Frailty and risk of complications in head and neck oncologic surgery. Systematic review and dose-response meta-analysis

BACKGROUND

There is emerging evidence that frail individuals present a decreased physiological reserve, decreased ability to maintain homeostasis, and increased vulnerability to stressors. The concept of frailty has become increasingly recognized as a valuable measure in oncological surgical patients, including those with head and neck cancer. Preoperative screening for frailty may provide an individualized risk assessment that can be used by an interdisciplinary team for preoperative counseling and to improve outcomes. The aim of this meta-analysis was to evaluate the relationship between frailty and the risk of major postoperative complications in frail individuals submitted to head and neck oncologic surgery.

MATERIAL AND METHODS

PubMed, SCOPUS, Web of Science, Google Scholar and OpenThesis were systematically searched to identify studies that evaluated the risk of major postoperative complications in frail individuals undergoing head and neck oncologic surgery. The search was performed on August 31, 2020, without language or date restrictions. Two independent investigators screened the searched studies based on each paper's title and abstract. Relevant studies were read in full and selected according to the eligibility criteria. Frailty was assessed by modified Frailty Index (mFI-11) and major postoperative complications were measured by the Clavien-Dindo classification. We performed a categorical and dose-response meta-analysis using a random-effects model to evaluate the association between frailty and the risk of major postoperative complications in patients submitted to head and neck oncologic surgery. The results of the meta-analysis were expressed as relative risk (RR) and 95% confidence interval (95% CI). The risk of bias was assessed using the Newcastle-Ottawa Scale (NOS).

RESULTS

Four studies (9,947 patients) were included in this systematic review and meta-analysis. Frail patients presented an increased risk of life-threatening complications requiring intensive care unit (ICU) admission (RR = 4.67; 95% CI 1.54-14.10) and 30-day mortality (RR = 8.10; 95% CI 2.30-28.57) compared to non-frail patients. We found evidence of dose-response trend between mFI-11 and major postoperative complications.

CONCLUSIONS

Higher frailty scores are associated with a significant increase in ICU-level complications and 30-day mortality after head and neck oncologic surgery.

RECK (reversion-inducing cysteine-rich protein with Kazal motifs) regulates migration, differentiation and Wnt/β-catenin signaling in human mesenchymal stem cells

The membrane-anchored glycoprotein RECK (reversion-inducing cysteine-rich protein with Kazal motifs) inhibits expression and activity of certain matrix metalloproteinases (MMPs), thereby suppressing tumor cell metastasis. However, RECK's role in physiological cell function is largely unknown. Human mesenchymal stem cells (hMSCs) are able to differentiate into various cell types and represent promising tools in multiple clinical applications including the regeneration of injured tissues by endogenous or transplanted hMSCs. RNA interference of RECK in hMSCs revealed that endogenous RECK suppresses the transcription and biosynthesis of tissue inhibitor of metalloproteinases (TIMP)-2 but does not influence the expression of MMP-2, MMP-9, membrane type (MT)1-MMP and TIMP-1 in these cells. Knockdown of RECK in hMSCs promoted monolayer regeneration and chemotactic migration of hMSCs, as demonstrated by scratch wound and chemotaxis assay analyses. Moreover, expression of endogenous RECK was upregulated upon osteogenic differentiation and diminished after adipogenic differentiation of hMSCs. RECK depletion in hMSCs reduced their capacity to differentiate into the osteogenic lineage whereas adipogenesis was increased, demonstrating that RECK functions as a master switch between both pathways. Furthermore, knockdown of RECK in hMSCs attenuated the Wnt/β-catenin signaling pathway as indicated by reduced stability and impaired transcriptional activity of β-catenin. The latter was determined by analysis of the β-catenin target genes Dickkopf1 (DKK1), axis inhibition protein 2 (AXIN2), runt-related transcription factor 2 (RUNX2) and a luciferase-based β-catenin-activated reporter (BAR) assay. Our findings demonstrate that RECK is a regulator of hMSC functions suggesting that modulation of RECK may improve the development of hMSC-based therapeutical approaches in regenerative medicine.

Efficacy and safety of 10% HES 130/0.4 versus 10% HES 200/0.5 for plasma volume expansion in cardiac surgery patients

AIM

Hydroxyethyl starch (HES) solutions are frequently used for perioperative volume replacement. Whereas older HES specimen tended to accumulate in the plasma and to cause negative effects on hemostasis, more recent products, e.g., HES 130/0.4, are characterised by improved pharmacological properties. The present study was designed to compare the efficacy and safety of 10% HES 130/0.4 and 10% HES 200/0.5.

METHODS

In this post-hoc analysis of a prospective, randomised, double-blind, multi-center therapeutic equivalence trial, 76 patients undergoing elective on-pump cardiac surgery received perioperative volume replacement using either 10% HES 130/0.4 (N.=37) or 10% HES 200/0.5 (N.=39) up to a maximum dose of 20 mL kg-1.

RESULTS

Equivalent volumes of investigational medication were infused until 24 hours after the first administration (1577 vs. 1540 mL; treatment difference 37 [-150; 223] mL; P<0.0001 for equivalence). Whereas standard laboratory tests of coagulation were comparable between groups, von Willebrand factor activity on the first postoperative morning tended to be higher following treatment with 10% HES 130/0.4 as compared to 10% HES 200/0.5 (P=0.025) with this difference being statistically significant only in the per-protocol analysis (P=0.02). Treatment groups were comparable concerning other safety parameters and the incidence of adverse drug reactions. In particular, renal function was well preserved in both groups.

CONCLUSION

Ten percent HES 130/0.4 was equally effective and safe as compared to 10% HES 200/0.5 for volume therapy in patients undergoing cardiovascular surgery. Postoperative coagulation and renal function, as measured by standard laboratory tests, were similar among groups.

[A rare cause of myocarditis in a 30-year-old patient]

CASE REPORT

A 30-year-old male was admitted to hospital because of chest pain and raised cardiac enzymes. Coronary heart disease was excluded by coronary angiography. Assuming myocarditis serological testing was performed and showed markedly raised antibody titers against Coxiella Burnetii. We treated the patient with doxycycline, 2 times 100 mg daily for 5 months.

CONCLUSION

Acute Q-fever should be considered as a possible cause of myocarditis, especially in rural areas.

Mechanical restitution and recirculation fraction in cardiac myocytes and left ventricular muscle of adult rats

Unloaded cell shortening was measured in electrically stimulated myocytes from adult rat hearts to compare the contractile response to stimulation with that in isometrically contracting left ventricular papillary muscles under similar experimental conditions, but preloaded to produce maximum twitch tension. Mechanical restitution in cells followed a biexponential function with time constants of 0.19 +/- 0.03 s and 36.4 +/- 10.2 s (7 cells from 5 hearts, n = 7/5). The time constants for papillary muscles were 0.58 +/- 0.05 s and 14.6 +/- 1.0 s (n = 6/6). In myocytes, maximum post-rest potentiation occurred after 30 to 60 s of rest. The potentiation after 60 s of rest was 2.48 +/- 0.31 times the steadystate in cells and 2.63 +/- 0.16 in papillary muscles. Recirculation fraction of C2+ as calculated from the decay of post-rest potentiation was 0.84 +/- 0.04 in single cells and 0.59 +/- 0.02 in papillary muscles (p < 0.005). Caffeine (3mM) abolished post-rest potentiation in both types of preparations. The numerical values for the time constants of mechanical restitution, potentiation factor and recirculation fraction in papillary muscles did not depend on preload. It is concluded that interval-dependent changes of contractility are preserved in single cardiac cells but the kinetics of decay of potentiation appear to have changed quantitatively.