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Keshvani C, Laylani N, Davila-Siliezar P, Kopel J, Lee AG. Neuro-ophthalmic challenges and multi-morbidity in vasculitis among the older adults. Expert Rev Clin Immunol 2024; 20:781-791. [PMID: 38572928 DOI: 10.1080/1744666x.2024.2339893] [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: 02/10/2023] [Accepted: 04/03/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Vasculitides are a heterogeneous group of disorders producing inflammation of blood vessels (e.g. arteries or veins). All major vasculitides potentially have ophthalmological symptoms and signs including visual loss. Co-morbidity, multimorbidity, polypharmacy, and geriatric syndromes all play important roles in patient outcomes for these rheumatic conditions in the elderly. This monograph reviews the NCBI PubMed database (Feb 2023) literature on the neuro-ophthalmic and geriatric considerations in vasculitis. AREAS COVERED Cogan Syndrome, Granulomatosis with Polyangiitis, Giant Cell Arteritis, Polyarteritis Nodosa, Takayasu Arteritis, Vasculitis epidemiology, and neuro-ophthalmological symptoms. EXPERT OPINION Geriatric patient care for vasculitis with neuro-ophthalmological manifestations can be complicated by the interplay of multiple co-morbidities, polypharmacy, and specific geriatric syndromes. The valuation and treatment of vasculitis and the complications associated with the disease can negatively impact patient care. Advances in noninvasive imaging and updates in diagnostic criteria have enabled increased identification of patients at earlier stages with less severe disease burden. Novel therapeutic agents can be glucocorticoid sparing and might reduce the adverse effects of chronic steroid use. Holistic care models like the 5 M geriatric care model (mind, mobility, medications, multicomplexity, and matters most) allow patients' needs to be in the forefront with biopsychosocial aspects of a patient being addressed.
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Affiliation(s)
- Caezaan Keshvani
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Noor Laylani
- Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | | | - Jonathan Kopel
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Andrew G Lee
- Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
- Department of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, NY, USA
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX, USA
- Department of Ophthalmology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Jones TS, Peters X, Robinson TN. Clin-STAR corner: Practice-changing advances at the interface of surgery and geriatrics. J Am Geriatr Soc 2024; 72:1959-1963. [PMID: 38280226 PMCID: PMC11226379 DOI: 10.1111/jgs.18783] [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: 12/07/2023] [Accepted: 12/24/2023] [Indexed: 01/29/2024]
Abstract
Older adults who undergo major operations are at high risk for complications, disability, and death. The physio-social compromises unique to older adults are not routinely assessed and managed in the perioperative setting. Currently, the most practice-changing topic nationally in geriatric surgery is the implementation of comprehensive, multidisciplinary geriatric care pathways to provide age-friendly care for older adults throughout their perioperative course. This review presents three recently published articles focused on defining evidence-based outcomes associated with implementation of a comprehensive geriatric surgery program for older adults undergoing major inpatient operations. These studies serve as the initial evidence evaluating the efficacy and effectiveness of comprehensive perioperative geriatric surgery programs. Each study was chosen due to their high potential for meaningful impact for both clinicians and healthcare systems looking to improve their surgical care of older adults.
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Affiliation(s)
- Teresa S Jones
- University of Colorado School of Medicine, Aurora, CO
- Rocky Mountain VA Medical Center, Aurora, CO
| | - Xane Peters
- American College of Surgeons Geriatric Surgery Clinical Scholars Program, Chicago, IL
| | - Thomas N Robinson
- University of Colorado School of Medicine, Aurora, CO
- Rocky Mountain VA Medical Center, Aurora, CO
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Ushimaru Y, Nagano S, Kawabata R, Nishikawa K, Takeoka T, Kitagawa A, Ohara N, Tomihara H, Maeda S, Imasato M, Noura S, Miyamoto A. Enhancing surgical outcomes in elderly gastric cancer patients: the role of comprehensive preoperative assessment and support. World J Surg Oncol 2024; 22:136. [PMID: 38778314 PMCID: PMC11112811 DOI: 10.1186/s12957-024-03421-6] [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: 03/27/2024] [Accepted: 05/21/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND As the prevalence of gastric cancer rises in aging populations, managing surgical risks and comorbidities in elderly patients presents a unique challenge. The Comprehensive Preoperative Assessment and Support (CPAS) program, through comprehensive preoperative assessments, aims to mitigate surgical stress and improve outcomes by enhancing patient awareness and preparation. This study investigates the efficacy of a CPAS program, incorporating frailty and sarcopenia evaluations, to improve short-term outcomes in elderly gastric cancer patients. METHODS A retrospective analysis was conducted on 127 patients aged 75 or older who underwent surgery with CPAS between 2018 and August 2023, compared to 170 historical controls from 2012 to 2017. Propensity score matching balanced both groups based on age-adjusted Charlson Comorbidity Index and surgical details. The primary focus was on the impact of CPAS elements such as rehabilitation, nutrition, psychological support, oral frailty, and social support on short-term surgical outcomes. RESULTS Among 83 matched pairs, the CPAS group, despite 40.4% of patients in the CPAS group and 21.2% in the control group had an ASA-PS score of 3 or higher (P < 0.001), demonstrated significantly reduced blood loss (100 ml vs. 190 ml, P = 0.026) and lower incidence of serious complications (19.3% vs. 33.7%, P = 0.034), especially in infections and respiratory issues. Sarcopenia was identified in 38.6% of CPAS patients who received tailored support. Additionally, the median postoperative hospital stay was notably shorter in the CPAS group (10 days vs. 15 days, P < 0.001), with no in-hospital deaths. These results suggest that personalized preoperative care effectively mitigates operative stress and postoperative complications. CONCLUSION Implementing CPAS significantly enhances surgical safety and reduces complication rates in elderly gastric cancer patients, emphasizing the critical role of personalized preoperative care in surgical oncology for this demographic.
