1
|
McGarrigle L, Norman G, Hurst H, Todd C. Rehabilitation interventions to modify physical frailty in adults before lung transplantation: a systematic review protocol. BMJ Open 2024; 14:e078561. [PMID: 38569690 PMCID: PMC11146394 DOI: 10.1136/bmjopen-2023-078561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 01/30/2024] [Indexed: 04/05/2024] Open
Abstract
INTRODUCTION Lung transplantation is the gold-standard treatment for end-stage lung disease for a small group of patients meeting strict acceptance criteria after optimal medical management has failed. Physical frailty is prevalent in lung transplant candidates and has been linked to worse outcomes both on the waiting list and postoperatively. Exercise has been proven to be beneficial in optimising exercise capacity and quality of life in lung transplant candidates, but its impact on physical frailty is unknown. This review aims to assess the effectiveness of exercise interventions in modifying physical frailty for adults awaiting lung transplantation. METHODS AND ANALYSIS This protocol was prospectively registered on the PROSPERO database. We will search four databases plus trial registries to identify primary studies of adult candidates for lung transplantation undertaking exercise interventions and assessing outcomes pertaining to physical frailty. Studies must include at least 10 participants. Article screening will be performed by two researchers independently at each stage. Extraction will be performed by one reviewer and checked by a second. The risk of bias in studies will be assessed by two independent reviewers using tools appropriate for the research design of each study; where appropriate, we will use Cochrane Risk of Bias 2 or ROBINS-I. At each stage of the review process, discrepancies will be resolved through a consensus or consultation with a third reviewer. Meta-analyses of frailty outcomes will be performed if possible and appropriate as will prespecified subgroup and sensitivity analyses. Where we are unable to perform meta-analysis, we will conduct narrative synthesis following Synthesis without Meta-analysis guidance. The review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. ETHICS AND DISSEMINATION No ethical issues are predicted due to the nature of this study. Dissemination will occur via conference abstracts, professional networks, peer-reviewed journals and patient support groups. PROSPERO REGISTRATION NUMBER CRD42022363730.
Collapse
Affiliation(s)
- Laura McGarrigle
- Cardiothoracic Transplantation, Manchester University NHS Foundation Trust, Manchester, UK
- National Institute for Health and Care Research Applied Research Collaboration Greater Manchester, Greater Manchester, UK
| | - Gill Norman
- National Institute for Health and Care Research Applied Research Collaboration Greater Manchester, Greater Manchester, UK
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK
| | - Helen Hurst
- School of Health and Society, University of Salford, Salford, UK
- Renal, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Chris Todd
- National Institute for Health and Care Research Applied Research Collaboration Greater Manchester, Greater Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
| |
Collapse
|
2
|
Ruiz-Margáin A, Macías-Rodríguez RU, Flores-García NC, Román Calleja BM, Fierro-Angulo OM, González-Regueiro JA. Assessing nutrition status, sarcopenia, and frailty in adult transplant recipients. Nutr Clin Pract 2024; 39:14-26. [PMID: 38097210 DOI: 10.1002/ncp.11107] [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: 09/01/2023] [Revised: 11/15/2023] [Accepted: 11/15/2023] [Indexed: 01/13/2024] Open
Abstract
The assessment of nutrition status, sarcopenia, and frailty holds significant relevance in the context of adult transplantation, as these factors are associated with an unfavorable prognosis; thus, transplant candidates must undergo a full nutrition assessment. Screening tools may be used to prioritize patients, this can be done using the Nutrition Risk Screening 2002 or Royal Free Hospital-Nutritional Prioritizing Tool. Subsequently, a thorough nutrition-focused physical examination should be conducted to evaluate clinical signs of nutrition deficiencies, fat and muscle loss, and fluid overload; dietary history and current intake must also be assessed. Apart from physical examination, specific testing for sarcopenia and frailty are recommended. For sarcopenia assessment, specifically for muscle quantification, the gold standard is the cross-sectional measurement of the muscle at L3 obtained from a computed tomography scan or magnetic resonance imaging; dual-energy x-ray absorptiometry is also a good tool especially when appendicular skeletal muscle index is calculated. Other more readily available options include phase angle from bioelectrical impedance or bioimpedance spectroscopy. In the sarcopenia assessment, muscle function evaluation is required, handgrip strength stands as the primary test for this purpose; this test is also part of the subjective global assessment and is included in some frailty scores. Finally, for frailty assessment, the Short Physical Performance Battery is useful for evaluating physical frailty, and for a multidimensional evaluation, the Fried frailty phenotype can be used. Specifically for liver transplant candidates, the use of Liver Frailty Index is recommended.
Collapse
Affiliation(s)
- Astrid Ruiz-Margáin
- Division of Hepatology, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ricardo U Macías-Rodríguez
- Division of Hepatology, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Nayelli C Flores-García
- Division of Hepatology, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Berenice M Román Calleja
- Division of Hepatology, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Oscar M Fierro-Angulo
- Division of Hepatology, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José A González-Regueiro
- Division of Hepatology, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| |
Collapse
|
3
|
de Paiva Azevedo M, Angelica de Miranda Silva Nogueira P, D’Souza L, Cheung B, Uy K, Patcai J, Mathur S, Janaudis-Ferreira T. Changes in Functional Outcomes After an Inpatient Rehabilitation Program for Solid-Organ Transplant Recipients. Prog Transplant 2023; 33:201-207. [PMID: 37491867 PMCID: PMC10466989 DOI: 10.1177/15269248231189861] [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] [Indexed: 07/27/2023]
Abstract
Introduction: Outpatient exercise training has been shown to be beneficial for solid organ transplant recipients. Little is known about the effects of inpatient rehabilitation programs for recipients with a more complicated postoperative course. Research Question: This study was designed to (1) describe the changes in functional outcomes after an inpatient rehabilitation program, and (2) determine whether the changes in lower body strength and quadriceps strength are associated with changes in functional exercise capacity. Design: This was a single-arm prospective longitudinal study. The recipients participated in an inpatient rehabilitation program twice a day, 7 days a week for 3 to 4 weeks. Outcome Measures Included: 2-Minute Walking Test, Timed Up and Go, Berg Balance Scale, 30-Second Sit to Stand, biceps and quadriceps strength, Functional Independence Measure, SF-36, and Canadian Occupational Performance Measure. Results: Twenty-eight patients (54% female, mean age = 55 [11]) completed the study. Participants were mostly liver (42%) and lung recipients (35%). There were statistically significant improvements in all outcomes after the intervention. There was no relationship between changes in functional exercise capacity and quadriceps strength or lower body strength. Conclusion: An inpatient rehabilitation program may improve several functional outcomes and health-related quality of life in transplant recipients with a complicated postoperative course.
