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Callan KT, Donnelly M, Lung B, McLellan M, DiGiovanni R, McMaster W, Yang S, Stitzlein R. Risk factors for postoperative delirium in orthopaedic hip surgery patients: a database review. BMC Musculoskelet Disord 2024; 25:71. [PMID: 38233831 PMCID: PMC10792907 DOI: 10.1186/s12891-024-07174-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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/05/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Postoperative delirium is a common problem affecting admitted patients that decreases patient satisfaction and increases the cost and complexity of care. The purpose of this study was to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to compare rates and risk factors of postoperative delirium for total hip arthroplasty (THA) and hemiarthroplasty patients indicated for osteoarthritis or proximal femur fracture. METHODS The 2021 NSQIP database was queried for patients using Current Procedural Terminology (CPT) codes for THA and hemiarthroplasty and ICD-10 codes for osteoarthritis or proximal femur fracture. Demographic, past medical history, preoperative labs, and functional status data were recorded. Procedural data were also collected. Finally, postoperative outcomes and complications were reviewed. RESULTS Overall, 16% of patients had postoperative delirium. Delirium patients were older on average (82.4 years vs. 80.7 years, p < 0.001), had a lower BMI (19.5 vs. 24.8, p < 0.001), were more likely to have a history of dementia (54.6% vs. 13.6%, p < 0.001), were less likely to have an independent functional status (p < 0.001) or live alone (p < 0.001), and were more likely to have sustained a recent fall (p < 0.001). Delirium patients were more likely to be hyponatremic or hypernatremic (p = 0.002), anemic (p < 0.001), and severely dehydrated (p < 0.001), among other lab abnormalities. Delirium patients were also more likely to experience additional postoperative complications, including pneumonia, pulmonary embolism, urinary tract infection, stroke, cardiac arrest, sepsis, and unplanned reoperation and readmission after discharge (all p < 0.05). CONCLUSIONS In this study, factors associated with postoperative delirium in patients undergoing hemiarthroplasty and THA were identified, including older age, lower BMI, certain medical conditions, decreased functional status, certain lab abnormalities, and postoperative complications. These findings can be used by clinicians to better inform care and to determine when orthopaedic joint replacement patients may be at an increased risk for postoperative delirium.
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Affiliation(s)
- Kylie T Callan
- University of California Irvine School of Medicine, Irvine, CA, USA.
| | - Megan Donnelly
- New York University Langone Medical Center, New York, NY, USA
| | - Brandon Lung
- University of California Irvine Health, Orange, CA, USA
| | | | | | | | - Steven Yang
- University of California Irvine Health, Orange, CA, USA
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Harris JP, Park J, Ku E, Seyedin S, Stitzlein R, Goldin A, Chen WP, McLaren C, Chen AM, Chow W. A Pilot Study of Pembrolizumab Combined With Stereotactic Ablative Radiotherapy for Patients With Advanced or Metastatic Sarcoma. Cancer Control 2024; 31:10732748241237331. [PMID: 38449377 PMCID: PMC10919132 DOI: 10.1177/10732748241237331] [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] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/07/2024] [Accepted: 02/19/2024] [Indexed: 03/08/2024] Open
Abstract
OBJECTIVES Immunotherapy with immune checkpoint inhibitors has shown only limited success in the management of metastatic soft tissue sarcoma. Overall response rates (ORR) with single agent pembrolizumab were 18% and median PFS was 18 weeks on the clinical trial SARC028. One strategy to improve the responses to immunotherapy is with stereotactic body radiation therapy (SBRT), which can enhance the antitumor CD8 T cell response through the release of tumor-specific antigens, potentially priming a more diverse class of T cell receptors. METHODS This is a phase 0, pilot prospective study taking place at a single center with 2 arms. In Arm A, patients are treated with pembrolizumab 400 mg IV infusion on day 1 of a 42-day cycle. Stereotactic body radiation therapy (SBRT) is delivered in 1-5 fractions starting on C1D15-28 and given every other day. In Arm B, patients who have started an immune checkpoint inhibitor within 60 days are treated with SBRT in addition to the current therapy. RESULTS In this study we outline testing the feasibility of adding SBRT to pembrolizumab. CONCLUSION The ultimate goal of combination therapy is improved overall response, including tumors not treated with SBRT. This trial can be found registered online: NCT05488366.
