundararajan
- Department of Intensive Care, Royal Adelaide Hospital, Adelaide, SA, Australia; University of Adelaide, Adelaide, SA, Australia
| | - Raghav Sundar
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Ashwin Subramaniam
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Peninsula Health, Frankston, VIC, Australia; Department of Intensive Care, Dandenong Hospital, Dandenong, VIC, Australia; Peninsula Clinical School, Monash University, Frankston, VIC, Australia
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Subramaniam A, Ling RR, Ridley EJ, Pilcher DV. The impact of body mass index on long-term survival after ICU admission due to COVID-19: A retrospective multicentre study. CRIT CARE RESUSC 2023; 25:182-192. [PMID: 38234325 PMCID: PMC10790021 DOI: 10.1016/j.ccrj.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 01/19/2024]
Abstract
Objective The impact of obesity on long-term survival after intensive care unit (ICU) admission with severe coronavirus disease 2019 (COVID-19) is unclear. We aimed to quantify the impact of obesity on time to death up to two years in patients admitted to Australian and New Zealand ICUs. Design Retrospective multicentre study. Setting 92 ICUs between 1st January 2020 through to 31st December 2020 in New Zealand and 31st March 2022 in Australia with COVID-19, reported in the Australian and New Zealand Intensive Care Society adult patient database. Participants All patients with documented height and weight to estimate the body mass index (BMI) were included. Obesity was classified patients according to the World Health Organization recommendations. Interventions and main outcome measures The primary outcome was survival time up to two years after ICU admission. The effect of obesity on time to death was assessed using a Cox proportional hazards model. Confounders were acute illness severity, sex, frailty, hospital type and jurisdiction for all patients. Results We examined 2,931 patients; the median BMI was 30.2 (IQR 25.6-36.0) kg/m2. Patients with a BMI ≥30 kg/m2 were younger (median [IQR] age 57.7 [46.2-69.0] vs. 63.0 [50.0-73.6]; p < 0.001) than those with a BMI <30 kg/m2. Most patients (76.6%; 2,244/2,931) were discharged alive after ICU admission. The mortality at two years was highest for BMI categories <18.5 kg/m2 (35.4%) and 18.5-24.9 kg/m2 (31.1%), while lowest for BMI ≥40 kg/m2 (14.5%). After adjusting for confounders and with BMI 18.5-24.9 kg/m2 category as a reference, only the BMI ≥40 kg/m2 category patients had improved survival up to 2 years (hazard ratio = 0.51; 95%CI: 0.34-0.76). Conclusions The obesity paradox appears to exist beyond hospital discharge in critically ill patients with COVID-19 admitted in Australian and New Zealand ICUs. A BMI ≥40 kg/m2 was associated with a higher survival time of up to two years.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia
- Department of Intensive Care, Dandenong Hospital, Monash Health, Dandenong, Victoria, Australia
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Emma J. Ridley
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Nutrition and Dietetics, Alfred Hospital, Melbourne, Victoria, Australia
| | - David V. Pilcher
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Victoria, Australia
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9
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Malik ME, Butt JH, Strange JE, Falkentoft AC, Jensen J, Andersson C, Zahir D, Fosbøl E, Petrie MC, Sattar N, McMurray JJV, Køber L, Schou M. Initiation of SGLT2 inhibitors and GLP-1 receptor agonists according to level of frailty in people with type 2 diabetes and cardiovascular disease in Denmark: a cross-sectional, nationwide study. Lancet Healthy Longev 2023; 4:e552-e560. [PMID: 37734395 DOI: 10.1016/s2666-7568(23)00164-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Whether frailty influences the initiation of two cardioprotective diabetes drug therapies (ie, SGLT2 inhibitors and GLP-1 receptor agonists) in people with type 2 diabetes and cardiovascular disease is unknown. We aimed to assess rates of initiation of SGLT2 inhibitors and GLP-1 receptor agonists according to frailty in people with type 2 diabetes and cardiovascular disease. METHODS For this cross-sectional, nationwide study, all people with type 2 diabetes and cardiovascular disease in Denmark between Jan 1, 2015, and Dec 31, 2021, from six Danish health-data registers were identified. People younger than 40 years, with end-stage renal disease, with registered contraindications to SGLT2 inhibitors or GLP-1 receptor agonists, or with previous use of either drug therapy were excluded. The Hospital Frailty Risk Score was used to categorise people as either non-frail, moderately frail, or severely frail. Cox proportional hazards models were used to analyse the association between frailty and initiation of an SGLT2 inhibitor or a GLP-1 receptor agonist. FINDINGS Of 119 390 people with type 2 diabetes and cardiovascular disease, 103 790 were included. Median follow-up time was 4·5 years (IQR 2·7-6·1) and median age across the three frailty groups was 71 years (64-79). 