Association of Frailty With Post-Operative Outcomes of Older Adults Undergoing Elective Ostomy Reversal

BACKGROUND

Ostomy reversal is a common surgical procedure; however, it is not without associated risks. Patient selection for this elective procedure is therefore critically important. Elderly patients represent a growing population and a substantial proportion of patients that present for evaluation after ostomy creation due to the most common etiologies. This study aims to assess the impact of frailty on the outcomes of ostomy reversal among older adults.

METHODS

Patients ≥65 years who underwent ostomy reversal from 2015 to 2019 were identified in the NSQIP database. Frailty was calculated using the 5-item Modified Frailty Index (MFI). Multivariate regression was performed to evaluate the association of frailty with post-operative 30-day mortality, 30-day serious complications, discharge to a facility, and 30-day readmission.

RESULTS

A total of 13,053 patients were included, of which 18.7% were frail (MFI ≥ 2). Patients who underwent colostomy reversal had higher rates of serious complications (P < .0001) and discharge to facility (P < .0001) compared to other reversals. In multivariate analysis, frailty was associated with increased odds of serious complications (OR 1.52, 95% CI 1.31-1.77), discharge to facility (OR 2.14, 95% CI 1.79-2.57), and readmission (OR 1.23, 95% CI 1.04-1.46), but not mortality. Frail patients had predicted probabilities 1.4 times higher for serious complications and 1.7-2.2 times greater for discharge to facility than non-frail patients.

CONCLUSIONS

Among older adults undergoing elective ostomy reversal, frailty is independently associated with increased odds of 30-day serious complications, discharge to facility, and 30-day readmission. As a potentially modifiable risk factor, identification of frailty offers the opportunity for shared decision-making and prehabilitation.

Impact of Automated Reminder Calls in a Safety-Net Setting on Surgical Clinic No-Show Rates

In surgical clinics, missed appointments may lead to delayed diagnosis and postponed surgical intervention. Automated reminder calls (robocalls) have replaced live staff phone calls in many systems as a cost-saving measure. This study aims to evaluate whether robocalls reduced the outpatient appointment no-show rate for surgical patients in a county hospital. Demographic and clinic data from two surgical clinics at a safety net hospital were collected over two time periods: 3-months immediately before robocalls went live and 3-months immediately after robocalls went live. No-show rates were compared between time periods. Multivariate analysis confirmed that robocalls were independently associated with reduced no-show rates (OR: 1.32; 95% CI: 1.0-1.7; P = .032). In addition, new appointments were independently predictive of higher no-show rates (OR: 1.32; 95% CI: 1.0-1.7; P = .048). Robocalls appear to be an effective tool for improving appointment attendance overall. Furthermore, robocalls may free limited staff to perform higher value work in the healthcare system.

The impact of waste reduction in general surgery operating rooms

INTRODUCTION

Operating rooms are responsible for a significant burden of waste and negative environmental impact. This study aimed to reduce OR waste and improve both environmental impact and hospital cost savings.

METHODS

The unused items in two standard single-use surgical packs were tracked for general surgery cases. A new pack was created excluding the most frequently unused items. The feasibility of the new pack was then tested, and a projected cost savings analysis was performed.

RESULTS

A total of 35 general surgery operations were tracked using two standard packs ($89.51 or $93.68 per case, each 23.2 lbs). The new pack ($46.88 per case, 20.8 lbs) was then successfully used in nine cases. The projected cost-savings of substituting the new pack was $45,719 annually with a 2437 pounds annual waste reduction.

CONCLUSIONS

Simple and feasible adjustments to standard single-use surgical packs can have a significant impact on waste reduction and cost-savings.

Is laparoscopic surgery safe for elderly patients with diverticulitis? A national database study

PURPOSE

Laparoscopy is the preferred approach to elective surgery for diverticulitis and is increasingly common in the emergent setting. Although diverticulitis is most prevalent among older adults, little is known about the safety of laparoscopy for elderly patients with diverticulitis. This study aims to compare 30-day outcomes of a laparoscopic versus open approach for diverticulitis among elderly patients undergoing elective and urgent/emergent surgery.

METHODS

Patients ≥ 65 years who underwent surgery for diverticulitis from 2015 to 2019 were identified from the ACS-NSQIP database. Elective and non-elective groups were analyzed separately. Coarsened exact matching matched laparoscopic and open patients 1:1 based on preoperative factors to minimize selection bias by creating comparable cohorts. Short-term outcomes of laparoscopic versus open surgery were compared.