Collapse
Affiliation(s)
| | | | - Lorna D’Souza
- St John's Rehab Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Betty Cheung
- St John's Rehab Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Karen Uy
- St John's Rehab Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - John Patcai
- Departments of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sunita Mathur
- School of Rehabilitation Therapy, Queen's University, Kingston, ON, Canada
| | - Tania Janaudis-Ferreira
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Canadian Donation and Transplantation Research Program, Li Ka Shing Centre for Health Research Innovation University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
4
|
Weimann A, Ahlert M, Seehofer D, Zieschang T, Schweda M. Old Age and Frailty in Deceased Organ Transplantation and Allocation-A Plea for Geriatric Assessment and Prehabilitation. Transpl Int 2023; 36:11296. [PMID: 37476294 PMCID: PMC10354295 DOI: 10.3389/ti.2023.11296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/21/2023] [Indexed: 07/22/2023]
Abstract
Due to demographic ageing and medical progress, the number and proportion of older organ donors and recipients is increasing. At the same time, the medical and ethical significance of ageing and old age for organ transplantation needs clarification. Advanced age is associated with the frailty syndrome that has a negative impact on the success of organ transplantation. However, there is emerging evidence that frailty can be modified by suitable prehabilitation measures. Against this backdrop, we argue that decision making about access to the transplant waiting list and the allocation of donor organs should integrate geriatric expertise in order to assess and manage frailty and impairments in functional capacity. Prehabilitation should be implemented as a new strategy for pre-operative conditioning of older risk patients' functional capacity. From an ethical point of view, advanced chronological age per se should not preclude the indication for organ transplantation and the allocation of donor organs.
Collapse
Affiliation(s)
- Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
| | - Marlies Ahlert
- Department of Economics, Martin-Luther-University of Halle, Halle, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Tania Zieschang
- Division of Geriatric Medicine, Department of Health Services Research, School of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany
| | - Mark Schweda
- Division of Medical Ethics, Department of Health Services Research, School of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany
| |
Collapse
|
5
|
Lorenz EC, Hickson LJ, Khairallah P, Najafi B, Kennedy CC. Cellular Senescence and Frailty in Transplantation. CURRENT TRANSPLANTATION REPORTS 2023; 10:51-59. [PMID: 37576589 PMCID: PMC10414789 DOI: 10.1007/s40472-023-00393-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 03/28/2023]
Abstract
Purpose of review To summarizes the literature on cellular senescence and frailty in solid-organ transplantation and highlight the emerging role of senotherapeutics as a treatment for cellular senescence. Recent findings Solid-organ transplant patients are aging. Many factors contribute to aging acceleration in this population, including cellular senescence. Senescent cells accumulate in tissues and secrete proinflammatory and profibrotic proteins which result in tissue damage. Cellular senescence contributes to age-related diseases and frailty. Our understanding of the role cellular senescence plays in transplant-specific complications such as allograft immunogenicity and infections is expanding. Promising treatments, including senolytics, senomorphics, cell-based regenerative therapies, and behavioral interventions, may reduce cellular senescence abundance and frailty in patients with solid-organ transplants. Summary Cellular senescence and frailty contribute to adverse outcomes in solid-organ transplantation. Continued pursuit of understanding the role cellular senescence plays in transplantation may lead to improved senotherapeutic approaches and better graft and patient outcomes.
Collapse
Affiliation(s)
| | - LaTonya J. Hickson
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | | | - Bijan Najafi
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Texas
| | - Cassie C. Kennedy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
6
|
Rudym D, Natalini JG, Trindade AJ. Listing Dilemmas: Age, Frailty, Weight, Preexisting Cancers, and Systemic Diseases. Clin Chest Med 2023; 44:35-46. [PMID: 36774166 DOI: 10.1016/j.ccm.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Selection of lung transplant candidates is an evolving field that pushes the boundaries of what is considered the norm. Given the continually changing demographics of the typical lung transplant recipient as well as the growing list of risk factors that predispose patients to poor posttransplant outcomes, we explore the dilemmas in lung transplant candidate selections pertaining to older age, frailty, low and high body mass index, preexisting cancers, and systemic autoimmune rheumatic diseases.
Collapse
Affiliation(s)
- Darya Rudym
- Division of Pulmonary and Critical Care Medicine, New York University, Langone Health, 530 First Avenue, HCC-4A, New York, NY 10016, USA.
| | - Jake G Natalini
- Division of Pulmonary and Critical Care Medicine, New York University, Langone Health, 530 First Avenue, HCC-4A, New York, NY 10016, USA
| | - Anil J Trindade
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Oxford House, Room 539, 1313 21st Avenue South, Nashville, TN 37232, USA
| |
Collapse
|
7
|
Tsuang WM, Lopez R, Tang A, Budev M, Schold JD. Place-based heterogeneity in lung transplant recipient outcomes. Am J Transplant 2022; 22:2981-2989. [PMID: 35962587 DOI: 10.1111/ajt.17170] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/14/2022] [Accepted: 08/11/2022] [Indexed: 01/25/2023]
Abstract
Place is defined as a social or environmental area of residence with meaning to a patient. We hypothesize there is an association between place and the clinical outcomes of lung transplant recipients in the United States. In a retrospective cohort study of transplants between January 1, 2010, and December 31, 2019, in the Scientific Registry of Transplant Recipients, multivariable Cox regression models were used to test the association between place (through social and environmental factors) with readmission, lung rejection, and survival. Among 18,465 recipients, only 20% resided in the same county as the transplant center. Recipients from the most socially vulnerable counties when compared to the least vulnerable were more likely to have COPD as a native disease, Black or African American race, and travel long distances to reach a transplant center. Higher local life expectancy was associated with lower likelihood for readmission (odds ratio [OR] = 0.90, 95% confidence interval [CI]: 0.84, 0.98, p = .01). Higher social vulnerability was associated with a higher likelihood of lung rejection (OR = 1.37, [CI]: 1.07, 1.76, p = .01). There was no association of residence with posttransplant survival. Recipient place-based factors were associated with complications and processes of care after transplant and warrant further investigation.
