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Dumitrascu F, Branje KE, Hladkowicz ES, Lalu M, McIsaac DI. Association of frailty with outcomes in individuals with COVID-19: A living review and meta-analysis. J Am Geriatr Soc 2021; 69:2419-2429. [PMID: 34048599 PMCID: PMC8242611 DOI: 10.1111/jgs.17299] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/08/2021] [Accepted: 05/16/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Frailty leaves older adults vulnerable to adverse health outcomes. Frailty assessment is recommended by multiple COVID-19 guidelines to inform care and resource allocation. We aimed to identify, describe, and synthesize studies reporting the association of frailty with outcomes (informed by the Institute for Healthcare Improvement's Triple Aim [health, resource use, and experience]) in individuals with COVID-19. DESIGN Systematic review and meta-analysis. SETTING Studies reporting associations between frailty and outcomes in the setting of COVID-19 diagnosis. PARTICIPANTS Adults with COVID-19. MEASUREMENTS Following review of titles, abstracts and full text, we included 52 studies that contained 118,373 participants with COVID-19. Risk of bias was assessed using the Quality in Prognostic studies tool. Our primary outcome was mortality, secondary outcomes included delirium, intensive care unit admission, need for ventilation and discharge location. Where appropriate, random-effects meta-analysis was used to pool adjusted and unadjusted effect measures by frailty instrument. RESULTS The Clinical Frailty Scale (CFS) was the most used frailty instrument. Mortality was reported in 37 studies. After confounder adjustment, frailty identified using the CFS was significantly associated with mortality in COVID-19 positive patients (odds ratio 1.79, 95% confidence interval [CI] 1.49-2.14; hazard ratio 1.87, 95% CI 1.33-2.61). On an unadjusted basis, frailty identified using the CFS was significantly associated with increased odds of delirium and reduced odds of intensive care unit admission. Results were generally consistent using other frailty instruments. Patient-reported, cost and experience outcomes were rarely reported. CONCLUSION Frailty is associated with a substantial increase in mortality risk in COVID-19 patients, even after adjustment. Delirium risk is also increased. Frailty assessment may help to guide prognosis and individualized care planning, but data relating frailty status to patient-reported outcomes are urgently needed to provide a more comprehensive overview of outcomes relevant to older adults.
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Affiliation(s)
| | - Karina E. Branje
- Department of Anesthesiology and Pain MedicineThe Ottawa HospitalOttawaCanada
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaCanada
| | - Emily S. Hladkowicz
- Department of Anesthesiology and Pain MedicineThe Ottawa HospitalOttawaCanada
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaCanada
- School of Rehabilitation TherapyQueen's UniversityKingstonCanada
| | - Manoj Lalu
- Department of Anesthesiology and Pain MedicineThe Ottawa HospitalOttawaCanada
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaCanada
- Department of Anesthesiology and Pain MedicineUniversity of OttawaOttawaCanada
| | - Daniel I. McIsaac
- Department of Anesthesiology and Pain MedicineThe Ottawa HospitalOttawaCanada
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaCanada
- Department of Anesthesiology and Pain MedicineUniversity of OttawaOttawaCanada
- School of Epidemiology and Public HealthUniversity of OttawaOttawaCanada
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Shanahan CW, Reding O, Holmdahl I, Keosaian J, Xuan Z, McAneny D, Larochelle M, Liebschutz J. Opioid analgesic use after ambulatory surgery: a descriptive prospective cohort study of factors associated with quantities prescribed and consumed. BMJ Open 2021; 11:e047928. [PMID: 34385249 PMCID: PMC8362709 DOI: 10.1136/bmjopen-2020-047928] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To prospectively characterise: (1) postoperative opioid analgesic prescribing practices; (2) experience of patients undergoing elective ambulatory surgeries and (3) impact of patient risk for medication misuse on postoperative pain management. DESIGN Longitudinal survey of patients 7 days before and 7-14 days after surgery. SETTING Academic urban safety-net hospital. PARTICIPANTS 181 participants recruited, 18 surgeons, follow-up data from 149 participants (82% retention); 54% women; mean age: 49 years. INTERVENTIONS None. PRIMARY AND SECONDARY OUTCOME MEASURES Total morphine equivalent dose (MED) prescribed and consumed, percentage of unused opioids. RESULTS Surgeons postoperatively prescribed a mean of 242 total MED per patient, equivalent to 32 oxycodone (5 mg) pills. Participants used a mean of 116 MEDs (48%), equivalent to 18 oxycodone (5 mg) pills (~145 mg of oxycodone remaining per patient). A 10-year increase in patient age was associated with 12 (95% CI (-2.05 to -0.35)) total MED fewer prescribed opioids. Each one-point increase in the preoperative Graded Chronic Pain Scale was associated with an 18 (6.84 to 29.60) total MED increase in opioid consumption, and 5% (-0.09% to -0.005%) fewer unused opioids. Prior opioid prescription was associated with a 55 (5.38 to -104.82) total MED increase in opioid consumption, and 19% (-0.35% to -0.02%) fewer unused opioids. High-risk drug use was associated with 9% (-0.19% to 0.002%) fewer unused opioids. Pain severity in previous 3 months, high-risk alcohol, use and prior opioid prescription were not associated with postoperative prescribing practices. CONCLUSIONS Participants with a preoperative history of chronic pain, prior opioid prescription, and high-risk drug use were more likely to consume higher amounts of opioid medications postoperatively. Additionally, surgeons did not incorporate key patient-level factors (eg, substance use, preoperative pain) into opioid prescribing practices. Opportunities to improve postoperative opioid prescribing include system changes among surgical specialties, and patient education and monitoring.
