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Duan L, Xiao M, Liu S, Wu Z, Chen R, Zeng R, Xie F, Ye D, Zhu W, Zhao Y, Li W, Wang J. Associations between modifiable risk factors and frailty progression among individuals with pre-frailty. Exp Gerontol 2024; 194:112494. [PMID: 38880184 DOI: 10.1016/j.exger.2024.112494] [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: 03/11/2024] [Revised: 06/02/2024] [Accepted: 06/13/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND In the context of the present global aging phenomenon, the senior population and pace of aging in China have emerged as prominent issues on the worldwide stage. Frailty, a complicated condition that is closely linked to the clinical syndrome of advancing age, poses a considerable health risk to older individuals. Frailty status was assessed by the frailty index (FI) ranging from 0 to 1, pre-frailty was defined as >0.10 to <0.25, and frailty was defined as ≥0.25. To look at the connection between modifiable risk factors and frailty progression among individuals in the pre-frailty population. METHODS Using pre-frailty patients as characterized by the 32-frailty index, the study focused on middle-aged and elderly persons from China and ultimately recruited 5,411 participants for analysis. The relationship between modifiable factors and changes in pre-frailty status throughout follow-up was investigated. Modifiable factors were body mass index (BMI), abdominal obesity, smoking status, alcohol use, and sleep status. We employed logistic regression to examine the relationships between modifiable risk factors and changes in pre-frailty status, as well as the associations between modifiable factors scores and the corresponding pre-frailty progression. Additionally, we generated the modifiable factors scores and examined how these related to modifications in the pre-frailty stage. RESULTS In this study, after a mean follow-up of 6 years, (OR = 0.59, 95%CI: 0.48-0.71) for BMI ≥ 25 kg/m2 and (OR = 0.74, 95%CI: 0.63-0.89) for concomitant abdominal obesity were significantly associated with lower reversal to a healthy state; (OR = 1.24, 95%CI:1.07-1.44) and (OR = 1.25, 95%CI: 1.10-1.42) for the group that negatively progressed further to frailty were significantly associated with increased frailty progression profile. Subsequently, investigation of modifiable factor scores and changes of pre-frailty status found that as scores increased further, frailty developed (OR = 1.12, 95%CI:1.05-1.18), with scores of 3 and 4 of (OR = 1.38, 95%CI: 1.08-1.77) and (OR = 1.52, 95%CI:1.09-2.14). Finally, we also performed a series of stratified analyses and found that rural unmarried men aged 45 to 60 years with less than a high school degree were more likely to develop a frailty state once they developed abdominal obesity. CONCLUSION In pre-frailty individuals, maintaining more favorable controllable variables considerably enhances the chance of return to normal and, conversely, increase the risk of progressing to the frailty.
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Affiliation(s)
- Lanzhi Duan
- School of Basic Medicine, JingGangshan University, Ji'an, Jiangxi Province, China; Online Collaborative Research Center for Evidence-Based Medicine Ministry of Education, JingGangshan Univesity Branch, China; Affiliated Hospital of Jinggangshan University, Center for Clinical Medicine Research of Jinggangshan University, Ji'an 343000, China
| | - Mengmeng Xiao
- School of Public Health of Southeast University, Nanjing 210009, China
| | - Sijia Liu
- School of Basic Medicine, JingGangshan University, Ji'an, Jiangxi Province, China; Online Collaborative Research Center for Evidence-Based Medicine Ministry of Education, JingGangshan Univesity Branch, China; Affiliated Hospital of Jinggangshan University, Center for Clinical Medicine Research of Jinggangshan University, Ji'an 343000, China
| | - Zhigang Wu
- School of Basic Medicine, JingGangshan University, Ji'an, Jiangxi Province, China; Online Collaborative Research Center for Evidence-Based Medicine Ministry of Education, JingGangshan Univesity Branch, China; Affiliated Hospital of Jinggangshan University, Center for Clinical Medicine Research of Jinggangshan University, Ji'an 343000, China
| | - Ruzhao Chen