Collapse
Affiliation(s)
- Wayne M Tsuang
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rocio Lopez
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anne Tang
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marie Budev
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jesse D Schold
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
8
|
Kao J, Reid N, Hubbard RE, Homes R, Hanjani LS, Pearson E, Logan B, King S, Fox S, Gordon EH. Frailty and solid-organ transplant candidates: a scoping review. BMC Geriatr 2022; 22:864. [PMCID: PMC9667636 DOI: 10.1186/s12877-022-03485-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
Abstract
Background
There is currently no consensus as to a standardized tool for frailty measurement in any patient population. In the solid-organ transplantation population, routinely identifying and quantifying frailty in potential transplant candidates would support patients and the multidisciplinary team to make well-informed, individualized, management decisions. The aim of this scoping review was to synthesise the literature regarding frailty measurement in solid-organ transplant (SOT) candidates.
Methods
A search of four databases (Cochrane, Pubmed, EMBASE and CINAHL) yielded 3124 studies. 101 studies (including heart, kidney, liver, and lung transplant candidate populations) met the inclusion criteria.
Results
We found that studies used a wide range of frailty tools (N = 22), including four ‘established’ frailty tools. The most commonly used tools were the Fried Frailty Phenotype and the Liver Frailty Index. Frailty prevalence estimates for this middle-aged, predominantly male, population varied between 2.7% and 100%. In the SOT candidate population, frailty was found to be associated with a range of adverse outcomes, with most evidence for increased mortality (including post-transplant and wait-list mortality), post-operative complications and prolonged hospitalisation. There is currently insufficient data to compare the predictive validity of frailty tools in the SOT population.
Conclusion
Overall, there is great variability in the approach to frailty measurement in this population. Preferably, a validated frailty measurement tool would be incorporated into SOT eligibility assessments internationally with a view to facilitating comparisons between patient sub-groups and national and international transplant services with the ultimate goal of improved patient care.
Collapse
|
9
|
Relationship of Exercise Capacity, Physical Function, and Frailty Measures With Clinical Outcomes and Healthcare Utilization in Lung Transplantation: A Scoping Review. Transplant Direct 2022; 8:e1385. [PMID: 36246000 PMCID: PMC9553387 DOI: 10.1097/txd.0000000000001385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 08/10/2022] [Indexed: 12/02/2022] Open
Abstract
Measures of exercise capacity, frailty, and physical function are commonly used in lung transplant candidates and recipients to evaluate their physical limitations and the effects of exercise training and to select candidates for transplantation. It is unclear how these measures are related to clinical outcomes and healthcare utilization before and after lung transplantation. The purpose of this scoping review was to describe how measures of exercise capacity, physical function, and frailty are related to pre- and posttransplant outcomes.
Collapse
|
10
|
Koons B, Anderson MR, Smith PJ, Greenland JR, Singer JP. The Intersection of Aging and Lung Transplantation: its Impact on Transplant Evaluation, Outcomes, and Clinical Care. CURRENT TRANSPLANTATION REPORTS 2022; 9:149-159. [PMID: 36341000 PMCID: PMC9632682 DOI: 10.1007/s40472-022-00365-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 10/18/2022]
Abstract
Purpose Older adults (age ≥ 65 years) are the fastest growing age group undergoing lung transplantation. Further, international consensus document for the selection of lung transplant candidates no longer suggest a fixed upper age limit. Although carefully selected older adults can derive great benefit, understanding which older adults will do well after transplant with improved survival and health-related qualiy of life is key to informed decision-making. Herein, we review the epidemiology of aging in lung transplantation and its impact on outcomes, highlight selected physiological measures that may be informative when evaluating and managing older lung transplant patients, and identify directions for future research. Recent Findings In general, listing and transplanting older, sicker patients has contributed to worse clinical outcomes and greater healthcare use. Emerging evidence suggest that measures of physiological age, such as frailty, body composition, and neurocognitive and psychosocial function, may better identify risk for poor transplant outcomes than chronlogical age. Summary The evidence base to inform transplant decision-making and improvements in care for older adults is small but growing. Multipronged efforts at the intersection of aging and lung transplantation are needed to improve the clinical and patient centered outcomes for this large and growing cohort of patients. Future research should focus on identifying novel and ideally modifiable risk factors for poor outcomes specific to older adults, better approaches to measuring physiological aging (e.g., frailty, body composition, neurocognitive and psychosocial function), and the underlying mechanisms of physiological aging. Finally, interventions that can improve clinical and patient centered outcomes for older adults are needed.
