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Arow Z, Gabarin M, Abu-Hosein H, Giladi E, Hilu R, Losin I, Mishaev R, Assali A, Pereg D. Eyeball Test for the Assessment of Frailty in Elderly Patients With Cardiovascular Disease: A Prospective Study. Am J Cardiol 2023; 204:9-13. [PMID: 37536207 DOI: 10.1016/j.amjcard.2023.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 07/03/2023] [Accepted: 07/08/2023] [Indexed: 08/05/2023]
Abstract
Frailty has been associated with poor outcomes in patients with cardiovascular diseases (CVDs). We aimed to assess the accuracy of the Eyeball test for frailty assessment in elderly patients with CVD. This is a prospective study including stable patients ≥75 years old who were followed-up in a cardiology clinic. Frailty assessment was performed separately through the Eyeball test and the Fried test in a blinded way. Cardiologists were asked to rate the frailty status of participants based on their routine clinical assessment and grade frailty on a Fried-type scale (1 to 5, with frailty defined as a score ≥3). Each patient then underwent formal frailty assessment using the Fried test. Included were 300 consecutive patients with a mean age of 81 ± 6 years. Frailty was diagnosed in 109 (36%) and 125 patients (41%) according to the Fried and Eyeball tests, respectively. The Eyeball test demonstrated 86% sensitivity and 82% specificity for the diagnosis of frailty. A receiver operating characteristics curve analysis demonstrated an area under the curve of 0.82 for the diagnosis of frailty. The Eyeball test demonstrated a very high negative predictive value of 90% and a modest positive predictive value of 73% for frailty assessment. Similar results were observed after subgroup analysis according to age and gender. In conclusion, the Eyeball test is an accurate method to rule out frailty in elderly patients with CVD. However, when frailty is suspected based on the Eyeball test, a formal tool such as the Fried test should be used to confirm the diagnosis.
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Affiliation(s)
- Ziad Arow
- Cardiology Department, Meir Medical Center, Kfar Saba, Israel; Cardiology Department, Meir Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Mustafa Gabarin
- Cardiology Department, Meir Medical Center, Kfar Saba, Israel; Cardiology Department, Meir Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hasan Abu-Hosein
- Cardiology Department, Meir Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Internal Medicine Department C, Meir Medical Center, Kfar Saba, Israel
| | - Ela Giladi
- Cardiology Department, Meir Medical Center, Kfar Saba, Israel; Cardiology Department, Meir Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ranin Hilu
- Cardiology Department, Meir Medical Center, Kfar Saba, Israel; Cardiology Department, Meir Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ilya Losin
- Cardiology Department, Meir Medical Center, Kfar Saba, Israel; Cardiology Department, Meir Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Raffael Mishaev
- Internal Medicine Department, Oregon Health and Science University, Portland, Oregon
| | - Abid Assali
- Cardiology Department, Meir Medical Center, Kfar Saba, Israel; Cardiology Department, Meir Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David Pereg
- Cardiology Department, Meir Medical Center, Kfar Saba, Israel; Cardiology Department, Meir Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Blackstone EH. Commentary: Frailty: I know it when I see it. J Thorac Cardiovasc Surg 2023; 166:879-880. [PMID: 35410690 DOI: 10.1016/j.jtcvs.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Eugene H Blackstone
- Sydell and Arnold Miller Family Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Bludevich BM, Emmerick I, Uy K, Maxfield M, Ash AS, Baima J, Lou F. Association Between the Modified Frailty Index and Outcomes Following Lobectomy. J Surg Res 2023; 283:559-571. [PMID: 36442255 DOI: 10.1016/j.jss.2022.11.014] [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: 02/09/2022] [Revised: 10/29/2022] [Accepted: 11/06/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Elective thoracic surgery is safe in well-selected elderly patients. The association of frailty with postoperative morbidity in elective-lobectomy patients is understudied. We examined frailty as defined by abbreviated modified frailty index (mFI-5), mFI-11 in the thoracic surgery population, and the correlation between frailty and postoperative complications. METHODS We studied outcomes of patients in two cohorts, 2010-2012 and 2013-2019, from the National Surgical Quality Improvement Program (NSQIP) database and used multivariable logistic regression models to predict all postoperative morbidity, mortality, and major morbidity. The mFI-5 could be calculated for all subjects (both 2010-2012, and 2013-2019); the mFI-11 could only be calculated for the 2010-2012 cohort. Patient frailty was defined as mFI≥3 (with either index). We used odds ratios (ORs) to examine associations of preoperative characteristics with postoperative complications and C-statistics to assess overall predictive power. RESULTS Complications were less prevalent in the 2013-2019 cohort (17.9% versus 19.5%, P = 0.008). Open lobectomies were more common in the 2010-2012 cohort (53.9% versus 34.6%) and were strongly associated with postoperative morbidity and mortality (ORs >1.5) in both cohorts. Each frailty measure was associated with morbidity and mortality (ORs >1.4) after adjusting for other significant preoperative factors. Models on the 2010-2012 cohort had nearly identical C-statistics using the mFI-11 versus mFI-5 frailty indices (0.6142 versus 0.6139; P > 0.8). CONCLUSIONS Frailty, as captured in the mFI-5, is a significant associated factor of postoperative morbidity and mortality following elective lobectomies. As a modifiable risk factor, frailty should be considered in surgical decision-making and when counseling patients regarding perioperative risks.