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Affiliation(s)
- Yuki Ushimaru
- Department of Gastroenterological Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-Cho, Nishi-Ku, Sakai City, Osaka, 593-8304, Japan
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
- Department of Next Generation Endoscopic Intervention (Project ENGINE), Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shinnosuke Nagano
- Department of Gastroenterological Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-Cho, Nishi-Ku, Sakai City, Osaka, 593-8304, Japan
| | - Ryohei Kawabata
- Department of Gastroenterological Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-Cho, Nishi-Ku, Sakai City, Osaka, 593-8304, Japan.
| | - Kazuhiro Nishikawa
- Department of Gastroenterological Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-Cho, Nishi-Ku, Sakai City, Osaka, 593-8304, Japan
| | - Tomohira Takeoka
- Department of Gastroenterological Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-Cho, Nishi-Ku, Sakai City, Osaka, 593-8304, Japan
| | - Akihiro Kitagawa
- Department of Gastroenterological Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-Cho, Nishi-Ku, Sakai City, Osaka, 593-8304, Japan
| | - Nobuyoshi Ohara
- Department of Gastroenterological Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-Cho, Nishi-Ku, Sakai City, Osaka, 593-8304, Japan
| | - Hideo Tomihara
- Department of Gastroenterological Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-Cho, Nishi-Ku, Sakai City, Osaka, 593-8304, Japan
| | - Sakae Maeda
- Department of Gastroenterological Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-Cho, Nishi-Ku, Sakai City, Osaka, 593-8304, Japan
| | - Mitsunobu Imasato
- Department of Gastroenterological Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-Cho, Nishi-Ku, Sakai City, Osaka, 593-8304, Japan
| | - Shingo Noura
- Department of Gastroenterological Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-Cho, Nishi-Ku, Sakai City, Osaka, 593-8304, Japan
| | - Atsushi Miyamoto
- Department of Gastroenterological Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-Cho, Nishi-Ku, Sakai City, Osaka, 593-8304, Japan
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Kwok VKY, Reid N, Hubbard RE, Thavarajah H, Gordon EH. Multicomponent perioperative interventions to improve outcomes for frail patients: a systematic review. BMC Geriatr 2024; 24:376. [PMID: 38671345 PMCID: PMC11055226 DOI: 10.1186/s12877-024-04985-4] [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: 04/20/2023] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Preoperative frailty is associated with increased risk of adverse outcomes. In 2017, McIsaac and colleagues' systematic review found that few interventions improved outcomes in this population and evidence was low-quality. We aimed to systematically review the evidence for multicomponent perioperative interventions in frail patients that has emerged since McIsaac et al.'s review. METHODS PUBMED, EMBASE, Cochrane, and CINAHL databases were searched for English-language studies published since January 1, 2016, that evaluated multicomponent perioperative interventions in patients identified as frail. Quality was assessed using the National Institute of Health Quality Assessment Tool. A narrative synthesis of the extracted data was conducted. RESULTS Of 2835 articles screened, five studies were included, all of which were conducted in elective oncologic gastrointestinal surgical populations. Four hundred and thirteen patients were included across the five studies and the mean/median age ranged from 70.1 to 87.0 years. Multicomponent interventions were all applied in the preoperative period. Two studies also applied interventions postoperatively. All interventions addressed exercise and nutritional domains with variability in timing, delivery, and adherence. Multicomponent interventions were associated with reduced postoperative complications, functional deterioration, length of stay, and mortality. Four studies reported on patient-centred outcomes. The quality of evidence was fair. CONCLUSIONS This systematic review provides evidence that frail surgical patients undergoing elective oncologic gastrointestinal surgery may benefit from targeted multicomponent perioperative interventions. Yet methodological issues and substantial heterogeneity of the interventions precludes drawing clear conclusions regarding the optimal model of care. Larger, low risk of bias studies are needed to evaluate optimal intervention delivery, effectiveness in other populations, implementation in health care settings and ascertain outcomes of importance for frail patients and their carers.
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Affiliation(s)
- Vivian Ka-Yan Kwok
- Princess Alexandra Hospital, Metro South Hospital and Health Service, Brisbane, QLD, Australia.
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia.
| | - Natasha Reid
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Ruth E Hubbard
- Princess Alexandra Hospital, Metro South Hospital and Health Service, Brisbane, QLD, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | | | - Emily H Gordon
- Princess Alexandra Hospital, Metro South Hospital and Health Service, Brisbane, QLD, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
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De Coninck L, Declercq A, Bouckaert L, Döpp C, Graff MJL, Aertgeerts B. Promoting meaningful activities by occupational therapy in elderly care in Belgium: the ProMOTE intervention. BMC Geriatr 2024; 24:275. [PMID: 38509458 PMCID: PMC10953191 DOI: 10.1186/s12877-024-04797-6] [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: 03/21/2023] [Accepted: 02/08/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Older people want to age in place. Despite advancing functional limitations and their desire of aging in place, they are not always faithful to therapy that maintains independence and promotes safety. Occupational therapists can facilitate aging in place. Occupational therapy is defined as the therapeutic use of everyday life occupations with persons, groups, or populations for the purpose of enhancing or enabling participation. AIM To describe the content a high-adherence-to-therapy and evidence-based occupational therapy intervention to optimize functional performance and social participation of home-based physically frail older adults and wellbeing of their informal caregiver, and the research activities undertaken to design this intervention. METHODS A roadmap was created to develop the occupational therapy intervention. This roadmap is based on the Medical Research Council (MRC) framework and is supplemented with elements of the Intervention Mapping approach. The TIDieR checklist is applied to describe the intervention in detail. A systematic review and two qualitative studies substantiated the content of the intervention scientifically. RESULTS The application of the first two phases of the MRC framework resulted in the ProMOTE intervention (Promoting Meaningful activities by Occupational Therapy in Elderly). The ProMOTE intervention is a high-adherence-to-therapy occupational therapy intervention that consists of six steps and describes in detail the evidence-based components that are required to obtain an operational intervention for occupational therapy practice. CONCLUSION This study transparently reflects on the process of a high-quality occupational therapy intervention to optimize the functional performance and social participation of the home-based physically frail older adult and describes the ProMOTE intervention in detail. The ProMOTE intervention contributes to safely aging in place and to maintaining social participation. The designed intervention goes beyond a description of the 'what'. The added value lies in the interweaving of the 'why' and 'how'. By describing the 'how', our study makes the concept of 'therapeutic use-of-self' operational throughout the six steps of the occupational therapy intervention. A further rigorous study of the effect of the ProMOTE intervention on adherence, functional performance and social participation is recommended based to facilitate the implementation of this intervention on a national level in Belgium.
