242 The Importance of Frailty Assessment as a Mortality Indicator and Surgical Decision-Making Tool

Background

Frailty is a multidimensional syndrome, which can lead to poorer health outcome. Frailty score is a proven reliable indicator of post-operative morbidity and mortality; however, its application in clinical practice is limited.

Aim

The study aimed to assess the association between frailty marker and one- year mortality rate and explore its impact in clinical decision making in patients with abdominal aortic aneurysms.

Method

Consecutive patients with abdominal, thoracic, and thoracoabdominal aortic aneurysms presented at dedicated aortic clinic between July 2019 and April 2020 were included. Markers for frailty and sarcopenia using Rockwood Clinical Frailty Scale, SARC-F questionnaire, morphometric analysis for sarcopenia, one-year mortality and fitness were recorded. Multi-disciplinary team (MDT) was blinded to frailty and sarcopenia data; surgical decisions made by MDT were recorded separately.

Results

We assessed 83 patients (median age 75 [72,82], 85% male; median aneurysm diameter 6cm [5.8,7.0]. Sixteen patients were deemed frail, five patients had sarcopenia and thirty-one patients had myopenia. Seventeen patients were deemed not fit for surgery; 41% of these were frail compared with 14% out of those who were deemed fit. The odds ratio of being frail and unfit for surgery was 4.33 (95% CI 1.27–14.82, p = 0.010). Frailty was significantly associated with one-year mortality irrespective of fitness for surgery, sarcopenia and myopenia (OR 10.28, 95%CI 1.82–57.93, p = 0.009). SARC-F and myopenia was not associated with one-year mortality at (OR 1.66, 95%CI 0.03–19.25, p = 0.523) and (OR 0.59, 95%CI 0.09–2.85, p = 0.514), respectively.

Conclusions

Frailty score was associated with both one-year mortality and fitness for surgery decision made by MDT.

Association of SARC-F Score and Rockwood Clinical Frailty Scale with CT-Derived Muscle Mass in Patients with Aortic Aneurysms

OBJECTIVES

Patients with aortic aneurysms (AA) are often co-morbid and susceptible to frailty. Low core muscle mass has been used as a surrogate marker of sarcopenia and indicator of frailty. This study aimed to assess association between core muscle mass with sarcopenia screening tool SARC-F and Clinical Frailty Scale (CFS) in patients with AA.

METHODS

Prospective audit of patients in pre-operative aortic clinic between 01/07/2019-31/01/2020 including frailty assessment using Rockwood CFS and sarcopenia screening using SARC-F questionnaire. Psoas and sartorius muscle area were measured on pre-operative CT scans and adjusted for height. Association was assessed using Spearman's rank correlation coefficient.

RESULTS

Of 84 patients assessed, median age was 75 years [72,82], 84.5% were men, 65.5% were multimorbid and 63.1% had polypharmacy. Nineteen percent were identified as frail (CFS score >3) and 6.1% positively screened for sarcopenia (SARC-F score 4 or more). Median psoas area (PMA) at L3 was 5.6cm2/m2 [4.8,6.6] and L4 was 7.4cm2/m2 [6.3,8.6]. Median sartorius area (SMA) was 1.8 cm2/m2 [1.5,2.2]. CFS demonstrated weak but statistically significant negative correlation with height-adjusted PMA at L3 (r=-0.25, p=0.034) but not at L4 (r=-0.23, p=0.051) or with SMA (r=-0.22, p=0.065). No association was observed between SARC-F score and PMA or SMA (L3 PMA r=-0.015, p=0.9; L4 PMA r=-0.0014, p= 0.99; SMA r=-0.051, p=0.67).

CONCLUSION

CFS showed higher association with CT-derived muscle mass than SARC-F. Comprehensive pre-operative risk-stratification tools which incorporate frailty assessment and body composition analysis may assist in decision making for surgery and allow opportunity for pre-habilitation.