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Affiliation(s)
- Jeremy P. Harris
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Jino Park
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Eric Ku
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Steven Seyedin
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Russell Stitzlein
- Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - Amanda Goldin
- Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - Wen-Pin Chen
- Biostatistics Shared Resource, University of California Irvine, Chao Family Comprehensive Cancer Center, Orange, CA, USA
| | - Christine McLaren
- Biostatistics Shared Resource, University of California Irvine, Chao Family Comprehensive Cancer Center, Orange, CA, USA
| | - Allen M. Chen
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Warren Chow
- Department of Medicine, Division of Hematology/Oncology, University of California Irvine, Orange, CA, USA
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Ku E, Harada G, Chiao E, Rao P, Hosseinian S, Seyedin S, Healy E, Maxim P, Chow W, Stitzlein R, Limoli C, Harris J. The Correlation Between Lymphocyte Nadir and Radiation Therapy for Soft Tissue Sarcoma: Defining Key Dosimetric Parameters and Outlining Clinical Significance. Adv Radiat Oncol 2024; 9:101309. [PMID: 38260229 PMCID: PMC10801664 DOI: 10.1016/j.adro.2023.101309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/28/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose The objectives of this study were to identify key dosimetric parameters associated with postradiation therapy lymphopenia and uncover any effect on clinical outcomes. Methods and Materials This was a retrospective review of 69 patients (between April 2010 and January 2023) who underwent radiation therapy (RT) as a part of curative intent for soft tissue sarcoma (STS) at a single academic institution. All patients with treatment plans available to review and measurable absolute lymphocyte count (ALC) nadir within a year after completion of RT were included. Results Median follow-up was 22 months after the start of RT. A decrease in lymphocyte count was noted as early as during treatment and persisted at least 3 months after the completion of RT. On multivariable linear regression, the strongest correlations with ALC nadir were mean body dose, body V10 Gy, mean bone dose, bone V10 Gy, and bone V20 Gy. Five-year overall survival was 60% and 5-year disease-free survival was 44%. Advanced T-stage, chemotherapy use, use of intensity-modulated RT, lower ALC nadir, and the development of grade ≥2 lymphopenia at nadir were associated with worse overall survival and disease-free survival. Conclusions Post-RT lymphopenia was associated with worse outcomes in STS. There were associations between higher body V10 Gy and bone V10 Gy and lower post-RT ALC nadir, despite the varying sites of STS presentation, which aligns with the well-known radiosensitivity of lymphocyte cell lines. These findings support efforts to reduce treatment-related hematopoietic toxicity as a way to improve oncologic outcomes. Additionally, this study supports the idea that the effect of radiation on lymphocyte progenitors in the bone marrow is more significant than that on circulating lymphocytes in treatments with limited involvement of the heart and lung.