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Affiliation(s)
- Leen De Coninck
- Academic Center for General Practice, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, Leuven, 3000, Belgium.
- CEBAM Belgian Center for Evidence-based Medicine vzw, Kapucijnenvoer 7, Leuven, 3000, Belgium.
| | - Anja Declercq
- LUCAS Center for Care Research and Consultancy & CESO Center for Sociological Research, KU Leuven, Minderbroedersstraat 8, Leuven, 3000, Belgium
| | - Leen Bouckaert
- Department of Occupational Therapy, Artevelde University of Applied Sciences, Voetweg 66, Ghent, 9000, Belgium
| | - Carola Döpp
- Scientific Institute for Quality of Health Care, Department of Rehabilitation, Radboudumc Research Institute, Radboud University Medical Center, Houtlaan 4, Nijmegen, 6525 XZ, The Netherlands
| | - Maud J L Graff
- Scientific Institute for Quality of Health Care, Department of Rehabilitation, Radboudumc Research Institute, Radboud University Medical Center, Houtlaan 4, Nijmegen, 6525 XZ, The Netherlands
| | - Bert Aertgeerts
- Academic Center for General Practice, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, Leuven, 3000, Belgium.
- CEBAM Belgian Center for Evidence-based Medicine vzw, Kapucijnenvoer 7, Leuven, 3000, Belgium.
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Mearns A, Siu ATY, Birdling M, Geddes T, Kenealy H. Preoperative comprehensive geriatric assessment and multidisciplinary team input in older people undergoing elective orthopaedic surgery: A feasibility trial. Australas J Ageing 2024. [PMID: 38497327 DOI: 10.1111/ajag.13302] [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: 08/30/2023] [Revised: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVE To determine the feasibility of preoperative comprehensive geriatric assessment (CGA) and multidisciplinary team (MDT) input for older people undergoing elective orthopaedic surgery in a tertiary New Zealand setting. METHODS This single-centre retrospective study included elective orthopaedic patients older than 65 years (and Māori/Pasifika aged greater than 55 years) with hyperpolypharmacy, frailty, neurocognitive disorders and poor functional status. Patients attended a preoperative clinic where they had a geriatrician-led CGA along with MDT input. The feasibility of this preoperative model was assessed using outcomes of acceptability, accessibility and adherence. A qualitative description of patient demographics along with clinic assessment and interventions further describes this pilot experience. RESULTS Sixty patients met inclusion criteria. This group were vulnerable older people (median age 77 years), with a high incidence of hyperpolypharmacy (85%), frailty (80%) and neurocognitive disorders (30%). Acceptability was high (97%), along with CGA accessibility (100%); however, MDT accessibility varied (53-90%). Adherence to MDT intervention was low; with only 26% of patients completing physiotherapy sessions and only 29% adhering to dietary advice. Accurate recall was a significant factor contributing to poor adherence. Comprehensive geriatric assessment was demonstrated to be a broad and flexible intervention. CONCLUSIONS CGA with MDT input is an acceptable and accessible intervention to be utilised as part of improved preoperative care for the older person undergoing elective orthopaedic surgery. Further consideration around methods to increase adherence in this patient group should be explored. Future research should focus on refining the intervention, and quantifying impact on patient outcomes.
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Affiliation(s)
- Anna Mearns
- Department of Anaesthesia and Perioperative Medicine, Te Whatu Ora Counties Manukau, Auckland, New Zealand
| | - Amanda Tsan Yue Siu
- Department of Anaesthesia and Perioperative Medicine, Te Whatu Ora Counties Manukau, Auckland, New Zealand
| | - Melisa Birdling
- Department of Geriatric Medicine, Te Whatu Ora Counties Manukau, Auckland, New Zealand
| | - Thomas Geddes
- Department of Orthopaedic Surgery, Te Whatu Ora Counties Manukau, Auckland, New Zealand
| | - Helen Kenealy
- Department of Geriatric Medicine, Te Whatu Ora Counties Manukau, Auckland, New Zealand
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Hung CY, Liu KH, Tsai CY, Lai CC, Hsu JT, Hsu CC, Hung YS, Chou WC. Impact of preoperative frailty on the surgical and survival outcomes in older patients with solid cancer after elective abdominal surgery. J Formos Med Assoc 2024; 123:257-266. [PMID: 37482474 DOI: 10.1016/j.jfma.2023.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/14/2023] [Accepted: 07/04/2023] [Indexed: 07/25/2023] Open
Abstract
BACKGROUND Frailty is common in older patients with cancer; however, its clinical impact on the survival outcomes has seldom been examined in these patients. This study aimed to investigate the association of frailty with the survival outcomes and surgical complications in older patients with cancer after elective abdominal surgery in Taiwan. METHODS We prospectively enrolled 345 consecutive patients aged ≥65 years with newly diagnosed cancer who underwent elective abdominal surgery between 2016 and 2018. They were allocated into the fit, pre-frail, and frail groups according to comprehensive geriatric assessment (CGA) findings. RESULTS The fit, pre-frail, and frail groups comprised 62 (18.0%), 181 (52.5%), and 102 (29.5%) patients, respectively. After a median follow-up of 48 (interquartile range, 40-53) months, the mortality rates were 12.9%, 31.5%, and 43.1%, respectively. The adjusted hazard ratio was 1.57 (95% confidence interval [CI], 0.73-3.39; p = 0.25) and 2.87 (95% CI, 1.10-5.35; p = 0.028) when the pre-frail and frail groups were compared with the fit group, respectively. The frail group had a significantly increased risk for a prolonged hospital stay (adjusted odds ratio, 2.22; 95% CI, 1.05-4.69; p = 0.022) compared with the fit group. CONCLUSION Pretreatment frailty was significantly associated with worse survival outcomes and more surgical complications, with prolonged hospital stay, in the older patients with cancer after elective abdominal surgery. Preoperative frailty assessment can assist physicians in identifying patients at a high risk for surgical complications and predicting the survival outcomes of older patients with cancer.