Collapse
Affiliation(s)
- Brittany Koons
- M. Louise Fitzpatrick College of Nursing, Villanova University, 800 Lancaster Avenue, Driscoll Hall Room 350, Villanova, PA 19085, USA
| | - Michaela R. Anderson
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick J. Smith
- Department of Psychiatry and Behavioral Sciences, Division of Behavioral Medicine and Neurosciences, Duke University Medical Center, Durham, NC, USA
| | - John R. Greenland
- Department of Medicine, University of California, San Francisco, CA, USA
- Medical Service, Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Jonathan P. Singer
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UC San Francisco, San Francisco, CA, USA
| |
Collapse
|
11
|
Lewis TC, Sureau K, Katz A, Fargnoli A, Lesko M, Rudym D, Angel LF, Chang SH, Kon ZN. Multimodal opioid-sparing pain management after lung transplantation and the impact of liposomal bupivacaine intercostal nerve block. Clin Transplant 2021; 36:e14512. [PMID: 34658078 DOI: 10.1111/ctr.14512] [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: 05/12/2021] [Revised: 09/28/2021] [Accepted: 10/08/2021] [Indexed: 11/29/2022]
Abstract
Opioid analgesics are commonly used post-lung transplant, but have many side effects and are associated with worse outcomes. We conducted a retrospective review of all lung transplant recipients who were treated with a multimodal opioid-sparing pain protocol. The use of liposomal bupivacaine intercostal nerve block was variable due to hospital restrictions. The primary objective was to describe opioid requirements and patient-reported pain scores early post-lung transplant and to assess the impact of intraoperative liposomal bupivacaine intercostal nerve block. We treated 64 lung transplant recipients with our protocol. Opioid utilization decreased to a mean of 43 milligram oral morphine equivalents by postoperative day 4. Median pain scores peaked at 4 on postoperative day 1 and decreased thereafter. Only three patients were discharged home with opioids, all of whom were taking opioid agonist therapy pre-transplant for opioid use disorder. Patients who received liposomal bupivacaine intercostal nerve block in the operating room had a significant reduction in opioid consumption over postoperative day 1 through 4 (228 mg vs. 517 mg, P= .032). A multimodal opioid-sparing pain management protocol is feasible and resulted in weaning of opioids prior to hospital discharge.
Collapse
Affiliation(s)
- Tyler C Lewis
- Department of Pharmacy, NYU Langone Health, New York, New York, USA.,Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Kimberly Sureau
- Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Alyson Katz
- Department of Pharmacy, NYU Langone Health, New York, New York, USA
| | - Anthony Fargnoli
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York, USA
| | - Melissa Lesko
- Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Darya Rudym
- Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Luis F Angel
- Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Stephanie H Chang
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York, USA
| | - Zachary N Kon
- Department of Cardiothoracic Surgery, Northwell Health, Manhasset, New York, USA
| |
Collapse
|
12
|
Gee S, Lee Y, Shah A, Izadmehr E, Belperio J, Shino Y, Weigt S, Goldwater D, Schaenman J. Predictive value of chart-based frailty evaluation for lung transplant candidates. Clin Transplant 2021; 36:e14461. [PMID: 34486175 DOI: 10.1111/ctr.14461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022]
Abstract
Frailty, defined as a state of decreased physiologic reserve, has been correlated with poorer outcomes after hospitalization or surgery. Studies in lung transplant patients have associated frailty with an increased risk of post-transplant mortality; however, a unified approach is lacking. The identification of frail patients can help clinicians pre-emptively target modifiable risk factors and may facilitate risk stratification. The Frailty Risk Score (FRS) is a chart review-based approach based on eight symptoms and four laboratory biomarkers. We applied this method in a retrospective study to investigate its utility in predicting post-transplant lung outcomes. Eighty-four lung transplant recipients were evaluated, including 51 older (≥ 60) and 33 younger (< 60) patients. Median FRS score was 3.9, with 63 categorized as frail (75%) and 21 as non-frail (25%), using a previously published cut-off of ≥3 to define frailty. A high FRS was associated with readmission in the first year after transplantation and with the number of readmissions. There was also an association between FRS score and death (p = .047). FRS may be a viable tool in the assessment of lung transplant candidates. Frail patients may benefit from earlier referral and targeted therapy prior to transplant, as well as close post-transplant follow-up.
Collapse
Affiliation(s)
- Serina Gee
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Yoon Lee
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Aloukika Shah
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Ehsan Izadmehr
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - John Belperio
- UCLA Department of Medicine, Division of Pulmonary Disease, Los Angeles, California, USA
| | - Yusaku Shino
- UCLA Department of Medicine, Division of Pulmonary Disease, Los Angeles, California, USA
| | - Sam Weigt
- UCLA Department of Medicine, Division of Pulmonary Disease, Los Angeles, California, USA
| | - Deena Goldwater
- UCLA Department of Medicine, Division of Geriatrics, Los Angeles, California, USA
| | - Joanna Schaenman
- UCLA Department of Medicine, Division of Infectious Disease, Los Angeles, California, USA
| |
Collapse
|
13
|
Abstract
Rationale: Sarcopenia is associated with disability and death. The optimal definition and clinical relevance of sarcopenia in lung transplantation remain unknown. Objectives: To assess the construct and predictive validity of sarcopenia definitions in lung transplant candidates. Methods: In a multicenter prospective cohort of 424 lung transplant candidates, we evaluated limited (muscle mass only) and expanded (muscle mass and quality) sarcopenia definitions from the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), the Foundation for the National Institutes of Health (FNIH), and a cohort-specific distribution-based lowest quartile definition. We assessed construct validity using associations with conceptually related factors. We evaluated the relationship between sarcopenia and frailty using generalized additive models. We also evaluated associations between sarcopenia definitions and key pretransplant outcomes, including disability (quantified by the Lung Transplant Valued Life Activities scale [range, 0-3; higher scores = worse disability; minimally important difference, 0.3]) and waitlist delisting/death, by multivariate linear and Cox regression, respectively. Results: Sarcopenia prevalence ranged from 6% to13% by definition used. The limited EWGSOP2 definition demonstrated the highest construct validity, followed by the expanded EWGSOP2 definition and both limited and expanded FNIH and lowest quartile definitions. Sarcopenia exhibited a linear association with the risk of frailty. The EWGSOP2 and expanded lowest quartile definitions were associated with disability, ranging from 0.20 to 0.25 higher Lung Transplant Valued Life Activities scores. Sarcopenia was associated with increased risk of waitlist delisting or death by the limited and expanded lowest quartile definitions (hazard ratio [HR], 3.8; 95% confidence interval [CI], 1.4-9.9 and HR, 3.5; 95% CI, 1.1-11.0, respectively) and the EWGSOP2 limited definition (HR, 2.8; 95% CI, 0.9-8.6) but not with the three other candidate definitions. Conclusions: The prevalence and validity of sarcopenia vary by definition; the EWGSOP2 limited definition exhibited the broadest validity in lung transplant candidates. The linear relationship between low muscle mass and frailty highlights sarcopenia's contribution to frailty and also questions the clinical utility of a sarcopenia cut-point in advanced lung disease. The associations between sarcopenia and important pretransplant outcomes support further investigation into using body composition for candidate risk stratification.
