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Rubel KE, Lopez A, Lubner RJ, Lee DL, Yancey K, Chandra RK, Chowdhury NI, Turner JH. Frailty is an independent predictor of postoperative rescue medication use after endoscopic sinus surgery. Int Forum Allergy Rhinol 2024; 14:1218-1225. [PMID: 38268092 PMCID: PMC11219267 DOI: 10.1002/alr.23324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 12/01/2023] [Accepted: 12/28/2023] [Indexed: 01/26/2024]
Abstract
INTRODUCTION The modified five-item frailty index (mFI-5) is a validated risk stratification tool with the ability to predict adverse outcomes following surgery. In this study, we sought to use mFI-5 to assess the potential relationship between unhealthy aging and postoperative endoscopic sinus surgery (ESS) outcomes. METHODS Patients who underwent sinus surgery at Vanderbilt between 2014 and 2018 were identified and assessed using the mFI-5, which is calculated based on the presence of five comorbidities: diabetes mellitus, hypertension requiring medication, chronic obstructive pulmonary disease, congestive heart failure, and non-independent functional status. Multivariate regression analyses were performed to quantify the association of mFI-5 score on need for rescue oral antibiotics, oral steroids, and antibiotic irrigations within 1 year following ESS, adjusting for relevant potential confounders. RESULTS Four hundred and three patients met inclusion criteria. Within 6 months of surgery, 312 (77%) required rescue antibiotics, 243 (60%) required oral corticosteroids (OCS), and 31 (8%) initiated antibiotic irrigations. Increasing mFI-5 scores were significantly associated with higher postoperative use of rescue antibiotics (p < 0.0001), OCS (p = 0.032), and antibiotic irrigation (p < 0.0001). Frailty scores remained as an independent predictor of these outcomes after adjustment for age, polyp status, preoperative sinonasal outcomes test (SNOT-22) score, and revision surgery status. CONCLUSIONS Modified frailty scores may be a useful clinical tool to predict the need for postoperative rescue medication use after ESS.
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Affiliation(s)
- Kolin E. Rubel
- Department of Otolaryngology-Head and Neck Surgery; University of Minnesota Medical Center; Minneapolis, MN 55455
| | - Andrea Lopez
- Department of Otolaryngology-Head and Neck Surgery; Vanderbilt University Medical Center; Nashville, TN 37232
| | - Rory J. Lubner
- Department of Otolaryngology-Head and Neck Surgery; Vanderbilt University Medical Center; Nashville, TN 37232
| | - Diane L Lee
- Department of Otolaryngology-Head and Neck Surgery; Vanderbilt University Medical Center; Nashville, TN 37232
| | - Kristen Yancey
- Department of Otolaryngology-Head and Neck Surgery; Weill Cornell Medicine; New York, NY 10021
| | - Rakesh K Chandra
- Department of Otolaryngology-Head and Neck Surgery; Vanderbilt University Medical Center; Nashville, TN 37232
| | - Naweed I Chowdhury
- Department of Otolaryngology-Head and Neck Surgery; Vanderbilt University Medical Center; Nashville, TN 37232
| | - Justin H. Turner
- Department of Otolaryngology-Head and Neck Surgery; Vanderbilt University Medical Center; Nashville, TN 37232
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Kshirsagar RS, Eide JG, Qatanani A, Harris J, Abello EH, Roman KM, Vasudev M, Jackson C, Lee JYK, Kuan EC, Palmer JN, Adappa ND. Impact of Frailty on Postoperative Outcomes in Extended Endonasal Skull Base Surgery for Suprasellar Pathologies. Otolaryngol Head Neck Surg 2024; 170:568-576. [PMID: 37746938 DOI: 10.1002/ohn.537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 08/29/2023] [Accepted: 09/05/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Frailty metrics estimate a patient's ability to tolerate physiologic stress and there are limited frailty data in patients undergoing expanded endonasal approaches (EEA) for suprasellar pathologies. Elevated frailty metrics have been associated with increased perioperative complications in patients undergoing craniotomies. We sought to examine this potential relationship in EEA. STUDY DESIGN Retrospective cohort study. SETTING Two tertiary academic skull base centers. METHODS Cases of patients undergoing EEA for suprasellar pathologies were reviewed. Demographic, treatment, survival, and postoperative outcomes data were recorded. Frailty was calculated using validated indexes, including the American Society of Anesthesiologists (ASA) classification, the modified 5-item frailty index (mFI-5), and the Charlson comorbidity index (CCI). Primary outcomes included 30-day medical and surgical complications. RESULTS A total of 88 patients were included, with 59 (67%) female patients and a mean age of 54 ± 15 years. The most common pathologies included 53 meningiomas (60.2%) and 21 craniopharyngiomas (23.9%). Most patients were ASA class 3 (54.5%) with mean mFI-5 0.82 ± 1.01 and CCI 4.18 ± 2.42. There was no association between increased frailty and 30-day medical or surgical outcomes (including postoperative cerebrospinal fluid leak), prolonged length of hospital stay, or mortality (all P > .05). Higher mFI-5 was associated with an increased risk for 30-day readmission (odds ratio: 2.35, 95% confidence Interval: 1.10-5.64, P = .04). CONCLUSION Despite the patient population being notably frail, we only identified an increased risk for 30-day readmission and observed no links with deteriorating surgical, medical, or mortality outcomes. This implies that conventional frailty metrics may not effectively align with EEA outcomes.