65 959 (63·6%) of 103 790 people were male and 37 831 (36·5%) were female. At index date, 66 910 (64·5%) people were non-frail, 29 250 (28·2%) were moderately frail, and 7630 (7·4%) were severely frail. Frailty was associated with a significantly lower probability of initiating therapy with an SGLT2 inhibitor or a GLP-1 receptor agonist than in people who were non-frail (moderately frail hazard ratio 0·91, 95% CI 0·88-0·94, p<0·0001; severely frail 0·75, 0·70-0·80, p<0·0001). This association persisted after adjustment for age, sex, socioeconomic status, year of inclusion, duration of type 2 diabetes, duration of cardiovascular disease, polypharmacy, and comorbidity. INTERPRETATION In people with type 2 diabetes and cardiovascular disease in Denmark, frailty was associated with a significantly lower probability of SGLT2-inhibitor or GLP-1 receptor-agonist initiation, despite their benefits. Formulating clear and updated guidelines on the use of SGLT2 inhibitors and GLP-1 receptor agonists in people who are frail with type 2 diabetes and cardiovascular disease should be a priority. FUNDING Department of Cardiology, Herlev and Gentofte University Hospital. TRANSLATION For the Danish translation of the abstract see Supplementary Materials section.
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Affiliation(s)
| | - Jawad Haider Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jarl Emanuel Strange
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | | | - Jesper Jensen
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Charlotte Andersson
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Deewa Zahir
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Emil Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
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10
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Christensen DM, Strange JE, Falkentoft AC, El-Chouli M, Ravn PB, Ruwald AC, Fosbøl E, Køber L, Gislason G, Sehested TSG, Schou M. Frailty, Treatments, and Outcomes in Older Patients With Myocardial Infarction: A Nationwide Registry-Based Study. J Am Heart Assoc 2023:e030561. [PMID: 37421279 PMCID: PMC10382124 DOI: 10.1161/jaha.123.030561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/30/2023] [Indexed: 07/10/2023]
Abstract
Background Guidelines recommend that patients with myocardial infarction (MI) receive equal care regardless of age. However, withholding treatment may be justified in elderly and frail patients. This study aimed to investigate trends in treatments and outcomes of older patients with MI according to frailty. Methods and Results All patients aged ≥75 years with first-time MI during 2002 to 2021 were identified through Danish nationwide registries. Frailty was categorized using the Hospital Frailty Risk Score. One-year risk and hazard ratios (HRs) for days 0 to 28 and 29 to 365 were calculated for all-cause death. A total of 51 022 patients with MI were included (median, 82 years; 50.2% women). Intermediate/high frailty increased from 26.7% in 2002 to 2006 to 37.1% in 2017 to 2021. Use of treatment increased substantially regardless of frailty: for example, 28.1% to 48.0% (statins), 21.8% to 33.7% (dual antiplatelet therapy), and 7.6% to 28.0% (percutaneous coronary intervention) for high frailty (all P-trend <0.001). One-year death decreased for low frailty (35.1%-17.9%), intermediate frailty (49.8%-31.0%), and high frailty (62.8%-45.6%), all P-trend <0.001. Age- and sex-adjusted 29- to 365-day HRs (2017-2021 versus 2002-2006) were 0.53 (0.48-0.59), 0.62 (0.55-0.70), and 0.62 (0.46-0.83) for low, intermediate, and high frailty, respectively (P-interaction=0.23). When additionally adjusted for treatment, HRs attenuated to 0.74 (0.67-0.83), 0.83 (0.74-0.94), and 0.78 (0.58-1.05), respectively, indicating that increased use of treatment may account partially for the observed improvements. Conclusions Use of guideline-based treatments and outcomes improved concomitantly in older patients with MI, irrespective of frailty. These results indicate that guideline-based management of MI may be reasonable in the elderly and frail.