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Affiliation(s)
- Christopher W Shanahan
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Olivia Reding
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Inga Holmdahl
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Julia Keosaian
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Ziming Xuan
- Community Health Sciences, Boston University, Boston, Massachusetts, USA
| | - David McAneny
- Department of General Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Marc Larochelle
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jane Liebschutz
- Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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103
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Morisson L, Laferrière-Langlois P, Carrier FM, Pagé G, Godbout C, Fortier LP, Ogez D, Létourneau G, Jarry S, Denault A, Fortier A, Guertin MC, Verdonck O, Richebé P. Effect of electroencephalography-guided anesthesia on neurocognitive disorders in elderly patients undergoing major non-cardiac surgery: A trial protocol The POEGEA trial (POncd Elderly GEneral Anesthesia). PLoS One 2021; 16:e0255852. [PMID: 34375362 PMCID: PMC8354438 DOI: 10.1371/journal.pone.0255852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/14/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction The number of elderly patients undergoing major surgery is rapidly increasing. They are particularly at risk of developing postoperative neurocognitive disorders (NCD). Earlier studies suggested that processed electroencephalographic (EEG) monitors may reduce the incidence of postoperative NCD. However, none of these studies controlled for intraoperative nociception levels or personalized blood pressure targets. Their results remain unclear if the reduction in the incidence of postoperative NCD relates to avoidance of any electroencephalographic pattern suggesting excessive anesthesia depth. Objective The objective of this trial is to investigate–in patients ≥ 70 years old undergoing major non-cardiac surgery–the effect of EEG-guided anesthesia on postoperative NCD while controlling for intraoperative nociception, personalized blood pressure targets, and using detailed information provided by the EEG monitor (including burst suppression ratio, density spectral array, and raw EEG waveform). Material and methods This prospective, randomized, controlled trial will be conducted in a single Canadian university hospital. Patients ≥ 70 years old undergoing elective major non-cardiac surgery will be included in the trial. The administration of sevoflurane will be adjusted to maintain a BIS index value between 40 and 60, to keep a Suppression Ratio (SR) at 0%, to keep a direct EEG display without any suppression time and a spectrogram with most of the EEG wave frequency within the alpha, theta, and delta frequencies in the EEG-guided group. In the control group, sevoflurane will be administered to achieve an age-adjusted minimum alveolar concentration of [0.8–1.2]. In both groups, a nociception monitor will guide intraoperative opioid administration, individual blood pressure targets will be used, and cerebral oximetry used to tailor intraoperative hemodynamic management. The primary endpoint will be the incidence of NCD at postoperative day 1, as evaluated by the Montreal Cognitive Assessment (MoCA). Secondary endpoints will include the incidence of postoperative NCD at different time points and the evaluation of cognitive trajectories up to 90 days after surgery among EEG-guided and control groups. Study registration NCT04825847 on ClinicalTrials.gov.
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Affiliation(s)
- Louis Morisson
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital – CIUSSS de L’Est de l’Ile de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Pascal Laferrière-Langlois
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital – CIUSSS de L’Est de l’Ile de Montréal, Université de Montréal, Montréal, Québec, Canada
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Québec, Canada
| | - François Martin Carrier
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Québec, Canada
- Department of Anesthesiology and Department of Medicine, Critical Care Division, Centre Hospitalier de l’Université de Montréal (CHUM), Université de Montréal, Montréal, Québec, Canada
- Research Center of the CHUM (Centre Hospitalier de l’Université de Montréal), Université de Montréal, Montréal, Québec, Canada
| | - Gabrielle Pagé
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Québec, Canada
- Research Center of the CHUM (Centre Hospitalier de l’Université de Montréal), Université de Montréal, Montréal, Québec, Canada
- Department of Psychology, Université de Montréal, Montréal, Québec, Canada
| | - Cédric Godbout
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital – CIUSSS de L’Est de l’Ile de Montréal, Université de Montréal, Montréal, Québec, Canada
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Québec, Canada
- Research Center of the CIUSSS de L’Est de l’Ile de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Louis-Philippe Fortier
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital – CIUSSS de L’Est de l’Ile de Montréal, Université de Montréal, Montréal, Québec, Canada
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Québec, Canada
- Research Center of the CIUSSS de L’Est de l’Ile de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - David Ogez
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital – CIUSSS de L’Est de l’Ile de Montréal, Université de Montréal, Montréal, Québec, Canada
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Québec, Canada
- Research Center of the CIUSSS de L’Est de l’Ile de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Geneviève Létourneau
- Research Center of the CIUSSS de L’Est de l’Ile de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Stéphanie Jarry