Collapse
|
14
|
Condensed Outpatient Rehabilitation Early After Lung Transplantation: A Retrospective Analysis of 6-Minute Walk Distance and Its Predictors. Cardiopulm Phys Ther J 2021. [DOI: 10.1097/cpt.0000000000000174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
15
|
Spiers GF, Kunonga TP, Hall A, Beyer F, Boulton E, Parker S, Bower P, Craig D, Todd C, Hanratty B. Measuring frailty in younger populations: a rapid review of evidence. BMJ Open 2021; 11:e047051. [PMID: 33753447 PMCID: PMC7986767 DOI: 10.1136/bmjopen-2020-047051] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/11/2021] [Accepted: 03/03/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Frailty is typically assessed in older populations. Identifying frailty in adults aged under 60 years may also have value, if it supports the delivery of timely care. We sought to identify how frailty is measured in younger populations, including evidence of the impact on patient outcomes and care. DESIGN A rapid review of primary studies was conducted. DATA SOURCES Four databases, three sources of grey literature and reference lists of systematic reviews were searched in March 2020. ELIGIBILITY CRITERIA Eligible studies measured frailty in populations aged under 60 years using experimental or observational designs, published after 2000 in English. DATA EXTRACTION AND SYNTHESIS Records were screened against review criteria. Study data were extracted with 20% of records checked for accuracy by a second researcher. Data were synthesised using a narrative approach. RESULTS We identified 268 studies that measured frailty in samples that included people aged under 60 years. Of these, 85 studies reported evidence about measure validity. No measures were identified that were designed and validated to identify frailty exclusively in younger groups. However, in populations that included people aged over and under 60 years, cumulative deficit frailty indices, phenotype measures, the FRAIL Scale, the Liver Frailty Index and the Short Physical Performance Battery all demonstrated predictive validity for mortality and/or hospital admission. Evidence of criterion validity was rare. The extent to which measures possess validity across the younger adult age (18-59 years) spectrum was unclear. There was no evidence about the impact of measuring frailty in younger populations on patient outcomes and care. CONCLUSIONS Limited evidence suggests that frailty measures have predictive validity in younger populations. Further research is needed to clarify the validity of measures across the adult age spectrum, and explore the utility of measuring frailty in younger groups.
Collapse
Affiliation(s)
- Gemma F Spiers
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tafadzwa Patience Kunonga
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alex Hall
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Fiona Beyer
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Elisabeth Boulton
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Stuart Parker
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter Bower
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Dawn Craig
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Chris Todd
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Barbara Hanratty
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
16
|
Diamond JM, Courtwright AM, Balar P, Oyster M, Zaleski D, Adler J, Brown M, Hays SR, Sutter N, Garvey C, Kukreja J, Gao Y, Bruun A, Smith PJ, Singer JP. Mobile health technology to improve emergent frailty after lung transplantation. Clin Transplant 2021; 35:e14236. [PMID: 33527520 DOI: 10.1111/ctr.14236] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 12/18/2022]
Abstract
We evaluated the feasibility, safety, and efficacy of a mHealth-supported physical rehabilitation intervention to treat frailty in a pilot study of 18 lung transplant recipients. Frail recipients were defined by a short physical performance battery (SPPB score ≤7). The primary intervention modality was Aidcube, a customizable rehabilitation mHealth platform. Our primary aims included tolerability, feasibility, and acceptability of use of the platform, and secondary outcomes were changes in SPPB and in scores of physical activity, and disability measured using the Duke Activity Status Index (DASI) and Lung Transplant-Value Life Activities (LT-VLA). Notably, no adverse events were reported. Subjects reported the app was easy to use, usability improved over time, and the app enhanced motivation to engage in rehabilitation. Comments highlighted the complexities of immediate post-transplant rehabilitation, including functional decline, pain, tremor, and fatigue. At the end of the intervention, SPPB scores improved a median of 5 points from a baseline of 4. Physical activity and patient-reported disability also improved. The DASI improved from 4.5 to 19.8 and LT-VLA score improved from 2 to 0.59 at closeout. Overall, utilization of a mHealth rehabilitation platform was safe and well received. Remote rehabilitation was associated with improvements in frailty, physical activity and disability. Future studies should evaluate mHealth treatment modalities in larger-scale randomized trials of lung transplant recipients.
Collapse
Affiliation(s)
- Joshua M Diamond
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew M Courtwright
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Priya Balar
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Michelle Oyster
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Derek Zaleski
- Good Shepherd Penn Partners at the University of Pennsylvania, Philadelphia, USA
| | - Joe Adler
- Good Shepherd Penn Partners at the University of Pennsylvania, Philadelphia, USA
| | - Melanie Brown
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven R Hays
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Nicole Sutter
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Chris Garvey
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jasleen Kukreja
- Division of Adult Cardiothoracic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Ying Gao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Jonathan P Singer
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
17
|
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.