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Affiliation(s)
| | - Jarl Emanuel Strange
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
- Department of Cardiology Rigshospitalet Copenhagen Denmark
| | | | | | - Pauline B Ravn
- Department of Cardiology Zealand University Hospital Roskilde Roskilde Denmark
| | | | - Emil Fosbøl
- Department of Cardiology Rigshospitalet Copenhagen Denmark
| | - Lars Køber
- Department of Cardiology Rigshospitalet Copenhagen Denmark
| | - Gunnar Gislason
- Danish Heart Foundation Copenhagen Denmark
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
- The National Institute of Public Health University of Southern Denmark Copenhagen Denmark
| | - Thomas S G Sehested
- Danish Heart Foundation Copenhagen Denmark
- Department of Cardiology Zealand University Hospital Roskilde Roskilde Denmark
| | - Morten Schou
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
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11
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Hao B, Chen T, Qin J, Meng W, Bai W, Zhao L, Ou X, Liu H, Xu W. A comparison of three approaches to measuring frailty to determine adverse health outcomes in critically ill patients. Age Ageing 2023; 52:afad096. [PMID: 37326605 DOI: 10.1093/ageing/afad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND studies comparing different frailty measures in intensive care unit settings are lacking. We aimed to compare the frailty index based on physiological and laboratory tests (FI-Lab), modified frailty index (MFI) and hospital frailty risk score (HFRS) to predict short-term outcomes for critically ill patients. METHODS we conducted a secondary analysis of data from the Medical Information Mart for Intensive Care IV database. Outcomes of interest included in-hospital mortality and discharge with need for nursing care. RESULTS the primary analysis was conducted with 21,421 eligible critically ill patients. After adjusting for confounding variables, frailty as diagnosed by all three frailty measures was found to be significantly associated with increased in-hospital mortality. In addition, frail patients were more likely to receive further nursing care after being discharged. All three frailty scores could improve the discrimination ability of the initial model generated by baseline characteristics for adverse outcomes. The FI-Lab had the best predictive ability for in-hospital mortality, whereas the HFRS had the best predictive performance for discharge with need for nursing care amongst the three frailty measures. A combination of the FI-Lab with either the HFRS or MFI improved the identification of critically ill patients at increased risk of in-hospital mortality. CONCLUSIONS frailty, as assessed by the HFRS, MFI and FI-Lab, was associated with short-term survival and discharge with need for nursing care amongst critically ill patients. The FI-Lab was a better predictor of in-hospital mortality than the HFRS and MFI. Future studies focusing on FI-Lab are warranted.
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Affiliation(s)
- Benchuan Hao
- Medical School of Chinese PLA, Beijing 100039, China
- Department of Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Tao Chen
- Department of Cardiology, The Sixth Medical Centre, Chinese PLA General Hospital, Beijing 100037, China
| | - Ji Qin
- Medical School of Chinese PLA, Beijing 100039, China
- Department of Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Wenwen Meng
- Department of Cardiology, The Sixth Medical Centre, Chinese PLA General Hospital, Beijing 100037, China
| | - Weimin Bai
- Department of Emergency, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou 463599, China
| | - Libo Zhao
- Medical School of Chinese PLA, Beijing 100039, China
- Department of Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Xianwen Ou
- College of Information Science & Technology Haikou, Hainan University, Hainan 570100, China
| | - Hongbin Liu
- Department of Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Weihao Xu
- Haikou Cadre's Sanitarium of Hainan Military Region, Haikou 570203, China
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12
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Chattaris T, Chahal K, Berry SD. Factors besides frailty index affect length of stay in older patients with hip fractures. Osteoporos Int 2023:10.1007/s00198-023-06798-4. [PMID: 37246196 PMCID: PMC10225280 DOI: 10.1007/s00198-023-06798-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/12/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Tanchanok Chattaris
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Karen Chahal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sarah D Berry
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Boston, MA, USA.