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Affiliation(s)
- Eric Ku
- Department of Radiation Oncology, University of California, Irvine, Orange, California
| | - Garrett Harada
- Department of Radiation Oncology, University of California, Irvine, Orange, California
| | - Elaine Chiao
- School of Medicine, University of California, Irvine, Irvine, California
| | - Pranathi Rao
- School of Medicine, University of California, Irvine, Irvine, California
| | - Sina Hosseinian
- School of Medicine, University of California, Irvine, Irvine, California
| | - Steven Seyedin
- Department of Radiation Oncology, University of California, Irvine, Orange, California
| | - Erin Healy
- Department of Radiation Oncology, University of California, Irvine, Orange, California
| | - Peter Maxim
- Department of Radiation Oncology, University of California, Irvine, Orange, California
| | - Warren Chow
- Department of Hematology/Oncology, University of California, Irvine, Orange, California
| | - Russell Stitzlein
- Orthopedic Surgery, University of California, Irvine, Orange, California
| | - Charles Limoli
- Department of Radiation Oncology, University of California, Irvine, Orange, California
| | - Jeremy Harris
- Department of Radiation Oncology, University of California, Irvine, Orange, California
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Boyd C, Ou S, Long S, Stitzlein R, Abi-Jaoudeh N. Abstract No. 578 Bone and soft tissue ablation of painful thoracic metastasis: single center review of palliative ablation of metastatic rib and intercostal lesions. J Vasc Interv Radiol 2022. [DOI: 10.1016/j.jvir.2022.03.560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Bershadsky B, Kane RL, Wuerz T, Jones M, Brighton B, Stitzlein R, Parker R, Iannotti JP. Preliminary validation of the Review of Musculoskeletal System (ROMS) questionnaire. J Bone Joint Surg Am 2015; 97:582-9. [PMID: 25834083 DOI: 10.2106/jbjs.m.01078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Measurement of clinical outcomes is necessary to define best practice. It requires a validated tool that can be easily applied as part of clinical practice. We present the preliminary validation of a brief self-reported Review of Musculoskeletal System (ROMS) questionnaire that captures functional limitations due to musculoskeletal problems and other medical and emotional conditions. METHODS Data were derived from a clinical outcomes database (Orthopaedic Minimal Data Set [OrthoMiDaS]) that combines patient-reported data collected as part of routine care and secondary data extracted from electronic medical records. The study utilized 82,873 encounters collected from 24,116 consecutive patients with problems in the upper and lower extremities. In addition to the ROMS, the study used version 2 of the Short Form-12 (SF-12v2), the Penn Shoulder Score (PSS), the Hip disability and Osteoarthritis Outcome Score (HOOS), and the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaires. Fifteen cross-sectional samples were used to evaluate the floor and ceiling effects as well as the construct and content validity. Five longitudinal cohorts were used to measure test-retest reliability and responsiveness. Standard statistical tests were applied. RESULTS The floor and ceiling effects of the ROMS questionnaire in patients with shoulder, hip, and knee problems ranged from 1.3% to 8.5%. Construct-validity tests confirmed convergent and divergent validity of the ROMS. The tests also justified its additional value when the ROMS was used with joint-specific tools. When measuring test-retest reliability of the ROMS scales, intraclass correlation ranged from 0.80 to 0.90 at approximately one week and from 0.71 to 0.87 at approximately four weeks. Responsiveness of the ROMS was greater than that of the SF-12 and less than that of the joint-specific questionnaires. CONCLUSIONS The ROMS is compatible with routine clinical process and has good psychometric properties in patients with shoulder, hip, and knee disorders. It can be used as a primary outcome tool for large observational studies and can supplement more specific tools in controlled studies. CLINICAL RELEVANCE The ROMS was developed as a tool to measure and monitor the clinical status of the musculoskeletal system in a population of patients during and after treatment as well as over time.
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Affiliation(s)
- Boris Bershadsky
- School of Public Health, University of Minnesota, 420 Delaware Street S.E., Minneapolis, MN 55455
| | - Robert L Kane
- School of Public Health, University of Minnesota, 420 Delaware Street S.E., Minneapolis, MN 55455
| | - Thomas Wuerz
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address for J.P. Iannotti:
| | - Morgan Jones
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address for J.P. Iannotti:
| | - Brian Brighton
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address for J.P. Iannotti:
| | - Russell Stitzlein
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address for J.P. Iannotti:
| | - Richard Parker
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address for J.P. Iannotti:
| | - Joseph P Iannotti
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address for J.P. Iannotti:
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