Collapse
|
18
|
Wickerson L, Rozenberg D, Gottesman C, Helm D, Mathur S, Singer LG. Pre-transplant short physical performance battery: Response to pre-habilitation and relationship to pre- and early post-lung-transplant outcomes. Clin Transplant 2020; 34:e14095. [PMID: 32970883 DOI: 10.1111/ctr.14095] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 08/30/2020] [Accepted: 09/15/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE To evaluate whether the short physical performance battery (SPPB) pre-lung transplant (LTx) was responsive to pre-habilitation and predicted pre- and early post-transplant outcomes. METHODS A retrospective study of LTx candidates accepted for transplant between 2016 and 2017. SPPB was categorized as frail/pre-frail (≤9/12) and non-frail (≥10/12). RESULTS 150 patients had LTx assessment SPPB data (53% male, 61 [52-67] years, 59% had interstitial lung disease (ILD), 26% frail/pre-frail). 131 (87%) underwent transplant by December 31, 2018. Adjusting for age, sex, diagnosis and Canadian transplant listing urgency, and frailty/pre-frailty at LTx assessment was associated with a lower 6MWD pre-transplant [-89 meters 95%CI (-125 to -53), P < .0001]. 62 patients underwent six weeks of pre-habilitation. SPPB increased (11 [10-12) vs. 12 [11-12], P = .01) reflected in the chair stand component (11.4 ± 4.4 vs. 9.8 ± 2.8 seconds, P = .007), with larger improvements in the frail/pre-frail group. A frail/pre-frail SPPB closest to the time of transplant was associated with a lower 6MWD [-77 m 95%CI (-128 to -25), P = .004] but not with hospital length of stay or gait aid use three months post-transplant. CONCLUSIONS Frailty/pre-frailty was associated with a decreased 6MWD pre- and post-transplant. The SPPB increased following pre-habilitation, which may reflect increased lower extremity strength.
Collapse
Affiliation(s)
- Lisa Wickerson
- Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Dmitry Rozenberg
- Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, Respirology, University of Toronto, Toronto, Ontario, Canada
| | - Chaya Gottesman
- Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Denise Helm
- Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Sunita Mathur
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, Respirology, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
19
|
Abstract
Lung transplantation has evolved to become an acceptable therapy for individuals with end-stage lung disease. Readmissions rates after lung transplantation remain high as compared to other medical surgical populations. The purpose of this review is to synthesize the current body of knowledge about patterns, risk factors, and outcomes of readmissions after lung transplantation. The literature revealed that the most common admission diagnoses linked to lung transplant readmissions are infections followed by tachyarrhythmias, airway complications, surgical complications, rejection, thromboembolic events, gastrointestinal complications, and renal dysfunction. Risk factors for these readmissions include male gender, longer intensive care unit stay, reintubation, prolonged chest tube air leak, frailty, and discharge to a long-term care facility. Outcomes of multiple readmissions after lung transplantation are associated with decreased survival and increased risk of mortality. Further research is needed to better understand which readmission diagnoses are preventable and whether multidisciplinary interventions can reduce readmission rates among patients after lung transplantation.
Collapse
Affiliation(s)
- Jane Simanovski
- Transplant Institute, 2971Henry Ford Hospital, Detroit, MI, USA
| | - Jody Ralph
- Faculty of Nursing, 8637University of Windsor, Windsor, Ontario, Canada
| |
Collapse
|
20
|
Fitz S, Diegel-Vacek L, Mahoney E. A Performance Improvement Initiative for Implementing an Evidence-Based Discharge Bundle for Lung Transplant Recipients. Prog Transplant 2020; 30:281-285. [PMID: 32552376 DOI: 10.1177/1526924820933832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Lung transplant recipients have high hospital readmission rates. Readmissions are costly to institutions and associated with higher mortality among patients within the first year of transplant. Strong evidence indicates that in hospitalized patients, the use of discharge bundles results in lower 30-day hospital readmission rates. LOCAL PROBLEM A lung transplant team at a Midwest academic medical center performs 40 to 50 lung transplants annually and provides comprehensive, ongoing care for approximately 300 lung transplant recipients. The objective of this quality improvement project was development and implementation of an evidence-based discharge bundle (standardized patient discharge process) to reduce 30-day hospital readmission rates for this patient population. METHODS A gap analysis was performed using focus groups to identify strategies to reduce readmissions. Using that data, a standardized discharge bundle was developed in collaboration with the transplant team. INTERVENTIONS The discharge bundle included improvements in discharge planning, scripted communication methods between team members, a standardized medication template for patient education, standardized follow-up appointment process, and increased telephone calls to the patient after discharge. RESULTS The primary outcome measured was the monthly 30-day hospital readmission rate of facility lung transplant recipients from June through August of 2019 as compared to the same time period in 2018. The readmission rate did not change during the evaluation period. Team members reported improved communication, efficiency, and improved standardization of follow-up care using the discharge bundle. CONCLUSIONS Implementing a discharge bundle for lung transplant recipients resulted in improved staff satisfaction with the discharge process.
Collapse
Affiliation(s)
- Sarah Fitz
- Department of Biobehavioral Health Science, College of Nursing, 16100University of Illinois, Chicago, IL, USA
| | - Lauren Diegel-Vacek
- Department of Biobehavioral Health Science, College of Nursing, 16100University of Illinois, Chicago, IL, USA
| | - Erin Mahoney
- 25815Loyola University Medical Center, Maywood, IL, USA
| |
Collapse
|
21
|
|
22
|
Goel AN, Raghavan G, St John MA, Long JL. Risk Factors, Causes, and Costs of Hospital Readmission After Head and Neck Cancer Surgery Reconstruction. JAMA FACIAL PLAST SU 2020; 21:137-145. [PMID: 30418467 DOI: 10.1001/jamafacial.2018.1197] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Thirty-day hospital readmissions have substantial direct costs and are increasingly used as a measure of quality care. However, data regarding the risk factors and reasons for readmissions in head and neck cancer surgery reconstruction are lacking. Objective To describe the rate, risk factors, and causes of 30-day readmission in patients with head and neck cancer following free or pedicled flap reconstruction. Design, Setting, and Participants This retrospective, population-based cohort study analyzed medical records from the Nationwide Readmissions Database of 9487 patients undergoing pedicled or free flap reconstruction of head and neck oncologic defects between January 1, 2010, and December 31, 2014. Data analysis was performed in October 2017. Exposures Pedicled or free flap reconstruction of an oncologic head and neck defect. Main Outcomes and Measures The primary outcome was 30-day all-cause readmissions. Secondary outcomes included risk factors, causes, and costs of readmission. Multivariate regression analyses were conducted to determine factors independently associated with 30-day readmissions. Results Among 9487 patients included in the study (6798 male; 71.7%), the median age was 63 years (interquartile range, 55-71 years), and the 30-day readmission rate was 19.4% (n = 1839), with a mean cost per readmission of $15 916 (standard error of the mean, $785). The most common indication for readmission was wound complication (26.5%, n = 487). On multivariate regression, significant risk factors for 30-day readmission were median household income in the lowest quartile (vs highest quartile: odds ratio [OR], 1.58; 95% CI, 1.18-2.11), congestive heart failure (OR, 1.68; 95% CI, 1.14-2.47), liver disease (OR, 2.02; 95% CI, 1.22- 3.33), total laryngectomy (OR, 1.40; 95% CI, 1.12-1.75), pharyngectomy (OR, 1.47; 95% CI, 1.08-2.01), blood transfusion (OR, 1.30; 95% CI, 1.04-1.64), discharge to home with home health care (vs routine: OR, 1.32; 95% CI, 1.04-1.67), and discharge to a nursing facility (vs routine: OR, 1.77; 95% CI, 1.30-2.40). Conclusions and Relevance Using the Nationwide Readmissions Database, we demonstrate that approximately 1 in 5 patients undergoing head and neck cancer surgery reconstruction is readmitted within 30 days of surgery. Readmissions are most commonly associated with wound complications. Socioeconomic status, complex ablative procedures, and patient comorbidities are independent risk factors for readmission. These findings may be useful to clinicians in developing perioperative interventions aimed to reduce hospital readmissions and improve quality of patient care.