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Affiliation(s)
- Bryce M Bludevich
- Division of Thoracic Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Isabel Emmerick
- Division of Thoracic Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Karl Uy
- Division of Thoracic Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Mark Maxfield
- Division of Thoracic Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Arlene S Ash
- Department of Quantitative Health Services, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jennifer Baima
- Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Feiran Lou
- Division of Thoracic Surgery, University of Massachusetts Medical School, Worcester, Massachusetts.
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Jensen GL, Hammonds KP, Haque W. Neoadjuvant versus definitive chemoradiation in locally advanced esophageal cancer for patients of advanced age or significant comorbidities. Dis Esophagus 2023; 36:6651301. [PMID: 35901451 DOI: 10.1093/dote/doac050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/23/2022] [Accepted: 07/10/2022] [Indexed: 02/01/2023]
Abstract
The addition of surgery to chemoradiation for esophageal cancer has not shown a survival benefit in randomized trials. Patients with more comorbidities or advanced age are more likely to be given definitive chemoradiation due to surgical risk. We aimed to identify subsets of patients in whom the addition of surgery to chemoradiation does not provide an overall survival (OS) benefit. The National Cancer Database was queried for patients with locally advanced esophageal cancer who received either definitive chemoradiation or neoadjuvant chemoradiation followed by surgery. Bivariate analysis was used to assess the association between patient characteristics and treatment groups. Log-rank tests and Cox proportional hazards models were performed to assess for differences in survival. A total of 15,090 with adenocarcinoma and 5,356 with squamous cell carcinoma met the inclusion criteria. Patients treated with neoadjuvant chemoradiation and surgery had significantly improved survival by Cox proportional hazards model regardless of histology if <50, 50-60, 61-70, or 71-80 years old. There was no significant benefit or detriment in patients 81-90 years old. Survival advantage was also significant with a Charlson/Deyo comorbidity condition score of 0, 1, 2, and ≥3 in adenocarcinoma squamous cell carcinoma with scores of 2 or ≥3 had no significant benefit or detriment. Patients 81-90 years old or with squamous cell carcinoma and a Charlson/Deyo comorbidity score ≥ 2 lacked an OS benefit from neoadjuvant chemoradiation followed by surgery compared with definitive chemoradiation. Careful consideration of esophagectomy-specific surgical risks should be used when recommending treatment for these patients.
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Affiliation(s)
- Garrett L Jensen
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kendall P Hammonds
- Department of Biostatistics, Baylor Scott & White Health, Temple, TX, USA
| | - Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
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Muir D, Antonowicz S, Whiting J, Low D, Maynard N. Implementation of the Esophagectomy Complication Consensus Group definitions: the benefits of speaking the same language. Dis Esophagus 2022; 35:6603615. [PMID: 35673848 DOI: 10.1093/dote/doac022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/17/2022] [Indexed: 12/24/2022]
Abstract
In 2015 the Esophagectomy Complication Consensus Group (ECCG) reported consensus definitions for complications after esophagectomy. This aimed to reduce variation in complication reporting, attributed to heterogeneous definitions. This systematic review aimed to describe the implementation of this definition set, including the effect on complication frequency and variation. A systematic literature review was performed, identifying all observational and randomized studies reporting complication frequencies after esophagectomy since the ECCG publication. Recruitment periods before and subsequent to the index ECCG publication date were included. Coefficients of variance were calculated to assess outcome heterogeneity. Of 144 studies which met inclusion criteria, 70 (48.6%) used ECCG definitions. The median number of separately reported complication types was five per study; only one study reported all ECCG complications. The coefficients of variance of the reported frequencies of eight of the 10 most common complications were reduced in studies which used the ECCG definitions compared with those that did not (P = 0.036). Among ECCG studies, the frequencies of postoperative pneumothorax, reintubation, and pulmonary emboli were significantly reduced in 2020-2021, compared with 2015-2019 (P = 0.006, 0.034, and 0.037 respectively). The ECCG definition set has reduced variation in esophagectomy morbidity reporting. This adds greater confidence to the observed gradual improvement in outcomes with time, and its ongoing use and wider dissemination should be encouraged. However, only a handful of outcomes are widely reported, and only rarely is it used in its entirety.