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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13
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Mousai O, Tafoureau L, Yovell T, Flaatten H, Guidet B, Beil M, de Lange D, Leaver S, Szczeklik W, Fjolner J, Nachshon A, van Heerden PV, Joskowicz L, Jung C, Hyams G, Sviri S. The role of clinical phenotypes in decisions to limit life-sustaining treatment for very old patients in the ICU. Ann Intensive Care 2023; 13:40. [PMID: 37162595 PMCID: PMC10170430 DOI: 10.1186/s13613-023-01136-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/02/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Limiting life-sustaining treatment (LST) in the intensive care unit (ICU) by withholding or withdrawing interventional therapies is considered appropriate if there is no expectation of beneficial outcome. Prognostication for very old patients is challenging due to the substantial biological and functional heterogeneity in that group. We have previously identified seven phenotypes in that cohort with distinct patterns of acute and geriatric characteristics. This study investigates the relationship between these phenotypes and decisions to limit LST in the ICU. METHODS This study is a post hoc analysis of the prospective observational VIP2 study in patients aged 80 years or older admitted to ICUs in 22 countries. The VIP2 study documented demographic, acute and geriatric characteristics as well as organ support and decisions to limit LST in the ICU. Phenotypes were identified by clustering analysis of admission characteristics. Patients who were assigned to one of seven phenotypes (n = 1268) were analysed with regard to limitations of LST. RESULTS The incidence of decisions to withhold or withdraw LST was 26.5% and 8.1%, respectively. The two phenotypes describing patients with prominent geriatric features and a phenotype representing the oldest old patients with low severity of the critical condition had the largest odds for withholding decisions. The discriminatory performance of logistic regression models in predicting limitations of LST after admission to the ICU was the best after combining phenotype, ventilatory support and country as independent variables. CONCLUSIONS Clinical phenotypes on ICU admission predict limitations of LST in the context of cultural norms (country). These findings can guide further research into biases and preferences involved in the decision-making about LST. Trial registration Clinical Trials NCT03370692 registered on 12 December 2017.
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Affiliation(s)
- Oded Mousai
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Lola Tafoureau
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Tamar Yovell
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint Antoine, service MIR, Paris, France
| | - Michael Beil
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Susannah Leaver
- General Intensive Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Jesper Fjolner
- Department of Anaesthesia and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Akiva Nachshon
- General Intensive Care Unit, Department of Anaesthesiology, Critical Care and Pain Medicine, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Peter Vernon van Heerden
- General Intensive Care Unit, Department of Anaesthesiology, Critical Care and Pain Medicine, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Leo Joskowicz
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Christian Jung
- Division of Cardiology, Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Gal Hyams
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Sigal Sviri
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
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14
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Milojevic M, Nikolic A. Management of Left Main Coronary Artery Disease in Nonemergent Settings: The Heart of Multidisciplinary Teamwork. JACC Cardiovasc Interv 2023; 16:289-291. [PMID: 36609039 DOI: 10.1016/j.jcin.2022.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/11/2022] [Accepted: 11/22/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Milan Milojevic
- Departments of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Aleksandar Nikolic
- Department of Cardiac Surgery, Acibadem Sistina Hospital, Skopje, North Macedonia
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15
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Chin M, Kendzerska T, Inoue J, Aw M, Mardiros L, Pease C, Andrew MK, Pakhale S, Forster AJ, Mulpuru S. Comparing the Hospital Frailty Risk Score and the Clinical Frailty Scale Among Older Adults With Chronic Obstructive Pulmonary Disease Exacerbation. JAMA Netw Open 2023; 6:e2253692. [PMID: 36729458 PMCID: PMC9896302 DOI: 10.1001/jamanetworkopen.2022.53692] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
IMPORTANCE Frailty is associated with severe morbidity and mortality among people with chronic obstructive pulmonary disease (COPD). Interventions such as pulmonary rehabilitation can treat and reverse frailty, yet frailty is not routinely measured in pulmonary clinical practice. It is unclear how population-based administrative data tools to screen for frailty compare with standard bedside assessments in this population. OBJECTIVE To determine the agreement between the Hospital Frailty Risk Score (HFRS) and the Clinical Frailty Scale (CFS) among hospitalized individuals with COPD and to determine the sensitivity and specificity of the HFRS (vs CFS) to detect frailty. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study was conducted among hospitalized patients with COPD exacerbation. The study was conducted in the respiratory ward of a single tertiary care academic hospital (The Ottawa Hospital, Ottawa, Ontario, Canada). Participants included consenting adult inpatients who were admitted with a diagnosis of acute COPD exacerbation from December 2016 to June 2019 and who used a clinical care pathway for COPD. There were no specific exclusion criteria. Data analysis was performed in March 2022. EXPOSURE Degree of frailty measured by the CFS. MAIN OUTCOMES AND MEASURES The HFRS was calculated using hospital administrative data. Primary outcomes were the sensitivity and specificity of the HFRS to detect frail and nonfrail individuals according to CFS assessments of frailty, and the secondary outcome was the optimal probability threshold of the HFRS to discriminate frail and nonfrail individuals. RESULTS Among 99 patients with COPD exacerbation (mean [SD] age, 70.6 [9.5] years; 56 women [57%]), 14 (14%) were not frail, 33 (33%) were vulnerable, 18 (18%) were mildly frail, and 34 (34%) were moderately to severely frail by the CFS. The HFRS (vs CFS) had a sensitivity of 27% and specificity of 93% to detect frail vs nonfrail individuals. The optimal probability threshold for the HFRS was 1.4 points or higher. The corresponding sensitivity to detect frailty was 69%, and the specificity was 57%. CONCLUSIONS AND RELEVANCE In this cross-sectional study, using the population-based HFRS to screen for frailty yielded poor detection of frailty among hospitalized patients with COPD compared with the bedside CFS. These findings suggest that use of the HFRS in this population may result in important missed opportunities to identify and provide early intervention for frailty, such as pulmonary rehabilitation.