- Department of Anesthesiology, Montréal Heart Institute, Montréal, Québec, Canada
| | - André Denault
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Québec, Canada
- Department of Anesthesiology, Montréal Heart Institute, Montréal, Québec, Canada
| | - Annik Fortier
- Department of Statistics, Montreal Health Innovations Coordinating Center (MHICC), Montréal, Québec, Canada
| | - Marie-Claude Guertin
- Department of Statistics, Montreal Health Innovations Coordinating Center (MHICC), Montréal, Québec, Canada
| | - Olivier Verdonck
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital – CIUSSS de L’Est de l’Ile de Montréal, Université de Montréal, Montréal, Québec, Canada
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Québec, Canada
- Research Center of the CIUSSS de L’Est de l’Ile de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital – CIUSSS de L’Est de l’Ile de Montréal, Université de Montréal, Montréal, Québec, Canada
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Québec, Canada
- Research Center of the CIUSSS de L’Est de l’Ile de Montréal, Université de Montréal, Montréal, Québec, Canada
- * E-mail:
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Howlett SE, Rutenberg AD, Rockwood K. The degree of frailty as a translational measure of health in aging. NATURE AGING 2021; 1:651-665. [PMID: 37117769 DOI: 10.1038/s43587-021-00099-3] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 07/06/2021] [Indexed: 04/30/2023]
Abstract
Frailty is a multiply determined, age-related state of increased risk for adverse health outcomes. We review how the degree of frailty conditions the development of late-life diseases and modifies their expression. The risks for frailty range from subcellular damage to social determinants. These risks are often synergistic-circumstances that favor damage also make repair less likely. We explore how age-related damage and decline in repair result in cellular and molecular deficits that scale up to tissue, organ and system levels, where they are jointly expressed as frailty. The degree of frailty can help to explain the distinction between carrying damage and expressing its usual clinical manifestations. Studying people-and animals-who live with frailty, including them in clinical trials and measuring the impact of the degree of frailty are ways to better understand the diseases of old age and to establish best practices for the care of older adults.
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Affiliation(s)
- Susan E Howlett
- Geriatric Medicine Research Unit, Department of Medicine, Dalhousie University & Nova Scotia Health, Halifax, Nova Scotia, Canada
- Department of Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Andrew D Rutenberg
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kenneth Rockwood
- Geriatric Medicine Research Unit, Department of Medicine, Dalhousie University & Nova Scotia Health, Halifax, Nova Scotia, Canada.
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105
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Zhao H, You J, Peng Y, Feng Y. Machine Learning Algorithm Using Electronic Chart-Derived Data to Predict Delirium After Elderly Hip Fracture Surgeries: A Retrospective Case-Control Study. Front Surg 2021; 8:634629. [PMID: 34327210 PMCID: PMC8313764 DOI: 10.3389/fsurg.2021.634629] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 06/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Elderly patients undergoing hip fracture repair surgery are at increased risk of delirium due to aging, comorbidities, and frailty. But current methods for identifying the high risk of delirium among hospitalized patients have moderate accuracy and require extra questionnaires. Artificial intelligence makes it possible to establish machine learning models that predict incident delirium risk based on electronic health data. Methods: We conducted a retrospective case-control study on elderly patients (≥65 years of age) who received orthopedic repair with hip fracture under spinal or general anesthesia between June 1, 2018, and May 31, 2019. Anesthesia records and medical charts were reviewed to collect demographic, surgical, anesthetic features, and frailty index to explore potential risk factors for postoperative delirium. Delirium was assessed by trained nurses using the Confusion Assessment Method (CAM) every 12 h during the hospital stay. Four machine learning risk models were constructed to predict the incidence of postoperative delirium: random forest, eXtreme Gradient Boosting (XGBoosting), support vector machine (SVM), and multilayer perception (MLP). K-fold cross-validation was deployed to accomplish internal validation and performance evaluation. Results: About 245 patients were included and postoperative delirium affected 12.2% (30/245) of the patients. Multiple logistic regression revealed that dementia/history of stroke [OR 3.063, 95% CI (1.231, 7.624)], blood transfusion [OR 2.631, 95% CI (1.055, 6.559)], and preparation time [OR 1.476, 95% CI (1.170, 1.862)] were associated with postoperative delirium, achieving an area under receiver operating curve (AUC) of 0.779, 95% CI (0.703, 0.856). The accuracy of machine learning models for predicting the occurrence of postoperative delirium ranged from 83.67 to 87.75%. Machine learning methods detected 16 risk factors contributing to the development of delirium. Preparation time, frailty index uses of vasopressors during the surgery, dementia/history of stroke, duration of surgery, and anesthesia were the six most important risk factors of delirium. Conclusion: Electronic chart-derived machine learning models could generate hospital-specific delirium prediction models and calculate the contribution of risk factors to the occurrence of delirium. Further research is needed to evaluate the significance and applicability of electronic chart-derived machine learning models for the detection risk of delirium in elderly patients undergoing hip fracture repair surgeries.