RESULTS

A total of 15,316 patients were included, 69.2% female and 88% White, with a mean age of 72.7 ± 6.1 years. Approximately half (50.9%) of cases were laparoscopic and 60.6% were elective. After matching, laparoscopy was associated with lower 30-day morbidity in both the elective (OR, 0.47; 95%CI, 0.38-0.58) and non-elective (OR, 0.76; 95%CI, 0.58-0.98) cohorts. Laparoscopic surgery in both cohorts was associated with fewer surgical site infections (SSIs) (elective, OR 0.43; 95%CI, 0.33-0.57; non-elective, OR, 0.66; 95%CI, 0.44-0.98) and shorter length of stay (LOS) (elective, mean difference, 1.7 days; 95%CI, 1.5-1.9; non-elective, mean difference, 1.2 days; 95%CI, 0.43-2.1).

CONCLUSION

Elderly patients undergoing both elective and non-elective laparoscopic surgery for diverticulitis have less 30-day morbidity, SSIs, and shorter LOS compared to an open approach. Therefore, laparoscopy for elderly patients is safe in elective surgery and in select emergent cases as well.

Early Outcomes of Subtotal vs Total Cholecystectomy for Acute Cholecystitis

This cohort study compares outcomes including hospital length of stay and 30-day rates of complications after nonelective subtotal cholecystectomy vs total cholecystectomy among patients with cholecystitis.

Early Cholecystectomy in Gallstone Pancreatitis Patients With and Without End Organ Dysfunction: A NQSIP Analysis

INTRODUCTION

While literature widely supports early cholecystectomy for mild gallstone pancreatitis (GSP), this has not been reflected in clinical practice. Early cholecystectomy for GSP with end organ dysfunction remains controversial.

OBJECTIVE

This study aims to evaluate the rate and outcomes of early cholecystectomy (<3 days from admission) in mild GSP patients with end organ dysfunction (+EOD) and without (-EOD).

METHODS

Patients with GSP without necrosis were identified from 2017 to 2019 NSQIP database and categorized into GSP±EOD. Coarsened Exact Matching was used to match patients based on preoperative risk factors in each group, and outcomes were compared.

RESULTS

There was a total of 3104 patients -EOD and 917 +EOD in the aggregate cohort. Early cholecystectomy was performed in 1520 (49.0%) of GSP-EOD and in 407 (44.4%) of GSP+EOD. In the matched cohorts, there were no significant differences in 30-day mortality, morbidity, or reoperation for early cholecystectomy in either group. In GSP-EOD, early cholecystectomy was associated with shorter LOS (2.9 ± 1.5 vs. 5.6 ± 3.0 days, P < .001), shorter operative time (69.7 ± 34.4 vs. 73.3 ± 36.6 min, P = .045), and more concurrent biliary procedures (52.1% vs. 35.4%, P < .001). Similarly, early cholecystectomy in GSP+EOD was associated with shorter LOS (3.3 ± 1.8 vs. 6.9 ± 6.6 days, P < .001), shorter operative time (65.9 ± 32.1 vs. 76.0 ± 40.7, P < .001), and more concurrent biliary procedure (46.0% vs. 34.9%, P = .002).

CONCLUSIONS

This study supports early cholecystectomy in patients with mild GSP. Even with end organ dysfunction, early cholecystectomy appears to be safe given there is no difference in morbidity and mortality, and the potential benefit of reduced LOS.

The Impact of Primary Care Physicians on the Surgical Presentation and Outcomes of Colorectal Cancer in Vulnerable Populations

BACKGROUND

Multiple socioeconomic and clinical factors have been implicated in the health disparities that exist amongst vulnerable populations with colorectal cancer. Efforts have been directed toward addressing these factors to improve outcomes. We evaluate the impact of primary care physicians (PCP) on the surgical presentation and outcomes of colorectal cancer at a safety-net hospital.

METHODS

A retrospective chart review of 331 patients diagnosed with colorectal adenocarcinoma between 2014 and 2020 at a single-institution urban county medical center.

RESULTS

The cohort was predominantly male (59%) and Hispanic (52.1%). Thirty-two percent of patients had a PCP at time of diagnosis. Patients with PCPs compared to those without PCPs had significantly lower rates of acute presentation (perforation or obstruction) (17.0 vs 38.1%, P < .001), higher rates of surgical resection (83.0 vs 70.7%, P = .016), and were less likely to have metastatic disease at presentation (20.4 vs 33.5%, P = .02). Overall, having a PCP also improved probability of survival (HR 1.36, P < .04).