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Affiliation(s)
- Melanie Chin
- Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Tetyana Kendzerska
- Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jiro Inoue
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Michael Aw
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Linda Mardiros
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Christopher Pease
- Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Melissa K. Andrew
- Department of Medicine (Geriatrics), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Smita Pakhale
- Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alan J. Forster
- The Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Sunita Mulpuru
- Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
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16
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Hao B, Xu W, Gao W, Huang T, Lyu L, Lyu D, Xiao H, Li H, Qin J, Sheng L, Liu H. Association between Frailty Assessed Using Two Electronic Medical Record-Based Frailty Assessment Tools and Long-Term Adverse Prognosis in Older Critically Ill Survivors. J Nutr Health Aging 2023; 27:649-655. [PMID: 37702338 DOI: 10.1007/s12603-023-1961-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 07/20/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVES Frailty has become an independent risk factor for adverse outcomes in critically ill patients. This study aimed to explore the predictive ability of two electronic medical record-based frailty assessment tools, the Hospital Frailty Risk Score (HFRS) and Frailty Index based on physiological and laboratory tests (FI-lab), for long-term adverse prognosis in older critically ill survivors. DESIGN Retrospective observational study. SETTING AND PARTICIPANTS 9,082 critically ill survivors aged ≥ 65 years. MEASUREMENTS The HFRS and the 33-item FI-lab were constructed based on the published literature. Cox and logistic regression models assessed the association between frailty and 1-year mortality and post-discharge care needs. RESULTS 2,586 patients died within 1 year of follow-up. In fully adjusted models, frailty assessed using both the HFRS (per point, hazard ratio [HR] 1.06, 95% confidential interval [CI] 1.05-1.06; intermediate frailty risk, HR 2.00, 95% CI 1.78-2.25; high frailty risk, HR 3.06, 95% CI 2.68-3.50) and FI-lab (per 0.01 points, HR 1.03, 95% CI 1.03-1.03; intermediate frailty risk, HR 1.59, 95% CI 1.44-1.76; high frailty risk, HR 2.30, 95% CI 2.06-2.57) was associated with mortality. Addition of frailty indicators improved the predictive validity of the Sequential Organ Failure Assessment score for mortality (HFRS alone ∆ C-index 0.034; FI-lab alone ∆ C-index 0.016; HFRS and FI-lab combined ∆ C-index 0.042). The HFRS but not the FI-lab was associated with higher probability of post-discharge care needs. CONCLUSION Both the HFRS and FI-lab could independently predict 1-year mortality in older critically ill survivors. Adding the HFRS to the SOFA score model improved it more than adding the FI-lab. The greatest improvement was achieved when both frailty indicators were used together. These findings suggest that electronic medical record-based frailty assessment methods can be useful tools for predicting long-term outcomes in older critically ill patients.