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Affiliation(s)
- Hong Zhao
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Jiaming You
- Key laboratory of Universal Wireless Communication lab, Ministry of Education, Beijing University of Posts and Telecommunications, Beijing, China
| | - Yuexing Peng
- Key laboratory of Universal Wireless Communication lab, Ministry of Education, Beijing University of Posts and Telecommunications, Beijing, China
| | - Yi Feng
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
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106
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Sigler LE, Reitschuler-Cross E, Arnold RM, Hall DE. Preoperative Frailty Assessment #407. J Palliat Med 2021; 24:285-286. [PMID: 33522858 DOI: 10.1089/jpm.2020.0629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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107
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Abstract
PURPOSE OF REVIEW As the surgical population ages, preoperative diagnosis and optimization of frailty becomes increasingly important. Various concepts are used to define frailty, and several tools have been validated for use in the perioperative period. This article reviews current conceptual frameworks of frailty, references current literature and provides a practical approach to the preoperative frailty assessment with a focus on potential interventions. RECENT FINDINGS A multipronged approach toward preoperative optimization should be used in patients with frailty syndrome. Oral protein supplementation and immunonutrition therapy can reduce complications in patients with malnutrition. Initiating a preoperative physical exercise regimen may mitigate frailty. Nonpharmacologic interventions to reduce preoperative anxiety and improve mood are effective, low-cost adjuncts associated with improvement in postoperative outcomes. Engaging in shared decision making is a critical component of the preoperative evaluation of frail patients. SUMMARY Emerging evidence suggests that frailty may be mitigated with patient-specific, multidimensional preoperative interventions, thus potentially improving postoperative outcomes in this vulnerable patient population.
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Affiliation(s)
| | - Jeanna Blitz
- Duke University School of Medicine, Durham, North Carolina, USA
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108
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Zhang J, Liu Z, Liu Y, Ye L. Exercise interventions for older people at risk for frailty: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e25940. [PMID: 34011071 PMCID: PMC8137036 DOI: 10.1097/md.0000000000025940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Frailty is a state of age-related reduced physiological reserve characterized by an increased risk of adverse clinical outcomes. Studies have shown that exercise can improve frailty in older people. However, it remains to be seen which exercises will most improve the fitness of older people with frailty or those at the risk for frailty.Objective: This protocol aims to determine whether physical exercise can improve frailty in older people, and if which methods are most effective. METHODS We searched the following databases for relevant articles published between January 1, 2012 and January 1, 2021: PubMed, EMBASE, the Cochrane Library, Wanfang, the China National Knowledge Infrastructure, Clinical Trials Database, and the Science Network. Two independent reviewers will carry out data extraction, discuss and resolve differences, and obtain consensus from the third author. We will select randomized control trials (RCTs) according to the preformulated inclusion criteria. The main outcomes in this study are scores from Fried Frailty Phenotype Criteria; the Frailty Trait Scale-short form; the SHARE Frailty Instrument; the FRAIL scale; the Gérontopôle Frailty Screening Tool; the Clinical Frailty Scale, the Rockwood and Mitnitsky Frailty Index; the Study of Osteoporotic Fractures Index; the Edmonton Frailty Scale; the Fatigue, Resistance, Ambulation, Illness and Loss of Weight Index; the Multidimensional Prognostic Index; the Tilburg Frailty Indicator; PRISMA-7; the Groningen Frailty Indicator; the Sherbrooke Postal Questionnaire; and the Kihon Checklist. Secondary outcomes are muscle strength, gait velocity, stair-climbing power, and level of spontaneous physical activity. If the heterogeneity test shows slight or no statistical heterogeneity, a fixed effects model will be used for data synthesis; otherwise, a random effects model will be used. We will develop a unified data extraction table that includes a number of parameters. The Cochrane Cooperative Bias Risk Tool will be used to evaluate the methodological quality of the selected RCTs. RevMan Manager 5.3 and STATA 14.0 will be used for data analysis if enough RCTs (more than 10) are identified and selected. RESULT The final results will provide information on the effectiveness of intervention programs for frail older adul and further demonstrate which exercise programs are more effective and which methods can significantly improve frailty. CONCLUSION This protocol will contribute to the development of more effective interventions for elderly individuals with frailty. ETHICS AND DISSEMINATION This study applies existing literature references; therefore, ethical approval is not required. INPLASY REGISTRATION NUMBER INPLASY202130107.