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Affiliation(s)
- Duncan Muir
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Stefan Antonowicz
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Jack Whiting
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Donald Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Nick Maynard
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
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Park MG, Haro G, Mabeza RM, Sakowitz S, Verma A, Lee C, Williamson C, Benharash P. Association of frailty with clinical and financial outcomes of esophagectomy hospitalizations in the United States. Surg Open Sci 2022; 9:80-85. [PMID: 35719414 PMCID: PMC9198451 DOI: 10.1016/j.sopen.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 04/28/2022] [Accepted: 05/14/2022] [Indexed: 11/11/2022] Open
Abstract
Background Frailty, defined as impaired physiologic reserve and function, has been associated with inferior results after surgery. Using a coding-based tool, we examined the clinical and financial impact of frailty on outcomes following esophagectomy. Methods Adults undergoing elective esophagectomy were identified using the 2010-2018 Nationwide Readmissions Database. Using the binary Johns Hopkins Adjusted Clinical Groups frailty indicator, patients were classified as frail or nonfrail. Multivariable regression models were used to evaluate the association of frailty with in-hospital mortality, complications, hospitalization duration, costs, nonhome discharge, and unplanned 30-day readmission. Results Of 45,361 patients who underwent esophagectomy, 18.7% were considered frail. Most frail patients were found to have diagnoses of malnutrition (70%) or weight loss (15%) at the time of surgery. After adjustment, frailty was associated with increased risk of in-hospital mortality (adjusted odds ratio 1.67, 95% confidence interval 1.29-2.16) and overall complications (adjusted odds ratio 1.57, 95% confidence interval 1.44-1.71). Frailty conferred a 5.6-day increment in length of stay (95% confidence interval 4.94-6.45) and an additional $19,900 hospitalization cost (95% confidence interval $16,700-$23,100). Frail patients had increased odds of nonhome discharge (adjusted odds ratio 1.53, 95% confidence interval 1.35-1.75) as well as unplanned 30-day readmissions (adjusted odds ratio 1.17, 95% confidence interval 1.02-1.34). Conclusion Frailty, as detected by an administrative tool, is associated with worse clinical and financial outcomes following esophagectomy. The inclusion of standardized assessment of frailty in risk models may better inform patient selection and shared decision-making prior to operative intervention.
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Affiliation(s)
- Mina G Park
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Greg Haro
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Russyan Mark Mabeza
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Cory Lee
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Tang A, Feczko A, Murthy SC, Raja S, Bribriesco A, Schraufnagel D, Ahmad U, Raymond DP, Sudarshan M. Select octogenarians with stage IIIa non–small cell lung cancer can benefit from trimodality therapy. JTCVS OPEN 2022; 10:395-403. [PMID: 36004217 PMCID: PMC9390188 DOI: 10.1016/j.xjon.2022.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 01/13/2022] [Indexed: 11/03/2022]
Abstract
Objectives Currently, more than 36% of patients diagnosed with lung cancer are 75 years of age or older. Management of stage IIIA cancer is variable, especially for octogenarians who might not be offered surgery because of questionable benefit. In this study we investigated the outcomes of definitive chemoradiotherapy (CR) and trimodality therapy (TM) management (CR and surgery) for clinical stage IIIA non–small cell lung cancer (NSCLC) in patients 80 years of age or older. Methods The National Cancer Data Base was queried for stage IIIA NSCLC in patients 80 years of age or older between 2004 and 2015. Patients were divided according to treatment type: definitive CR and TM. Patient demographic characteristics, facility type, Charlson–Deyo score, final tumor pathology, and survival data were extracted. Univariate analysis was performed, followed by 3:1 propensity matching to analyze overall survival differences. Unadjusted and adjusted Kaplan–Meier survival analyses were performed. Results From the database, 6048 CR and 190 TM octogenarians were identified. Patients in the TM group were younger (82 years old [TM] vs 83 years old [CR]; P < .0001), more likely to be treated at an academic/research institution (36% [TM] vs 26% [CR]; P = .003), had greater proportion of adenocarcinoma (52% [TM] vs 34% [CR]; P < .001), and a smaller tumor size (38 mm [TM] vs 33 mm [CR]; P = .025). After 3:1 matching, the 5-year overall survival for the TM group was 29% (95% CI, 22%-38%) versus 15% (95% CI, 11%-20%) for the CR group. Conclusions Selected elderly patients with stage IIIa NSCLC can benefit from an aggressive TM approach.
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Alicuben ET, Kim AW. Weighing in on Ghrelin and the Preservation of Muscle After Esophagectomy. Ann Surg Oncol 2022; 29:3375-3376. [DOI: 10.1245/s10434-022-11452-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 01/29/2022] [Indexed: 11/18/2022]
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Grenda TR, Chang AC. Commentary: Quantifying "fit for esophagectomy"-Grasping for more metrics. J Thorac Cardiovasc Surg 2020; 161:833-834. [PMID: 33317784 DOI: 10.1016/j.jtcvs.2020.11.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Tyler R Grenda
- Division of Thoracic Surgery, Sidney Kimmel Medical College, Philadelphia, Pa
| | - Andrew C Chang
- Section of Thoracic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Mich.
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Commentary: Surgical risk assessment in 2020: Is a handshake and a walking test really the best we've got? J Thorac Cardiovasc Surg 2020; 161:834-835. [PMID: 33422318 DOI: 10.1016/j.jtcvs.2020.11.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 12/16/2022]
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