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Affiliation(s)
- B Hao
- Li Sheng, Department of Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing, China, ; Hongbin Liu, Department of Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing, China, e-mail:
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Muacevic A, Adler JR, Shieh MS, Demir-Yavuz S, Steingrub JS. The Association of Frailty With Long-Term Outcomes in Patients With Acute Respiratory Failure Treated With Noninvasive Ventilation. Cureus 2022; 14:e33143. [PMID: 36726891 PMCID: PMC9886411 DOI: 10.7759/cureus.33143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2022] [Indexed: 12/31/2022] Open
Abstract
The objective of this study was to investigate the prevalence and impact of frailty on mortality in patients with acute respiratory failure (ARF) treated with noninvasive ventilation (NIV). This was a single-center, prospective study of patients who developed ARF (irrespective of etiology) and were treated with NIV support. Frailty was assessed using the Clinical Frailty Scale (CFS). We modeled the relationship of CFS with one-year mortality using Cox proportional hazards regression, adjusting for other clinical and demographic characteristics. Of the 166 patients enrolled, 48% had moderate to severe frailty. These patients were more likely to be female (67% versus 33%) and on oxygen therapy at home (46% versus 28%). The median CFS score was 5 (interquartile range (IQR): 5-6). Moderate to severe frailty was associated with a 60% higher risk of one-year mortality (hazard ratio (HR): 1.63, 95% confidence interval (CI): 1.15-2.31). Frailty assessment may identify patients in need of ventilatory support who are at increased risk of mortality and may be an important factor to consider when discussing goals of care in this vulnerable population.
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Subramaniam A, Ueno R, Tiruvoipati R, Darvall J, Srikanth V, Bailey M, Pilcher D, Bellomo R. Comparing the Clinical Frailty Scale and an International Classification of Diseases-10 Modified Frailty Index in Predicting Long-Term Survival in Critically Ill Patients. Crit Care Explor 2022; 4:e0777. [PMID: 36259062 DOI: 10.1097/CCE.0000000000000777] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The Clinical Frailty Scale (CFS) is the most used frailty measure in intensive care unit (ICU) patients. Recently, the modified frailty index (mFI), derived from 11 comorbidities has also been used. It is unclear to what degree the mFI is a true measure of frailty rather than comorbidity. Furthermore, the mFI cannot be freely obtained outside of specific proprietary databases. OBJECTIVE To compare the performance of CFS and a recently developed International Classification of Diseases-10 (ICD-10) mFI (ICD-10mFI) as frailty-based predictors of long-term survival for up to 1 year. DESIGN A retrospective multicentric observational study. SETTING AND PARTICIPANTS All adult (≥16 yr) critically ill patients with documented CFS scores admitted to sixteen Australian ICUs in the state of Victoria between April 1, 2017 to June 30, 2018 were included. We used probabilistic methods to match de-identified ICU admission episodes listed in the Australia and New Zealand Intensive Care Society Adult Patient Database with the Victorian Admission Episode Dataset and the Victorian Death Index via the Victorian Data Linkage Centre. MAIN OUTCOMES AND MEASURES The primary outcome was the longest available survival following ICU admission. We compared CFS and ICD-10mFI as primary outcome predictors, after adjusting for key confounders. RESULTS The CFS and ICD-10mFI were compared in 7,001 ICU patients. The proportion of patients categorized as frail was greater with the CFS than with the ICD-10mFI (18.9% [n = 1,323] vs. 8.8% [n = 616]; p < 0.001). The median (IQR) follow-up time was 165 (82-276) days. The CFS predicted long-term survival up to 6 months after adjusting for confounders (hazard ratio [HR] = 1.26, 95% CI, 1.21-1.31), whereas ICD-10mFI did not (HR = 1.04, 95% CI, 0.98-1.10). The ICD-10mFI weakly correlated with the CFS (Spearman's rho = 0.22) but had a poor agreement (kappa = 0.06). The ICD-10mFI more strongly correlated with the Charlson comorbidity index (Spearman's rho 0.30) than CFS (Spearman's rho = 0.25) (p < 0.001). CONCLUSIONS CFS, but not ICD-10mFI, predicted long-term survival in ICU patients. ICD-10mFI correlated with co-morbidities more than CFS. These findings suggest that CFS and ICD-10mFI are not equivalent. RELEVANCE CFS and ICD-10mFI are not equivalent in screening for frailty in critically ill patients and therefore ICD-10mFI in its current form should not be used.
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Fowler AJ, Stephens TJ, Partridge J, Dhesi J. Surgery in older patients: learning from shared decision-making in intensive care. Br J Anaesth 2022:S0007-0912(22)00440-8. [PMID: 36109204 DOI: 10.1016/j.bja.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 11/21/2022] Open
Abstract
An increasing number of older patients are having surgical treatments. Similar to older patients admitted to intensive care, they present with additional problems including multimorbidity, frailty, and cognitive impairment. In both intensive care and surgical settings, comprehensive assessment can inform targeted interventions and shared decision-making. We explore the challenges faced by older patients, and by the clinicians treating them.
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