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Affiliation(s)
- Chia-Yen Hung
- Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Hematology and Oncology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Keng-Hao Liu
- Department of General Surgery, and Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Yi Tsai
- Department of General Surgery, and Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Chou Lai
- Department of Colon and Rectal Surgery, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jun-Te Hsu
- Department of General Surgery, and Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Chung Hsu
- Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Shin Hung
- Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Chi Chou
- Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Schenning KJ, Mahanna-Gabrielli E, Deiner SG. Update on Perioperative Delirium. Anesthesiol Clin 2023; 41:567-581. [PMID: 37516495 DOI: 10.1016/j.anclin.2023.02.007] [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: 07/31/2023]
Abstract
A strong association between frailty and in-hospital delirium in nonsurgical patients has been shown. Physical and cognitive frailties have been associated with decline and dysfunction in the frontal cognitive domains. Risk factors for frailty are similar to risk factors for postoperative delirium (POD). Frailty can be screened and diagnosed by various tools and instruments. Different anesthetic techniques have been studied to decrease the incidence of POD. However, no anesthetic technique has been conclusively proven to decrease the risk of POD. Patients with dementia develop delirium more often, and delirium is associated with accelerated cognitive decline.
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Affiliation(s)
- Katie J Schenning
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road L459, Portland, OR 97239, USA.
| | - Elizabeth Mahanna-Gabrielli
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, 2000 S Bayshore Drive Apartment 51, Miami, FL 33133, USA
| | - Stacie G Deiner
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
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Waring J, Martin GP, Hartley P, Partridge JSL, Dhesi JK. Implementing a perioperative care of older people undergoing surgery (POPS) service: findings from a multi-site qualitative implementation study. Age Ageing 2023; 52:afad149. [PMID: 37566561 PMCID: PMC10418147 DOI: 10.1093/ageing/afad149] [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: 03/22/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND The Perioperative care for Older People undergoing Surgery (POPS) service model is increasingly being implemented across care providers in the English and Welsh National Health Services. OBJECTIVE The study aimed to produce evidence regarding clinical leaders' activities to implement POPS across different service contexts and to produce generalisable recommendations for future implementation. METHODS A qualitative interview study was undertaken across six National Health Services hospitals with established POPS services. Interview participants were recruited on the basis of their direct involvement in the implementation and leadership of the service. Data collection involved semi-structured interviews with 26 people carried out between November 2022 and May 2023. RESULTS The implementation of POPS is often hampered by a lack of managerial and financial support, and apprehension amongst surgeons and anaesthetist about new ways of working. POPS leaders address these through five interconnected activities, each targeted at a combination of implementation factors. (i) Securing management and financial support. (ii) Professional engagement. (iii) Evidence building as a resource for demonstrating the clinical and operational benefits of POPS. (iv) Communication and engagement activities to promote and legitimise POPS to stakeholder groups. (v) Designated and distributed leadership to promote and coordinate implementation activities and to spread the service to new pathways. CONCLUSIONS Through a combination of activities POPS can be effectively implemented across different organisational contexts. Some aspects of these activities can be guided by shared resources and learning across sites, but others require adaption to local contextual barriers and drivers.
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Affiliation(s)
- Justin Waring
- Health Services Management Centre, University of Birmingham, Birmingham, UK
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Graham P Martin
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Peter Hartley
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Judith S L Partridge
- Division of Health and Social Care Research, Kings College London, London, UK
- Department of Ageing and Health, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Jugdeep K Dhesi
- Division of Health and Social Care Research, Kings College London, London, UK
- Department of Ageing and Health, Guy's and St Thomas’ NHS Foundation Trust, London, UK
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10
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McKenzie GAG, Johnson MJ, Lind MJ, Kelly C, Parrott S. Geriatric assessment prior to cancer treatment: A health economic evaluation. J Geriatr Oncol 2023; 14:101504. [PMID: 37320931 DOI: 10.1016/j.jgo.2023.101504] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/16/2022] [Accepted: 04/12/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION To address uncertainty regarding the cost-effectiveness of implementing geriatric assessment (GA) in oncology practice, we undertook a synthetic, model-based economic evaluation. MATERIALS AND METHODS A decision-analytic model with embedded Markov chains was developed to simulate a cost-effectiveness analysis of implementing GA within standard oncological care compared to current practice. This was for patients aged 77 years (the mean age in included trials) receiving chemotherapy or surgery as first-line treatment. Assumptions were made about model parameters, based on available literature, to calculate the incremental net health benefit (INHB) of GA, using a data synthesis. RESULTS GA has additional costs over standard care alone of between £390 and £576, depending upon implementation configuration. When major assumptions about the effectiveness of GA were modelled, INHB was marginally positive (0.09-0.12) at all cost-effectiveness thresholds (CETs). If no reduction in postoperative complications was assumed, the intervention was shown not to be cost-effective (INHB negative at all CETs). When used before chemotherapy, with minimal healthcare staffing inputs and technological assistance, GA is cost-effective (INHB positive between 0.06 and 0.07 at all CETs). DISCUSSION Considering emerging evidence that GA improves outcomes in oncology, GA may not be a cost-effective intervention when used for all older adults with cancer. However, with judicious selection of implementation models, GA has the potential to be cost-effective. Due to significant heterogeneity and centre dependent success in implementation and effectiveness, GA is difficult to study in oncology settings. Stakeholders could take a pragmatic approach towards GA introduction with local evaluation favoured over generalisable research. Because GA tends towards utilitarianism and has no safety issues, it is a suitable intervention for more widespread implementation.
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Affiliation(s)
- Gordon A G McKenzie
- Cancer Research Group, Hull York Medical School, University of Hull, Hull, UK.
