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Shinall MC, Arya S, Youk A, Varley P, Shah R, Massarweh NN, Shireman PK, Johanning JM, Brown AJ, Christie NA, Crist L, Curtin CM, Drolet BC, Dhupar R, Griffin J, Ibinson JW, Johnson JT, Kinney S, LaGrange C, Langerman A, Loyd GE, Mady LJ, Mott MP, Patri M, Siebler JC, Stimson CJ, Thorell WE, Vincent SA, Hall DE. Association of Preoperative Patient Frailty and Operative Stress With Postoperative Mortality. JAMA Surg 2020; 155:e194620. [PMID: 31721994 DOI: 10.1001/jamasurg.2019.4620] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance Patients with frailty have higher risk for postoperative mortality and complications; however, most research has focused on small groups of high-risk procedures. The associations among frailty, operative stress, and mortality are poorly understood. Objective To assess the association between frailty and mortality at varying levels of operative stress as measured by the Operative Stress Score, a novel measure created for this study. Design, Setting, and Participants This retrospective cohort study included veterans in the Veterans Administration Surgical Quality Improvement Program from April 1, 2010, through March 31, 2014, who underwent a noncardiac surgical procedure at Veterans Health Administration Hospitals and had information available on vital status (whether the patient was alive or deceased) at 1 year postoperatively. A Delphi consensus method was used to stratify surgical procedures into 5 categories of physiologic stress. Exposures Frailty as measured by the Risk Analysis Index and operative stress as measured by the Operative Stress Score. Main Outcomes and Measures Postoperative mortality at 30, 90, and 180 days. Results Of 432 828 unique patients (401 453 males [92.8%]; mean (SD) age, 61.0 [12.9] years), 36 579 (8.5%) were frail and 9113 (2.1%) were very frail. The 30-day mortality rate among patients who were frail and underwent the lowest-stress surgical procedures (eg, cystoscopy) was 1.55% (95% CI, 1.20%-1.97%) and among patients with frailty who underwent the moderate-stress surgical procedures (eg, laparoscopic cholecystectomy) was 5.13% (95% CI, 4.79%-5.48%); these rates exceeded the 1% mortality rate often used to define high-risk surgery. Among patients who were very frail, 30-day mortality rates were higher after the lowest-stress surgical procedures (10.34%; 95% CI, 7.73%-13.48%) and after the moderate-stress surgical procedures (18.74%; 95% CI, 17.72%-19.80%). For patients who were frail and very frail, mortality continued to increase at 90 and 180 days, reaching 43.00% (95% CI, 41.69%-44.32%) for very frail patients at 180 days after moderate-stress surgical procedures. Conclusions and Relevance We developed a novel operative stress score to quantify physiologic stress for surgical procedures. Patients who were frail and very frail had high rates of postoperative mortality across all levels of the Operative Stress Score. These findings suggest that frailty screening should be applied universally because low- and moderate-stress procedures may be high risk among patients who are frail.
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Affiliation(s)
- Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California.,Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick Varley
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rupen Shah
- Department of Surgery, Henry Ford Health System, Detroit, Michigan
| | - Nader N Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio
| | - Jason M Johanning
- Department of Surgery, University of Nebraska Medical Center, Omaha.,Nebraska Western Iowa Veterans Affairs Health System, Omaha
| | - Alaina J Brown
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neil A Christie
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lawrence Crist
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Brian C Drolet
- Deparment of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rajeev Dhupar
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jennifer Griffin
- Department of Obstetrics and Gynecology, University of Nebraska Medical Center, Omaha
| | - James W Ibinson
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonas T Johnson
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sonja Kinney
- Department of Obstetrics and Gynecology, University of Nebraska Medical Center, Omaha
| | - Chad LaGrange
- Division of Urology, University of Nebraska Medical Center, Omaha
| | - Alexander Langerman
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gary E Loyd
- Perioperative Surgical Home, Henry Ford Health System, Detroit, Michigan
| | - Leila J Mady
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael P Mott
- Department of Orthopedic Surgery, Henry Ford Health System, Detroit, Michigan
| | - Murali Patri
- Department of Anesthesiology, Henry Ford Health System, Detroit, Michigan
| | - Justin C Siebler
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha
| | - C J Stimson
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William E Thorell
- Department of Neurosurgery, University of Nebraska Medical Center, Omaha
| | - Scott A Vincent
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Tibballs J, Kinney S, Duke T, Oakley E, Hennessy M. Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results. Arch Dis Child 2005; 90:1148-52. [PMID: 16243869 PMCID: PMC1720176 DOI: 10.1136/adc.2004.069401] [Citation(s) in RCA: 141] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To determine the impact of a paediatric medical emergency team (MET) on cardiac arrest, mortality, and unplanned admission to intensive care in a paediatric tertiary care hospital. METHODS Comparison of the retrospective incidence of cardiac arrest and death during 41 months before introduction of a MET service with the prospective incidence of these events during 12 months after its introduction. Comparison of transgression of MET call criteria in patients who arrested and died before and after introduction of MET. RESULTS Cardiac arrest decreased from 20 among 104 780 admissions (0.19/1000) to 4 among 35 892 admissions (0.11/1000) (risk ratio 1.71, 95% CI 0.59 to 5.01), while death decreased from 13 (0.12/1000) to 2 (0.06/1000) during these periods (risk ratio 2.22, 95% CI 0.50 to 9.87). Unplanned admissions to intensive care increased from 20 (SD 6) to 24 (SD 9) per month. The incidence of transgression of MET call criteria in patients who arrested decreased from 17 to 0 (risk difference 0.16/1000, 95% CI 0.09 to 0.24), and in those who died, decreased from 12 to 0 (risk difference 0.11/1000, 95% CI 0.05 to 0.18) after introduction of MET. CONCLUSIONS Introduction of a medical emergency team service was coincident with a reduction of cardiac arrest and mortality and a slight increase in admissions to intensive care.