Temporal effect of feeding on the body temperature and behaviour of captive koalas (Phascolarctos cinereus)

Free-ranging koalas generally feed at night; however, captive koalas are usually fed during the day in order to encourage activity for display purposes. We studied the temporal effect of feeding on body temperature of captive koalas in Queensland, to determine whether nocturnal feeding may be beneficial for koalas in warmer climates. Six adult koalas were implanted with thermal transmitters and data loggers, waxed together as a single package, to record internal body temperature. Koalas were exposed to two treatments: koalas were fed in the morning (between 0730 and 0830 hours) during the AM treatment or late afternoon (between 1700 and 1800 hours) for the PM treatment. The body temperature of koalas fed in the mornings was on average 0.5°C higher at its peak (P ≤ 0.01) when compared to koalas fed in the evening. Furthermore, the body temperature maxima of morning-fed koalas was reached ~2 h earlier in the afternoon, compared with those fed in the evening. There was no significant difference between behaviours associated with the two feeding regimes: inactivity (P = 0.840), feeding (P = 0.472) and activity (P = 0.634). We postulate that nocturnal feeding by koalas may be an adaptive mechanism that reduces diurnal heat load during times of high environmental temperatures.

In this study: Adapting to the new normal in COVID-19 pandemic; a global survey & literature review

Introduction

Globally, governments have enforced protective measures of social distancing to prevent COVID-19 spread. The lifestyles of public have essentially transformed due to these actions. This study evaluates the effects of COVID-19 on connections and behavior/life adaptations.

Objectives

Changes in life style and behavior in COVID-19-Pandemic

Methods

We conducted a global cross-sectional study via survey on phone apps and social media platforms in population aged ≥ 16, including questions regarding demographic data and lifestyle changes. We also searched databases APA PsycNet, PubMed, PsycINFO, and Medline; reviewed 40 articles and included 3 in this review, a cross-sectional online survey1, a planned questionnaire2, and a study on 600 adolescents, age 10-19 in Palestine3

Results

Our survey data showed total of 1002 responses, 31.7% decreased sleep, 42.1% increased appetite, 70.6% bulk-buying, and 50.2% weight gain. 43.1% less socialization than before, 78.7% increased screen time, 53.5% excessive hand washing/wiping surfaces, 45% reported social distancing facilitated in overpowering the fear of contracting infection, 29.4% negative impact on relationships, 80.7% noticed changes in behavior including shaking hands/hugging/speaking with a mask on, 49.5% adopted new hobbies, 34.9% showed increase in meditation. The literature review revealed that since COVID-19, there is an increase in screen time, weight, appetite, sleep, and a decrease in physical activity1-3, and greater adherence to the Mediterranean diet in younger population2

Conclusions

COVID-19 induced quarantine has caused increased screen time, appetite, weight gain, adoption of new hobbies, bulk-buying, hand washing, meditation, reduced sleep, and negatively impacted interaction/relationships. COVID-19 pandemic is ongoing and our data needs further assessment in more population studies.

Disclosure

No significant relationships.

Body temperature of free-ranging koalas (Phascolarctos cinereus) in south-east Queensland

The distribution of the koala (Phascolarctos cinereus) in Queensland is predicted to contract as a result of climate change, driven by the frequency, intensity and duration of heatwaves and drought. However, little is known about the physiological responses of this species to environmental extremes under field conditions. This study aimed to establish the efficacy of surgically implanted thermal radio transmitters and data loggers to measure the body temperature of free-ranging koalas across a range of environmental conditions and ambient temperatures. Five free-ranging koalas in southeast Queensland were implanted with thermal transmitters and data loggers waxed together as a single package. Body temperatures were recorded for variable periods ranging from 3 to 12 months. Diurnal rhythms in body temperature were detected irrespective of season. The long-term diurnal body temperature peak for all koalas occurred between 16:00 and 17:00 h and body temperature was 36.7-36.9 °C, the long-term nadir occurred between 07:00 and 08:00 h and body temperature was 35.4-35.7 °C. Koala body temperatures as low as 34.2 °C and as high as 39.0 °C were recorded. Thermolability became apparent when ambient temperatures were outside the deduced thermal neutral zone for koalas (14.5-24.5 °C): heat was accumulated during the day and dissipated during the cool of the night. While this study is the first to report on body temperature of free-ranging koalas in their normal behavioural context, further investigations are necessary to determine the physiological boundaries of the thermal niche for this species, in order to better equip models that will more accurately predict the impacts of climate change on koalas.