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Affiliation(s)
- Jianna Zhang
- West China School of Nursing
- Department of Emergency Medicine, Disaster Medical Center, West China Hospital, Sichuan University, Chengdu, China
| | - Zhixi Liu
- West China School of Nursing
- Department of Emergency Medicine, Disaster Medical Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Liu
- West China School of Nursing
- Department of Emergency Medicine, Disaster Medical Center, West China Hospital, Sichuan University, Chengdu, China
| | - Lei Ye
- West China School of Nursing
- Department of Emergency Medicine, Disaster Medical Center, West China Hospital, Sichuan University, Chengdu, China
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Alkadri J, Hage D, Nickerson LH, Scott LR, Shaw JF, Aucoin SD, McIsaac DI. A Systematic Review and Meta-Analysis of Preoperative Frailty Instruments Derived From Electronic Health Data. Anesth Analg 2021; 133:1094-1106. [PMID: 33999880 DOI: 10.1213/ane.0000000000005595] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Frailty is a strong predictor of adverse outcomes in the perioperative period. Given the increasing availability of electronic medical data, we performed a systematic review and meta-analysis with primary objectives of describing available frailty instruments applied to electronic data and synthesizing their prognostic value. Our secondary objectives were to assess the construct validity of frailty instruments that have been applied to perioperative electronic data and the feasibility of electronic frailty assessment. METHODS Following protocol registration, a peer-reviewed search strategy was applied to Medline, Excerpta Medica dataBASE (EMBASE), Cochrane databases, and the Comprehensive Index to Nursing and Allied Health literature from inception to December 31, 2019. All stages of the review were completed in duplicate. The primary outcome was mortality; secondary outcomes included nonhome discharge, health care costs, and length of stay. Effect estimates adjusted for baseline illness, sex, age, procedure, and urgency were of primary interest; unadjusted and adjusted estimates were pooled using random-effects models where appropriate or narratively synthesized. Risk of bias was assessed. RESULTS Ninety studies were included; 83 contributed to the meta-analysis. Frailty was defined using 22 different instruments. In adjusted data, frailty identified from electronic data using any instrument was associated with a 3.57-fold increase in the odds of mortality (95% confidence interval [CI], 2.68-4.75), increased odds of institutional discharge (odds ratio [OR], 2.40; 95% CI, 1.99-2.89), and increased costs (ratio of means, 1.54; 95% CI, 1.46-1.63). Most instruments were not multidimensional, head-to-head comparisons were lacking, and no feasibility data were reported. CONCLUSIONS Frailty status derived from electronic data provides prognostic value as it is associated with adverse outcomes, even after adjustment for typical risk factors. However, future research is required to evaluate multidimensional instruments and their head-to-head performance and to assess their feasibility and clinical impact.
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Affiliation(s)
- Jamal Alkadri
- From the Department of Anesthesiology & Pain Medicine
| | - Dima Hage
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Lia R Scott
- Department of General Surgery, Queen's University, Ottawa, Ontario, Canada
| | - Julia F Shaw
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Daniel I McIsaac
- From the Department of Anesthesiology & Pain Medicine.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Abstract
PURPOSE OF REVIEW This review examines how functional capacity informs preoperative risk stratification, as well as strengths and limitations of options for estimating functional capacity. RECENT FINDINGS Functional capacity (or cardiopulmonary fitness) overlaps with other important characteristics, including muscular strength, balance, and frailty. Poor functional capacity is associated with postoperative morbidity, especially noncardiovascular complications. Both patient interviews and exercise tests are used to assess functional capacity. The usual approach of an unstructured patient interview does not predict outcomes. Structured interviews that incorporate validated questionnaires (Duke Activity Status Index) or standardized questions about physical activity (ability to climb stairs) do predict moderate-or-severe complications and cardiovascular complications. Among exercise tests, cardiopulmonary exercise testing (CPET) has shown the most consistent association with risks of complications. Other tests (6-min walk test, incremental shuttle walk test, stair climbing) might predict complications, but still require further high-quality evaluation. SUMMARY A straightforward way to better assess functional capacity is a structured interview with validated questionnaires or standardized questions about physical activities. Functional capacity can also be assessed by exercise tests, with the strongest evidence supporting CPET. Although some simpler exercise tests have shown promise, more research remains needed to better define their role in preoperative evaluation.
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111
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Abstract
As octogenarians in the operation room are no longer an exemption but the norm, perioperative management needs to be adopted to meet the special requirements of this group of patients. Anaesthesia does not need to be re-invented to fit the elderly. However, as elderly patients are among those most affected by adverse postoperative outcomes, the same diligence that is as a matter of course exercised in anaesthesiologic care of the youngest patients needs to be exercised for the eldest as well. Aging is associated with characteristic physiologic changes and an overall reduction in compensation width. However, the individual relevance of these changes varies distinctly. A comprehensive preoperative assessment is therefore essential to identify those at high risk. Maintaining functionality and preventing cognitive decline are central elements of perioperative care for frail elders, often only requiring unspectacular, but effective adjustments to established routine care processes. This review focuses on current recommendations in the perioperative anaesthesiologic management of elderly patients with a view towards assisting clinical anaesthesiologists in implementing respective structures in their setting and adjusting care pathways to meet the needs of this vulnerable but growing group of patients and improve their postoperative outcome.