- School of Basic Medicine, JingGangshan University, Ji'an, Jiangxi Province, China; Online Collaborative Research Center for Evidence-Based Medicine Ministry of Education, JingGangshan Univesity Branch, China; Affiliated Hospital of Jinggangshan University, Center for Clinical Medicine Research of Jinggangshan University, Ji'an 343000, China
| | - Rui Zeng
- School of Clinical Medicine, Jinggangshan University, Ji'an, Jiangxi Province, China
| | - Fayi Xie
- School of Clinical Medicine, Jinggangshan University, Ji'an, Jiangxi Province, China
| | - Dongmei Ye
- School of Clinical Medicine, Jinggangshan University, Ji'an, Jiangxi Province, China
| | - Wan Zhu
- School of Clinical Medicine, Jinggangshan University, Ji'an, Jiangxi Province, China
| | - Yueyue Zhao
- School of Clinical Medicine, Jinggangshan University, Ji'an, Jiangxi Province, China
| | - Wei Li
- School of Clinical Medicine, Jinggangshan University, Ji'an, Jiangxi Province, China
| | - Jiang Wang
- School of Basic Medicine, JingGangshan University, Ji'an, Jiangxi Province, China; Online Collaborative Research Center for Evidence-Based Medicine Ministry of Education, JingGangshan Univesity Branch, China; Affiliated Hospital of Jinggangshan University, Center for Clinical Medicine Research of Jinggangshan University, Ji'an 343000, China.
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Tang A, Abdallah HM, Chang YF, Zenonos GA, Gardner PA, Choby GW, Wang EW, Snyderman CH. Changes in pituitary adenoma patient presentation and outcomes during the COVID pandemic at a Pituitary Center of Excellence. Pituitary 2024:10.1007/s11102-024-01435-7. [PMID: 39046590 DOI: 10.1007/s11102-024-01435-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2024] [Indexed: 07/25/2024]
Abstract
PURPOSE The COVID-19 pandemic caused significant disruption to the surgical care of patients. The aim of this study was to analyze the impact of the pandemic on endoscopic endonasal surgery (EES) for patients with a pituitary adenoma. METHODS Patients from 2015 to 2022 that had EES for a pituitary adenoma were included in this study. Patients were separated into pre-COVID (January 2015-March 2020) and COVID (March 2020-September 2022) groups. Univariate analysis was done using chi-square, fisher exact tests, and t-tests to compare groups. RESULTS This study included 492 patients that had EES for their pituitary adenoma. There were 314 patients in the pre-COVID group and 178 patients in the COVID group. Patients in the COVID group had a higher risk analysis index (RAI) frailty score (15 ± 10 pre-COVID vs. 20 ± 9 COVID, P < 0.001) and a higher American Society of Anesthesiology (ASA) physical status score (3 or 4) (72.0% pre-COVID vs. 81.9% COVID, P = 0.02). There were significantly more macroadenoma cases (87.6% pre-COVID vs. 94.4% COVID, P = 0.02) and extrasellar surgical approaches (45.2% pre-COVID vs. 61.2% COVID, P < 0.001) during COVID. There was no significant difference in length of stay (LOS) and readmission rates between groups. CONCLUSIONS Patients that presented during the pandemic tended to be more frail, have more comorbidities, and require additional extrasellar surgical approaches. Despite changes in clinical presentation and operative management, the LOS and readmission rate remained stable during COVID, supporting the safety of this procedure during the recent pandemic.
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Affiliation(s)
- Anthony Tang
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hussein M Abdallah
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yue-Fang Chang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Georgios A Zenonos
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Garret W Choby
- Department of Otolaryngology, Center for Skull Base Surgery, University of Pittsburgh, UPMC Presbyterian, 203 Lothrop Street, EEI Suite 500, Pittsburgh, PA, 15213, USA
| | - Eric W Wang
- Department of Otolaryngology, Center for Skull Base Surgery, University of Pittsburgh, UPMC Presbyterian, 203 Lothrop Street, EEI Suite 500, Pittsburgh, PA, 15213, USA
| | - Carl H Snyderman
- Department of Otolaryngology, Center for Skull Base Surgery, University of Pittsburgh, UPMC Presbyterian, 203 Lothrop Street, EEI Suite 500, Pittsburgh, PA, 15213, USA.