Idiopathic normal pressure hydrocephalus

Idiopathic normal pressure hydrocephalus (INPH) is a neurodegenerative disease which affects the elderly, with a significant prevalence in the general population (0,2% - 5,9%), thus a common pathology encountered by neurologists and neurosurgeons, alike. Although the widespread availability of modern imaging techniques has facilitated the diagnosis of this disorder, the clinical manifestations can often be misleading. Also, an overlap with other degenerative or psychiatric diseases can make the differential diagnosis even more challenging. Cerebrospinal fluid (CSF) diversion procedures are the first line of treatment for INPH. Nowadays, there are several shunting options available, including: ventriculoperitoneal (the most commonly used), ventriculoatrial, ventriculopleural, ventriculosternal, lumboperitoneal, endoscopic third ventriculostomy. Choosing a procedure tailored to the individual patient is essential for therapeutic success. Although they are generally straightforward surgical interventions, they associate a high rate of failure, regardless of procedure used, which emphasizes the need for regular clinical and imagistic follow-up. Thus, INPH remains a disease where there is significant room for improvement, both in diagnosis and treatment.

Tailored approach for the resection of planum sphenoidale meningiomas

Background and importance. Planum sphenoidale meningiomas are relatively rare tumours that can grow to a considerable size before determining noticeable symptoms. Modern imaging techniques can detect these tumours of varying size. Surgical resection of planum sphenoidale meningiomas can be performed by adapting the approach to the size of the tumour.Clinical presentation. A 56-year-old woman presented with a small (2 cm in diameter) planum sphenoidale meningioma that was resected through a frontal craniotomy performed with a 4,5 cm trephine at the level of the frontal sinus. The second case is that of a 55-year-old woman that presented with a large planum sphenoidale meningioma (5,6 cm in the antero-posterior plane and 5,5 cm cranio-caudally) extending to the tuberculum sellae and sellar diaphragm, reaching the anterior wall of the third ventricle. In this case, a bifrontal craniotomy was performed with frontal sinus cranialization and resection of falx cerebri, achieving a Simpson II resection. Both cases presented a favourable postoperative evolution, without any deficits and an excellent cosmetic result.Conclusion. The approach for tumours of the anterior skull base must be tailored to the size of the tumour. A minimally invasive approach through the frontal sinus should not be avoided in cases with small tumours.

Costs of F-18-FDG PET: Experience with a satellite concept

Aim: One of the main arguments against the acceptance and introduction of FDG PET as a regular benefit in the statutory Medical Insurance system in Germany are its (alleged) high costs. The aim of the present study has been to determine empirically over a period of twelve months the costs of FDG PET, making use of a satellite concept. Methods: Documentation on performance and consumption data has been assembled for purposes of cost analysis. After analysis these data provided the basis for an assessment of the costs. In view of the high proportion of fixed overheads and strong fluctuations in consumption values, it was not possible to allocate reliably in an individual FDG PET investigation the various types of costs to individual causes. A monthly cost assessment procedure was therefore adopted. For this purpose data were recorded in the department for Nuclear Medicine, while the statistical assessment of the consumption data and analysis of the costs were undertaken in the Institute of Industrial and Hospital Management. Results: Over the twelve month observation period (November 1995 to October 1996, 177 working days) 433 patients were included in the study: 244 with brain diseases 37 cardiac patients, 130 whole body studies and 22 combined studies (brain and whole body scans). The non volume based costs, maintenance charges and depreciation accounted for the highest proportion of the total costs (48%). The FDG- related costs accounted for 41 % of the total costs, while the personnel costs amounted to 11% and the film costs to only 0.45%. The total costs incurred amounted to DM 1,205,050. Conclusion: These data represent a first empirical cost analysis for FDG PET based on a satellite concept and form a starting point for a cost/benefit analysis of this procedure.