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Michael J Lind
- Cancer Research Group, Hull York Medical School, University of Hull, Hull, UK
| | - Charlotte Kelly
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
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Yueh FR, Pan JH, Lee HF, Yen M, Hu FW. A Qualitative Exploration of Older Patients' Experiences With Frailty and Related Management Strategies. J Nurs Res 2023:00134372-990000000-00069. [PMID: 37351562 DOI: 10.1097/jnr.0000000000000565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Frailty is highly prevalent in hospitalized older patients and may increase the risk of adverse health outcomes. Understanding the experiences of older patients and the management strategies they use to recover from frailty is crucial to developing appropriate interventions. PURPOSE This study was designed to explore the frailty experiences of older adults and the management strategies they use to recover from frailty. METHODS Using purposive sampling, semistructured, face-to-face interviews were conducted with 16 older patients with frailty. Data were analyzed using content analysis. RESULTS The experiences of participants were classified into three phases, including the (a) individual sensing phase, (b) daily-living-threatening phase, and (c) acclimatization and acceptance phase. When experiencing frailty, the participants developed management strategies to facilitate recovery, which manifested in three phases: (a) making flexible adjustments to the daily routine, (b) using adequate support systems, and (c) adopting positive thinking. CONCLUSIONS/IMPLICATIONS FOR PRACTICE The results indicate that familial support and positive thinking are important management strategies for successful recovery in frail individuals. Older patients require adequate support systems. Positive thinking was also found to be an effective management strategy for recovery. Healthcare professionals should not only focus on providing supportive resources but also provide support to older patients to facilitate their adoption of positive thinking to face life changes brought on by frailty.
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Affiliation(s)
- Fang-Ru Yueh
- MS, RN, Doctoral Student, International Doctoral Program in Nursing, Department of Nursing, College of Medicine, National Cheng Kung University; and Assistant Head Nurse, Department of Nursing, National Cheng Kung University Hospital, Taiwan, ROC
| | - Jin-Hua Pan
- MS, RN, Doctoral Student, International Doctoral Program in Nursing, Department of Nursing, College of Medicine, National Cheng Kung University; and Assistant Head Nurse, Department of Nursing, National Cheng Kung University Hospital, Taiwan, ROC
| | - Huan-Fang Lee
- MS, RN, Clinical Nursing Teacher, Department of Nursing, College of Pharmacy & Health Care, Tajen University, Taiwan, ROC
| | - Miaofen Yen
- PhD, RN, Professor, International Studies Department of Nursing, Department of Nursing, College of Medicine, National Cheng Kung University, Taiwan, ROC
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Ehrlich AL, Owodunni OP, Mostales JC, Qin CX, Hadvani PJ, Sirisegaram L, Bettick D, Gearhart SL. Early Outcomes Following Implementation of a Multispecialty Geriatric Surgery Pathway. Ann Surg 2023; 277:e1254-e1261. [PMID: 35837966 DOI: 10.1097/sla.0000000000005567] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine geriatric-specific outcomes following implementation of a multispecialty geriatric surgical pathway (GSP). BACKGROUND In 2018, we implemented a GSP in accordance with the proposed 32 standards of American College of Surgeons' Geriatric Surgery Verification Program. METHODS This observational study combined data from the electronic health record system (EHR) and ACS-National Surgery Quality Improvement Program (NSQIP) to identify patients ≥65 years undergoing inpatient procedures from 2016 to 2020. GSP patients (2018-2020) were identified by preoperative high-risk screening. Frailty was measured with the modified frailty index. Surgical procedures were ranked according to the operative stress score (1-5). Loss of independence (LOI), length of stay, major complications (CD II-IV), and 30-day all-cause unplanned readmissions were measured in the pre/postpatient populations and by propensity score matching of patients by operative procedure and frailty. RESULTS A total of 533 (300 pre-GSP, 233 GSP) patients similar by demographics (age and race) and clinical profile (frailty) were included. On multivariable analysis, GSP patients showed decreased risk for LOI [odds ratio (OR) 0.26 (0.23, 0.29) P <0.001] and major complications [OR: 0.63 (0.50, 0.78) P <0.001]. Propensity matching demonstrated similar findings. Examining frail patients alone, GSP showed decreased risk for LOI [OR: 0.30 (0.25, 0.37) P <0.001], major complications [OR: 0.31 (0.24, 0.40) P <0.001], and was independently associated with a reduction in length of stay [incidence rate ratios: 0.97 (0.96, 0.98), P <0.001]. CONCLUSIONS In our diverse patient population, implementation of a GSP led to improved geriatric-specific surgical outcomes. Future studies to examine pathway compliance would promote the identification of further interventions.
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Affiliation(s)
- April L Ehrlich
- Division of Geriatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Oluwafemi P Owodunni
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Joshua C Mostales
- Division of Geriatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caroline Xu Qin
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Priyanka J Hadvani
- Division of Geriatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Susan L Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Bayview Medical Center, Baltimore, MD
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Perioperative medicine for Older People undergoing Surgery (POPS): Comprehensive Geriatric Assessment (CGA) and optimization in the perioperative setting. Int Anesthesiol Clin 2023; 61:62-69. [PMID: 36892984 DOI: 10.1097/aia.0000000000000396] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
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14
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Lai CC, Liu KH, Tsai CY, Hsu JT, Hsueh SW, Hung CY, Chou WC. Risk factors and effect of postoperative delirium on adverse surgical outcomes in older adults after elective abdominal cancer surgery in Taiwan. Asian J Surg 2023; 46:1199-1206. [PMID: 36041906 DOI: 10.1016/j.asjsur.2022.08.079] [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: 06/29/2022] [Revised: 07/27/2022] [Accepted: 08/18/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common complication in older adults, with unknown epidemiology and effects on surgical outcomes in Asian geriatric cancer patients. This study evaluated incidence, risk factors, and association between adverse surgical outcomes and POD after intra-abdominal cancer surgery in Taiwan. METHODS Overall, 345 patients aged ≥65 years who underwent elective abdominal cancer surgery at a medical center in Taiwan were prospectively enrolled. Delirium was assessed daily using the Confusion Assessment Method. Univariate and multivariate logistic regression analyses investigated risk factors for POD occurrence and estimated the association with adverse surgical outcomes. RESULTS POD occurred in 19 (5.5%) of the 345 patients. Age ≥73 years, Charlson comorbidity index ≥3, and operative time >428 min were independent predictors for POD occurrence. Patients presenting with one, two, and three risk factors had 4.1-fold (95% confidence interval [CI], 0.4-35.8, p = 0.20), 17.4-fold (95% CI, 2.2-138, p = 0.007), and 30.8-fold likelihood (95% CI, 2.9-321, p = 0.004) for POD occurrence, respectively. Patients with POD had a higher probability of prolonged hospital stay (adjusted odds ratio [OR] 2.8; 95% CI, 1.0-8.1; p = 0.037), intensive care stay (adjusted OR: 3.9; 95% CI, 1.5-10.5; p = 0.008), 30-day readmission (adjusted OR 3.1; 95% CI, 1.1-9.7; p = 0.039), and 90-day postoperative death (adjusted OR: 4.2; 95% CI, 1.0-17.7; p = 0.041). CONCLUSION POD occurrence was significantly associated with adverse surgical outcomes in geriatric patients undergoing elective abdominal cancer surgery, highlighting the importance of early POD identification in geriatric patients to improve postoperative care quality.