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Affiliation(s)
- Cynthia Olotu
- Geriatric Anaesthesiology Research Group, Department of Anaesthesiology, Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg, Hamburg, Germany - .,Commission of Geriatric Anaesthesiology, German Society of Anaesthesiology and Intensive Care Medicine -
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112
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Complications as a Mediator of the Perioperative Frailty-Mortality Association. Anesthesiology 2021; 134:577-587. [PMID: 33529334 DOI: 10.1097/aln.0000000000003699] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Preoperative frailty is strongly associated with postoperative complications and mortality. However, the pathways between frailty, postoperative complications, and mortality are poorly described. The authors hypothesized that the occurrence of postoperative complications would mediate a substantial proportion of the total effect of frailty on mortality after elective noncardiac surgery. METHODS Following protocol registration, the authors conducted a retrospective cohort study of intermediate- to high-risk elective noncardiac surgery patients (2016) using National Surgical Quality Improvement Program data. The authors conducted Bayesian mediation analysis of the relationship between preoperative frailty (exposure, using the Risk Analysis Index), serious complications (mediator), and 30-day mortality (outcome), comprehensively adjusting for confounders. The authors estimated the total effect of frailty on mortality (composed of the indirect effect mediated by complications and the remaining direct effect of frailty) and estimated the proportion of the frailty-mortality association mediated by complications. RESULTS The authors identified 205,051 patients; 1,474 (0.7%) died. Complications occurred in 20,211 (9.9%). A 2 SD increase in frailty score resulted in a total association with mortality equal to an odds ratio of 3.79 (95% credible interval, 2.48 to 5.64), resulting from a direct association (odds ratio, 1.76; 95% credible interval, 1.34 to 2.30) and an indirect association mediated by complications (odds ratio, 2.15; 95% credible interval, 1.58 to 2.96). Complications mediated 57.3% (95% credible interval, 40.8 to 73.8) of the frailty-mortality association. Cardiopulmonary complications were the strongest mediators among complication subtypes. CONCLUSIONS Complications mediate more than half of the association between frailty and postoperative mortality in elective noncardiac surgery. EDITOR’S PERSPECTIVE
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McIsaac DI, Fottinger A, Sucha E, McDonald B. Association of frailty with days alive at home after cardiac surgery: a population-based cohort study. Br J Anaesth 2021; 126:1103-1110. [PMID: 33743980 DOI: 10.1016/j.bja.2021.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/01/2021] [Accepted: 02/18/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Frailty is a geriatric syndrome that leaves people vulnerable to adverse outcomes. In cardiac surgery, minimal data describe associations between frailty and patient-centred outcomes. Our objective was to estimate the association between frailty and days alive at home after cardiac surgery. METHODS We conducted a population-based cohort study using linked health administrative data in the Canadian province of Ontario. All individuals >65 yr at the time of cardiac surgery were assigned a frailty score using a validated frailty index. Days alive and at home in the 30 and 365 days after surgery were calculated. The unadjusted and adjusted associations between frailty and days alive at home were calculated. RESULTS We identified 61 389 patients from 2009 to 2015. Frailty was associated with reduced days at home within 30 days (adjusted ratio of means for every 10% increase in frailty=0.79; 95% confidence interval [CI], 0.78-0.81; P<0.0001) and 365 days (adjusted ratio of means for every 10% increase in frailty=0.92; 95% CI, 0.91-0.93; P<0.0001) of surgery. Results were consistent in sensitivity analyses (5.0 fewer days alive at home [95% CI, 4.8-5.2] within 30 days and 9.0 fewer days alive at home [95% CI, 8.7-9.2] within 365 days after surgery). CONCLUSION Frailty is associated with a reduction in days alive at home after major cardiac surgery. This information should be considered in prognostic discussions before surgery and in care planning for vulnerable older patient groups. Days alive at home may be a useful outcome for routine measurement in quality, reporting, and studies using routinely collected data.