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Affiliation(s)
- Rijul S Kshirsagar
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jacob G Eide
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anas Qatanani
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jacob Harris
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric H Abello
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Kelsey M Roman
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Milind Vasudev
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Christina Jackson
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y K Lee
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - James N Palmer
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Kshirsagar RS, Eide JG, Qatanani A, Harris J, Birkenbeuel JL, Wang BY, Kuan EC, Palmer JN, Adappa ND. Frailty does not worsen postoperative outcomes in sinonasal squamous cell carcinoma. Am J Otolaryngol 2023; 44:103972. [PMID: 37459744 DOI: 10.1016/j.amjoto.2023.103972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 09/24/2023]
Abstract
PURPOSE Sinonasal squamous cell carcinoma (SCC) is an aggressive malignancy frequently requiring surgical resection and adjuvant treatment. Frailty is a metric that attempts to estimate a patient's ability to tolerate the physiologic stress of treatment. There is limited work describing frailty in patients with sinonasal cancer. We sought to determine the impact of frailty on postoperative outcomes in patients undergoing treatment for sinonasal SCC. MATERIALS AND METHODS Cases of patients undergoing surgical resection of sinonasal SCC at two tertiary medical centers were queried. Demographic, treatment, and survival data were recorded. Frailty was calculated using validated indexes, including the American Society of Anesthesiologists (ASA) classification, modified 5-item frailty index (mFI-5), and the Charlson Comorbidity Index (CCI). Primary outcomes included medical and surgical complications, readmission, and length of stay (LOS). RESULTS 38 patients were included. There were 23 (60.5 %) men and 15 (39.5 %) women with an average age of 59.6 ± 12.1 years. MFI-5 was 0.76 ± 0.54 and CCI was 5.71 ± 2.64. No significant association was noted between frailty measures and postoperative outcomes including 30-day medical complications, 30-day surgical complications, any 30-day complication, and readmission. Increased ASA was noted to be predictive of increased length of stay (Incidence Rate Ratio: 1.80, 95 % confidence interval [CI]: 1.16-2.83, p = 0.009). CONCLUSIONS We found no association between frailty metrics and worsening surgical or medical postoperative outcomes. This suggests that frailty metrics may not be as relevant for sinonasal surgery even for advanced pathologies, given the more limited physiologic impact of minimally invasive surgery.
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Affiliation(s)
- Rijul S Kshirsagar
- Department of Head and Neck Surgery, Kaiser Permanente Redwood City Medical Center, Redwood City, CA, United States of America
| | - Jacob G Eide
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, MI, United States of America
| | - Anas Qatanani
- Department of Otolaryngology-Head and Neck Surgery, Geisinger Medical Center, Danville, PA, United States of America
| | - Jacob Harris
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Jack L Birkenbeuel
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, CA, United States of America
| | - Beverly Y Wang
- Department of Pathology, University of California Irvine, Orange, CA, United States of America
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, CA, United States of America
| | - James N Palmer
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Nithin D Adappa
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States of America.
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Zhang D, Ostergaard PJ, Hall MJ, Shoji M, Earp BE. The Relationship Between Frailty and Functional Outcomes, Range of Motion, and Reoperation After Reverse Total Shoulder Arthroplasty for Proximal Humerus Fracture. Orthopedics 2023; 46:274-279. [PMID: 37018624 DOI: 10.3928/01477447-20230330-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
The objective of this study was to investigate whether frailty is associated with functional outcomes, motion, and reoperation at a minimum of 2 years after reverse total shoulder arthroplasty (rTSA) for proximal humerus fracture. We performed a retrospective study of 153 patients who underwent rTSA for proximal humerus fracture at two level 1 trauma centers from 2003 to 2018 with minimum 2-year follow-up. Frailty was assessed using the modified 5-item frailty index (mFI). The primary outcome variable was the American Shoulder and Elbow Surgeons (ASES) shoulder score at minimum 2-year follow-up. The secondary outcome variables were the Shoulder Pain and Disability Index (SPADI), the Shoulder Subjective Value (SSV), the 0 to 10 numeric rating scale (NRS) pain score, surgical complication, and reoperation. Bivariate comparisons were made between mFI and outcome variables. The mean age of the 153 patients was 70 years, and 76% were women. Forty patients (26%) had a mFI score of 0, 65 patients (42%) had a mFI score of 1, 40 patients (26%) had a mFI score of 2, and 8 patients (5%) had a mFI score of 3. Twenty-seven patients (18%) had complications, and 21 patients (14%) underwent reoperation. At minimum 2-year follow-up, mFI was not associated with ASES shoulder score, SPADI, SPADI pain or disability subscales, SSV, NRS pain score, active and passive shoulder forward flexion, abduction, and external rotation, complication, or reoperation. Provided they survive the initial physiologic insults of trauma and surgery, patients with higher mFI scores treated with rTSA for proximal humerus fracture can expect similar medium-term restoration of shoulder function. [Orthopedics. 2023;46(5):274-279.].