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Affiliation(s)
- Cheng-Chou Lai
- Department of Colon and Rectal Surgery, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, 333, Taoyuan, Taiwan
| | - Keng-Hao Liu
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, 333, Taoyuan, Taiwan
| | - Chun-Yi Tsai
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, 333, Taoyuan, Taiwan
| | - Jun-Te Hsu
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, 333, Taoyuan, Taiwan
| | - Shun-Wen Hsueh
- Department of Oncology, Chang Gung Memorial Hospital at Keelung, 204, Keelung, Taiwan
| | - Chia-Yen Hung
- Division of Hematology and Oncology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, 104, Taiwan; Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Wen-Chi Chou
- Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan.
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15
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Au E, Thangathurai G, Saripella A, Yan E, Englesakis M, Nagappa M, Chung F. Postoperative Outcomes in Elderly Patients Undergoing Cardiac Surgery With Preoperative Cognitive Impairment: A Systematic Review and Meta-Analysis. Anesth Analg 2023; 136:1016-1028. [PMID: 36728298 DOI: 10.1213/ane.0000000000006346] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Older patients with preoperative cognitive impairment are at risk for increased postoperative complications after noncardiac surgery. This systematic review and meta-analysis aimed to determine the association between preoperative cognitive impairment and dementia and postoperative outcomes in older surgical patients after cardiac surgery. METHODS Eight electronic databases were searched from inception to January 4, 2022. Inclusion criteria were cardiac surgery patients ≥60 years of age; preoperative cognitive impairment; ≥1 postoperative complication reported; comparator group with no preoperative cognitive impairment; and written in English. Using a random-effects model, we calculated effect sizes as odds ratio (OR) and standardized mean differences (SMDs). Risk of random error was assessed by applying trial sequential analysis. RESULTS Sixteen studies (62,179 patients) were included. Preoperative cognitive impairment was associated with increased risk of delirium in older patients after cardiac surgery (70.0% vs 20.5%; OR, 8.35; 95% confidence interval [CI], 4.25-16.38; I2, 0%; P < .00001). Cognitive impairment was associated with increased hospital length of stay (LOS; SMD, 0.36; 95% CI, 0.20-0.51; I2, 22%; P < .00001) and intensive care unit (ICU) LOS (SMD, 0.39; 95% CI, 0.09-0.68; I2, 70%; P = .01). No significant association was seen for 30-day mortality (1.7% vs 1.1%; OR, 2.58; 95% CI, 0.64-10.44; I2, 55%; P = .18). CONCLUSIONS In older patients undergoing cardiac surgery, cognitive impairment was associated with an 8-fold increased risk of delirium, a 5% increase in absolute risk of major postoperative bleeding, and an increase in hospital and ICU LOS by approximately 0.4 days. Further research on the feasibility of implementing routine neurocognitive testing is warranted.
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Affiliation(s)
- Emily Au
- From the Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Aparna Saripella
- From the Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Ellene Yan
- From the Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Marina Englesakis
- Department of Library & Information Services, University Health Network, Toronto, Ontario, Canada
| | - Mahesh Nagappa
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre and St Joseph Health Care, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Frances Chung
- From the Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Sumin AN. Assessment and Correction of the Cardiac Complications Risk in Non-cardiac Operations – What's New? RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-10-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Cardiovascular complications after non-cardiac surgery are the leading cause of 30-day mortality. The need for surgical interventions is approximately 5,000 procedures per 100,000 population, according to experts, the risks of non-cardiac surgical interventions are markedly higher in the elderly. It should be borne in mind that the aging of the population and the increased possibilities of medicine inevitably lead to an increase in surgical interventions in older people. Recent years have been characterized by the appearance of national and international guidelines with various algorithms for assessing and correcting cardiac risk, as well as publications on the validation of these algorithms. The purpose of this review was to provide new information about the assessment and correction of the risk of cardiac complications in non-cardiac operations. Despite the proposed new risk assessment scales, the RCRI scale remains the most commonly used, although for certain categories of patients (with oncopathology, in older age groups) the possibility of using specific questionnaires has been shown. In assessing the functional state, it is proposed to use not only a subjective assessment, but also the DASI questionnaire, 6-minute walking test and cardiopulmonary exercise test). At the next stage, it is proposed to evaluate biomarkers, primarily BNP or NT-proBNP, with a normal level – surgery, with an increased level – either an additional examination by a cardiologist or perioperative troponin screening. Currently, the prevailing opinion is that there is no need to examine patients to detect hidden lesions of the coronary arteries (non-invasive tests, coronary angiography), since this leads to excessive examination of patients, delaying the implementation of non-cardiac surgery. The extent to which this approach has an advantage over the previously used one remains to be studied.
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Affiliation(s)
- A. N. Sumin
- Research Institute for Complex Issues of Cardiovascular Diseases
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17
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Osseis M, Nehmeh WA, Rassy N, Derienne J, Noun R, Salloum C, Rassy E, Boussios S, Azoulay D. Surgery for T4 Colorectal Cancer in Older Patients: Determinants of Outcomes. J Pers Med 2022; 12:jpm12091534. [PMID: 36143319 PMCID: PMC9504737 DOI: 10.3390/jpm12091534] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/16/2022] [Accepted: 09/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background: This study aimed to compare the outcomes of older and younger patients with T4 colorectal cancer (CRC) treated with surgery. Methods: Consecutive patients with T4 CRC treated surgically at Henri Mondor Hospital between 2008 and 2016 were retrospectively analyzed in age subgroups (1) 50−69 years and (2) ≥70 years for overall and relative survival. The multivariable analyses were adjusted for adjusted for age, margin status, lymph node involvement, CEA level, postoperative complications (POC), synchronous metastases, and type of surgery. Results: Of 106 patients with T4 CRC, 57 patients (53.8%) were 70 years or older. The baseline characteristics were generally balanced between the two age groups. Older patients underwent adjuvant therapy less commonly (42.9 vs. 57.1%; p = 0.006) and had a longer delay between surgery and chemotherapy (median 40 vs. 34 days; p < 0.001). A higher trend for POC was reported among the older patients but did not impact the survival outcomes. After adjusting for confounding factors, the overall survival was shorter among the older patients (HR = 3.322, 95% CI 1.49−7.39), but relative survival was not statistically correlated to the age group (HR = 0.873, 95% CI 0.383−1.992). Conclusions: Older patients with CRC were more prone to severe POC, but age did not impact the relative survival of patients with T4 colorectal cancer. Older patients should not be denied surgery based on age alone.