CONCLUSION

Having a PCP at the time of colorectal cancer diagnosis is associated with improved outcomes in a safety-net population, with significant differences in surgical presentation and resection.

Outcomes of Highest Grade (IV and V) Liver Injuries in Blunt and Penetrating Trauma

BACKGROUND

High-grade hepatic trauma can be devastating, with complications being common if patients survive. Studies comparing outcome differences between blunt and penetrating mechanism are lacking. This study aimed to describe and evaluate the association of traumatic mechanism with complications in patients sustaining grades IV and V liver injuries.

METHODS

A retrospective review of all adults who suffered grades IV and V liver injury from 2015-2020 was performed at a level I trauma center in an urban area. Outcomes in patients with blunt and penetrating mechanisms were compared.

RESULTS

A total of 103 patients were included, of which 44 (43%) were penetrating and the remainder blunt. Patients with penetrating injuries were younger, more often male, and more likely to undergo initial operative management (82% vs 40%, P < .001). Regardless of mechanism, high grade liver injuries had similar rates of complications, including bile leak (17% vs 23%, P = .559) and intrabdominal abscess (7% vs 16%, P = .239), and similar need for endoscopic retrograde cholangiopancreatography (12% vs 19%, P = .379). Penetrating injuries required more re-interventions (42% vs 19%, P = .033), specifically more percutaneous drainage procedures (36% vs 12%, P = .016). Overall mortality was 29% and did not differ by mechanism.

DISCUSSION

Morbidity and mortality are high for grades IV and V liver injuries. Penetrating high-grade hepatic injuries are more likely to be managed operatively, but mortality and overall complications are similar to blunt mechanisms. This may allow for uniform algorithms to define management strategies regardless of mechanism.

Vascular Function Is Improved After an Environmental Enrichment Program

Environmental enrichment may slow cognitive decay possibly acting through an improvement in vascular function. Aim of the study was to assess the effects of a 7-month cognitive, social, and physical training program on cognitive and vascular function in patients with mild cognitive impairment. In a single-center, randomized, parallel-group study, 113 patients (age, 65–89 years) were randomized to multidomain training (n=55) or usual care (n=58). All participants underwent neuropsychological tests and vascular evaluation, including brachial artery flow-mediated dilation, carotid–femoral pulse wave velocity, carotid distensibility, and assessment of circulating hematopoietic CD34+ and endothelial progenitor cells. At study entry, an age-matched control group (n=45) was also studied. Compared with controls, patients had at study entry a reduced flow-mediated dilation (2.97±2.14% versus 3.73±2.06%; P =0.03) and hyperemic stimulus (shear rate area under the curve, 19.1±15.7 versus 25.7±15.1×10 −3 ; P =0.009); only the latter remained significant after adjustment for confounders ( P =0.03). Training improved Alzheimer disease assessment scale cognitive (training, 14.0±4.8 to 13.1±5.5; nontraining, 12.1±3.9 to 13.2±4.8; P for interaction visit×training=0.02), flow-mediated dilation (2.82±2.19% to 3.40±1.81%, 3.05±2.08% to 2.24±1.59%; P =0.006; P =0.023 after adjustment for diameter and shear rate area under the curve), and circulating hematopoietic CD34 + cells and prevented the decline in carotid distensibility (18.4±5.3 to 20.0±6.6, 23.9±11.0 to 19.5±7.1 Pa −1 ; P =0.005). The only clinical predictor of improvement of cognitive function after training was established hypertension. There was no correlation between changes in measures of cognitive and vascular function. In conclusion, a multidomain training program slows cognitive decline, especially in hypertensive individuals. This effect is accompanied by improved systemic endothelial function, mobilization of progenitor CD34 + cells, and preserved carotid distensibility.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01725178.

Characteristics of Vitamin B12 Deficiency in Patients With Plasma Cell Disorders

BACKGROUND

Although increased rates of vitamin B12 deficiency have been reported in patients with plasma cell dyscrasias (PCDs), no mechanism has been identified. Excess free light chains (FLCs) could disrupt the renal proximal tubule receptors where B12 is reabsorbed. We sought to characterize the relationship between B12 deficiency and PCDs. We hypothesized that rates of B12 deficiency would be highest in patients with PCDs with high FLC burdens.

METHODS

We reviewed the electronic medical records of 501 patients who met inclusion criteria (diagnosed PCD with documented serum B12 and FLC levels) to obtain clinical data recorded prior to patients' lowest B12 levels.