Multilevel “fish vertebrae” in a patient with tumor-induced osteomalacia

Background and importance: “Fish vertebra” is an uncommon anomaly of vertebral body shape, consisting of central depression of the superior and inferior vertebral surfaces. It has been associated with various conditions: osteoporosis, osteomalacia, hyperparathyroidism, Paget disease, sickle cell disease, multiple myeloma and systemic lupus erythematosus.

Clinical presentation: A 29-year-old male patient, previously treated for ankylosing spondylitis (with NSAIDs and TNFα inhibitor), without any clinical improvement, was admitted to our Neurosurgical Department. He complained of difficult gait, possible only with the aid of a cane, low back pain and bilateral hip pain, but without leg pain. He denied any history of recent trauma. Neurological examination was normal. Plain thoracic and lumbar spine X-rays revealed multilevel “fish vertebrae”. Lumbar spine MRI and contrast thoraco-abdominal CT scan showed fractures of multiple structures: left L4 pedicle, right L4 lamina and pars interarticularis, right II-VII costal arches, left I-V costal arches and bilateral sacral alae. We performed extensive laboratory tests that detected low seric phosphorous and PTH levels, with increased alkaline phosphatase, indicating a possible endocrinological cause for this condition. Subsequently, we decided to transfer the patient to an Endocrinological Department. A diagnosis of hypophosphatemic osteomalacia was established and increased FGF23 levels, later determined, suggested it was tumor-induced osteomalacia. Whole-body MRI was unable to locate the tumor, but Gallium-68 DOTATATE PET/CT revealed a small (15 mm in diameter), hyperfixating mass in the head of the right femur. The patient was treated with oral calcitriol and phosphate, with alleviation of symptoms. Surgical excision of the tumor was recommended, but the patient decided to postopone the operation.

Conclusion: Modern medical imaging and biochemical testing have made the leap from merely observing vertebral biconcavities to diagnosing their cause and, consequently, the possibility to adequately treat uncommon causes of “fish vertebra”, such as neuroendocrine tumor-induced osteomalacia.

Butterfly vertebra: a case report

Background and importance: Butterfly vertebra is an uncommon congenital spinal anomaly, which can be easily mistaken for vertebral fracture, infection or tumor.

Clinical presentation: We report the case of a 20-year-old male patient with a 3-year history of intermittent mid-thoracic spinal pain. Local examination showed a mild thoracic kyphoscoliosis. Neurological examination was normal. Computer tomography revealed the presence of a T6 butterfly vertebra associated with morphological anomalies in adjacent vertebral bodies and T6-T9 Schmorl’s nodes. MRI scan confirmed the diagnosis and additionally showed a mild spinal stenosis caused by apparent posterior epidural fat hypertrophy. The patient was treated with painkillers and physical therapy.

Conclusion: Butterfly vertebra is a benign condition. Once diagnosed, additional diagnostic procedures are not necessary. Neurosurgeons must be aware of this congenital anomaly that should not be confused with a vertebral fracture.

Analysis of 30-day unplanned readmissions after degenerative spinal disease surgery

Background: Degenerative spinal disease surgery is frequently performed in most neurosurgical departments. Unplanned 30-day readmissions represent a significant economic burden and have been used in several studies as a tool to evaluate quality of patient care.

Objective: To review 30-day unplanned readmission rates after degenerative spinal disease surgery in our department, in order to identify their causes and determine strategies aimed at decreasing their frequency.

Methods: A retrospective analysis was performed on all patients operated in our department for spinal stenosis or disc herniation over a 3 year period (January 2014 – December 2016), evaluating the rate and causes of unplanned readmission in the first month after discharge. Complications were divided in medical and surgical.

Results: Out of the 1106 patients included, 33 (2,98%) presented a 30-day unplanned readmission. The percentage was higher after disc herniation surgery (3,40%), compared to spinal stenosis (1,92%). Pain management was the most common medical cause for readmission (45,45%), while in the surgical group, CSF leaks were the most frequent complication (18,18%).

Conclusions: The rate of 30-day readmissions was low in our series but, even so, they associate significant costs. They could be avoided by applying correct and aseptic surgical technique, proper availability of dural sealing agents and superior patient medical education.