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Affiliation(s)
- Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada; Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
| | - Alexandra Fottinger
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ewa Sucha
- Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada
| | - Bernard McDonald
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Stenberg Y, Wallinder L, Lindberg A, Walldén J, Hultin M, Myrberg T. Preoperative Point-of-Care Assessment of Left Ventricular Systolic Dysfunction With Transthoracic Echocardiography. Anesth Analg 2021; 132:717-725. [PMID: 33177328 DOI: 10.1213/ane.0000000000005263] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Left ventricular (LV) systolic dysfunction is an acknowledged perioperative risk factor and should be identified before surgery. Conventional echocardiographic assessment of LV ejection fraction (LVEF) obtained by biplane LV volumes is the gold standard to detect LV systolic dysfunction. However, this modality needs extensive training and is time consuming. Hence, a feasible point-of-care screening method for this purpose is warranted. The aim of this study was to evaluate 3 point-of-care echocardiographic methods for identification of LV systolic dysfunction in comparison with biplane LVEF. METHODS One hundred elective surgical patients, with a mean age of 63 ± 12 years and body mass index of 27 ± 4 kg/m2, were consecutively enrolled in this prospective observational study. Transthoracic echocardiography was conducted 1-2 hours before surgery. LVEF was obtained by automatic two-dimensional (2D) biplane ejection fraction (EF) software. We evaluated if Tissue Doppler Imaging peak systolic myocardial velocities (TDISm), anatomic M-mode E-point septal separation (EPSS), and conventional M-mode mitral annular plane systolic excursion (MAPSE) could discriminate LV systolic dysfunction (LVEF <50%) by calculating accuracy, efficiency, correlation, positive (PPV) respective negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC) for each point-of-care method. RESULTS LVEF<50% was identified in 22% (21 of 94) of patients. To discriminate an LVEF <50%, AUROC for TDISm (mean <8 cm/s) was 0.73 (95% confidence interval [CI], 0.62-0.84; P < .001), with a PPV of 47% and an NPV of 90%. EPSS with a cutoff value of >6 mm had an AUROC 0.89 (95% CI, 0.80-0.98; P < .001), with a PPV of 67% and an NPV of 96%. MAPSE (mean <12 mm) had an AUROC 0.80 (95% CI, 0.70-0.90; P < 0.001) with a PPV of 57% and an NPV of 98%. CONCLUSIONS All 3 point-of-care methods performed reasonably well to discriminate patients with LVEF <50%. The clinician may choose the most suitable method according to praxis and observer experience.
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Affiliation(s)
- Ylva Stenberg
- From the Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Sunderby)
| | - Lina Wallinder
- From the Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Sunderby)
| | - Anne Lindberg
- Department of Public Health and Clinical Medicine, Section of Medicine
| | - Jakob Walldén
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Sundsvall)
| | - Magnus Hultin
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Tomi Myrberg
- From the Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Sunderby)
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Awake Major Abdominal Surgeries in the COVID-19 Era. Pain Res Manag 2021; 2021:8763429. [PMID: 33688385 PMCID: PMC7920720 DOI: 10.1155/2021/8763429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 12/08/2020] [Accepted: 02/16/2021] [Indexed: 12/12/2022]
Abstract
Background During the outbreak of coronavirus disease 2019 (COVID-19), allocating intensive care beds to patients needing acute care surgery became a very difficult task. Moreover, since general anesthesia is an aerosol-generating procedure, its use became controversial. This strongly restricted therapeutic strategies. Here, we report a series of undeferrable surgical cases treated with awake surgery under neuraxial anesthesia. Contextual benefits of this approach are deepened. Methods During the first pandemic surge, thirteen patients (5 men and 8 women) with a mean age of 80 years, needing undelayable surgery due to abdominal emergencies, underwent awake open surgery at our Hospital. Prior to surgery, all patients underwent nasopharyngeal swab tests for COVID-19 diagnosis. In all cases, regional anesthesia (spinal, epidural, or combined spinal-epidural anesthesia) was performed. Intraoperative and postoperative pain intensities have been monitored and regularly assessed. A distinct pathway has been set up to keep patients of uncertain COVID-19 diagnosis separated from all other patients. Postoperative course has been examined. Results The mean operative time was 87 minutes (minimum 60 minutes; maximum 165 minutes). In one case, conversion to general anesthesia was necessary. Postoperative pain was always well controlled. None of them required postoperative intensive care support. No perioperative major complications (Clavien–Dindo ≥3) occurred. Early readmission after surgery never occurred. All nasopharyngeal swabs resulted negative. Conclusions In our experience, awake laparotomy under regional anesthesia resulted feasible, safe, painless, and, in specific cases, was the only viable option. This approach allowed prevention of the need of postoperative intensive monitoring during the COVID-19 era. In such a peculiar time, we believe it could become part of an ICU-preserving strategy and could limit viral transmission inside theatres.
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Zhang XM, Jiao J, Xie XH, Wu XJ. The Association Between Frailty and Delirium Among Hospitalized Patients: An Updated Meta-Analysis. J Am Med Dir Assoc 2021; 22:527-534. [PMID: 33549566 DOI: 10.1016/j.jamda.2021.01.065] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The aim of our meta-analysis was to update evidence for the association between frailty and delirium in different types of hospitalized patients, given the large volume of new studies with inconsistent results. DESIGN Systematic review and meta-analysis. SETTING AND PARTICIPANTS In this updated meta-analysis, we searched 3 databases (Embase, PubMed, and the Cochrane Library) for observational studies, exploring the association between frailty and delirium from database inception to September 21, 2020, among hospitalized patients. Relevant data were extracted from the studies that were included. A random effects model was conducted to synthesize and pool the effect size of frailty on delirium due to different frailty score instruments, different countries, and various delirium assessments that were used. The participants enrolled in this meta-analysis were hospitalized patients. MEASURES Delirium risk due to frailty. RESULTS A total of 30 independent studies from 9 countries, consisting of 217,623 patients, was identified, and the prevalence of frailty ranged from 16.20% to 78.00%. Frail patients exhibited an increased risk for delirium compared to those without frailty [odds ratio (OR) 2.96, 95% confidence interval (CI) 2.36-3.71]. In addition, different types of hospitalized patients had various OR values, which were 2.43 for selective surgical patients (95% CI 1.88-3.14), 3.61 for medical patients (95% CI 3.61-7.89), 3.76 for urgent surgical patients (95% CI 2.88-4.92), and 6.66 for emergency or critical illness patients (95% CI 1.41-31.47). Subgroup analysis based on the frailty score instrument showed the association still existed when using the Clinical Frailty Scale (OR 4.07, 95% CI 2.71-6.11), FRAIL Scale (OR 2.83, 95% CI 1.56-5.13), Frailty Index (OR 6.15, 95% CI 3.75-10.07), frailty phenotype (OR 2.30, 95%CI 1.35-5.66), or Erasmus Frailty Score (OR 2.79, 95% CI 1.63-4.77). However, an association between frailty and delirium was not observed when the Edmonton Frail Scale was used (OR 1.45, 95% CI 0.91-2.30). CONCLUSIONS AND IMPLICATIONS A 2.96-fold incremental risk of delirium in frail patients underscores the need for early screening of frailty and comprehensive delirium prevention. Appropriate interventions by clinicians should be performed to manage delirium, potentially reducing adverse clinical outcomes for hospitalized patients.