RESULTS

Overall, 20.0% of patients had low vitamin B12. There was an expected negative correlation between estimated glomular filtration rate and FLC (r_s = -0.317; P < .001). However, low B12 levels were more prevalent in patients with preserved renal function (P = .047). Low B12 was associated with lower mean corpuscular volume (P = .037).

CONCLUSION

Higher FLC burden was associated with poor kidney function but not with low B12. Low B12 was seen more commonly in patients with preserved kidney function. Mean corpuscular volume was statistically but not clinically different between patients with low and normal B12 and, therefore, may not be a reliable indicator of B12 deficiency in PCDs. Prospective studies should compare B12 metabolites with FLC levels. Detection of B12 deficiency among patients with PCDs remains important to reduce neurologic dysfunction and cytopenias, sequelae common to B12 deficiency and PCDs.

Culturally targeted patient navigation for increasing african americans' adherence to screening colonoscopy: a randomized clinical trial

BACKGROUND

Patient navigation has been an effective intervention to increase cancer screening rates. This study focuses on predicting outcomes of screening colonoscopy for colorectal cancer among African Americans using different patient navigation formats.

METHODS

In a randomized clinical trial, patients more than 50 years of age without significant comorbidities were randomized into three navigation groups: peer-patient navigation (n = 181), pro-patient navigation (n = 123), and standard (n = 46). Pro-patient navigations were health care professionals who conducted culturally targeted navigation, whereas peer-patient navigations were community members trained in patient navigation who also discussed their personal experiences with screening colonoscopy. Two assessments gathered sociodemographic, medical, and intrapersonal information.

RESULTS

Screening colonoscopy completion rate was 75.7% across all groups with no significant differences in completion between the three study arms. Annual income more than $10,000 was an independent predictor of screening colonoscopy adherence. Unexpectedly, low social influence also predicted screening colonoscopy completion.

CONCLUSIONS

In an urban African American population, patient navigation was effective in increasing screening colonoscopy rates to 15% above the national average, regardless of patient navigation type or content.

IMPACT

Because patient navigation successfully increases colonoscopy adherence, cultural targeting may not be necessary in some populations.

Culturally targeted patient navigation for increasing african americans' adherence to screening colonoscopy: a randomized clinical trial

BACKGROUND

Patient navigation has been an effective intervention to increase cancer screening rates. This study focuses on predicting outcomes of screening colonoscopy for colorectal cancer among African Americans using different patient navigation formats.

METHODS

In a randomized clinical trial, patients more than 50 years of age without significant comorbidities were randomized into three navigation groups: peer-patient navigation (n = 181), pro-patient navigation (n = 123), and standard (n = 46). Pro-patient navigations were health care professionals who conducted culturally targeted navigation, whereas peer-patient navigations were community members trained in patient navigation who also discussed their personal experiences with screening colonoscopy. Two assessments gathered sociodemographic, medical, and intrapersonal information.

RESULTS

Screening colonoscopy completion rate was 75.7% across all groups with no significant differences in completion between the three study arms. Annual income more than $10,000 was an independent predictor of screening colonoscopy adherence. Unexpectedly, low social influence also predicted screening colonoscopy completion.

CONCLUSIONS

In an urban African American population, patient navigation was effective in increasing screening colonoscopy rates to 15% above the national average, regardless of patient navigation type or content.

IMPACT

Because patient navigation successfully increases colonoscopy adherence, cultural targeting may not be necessary in some populations.

Nurturing brain plasticity: impact of environmental enrichment

Environmental enrichment (EE) is known to profoundly affect the central nervous system (CNS) at the functional, anatomical and molecular level, both during the critical period and during adulthood. Recent studies focusing on the visual system have shown that these effects are associated with the recruitment of previously unsuspected neural plasticity processes. At early stages of brain development, EE triggers a marked acceleration in the maturation of the visual system, with maternal behaviour acting as a fundamental mediator of the enriched experience in both the foetus and the newborn. In adult brain, EE enhances plasticity in the cerebral cortex, allowing the recovery of visual functions in amblyopic animals. The molecular substrate of the effects of EE on brain plasticity is multi-factorial, with reduced intracerebral inhibition, enhanced neurotrophin expression and epigenetic changes at the level of chromatin structure. These findings shed new light on the potential of EE as a non-invasive strategy to ameliorate deficits in the development of the CNS and to treat neurological disorders.