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Cheng MZ, Saraswathula A, Qureshi HA, Mukherjee D, Rowan NR. Otolaryngology Considerations of Pituitary Surgery: What an Endocrinologist Should Know. J Endocr Soc 2023; 7:bvad058. [PMID: 37313347 PMCID: PMC10259068 DOI: 10.1210/jendso/bvad058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Indexed: 06/15/2023] Open
Abstract
Endoscopic endonasal skull base surgery is the preferred surgical approach for the management of pituitary adenomas. Perioperative management of pituitary lesions requires multidisciplinary care and typically includes a dual surgeon team consisting of a neurosurgeon and an otolaryngologist. The involvement of the otolaryngologist allows for a safe surgical approach with excellent intraoperative visualization of the tumor to enable an effective resection of the tumor by the neurosurgeon. Detection and treatment of sinonasal pathology is essential prior to surgery. Patients may experience sinonasal complaints following endoscopic transsphenoidal surgery, although this is typically temporary. Sinonasal care in the postoperative period can expedite recovery to baseline. Here we discuss the perioperative factors of endoscopic pituitary surgery that endocrinologists should be aware of, ranging from preoperative patient selection and optimization to postoperative care, with a particular emphasis on anatomic and surgical factors.
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Affiliation(s)
- Michael Z Cheng
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medicine, Baltimore, MD 21287, USA
| | - Anirudh Saraswathula
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medicine, Baltimore, MD 21287, USA
| | - Hannan A Qureshi
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medicine, Baltimore, MD 21287, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins Medicine, Baltimore, MD 21287, USA
| | - Nicholas R Rowan
- Correspondence: Nicholas R Rowan, MD, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medicine, 601 N Caroline St, 6th floor, Baltimore, MD 21287, USA.
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Merna C, Lehrich BM, Kshirsagar RS, Eide JG, Diaz-Aguilar LD, Goshtasbi K, Yasaka TM, Sahyouni R, Palmer JN, Adappa ND, Hsu FPK, Kuan EC. Determinants of Survival in Skull Base Chondrosarcoma: A National Cancer Database Study. World Neurosurg 2021; 158:e766-e777. [PMID: 34808412 DOI: 10.1016/j.wneu.2021.11.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/14/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Chondrosarcomas of the skull base are rare tumors most commonly treated surgically with or without adjuvant radiation therapy. Using the National Cancer Database (NCDB), we analyzed overall survival (OS), treatment modalities, and prognosticators. METHODS The NCDB was queried for all cases of histologically confirmed skull base chondrosarcoma treated between 2004 and 2015, excluding patients with more than 1 malignant tumor, on palliative care, receiving unrelated concurrent treatments, or having less than 1 month of follow-up. The χ2 test for categorical variables, Cox proportional hazards models, and Kaplan-Meier log-rank analysis were used to test associations with the use of adjuvant radiation, OS, and survival time. RESULTS A total of 498 patients with skull base chondrosarcoma were identified in the NCDB. Of them, 224 (45.0%) and 198 (39.8%) were treated with either surgery alone or surgery with adjuvant radiation therapy, respectively. Patients more likely to undergo surgery with adjuvant radiation had higher tumor grade (P = 0.008), later year of diagnosis (P = 0.002), positive surgical margins (P < 0.001), and treatment at an academic institution (P = 0.02). Patient, tumor, and socioeconomic factors associated with worse OS on multivariate analysis included the Charlson/Deyo Comorbidity Score ≥2 (P = 0.017), as well as clear cell (P = 0.02) and dedifferentiated (P = 0.006) histology. Age, tumor grade, tumor size, treatment modality, insurance status, facility type, and urban/rural population did not show a statistically significant impact on OS. CONCLUSION The mainstay of treatment for skull base chondrosarcoma is surgery, with consideration of adjuvant radiation. This study demonstrated worse overall survival associated with more frail patients and aggressive histology types. It is important to consider these factors when planning the clinical management of these patients.
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Affiliation(s)
- Catherine Merna
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Brandon M Lehrich
- School of Medicine, University of California, Irvine, Orange, California, USA
| | - Rijul S Kshirsagar
- Division of Rhinology, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jacob G Eide
- Division of Rhinology, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Luis Daniel Diaz-Aguilar
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA
| | - Khodayar Goshtasbi
- School of Medicine, University of California, Irvine, Orange, California, USA
| | - Tyler M Yasaka
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Ronald Sahyouni
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA
| | - James N Palmer
- Division of Rhinology, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Division of Rhinology, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA.
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