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Affiliation(s)
- J Tibballs
- Intensive Care Unit, Royal Children's Hospital, Melbourne, Australia.
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Liesenfeld O, Montoya JG, Kinney S, Press C, Remington JS. Effect of testing for IgG avidity in the diagnosis of Toxoplasma gondii infection in pregnant women: experience in a US reference laboratory. J Infect Dis 2001; 183:1248-53. [PMID: 11262207 DOI: 10.1086/319672] [Citation(s) in RCA: 136] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2000] [Revised: 01/10/2001] [Indexed: 11/03/2022] Open
Abstract
The usefulness of testing for IgG avidity in association with Toxoplasma gondii was evaluated in a US reference laboratory. European investigators have reported that high-avidity IgG toxoplasma antibodies exclude acute infection in the preceding 3 months. In this US study, 125 serum samples taken from 125 pregnant women in the first trimester were chosen retrospectively, because either the IgM or differential agglutination (AC/HS) test in the Toxoplasma serologic profile suggested or was equivocal for a recently acquired infection. Of 93 (74.4%) serum samples with either positive or equivocal results in the IgM ELISA, 52 (55.9%) had high-avidity antibodies, which suggests that the infection probably was acquired before gestation. Of 87 (69.6%) serum samples with an acute or equivocal result in the AC/HS test, 35 (40.2%) had high-avidity antibodies. Forty women were given spiramycin, to prevent congenital transmission, and 7 (17.5%) had high-avidity antibodies. These findings highlight the value of testing a single serum sample obtained in the first trimester of pregnancy for IgG avidity.
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Affiliation(s)
- O Liesenfeld
- Department of Immunology and Infectious Diseases, Research Institute, Palo Alto Medical Foundation, Ames Bldg., 795 El Camino Real, Palo Alto, CA 94301, USA
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Therrell BL, Hannon WH, Pass KA, Lorey F, Brokopp C, Eckman J, Glass M, Heidenreich R, Kinney S, Kling S, Landenburger G, Meaney FJ, McCabe ER, Panny S, Schwartz M, Shapira E. Guidelines for the retention, storage, and use of residual dried blood spot samples after newborn screening analysis: statement of the Council of Regional Networks for Genetic Services. Biochem Mol Med 1996; 57:116-24. [PMID: 8733889 DOI: 10.1006/bmme.1996.0017] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
These guidelines provide scientific information for policy development by state health departments considering appropriate use of newborn screening specimens after screening tests are finished. Information was collected, debated, and formulated into a policy statement by the Newborn Screening Committee of the Council of Regional Networks for Genetic Services (CORN), a federally funded national consortium of representatives from 10 regional genetics networks. Newborn screening programs vary widely in approaches and policies concerning residual dried blood spot samples (DBS) collected for newborn screening. Recognition of the epidemiological utility of DBS samples for HIV seroprevalence surveys and a growing interest in DBSs for DNA analysis has intensified consideration of issues regarding retention, storage, and use of residual DBS samples. Potentially these samples provide a genetic material "bank" for all newborns nationwide. Their values as a resource for other uses has already been recognized by scientists, administrators, and judicial officials. Programs should promulgate rules for retention and use of residual newborn screening DBS samples based on scientifically valid information. Banking of newborn samples as sources of genetic material should be considered in light of potential benefit or harm to society.
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Affiliation(s)
- B L Therrell
- Bureau of Laboratories, Texas Department of Health, Austin 78756, USA.
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