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3
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Min S, Zhang G, Hu A, Petito GT, Tripathi SH, Shukla G, Kumar A, Shah S, Phillips KM, Forbes JA, Zuccarello M, Andaluz NO, Sedaghat AR. A Comprehensive Analysis of Tobacco Smoking History as a Risk for Outcomes after Endoscopic Transsphenoidal Resection of Pituitary Adenoma. J Neurol Surg B Skull Base 2024; 85:255-260. [PMID: 38778915 PMCID: PMC11111311 DOI: 10.1055/a-2043-0263] [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: 10/08/2022] [Accepted: 02/21/2023] [Indexed: 02/27/2023] Open
Abstract
Objectives This study seeks to comprehensively analyze the impact of smoking history on outcomes after endoscopic transsphenoidal hypophysectomy (TSH) for pituitary adenoma. Design This was a retrospective study. Setting This study was done at the tertiary care center. Participants Three hundred and ninety-eight adult patients undergoing TSH for a pituitary adenoma. Main Outcome Measures Clinical and tumor characteristics and operative factors were collected. Patients were categorized as never, former, or active smokers, and the pack-years of smoking history was collected. Years since cessation of smoking was obtained for former smokers. Specific outcomes included postoperative cerebrospinal fluid (CSF) leak, length of hospitalization, 30-day return to the operating room, and 30-day readmission. Smoking history details were comprehensively analyzed for association with outcomes. Results Any history of smoking tobacco was associated with return to the operating room (odds ratio [OR] = 2.67, 95% confidence interval [CI]: 1.05-6.76, p = 0.039), which was for persistent CSF leak in 58.3%. Among patients with postoperative CSF leak, any history of smoking was associated with need for return to the operating room to repair the CSF leak (OR = 5.25, 95% CI: 1.07-25.79, p = 0.041). Pack-years of smoking was positively associated with a return to the operating room (OR = 1.03, 95% CI: 1.01-1.06, p = 0.048). In all multivariable models, all negative outcomes were significantly associated with the covariate: occurrence of intraoperative CSF leak. Conclusion This is the first study to show smoking may have a negative impact on healing of CSF leak repairs after TSH, requiring a return to the operating room. This effect appears to be dose dependent on the smoking history. Secondarily, intraoperative CSF leak as covariate in multivariable models was significantly associated with all negative outcomes.
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Affiliation(s)
- Susie Min
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Grace Zhang
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Alex Hu
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Gabrielle T. Petito
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Siddhant H. Tripathi
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Geet Shukla
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Adithya Kumar
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Sanjit Shah
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Katie M. Phillips
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Jonathan A. Forbes
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Norberto O. Andaluz
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Ahmad R. Sedaghat
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
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Kshirsagar RS, Eide JG, Qatanani A, Harris J, Abello EH, Roman KM, Vasudev M, Jackson C, Lee JYK, Kuan EC, Palmer JN, Adappa ND. Impact of Frailty on Postoperative Outcomes in Extended Endonasal Skull Base Surgery for Suprasellar Pathologies. Otolaryngol Head Neck Surg 2024; 170:568-576. [PMID: 37746938 DOI: 10.1002/ohn.537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 08/29/2023] [Accepted: 09/05/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Frailty metrics estimate a patient's ability to tolerate physiologic stress and there are limited frailty data in patients undergoing expanded endonasal approaches (EEA) for suprasellar pathologies. Elevated frailty metrics have been associated with increased perioperative complications in patients undergoing craniotomies. We sought to examine this potential relationship in EEA. STUDY DESIGN Retrospective cohort study. SETTING Two tertiary academic skull base centers. METHODS Cases of patients undergoing EEA for suprasellar pathologies were reviewed. Demographic, treatment, survival, and postoperative outcomes data were recorded. Frailty was calculated using validated indexes, including the American Society of Anesthesiologists (ASA) classification, the modified 5-item frailty index (mFI-5), and the Charlson comorbidity index (CCI). Primary outcomes included 30-day medical and surgical complications. RESULTS A total of 88 patients were included, with 59 (67%) female patients and a mean age of 54 ± 15 years. The most common pathologies included 53 meningiomas (60.2%) and 21 craniopharyngiomas (23.9%). Most patients were ASA class 3 (54.5%) with mean mFI-5 0.82 ± 1.01 and CCI 4.18 ± 2.42. There was no association between increased frailty and 30-day medical or surgical outcomes (including postoperative cerebrospinal fluid leak), prolonged length of hospital stay, or mortality (all P > .05). Higher mFI-5 was associated with an increased risk for 30-day readmission (odds ratio: 2.35, 95% confidence Interval: 1.10-5.64, P = .04). CONCLUSION Despite the patient population being notably frail, we only identified an increased risk for 30-day readmission and observed no links with deteriorating surgical, medical, or mortality outcomes. This implies that conventional frailty metrics may not effectively align with EEA outcomes.