Collapse
Affiliation(s)
- Alexander N Goel
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA)
| | - Govind Raghavan
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA)
| | - Maie A St John
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA).,Jonsson Comprehensive Cancer Center, UCLA Medical Center, Los Angeles, California.,UCLA Head and Neck Cancer Program, UCLA Medical Center, Los Angeles, California
| | - Jennifer L Long
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA).,Research Service, Department of Veterans Affairs, Los Angeles, California
| |
Collapse
|
23
|
Montgomery E, Macdonald PS, Newton PJ, Jha SR, Malouf M. Frailty in lung transplantation: a systematic review. Expert Rev Respir Med 2019; 14:219-227. [DOI: 10.1080/17476348.2020.1702527] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Elyn Montgomery
- Heart & Lung Transplant Program, St Vincent’s Hospital, Sydney, Australia
- Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Peter S. Macdonald
- Heart & Lung Transplant Program, St Vincent’s Hospital, Sydney, Australia
| | - Phillip J. Newton
- School of Nursing and Midwifery, Western Sydney University, Sydney, Australia
| | - Sunita R. Jha
- Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Monique Malouf
- Heart & Lung Transplant Program, St Vincent’s Hospital, Sydney, Australia
| |
Collapse
|
24
|
Anderson MR, Kolaitis NA, Gao Y, Kukreja J, Greenland J, Hays S, Wolters P, Golden J, Diamond J, Palmer S, Arcasoy S, Udupa J, Christie JD, Lederer DJ, Singer JP. A nonlinear relationship between visceral adipose tissue and frailty in adult lung transplant candidates. Am J Transplant 2019; 19:3155-3161. [PMID: 31278829 PMCID: PMC7863776 DOI: 10.1111/ajt.15525] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/12/2019] [Accepted: 06/22/2019] [Indexed: 01/25/2023]
Abstract
Frailty is a state of decreased physiologic reserve associated with poor outcomes before and after lung transplantation. Obesity, particularly central obesity characterized by excess proinflammatory visceral adipose tissue (VAT), is associated with incident frailty in middle-aged and older adults. The association between VAT and frailty in advanced lung disease, however, is unknown. In two, nonoverlapping multicenter cohorts of adults listed for lung transplantation, we measured VAT area on bioelectrical impedance assay (BIA) in one cohort and cross-sectional VAT and subcutaneous adipose tissue (SAT) areas on abdominal computed tomography (CT) in the other. We identified a nonlinear relationship between greater VAT by BIA and frailty. In fully adjusted piecewise regression models, every 20 cm2 increase in VAT area was associated with 50% increased odds of frailty in subjects with high VAT (95% CI 1.2-1.9, P < .001), and 10% decreased odds of frailty (95% CI 0.7-1.04, P = .12) in subjects with low VAT. Compared to frail subjects with low VAT, those with high VAT were more likely to have low grip strength and less likely to have weight loss, suggesting that mechanisms of frailty may differ by VAT. Further investigation of mechanisms linking VAT and frailty may identify new targets for prevention and treatment.