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Affiliation(s)
- Michael Osseis
- Department of General Surgery Hôtel-Dieu de France Hospital, Saint-Joseph University, Beirut 1107 2180, Lebanon
- Correspondence:
| | - William A Nehmeh
- Department of General Surgery Hôtel-Dieu de France Hospital, Saint-Joseph University, Beirut 1107 2180, Lebanon
| | - Nathalie Rassy
- Department of General Surgery Hôtel-Dieu de France Hospital, Saint-Joseph University, Beirut 1107 2180, Lebanon
| | - Joseph Derienne
- Department of General Surgery Hôtel-Dieu de France Hospital, Saint-Joseph University, Beirut 1107 2180, Lebanon
| | - Roger Noun
- Department of General Surgery Hôtel-Dieu de France Hospital, Saint-Joseph University, Beirut 1107 2180, Lebanon
| | - Chady Salloum
- Department of Hepatobiliary and Liver Transplantation Surgery, Paul Brousse Hospital, Assistance Publique-Hôpitaux de Paris, 75610 Villejuif, France
| | - Elie Rassy
- Department of Medical Oncology, Gustave Roussy, 114 Rue Edouard Vaillant, 94800 Villejuif, France
| | - Stergios Boussios
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK
- Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, King’s College London, London SE1 9RT, UK
- AELIA Organization, 9th Km Thessaloniki-Thermi, 57001 Thessaloniki, Greece
| | - Daniel Azoulay
- Department of Hepatobiliary and Liver Transplantation Surgery, Paul Brousse Hospital, Assistance Publique-Hôpitaux de Paris, 75610 Villejuif, France
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Kołodziejska K, Witowski J, Tylec P, Grochowska A, Przytuła N, Lis M, Pędziwiatr M, Rubinkiewicz M. Radiological Features for Frailty Assessment in Patients Requiring Emergency Laparotomy. J Clin Med 2022; 11:jcm11185365. [PMID: 36143012 PMCID: PMC9505058 DOI: 10.3390/jcm11185365] [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: 07/29/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: As the number of elderly patients requiring surgical intervention rises, it is believed that frailty syndrome has a greater impact on perioperative course than on chronological age. The aim of this study was to evaluate the efficacy of various imaging features for frailty assessment in patients undergoing emergency laparotomy. Methods: The study included all patients that qualified for emergency surgery with preoperative CT scans between 2016 and 2020 in the Second Department of General Surgery. Multiple trauma patients were excluded from the analysis. The modified frailty index and brief geriatric assessment were used in the analysis. CT images were reviewed for the assessment of osteopenia, sarcopenia, sarcopenic obesity, renal volume and abdominal aorta calcification rate. Results: A total of 261 patients were included in the analysis. Multivariate logistic regression identified every next ASA class (OR: 4.161, 95%CI: 1.672–10.355, p = 0.002), intraoperative adverse events (OR: 12.397, 95%CI: 2.166–70.969, p = 0.005) and osteopenia (OR: 4.213, 95%CI: 1.235–14.367, p = 0.022) as a risk factor for 30-day mortality. Our study showed that every next ASA class (OR: 1.952, 95%Cl: 1.171–3.256, p = 0.010) and every point of the BGA score (OR: 1.496, 95%Cl: 1.110–2.016, p = 0.008) are risk factors for major complications. Conclusions: Osteopenia was the best parameter for perioperative mortality risk stratification in patients undergoing emergency surgical intervention. Sarcopenia (measured as psoas muscle area), sarcopenic obesity, aortic calcifications and mean kidney volume do not predict poor outcomes in those patients. None of the radiological markers appeared to be useful for the prediction of perioperative morbidity.
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Affiliation(s)
- Katarzyna Kołodziejska
- Department of Medical Education, Faculty of Medicine, Jagiellonian University Medical College, 30-688 Kraków, Poland
| | - Jan Witowski
- Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Piotr Tylec
- Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland
| | - Anna Grochowska
- Department of Radiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Natalia Przytuła
- Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland
| | - Maciej Lis
- Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, 31-008 Kraków, Poland
| | - Mateusz Rubinkiewicz
- 2nd Department of General Surgery, Jagiellonian University Medical College, 31-008 Kraków, Poland
- Correspondence:
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Partridge JSL, Moonesinghe SR, Lees N, Dhesi JK. Perioperative care for older people. Age Ageing 2022; 51:6678855. [PMID: 36040439 DOI: 10.1093/ageing/afac194] [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: 07/06/2022] [Indexed: 01/25/2023] Open
Abstract
Increasing numbers of older people are undergoing surgery with benefits including symptom relief and extended longevity. Despite these benefits, older people are more likely than younger patients to experience postoperative complications, which are predominantly medical as opposed to surgical. Comprehensive Geriatric Assessment and optimisation offers a systematic approach to risk assessment and risk modification in the perioperative period. Clinical evidence shows that Comprehensive Geriatric Assessment and optimisation reduces postoperative medical complications and is cost effective in the perioperative setting. These benefits have been observed in patients undergoing elective and emergency surgery. Challenges in the implementation of perioperative Comprehensive Geriatric Assessment and optimisation services are acknowledged. These include the necessary involvement of a wide stakeholder group, limited available geriatric medicine workforce and ensuring fidelity to Comprehensive Geriatric Assessment methodology with adaptation to the local context. Addressing these challenges needs a cross-specialty, interdisciplinary approach underpinned by evidence-based medicine and implementation science with upskilling to facilitate innovative use of the extended workforce. Future delivery of quality patient-centred perioperative care requires proactive engagement with national audit, collaborative guidelines and establishment of networks to share best practice.