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Affiliation(s)
- Rijul S Kshirsagar
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jacob G Eide
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anas Qatanani
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jacob Harris
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric H Abello
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Kelsey M Roman
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Milind Vasudev
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Christina Jackson
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y K Lee
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - James N Palmer
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Varela S, Thommen R, Rumalla K, Faraz Kazim S, Couldwell WT, Schmidt MH, Bowers CA. The risk analysis index demonstrates superior discriminative ability in predicting extended length of stay in pituitary adenoma resection patients when compared to the 5-point modified frailty index. World Neurosurg X 2024; 21:100259. [PMID: 38292022 PMCID: PMC10826816 DOI: 10.1016/j.wnsx.2023.100259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 07/06/2023] [Accepted: 11/28/2023] [Indexed: 02/01/2024] Open
Abstract
Objective To compare the predictive abilities of two frailty indices on post-operative morbidity and mortality in patients undergoing pituitary adenoma resection. Methods The National Surgical Quality Improvement Program (NSQIP) database was used to retrospectively collect data for patients undergoing pituitary adenoma resection between 2015-2019. To compare the predictive abilities of two of the most common frailty indices, the 5-point modified frailty index (mFI-5) and the risk analysis index (RAI), receiver operating curve analysis (ROC) and area under the curve (AUC)/Cstatistic were used. Results In our cohort of 1,454 patients, the RAI demonstrated superior discriminative ability to the mFI-5 in predicting extended length of stay (C-statistic 0.59, 95% CI 0.56-0.62 vs. C-statistic 0.51, 95% CI: 0.48-0.54, p = 0.0002). The RAI only descriptively appeared superior to mFI-5 in determining mortality (C-statistic 0.89, 95% CI 0.74-0.99 vs. Cstatistic 0.63, 95% CI 0.61-0.66, p=0.11), and NHD (C-statistic 0.68, 95% CI 0.60-0.76 vs. C-statistic 0.60, 95% CI: 0.57-0.62, p=0.15). Conclusions Pituitary adenomas account for one of the most common brain tumors in the general population, with resection being the preferred treatment for patients with most hormone producing tumors or those causing compressive symptoms. Although pituitary adenoma resection is generally safe, patients who experience post-operative complications frequently share similar pre-operative characteristics and comorbidities. Therefore, appropriate pre-operative risk stratification is imperative for adequate patient counseling and informed consent in these patients. Here we present the first known report showing the superior discriminatory ability of the RAI in predicting eLOS when compared to the mFI-5.