Collapse
Affiliation(s)
| | - Nicholas A. Kolaitis
- Department of Medicine, University of California at San Francisco, San Francisco, California
| | - Ying Gao
- Department of Medicine, University of California at San Francisco, San Francisco, California
| | - Jasleen Kukreja
- Department of Medicine, University of California at San Francisco, San Francisco, California
| | - John Greenland
- Department of Medicine, University of California at San Francisco, San Francisco, California
| | - Steven Hays
- Department of Medicine, University of California at San Francisco, San Francisco, California
| | - Paul Wolters
- Department of Medicine, University of California at San Francisco, San Francisco, California
| | - Jeff Golden
- Department of Medicine, University of California at San Francisco, San Francisco, California
| | - Joshua Diamond
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott Palmer
- Department of Medicine, Duke University, Durham, North Carolina
| | - Selim Arcasoy
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Jayaram Udupa
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D. Christie
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J. Lederer
- Department of Medicine, Columbia University Medical Center, New York, New York,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Jonathan P. Singer
- Department of Medicine, University of California at San Francisco, San Francisco, California
| |
Collapse
|
25
|
Nolley EP, DeSensi R, Nouraie M, Schenker Y, Morrell MR. Characteristics, Trends, and Predictors of Specialty Palliative Care Utilization after Lung Transplantation. J Palliat Med 2019; 22:1092-1098. [PMID: 30964390 DOI: 10.1089/jpm.2018.0560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Lung transplant recipients who experience serious illness could benefit from specialty palliative care (SPC), but evidence suggests that referral has been rare. Objective: Examine the characteristics of post-transplant SPC encounters, utilization trends, and patient characteristics associated with SPC at a center with established SPC services. Design: Retrospective cohort study of SPC utilization by 597 lung transplant recipients transplanted between 2010 and 2015. We collected data on pretransplant demographics and post-transplant SPC encounters, including timing, location, and referral reasons. Cumulative incidence of SPC and patient characteristics associated with SPC were examined by competing risks methods. Utilization in the first two post-transplant years was compared between subcohorts defined by year of transplantation. Results: SPC cumulative incidence was 27% and 43% at one and five years. More than 60% of encounters occurred in the first post-transplant year including 34% during the index transplant hospitalization. Over 90% of encounters occurred in the inpatient setting. The majority of consults were for symptom management. From 2010 to 2015 inpatient utilization in the first two post-transplant years increased from 23% to 42%, and outpatient utilization increased from 2% to 16%. Accounting for increasing utilization, pretransplant SPC and double-lung transplantation were associated with greater incidence of post-transplant SPC. Conclusions: Lung transplant recipients may have palliative care needs early after transplantation. Increasing utilization suggests greater awareness of or changing attitudes about the utility of SPC for lung transplant recipients. Understanding transplant recipients' palliative care needs and transplant physicians' views of SPC is critical to improving the provision of SPC in lung transplantation.
Collapse
Affiliation(s)
- Eric P Nolley
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rebecca DeSensi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mehdi Nouraie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew R Morrell
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
26
|
Venado A, McCulloch C, Greenland JR, Katz P, Soong A, Shrestha P, Hays S, Golden J, Shah R, Leard LE, Kleinhenz ME, Kukreja J, Zablotska L, Allen IE, Covinsky K, Blanc P, Singer JP. Frailty trajectories in adult lung transplantation: A cohort study. J Heart Lung Transplant 2019; 38:699-707. [PMID: 31005571 DOI: 10.1016/j.healun.2019.03.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 01/31/2019] [Accepted: 03/13/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Frailty is common in adults with advanced lung disease and is associated with death before and after lung transplantation. We aimed to determine whether frailty changes from before to after the lung transplant. METHODS In a single-center, prospective cohort study among adults undergoing lung transplantation from 2010 to 2017, we assessed frailty by the Short Physical Performance Battery (SPPB; higher scores reflect less frailty) and Fried Frailty Phenotype (FFP; higher scores reflect greater frailty) before and repeatedly up to 36 months after transplant. We tested for changes in frailty scores over time using segmented mixed effects models, adjusting for age, sex, and diagnosis. We quantified the proportion of subjects transitioning between frailty states (frail vs not frail) from before to after the transplant. RESULTS In 246 subjects, changes in frailty occurred within the first 6 post-operative months and remained stable thereafter. The overall change in frailty was attributable to improvements among those subjects who were frail before transplant. They experienced a 5.1-point improvement in SPPB (95% confidence interval [CI] 4.6-5.7) and a 1.8-point improvement in FFP (95% CI -2.1 to -1.6) during the early period. Frailty by SPPB and FFP did not change in those who were not frail before transplant. Approximately 84% of survivors who were frail before transplant became not frail after transplant. CONCLUSIONS Pre-operative frailty resolves in many patients after lung transplantation. Because a large proportion of frailty may be attributable to advanced lung disease, frailty alone should not be an absolute contraindication to transplantation.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Jasleen Kukreja
- Departments of Surgery, University of California, San Francisco, San Francisco, California, USA
| | | | | | | | | | | |
Collapse
|
27
|
Rozenberg D, Mathur S, Wickerson L, Chowdhury NA, Singer LG. Frailty and clinical benefits with lung transplantation. J Heart Lung Transplant 2018; 37:1245-1253. [PMID: 30293618 DOI: 10.1016/j.healun.2018.06.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 05/18/2018] [Accepted: 06/11/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The Fried frailty phenotype is associated with morbidity and mortality in lung transplant (LTx) candidates, but its clinical application and association with post-transplant outcomes are not well defined. We assessed 2 alternate frailty indices in LTx candidates and evaluated associations of frailty with early post-transplant outcomes and 1-year mortality. METHODS Frailty was prospectively evaluated in 50 LTx candidates using the Fried and 2 alternate phenotypic indices, one using variables readily available to clinicians and one using variables from an existing data set. Agreement between indices and associations with related measures were assessed to establish validity. The data set index was then applied retrospectively to 221 LTx patients. Post-transplant outcomes were compared between frail and non-frail patients using t-tests and multivariable regression analysis. RESULTS Frailty prevalence among the 3 indices was 26% to 30%, and the κ agreement was 0.38 to 0.41. All indices had moderate correlations with London Chest Activity of Daily Living (r = 0.48-0.62) and Short-Physical Performance Battery (r = -0.43 to -0.52). In the retrospective cohort, frail LTx candidates had a worse St. George's Respiratory Questionnaire total score (73 ± 12vs 62 ± 12, p < 0.001). Frail candidates had a larger improvement with transplant in the St. George's Respiratory Questionnaire (-52 ± 19vs -43 ± 18, p = 0.002) and 6-minute walk distance (191 ± 119vs 129 ± 94m, p = 0.001). Frailty was not associated with hospital length of stay or 1-year mortality. CONCLUSIONS There was good construct validity and acceptable agreement among the frailty indices. Despite significant disability pre-transplant, frail LTx candidates derived significant benefit with transplantation.
Collapse
Affiliation(s)
- Dmitry Rozenberg
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Sunita Mathur
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Wickerson
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Noori A Chowdhury
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Lianne G Singer
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.
| |
Collapse
|
28
|
Quantifying Frailty in Post-Lung Transplant Patients-Can We Predict Who Will Need Readmission? Transplantation 2018; 102:723-724. [PMID: 29346258 DOI: 10.1097/tp.0000000000002102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|