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Affiliation(s)
- Xiao-Ming Zhang
- Department of Nursing, Chinese Academy of Medical Sciences-Peking Union Medical College, Peking Union Medical College Hospital (Dongdan Campus), Beijing, China
| | - Jing Jiao
- Department of Nursing, Chinese Academy of Medical Sciences-Peking Union Medical College, Peking Union Medical College Hospital (Dongdan Campus), Beijing, China
| | - Xiao-Hua Xie
- Shenzhen Second People's Hospital, Shenzhen, China
| | - Xin-Juan Wu
- Department of Nursing, Chinese Academy of Medical Sciences-Peking Union Medical College, Peking Union Medical College Hospital (Dongdan Campus), Beijing, China.
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Frailty in Lung Transplantation - Candidate Assessment and Optimization. Transplantation 2021; 105:2201-2212. [PMID: 33982913 DOI: 10.1097/tp.0000000000003671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The concept of frailty has gained considerable interest in clinical solid organ transplantation over the past decade. Frailty as a phenotypic construct to describe a patient's risk from biologic stresses, has an impact on posttransplant survival. There is keen interest in characterizing frailty in lung transplantation, both to determine which patients are suitable candidates for listing and also to prepare for their care in the aftermath of lung transplantation. Here we review the current status of research on frailty in lung transplant candidates and recipients. This review will highlight areas of uncertainty for frailty in clinical lung transplantation which are likely to impact the state-of-the-art in the field for the next decade.
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Abstract
PURPOSE OF REVIEW To provide an overview of the recent advancements in predicting toxicity associated with cancer treatment in older patients. RECENT FINDINGS Various screening tools and validated risk calculators have been shown to help predict toxicity from surgery and chemotherapy. Radiation therapy has been more challenging to select the appropriate tool to reliably predict patients at risk for toxicity and noncompliance. Ongoing work on electronic geriatric assessment tools is showing promise in making comprehensive assessment more feasible. SUMMARY Selecting appropriate cancer therapy is particularly important in older patients, and validated tools have been developed to guide clinicians for surgery and chemotherapy; however, radiotherapy toxicity remains an area for further development, as does the uptake of existing tools into routine oncology practice.
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Zhang M, Hayden Gephart M, Zygourakis CC. Commentary: Predicting Postoperative Outcomes in Brain Tumor Patients With a 5-Factor Modified Frailty Index. Neurosurgery 2020; 88:E36-E38. [PMID: 32888308 DOI: 10.1093/neuros/nyaa407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/19/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Michael Zhang
- Department of Neurosurgery, Stanford Medical Center, Palo Alto, California
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Price A. Improving outcomes for older people undergoing emergency surgery: Opportunities for advanced practice. J Adv Nurs 2020; 77:504-505. [PMID: 33249642 DOI: 10.1111/jan.14686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Angeline Price
- Salford Royal Hospital Ringgold Standard Institution - Ageing and Complex Medicine, Salford, UK
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Okazawa Y, Yonekura H. Impact of neuraxial anaesthesia on short-term outcomes after elective open abdominal aortic aneurysm repair. Comment on Br J Anaesth 2020; 124: 544-52. Br J Anaesth 2020; 125:e355-e356. [PMID: 32654747 DOI: 10.1016/j.bja.2020.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/19/2020] [Accepted: 06/19/2020] [Indexed: 11/24/2022] Open
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Whitlock EL, Whittington RA. The Frailty Syndrome: Anesthesiologists Must Understand More and Fear Less. Anesth Analg 2020; 130:1445-1448. [PMID: 32384332 PMCID: PMC7678012 DOI: 10.1213/ane.0000000000004789] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Elizabeth L. Whitlock
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Robert A. Whittington
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA
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Nathan N. Handle with Care. Anesth Analg 2020; 130:1449. [DOI: 10.1213/ane.0000000000004819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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