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Affiliation(s)
- Judith S L Partridge
- Consultant Geriatrician, Perioperative Medicine for Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Honorary Senior Lecturer, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - S Ramani Moonesinghe
- Professor of Perioperative Medicine, University College London (UCL), London, UK
- Consultant in Anaesthesia, Department of Critical and Perioperative Care, University College Hospitals, London, UK
| | - Nicholas Lees
- Consultant General & Colorectal Surgeon, Salford Royal, Northern Care Alliance NHS Foundation Trust, UK
| | - Jugdeep K Dhesi
- Consultant Geriatrician, Perioperative Medicine for Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Honorary Professor, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Honorary Associate Professor, Division of Surgery and Interventional Science, University College London, London, UK
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20
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Clinical Observation of Patients Undergoing Glioma Surgery under Propofol and Sevoflurane Anesthesia: A Retrospective Study. JOURNAL OF ONCOLOGY 2022; 2022:4516537. [PMID: 35720226 PMCID: PMC9200574 DOI: 10.1155/2022/4516537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/27/2022] [Accepted: 05/04/2022] [Indexed: 11/22/2022]
Abstract
Objective To observe the effects of propofol and sevoflurane anesthesia on patients undergoing glioma surgery. Methods 192 patients with gliomas treated in our hospital from January 2016 to January 2021 were selected. All patients were randomly divided into observation group and control group. The observation group was given sevoflurane and the control group was given propofol. The clinical effects of the two groups were observed. Results Comparison of clinical indexes related to intraoperative conditions between the two groups revealed that the time of anesthesia and extubation after operation in the observation group were shorter than those in the control group, and the difference was statistically significant (P < 0.05). The amount of intraoperative bleeding in the observation group was less than that in the control group, and the difference was statistically significant (P < 0.05). There was no significant difference in intracranial operation time, operation time, fluid volume, and urine volume between the two groups (P < 05). Comparing the recovery time of anesthesia between the two groups, the recovery time of orientation and the time of eye-opening in the observation group were significantly shorter than those in the control group (P < 0.05). Comparing the consciousness and cognitive function of the two groups, the OAAS score of the observation group after extubation, before leaving the operating room and 1 hour after extubation, was significantly higher than that of the control group (P < 0.05), and the MMSE score l h after extubation was significantly higher than that of the control group (P < 0.05). Comparing the incidence of postoperative complications between the two groups, the number of cases of restlessness, urinary infection, deep vein thrombosis, and hypertension in the observation group was lower than that in the control group, with statistical significance (P < 0.05). Conclusion The anesthesia time and extubation time of the sevoflurane anesthesia group were shorter than that of the propofol anesthesia group, and the orientation recovery time and eye-opening time were shortened. The OAAS score of the sevoflurane anesthesia group was higher than that of the propofol anesthesia group after extubation, before extubation, and 1 hour after extubation. The probability of postoperative complications in the sevoflurane anesthesia group was lower than that in the propofol anesthesia group. Sevoflurane anesthesia may be more suitable for surgical induction of glioma patients than propofol anesthesia.
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Rapid cognitive assessment tools for screening of mild cognitive impairment in the preoperative setting: A systematic review and meta-analysis. J Clin Anesth 2022; 78:110682. [DOI: 10.1016/j.jclinane.2022.110682] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/21/2022] [Accepted: 02/07/2022] [Indexed: 12/29/2022]
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22
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Chen L, Au E, Saripella A, Kapoor P, Yan E, Wong J, Tang-Wai DF, Gold D, Riazi S, Suen C, He D, Englesakis M, Nagappa M, Chung F. Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis. J Clin Anesth 2022; 80:110883. [PMID: 35623265 DOI: 10.1016/j.jclinane.2022.110883] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/02/2022] [Accepted: 05/10/2022] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE To determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients. DESIGN A systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021. SETTING Preoperative assessment. PATIENTS Older patients (≥ 60 years) undergoing non-cardiac surgery. MEASUREMENTS Outcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies. RESULTS Fifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I2: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I2: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I2: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001). CONCLUSIONS Preoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.
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Affiliation(s)
- Lina Chen
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Emily Au
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Aparna Saripella
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Paras Kapoor
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ellene Yan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, Women's College Hospital, Toronto, ON, Canada
| | - David F Tang-Wai
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - David Gold
- Department of Psychiatry, Krembil Brain Institute, University of Toronto, Toronto, ON, Canada
| | - Sheila Riazi
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Colin Suen
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - David He
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Marina Englesakis
- Library & Information Services, University Health Network, Toronto, ON, Canada
| | - Mahesh Nagappa
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
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Challenges in the management of older patients with inflammatory rheumatic diseases. Nat Rev Rheumatol 2022; 18:326-334. [PMID: 35314796 DOI: 10.1038/s41584-022-00768-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 12/20/2022]
Abstract
The rise in the number of people aged 65 years and older living with inflammatory rheumatic diseases such as rheumatoid arthritis is causing considerable challenges for clinicians. As patients get older, they are at an increased risk of multiple chronic diseases, a situation termed multimorbidity. Multimorbidity inevitably drives polypharmacy, where by a patient requires treatment with multiple medications. In addition, advancing age, multimorbidity and polypharmacy all place a patient at an increased risk of developing geriatric syndromes, which are clinical conditions in older people that do not fit into disease categories and include malnutrition, sarcopenia and frailty. Geriatric syndromes further increase the risk of adverse outcomes, including the accrual of additional morbidity, nursing home admission and mortality. Patients with inflammatory rheumatic diseases are especially prone to developing geriatric syndromes. Some predisposing risk factors for geriatric syndromes, such as joint swelling and functional limitations, are also inherent to rheumatic inflammatory disease itself. The frequent coexistence of multimorbidity, polypharmacy and geriatric syndromes in this patient group requires individually tailored interventions to preserve patient independence and overall functioning. To prepare for the changing demography, rheumatologists should gain more insight into the implications of multimorbidity, polypharmacy and geriatric syndromes for the management of older patients with inflammatory rheumatic diseases.
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Siu ATY, Poulton T, Ismail H, Riedel B, Dhesi J. Prehabilitation in the Older People: Current Developments. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00496-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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