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Affiliation(s)
- Samantha Varela
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Rachel Thommen
- School of Medicine, New York Medical College (NYMC), Valhalla, NY, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - William T. Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Meic H. Schmidt
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Christian A. Bowers
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
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Nasrollahi TS, Shahrestani S, Borrelli M, Hopp ML, Wu AW, Tang DM, Yu JS. The Influence of Modifiable Risk Factors on Postoperative Outcomes in Patients Receiving Surgery for Resection for Acoustic Neuroma. EAR, NOSE & THROAT JOURNAL 2023:1455613231191020. [PMID: 37605484 DOI: 10.1177/01455613231191020] [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: 08/23/2023] Open
Abstract
Acoustic neuromas are the most common tumor of the cerebellopontine angle that are associated with a number of symptoms that negatively impact a patient's quality of life. While the mainstay of treatment for these benign tumors remains microsurgical resection, there is limited research exploring how certain modifiable risk factors (MRFs) may affect the perioperative course. The purpose of this study was to investigate how MRFs including malnutrition, obesity, dyslipidemia, uncontrolled hypertension, and smoking may affect postoperative rates of readmission and nonroutine discharges. We utilized the 2016 and 2017 Healthcare Cost and Utilization Project Nationwide Readmissions Database. MRFs were queried using appropriate International Classification of Diseases, Tenth Revision (ICD-10) coding for categories including malnutrition, obesity, dyslipidemia, smoking, alcohol, and hypertension. The statistical analysis was done using RStudio (Version 1.3.959). Chi-squared tests were done to evaluate differences between categorical variables. The Mann-Whitney U-testing was utilized to evaluate for statistically significant differences in continuous data. The "Epitools" package was used to develop logistic regression models for postoperative complications and post hoc receiver operating characteristic curves were developed. Pertaining to nonroutine discharge, predictive models using malnutrition outperformed all other MRFs as well as those with no MRFs (P < .05). In the case of readmission, models using malnutrition outperformed those of obesity and smoking (P < .05). Again, an increase in predictive power is seen in models using dyslipidemia when compared to obesity, smoking, or uncontrolled hypertension. Lastly, models using no MRFs outperformed those of obesity, smoking, and uncontrolled hypertension (P < .05). This is the first study of its kind to evaluate the role of MRFs in those undergoing surgical resection of their acoustic neuroma. We concluded that certain MRFs may play a role in complicating a patient's perioperative surgical course.
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Affiliation(s)
- Tasha S Nasrollahi
- Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Sinus Center of Excellence, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shane Shahrestani
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michela Borrelli
- Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Sinus Center of Excellence, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Martin L Hopp
- Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Sinus Center of Excellence, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Arthur W Wu
- Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Sinus Center of Excellence, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Dennis M Tang
- Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Sinus Center of Excellence, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John S Yu
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Zhu J, Qiu X, Ji C, Wang F, Tao A, Chen L. Frailty as a predictor of neurosurgical outcomes in brain tumor patients: A systematic review and meta-analysis. Front Psychiatry 2023; 14:1126123. [PMID: 36873196 PMCID: PMC9982160 DOI: 10.3389/fpsyt.2023.1126123] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 01/23/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Patients with frailty are at a high risk of poor health outcomes, and frailty has been explored as a predictor of adverse events, such as perioperative complications, readmissions, falls, disability, and mortality in the neurosurgical literature. However, the precise relationship between frailty and neurosurgical outcomes in patients with brain tumor has not been established, and thus evidence-based advancements in neurosurgical management. The objectives of this study are to describe existing evidence and conduct the first systematic review and meta-analysis of the relationship between frailty and neurosurgical outcomes among brain tumor patients. METHODS Seven English databases and four Chinese databases were searched to identify neurosurgical outcomes and the prevalence of frailty among patients with a brain tumor, with no restrictions on the publication period. According to the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis and the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines, two independent reviewers employed the Newcastle-Ottawa scale in cohort studies and JBI Critical Appraisal Checklist for Cross-sectional Studies to evaluate the methodological quality of each study. Then random-effects or fixed-effects meta-analysis was used in combining odds ratio (OR) or hazard ratio (RR) for the categorical data and continuous data of neurosurgical outcomes. The primary outcomes are mortality and postoperative complications, and secondary outcomes include readmission, discharge disposition, length of stay (LOS), and hospitalization costs. RESULTS A total of 13 papers were included in the systematic review, and the prevalence of frailty ranged from 1.48 to 57%. Frailty was significantly associated with increased risk of mortality (OR = 1.63; CI = 1.33-1.98; p < 0.001), postoperative complications (OR = 1.48; CI = 1.40-1.55; p < 0.001; I 2 = 33%), nonroutine discharge disposition to a facility other than home (OR = 1.72; CI = 1.41-2.11; p < 0.001), prolonged LOS (OR = 1.25; CI = 1.09-1.43; p = 0.001), and high hospitalization costs among brain tumor patients. However, frailty was not independently associated with readmission (OR = 0.99; CI = 0.96-1.03; p = 0.74). CONCLUSION Frailty is an independent predictor of mortality, postoperative complications, nonroutine discharge disposition, LOS, and hospitalization costs among brain tumor patients. In addition, frailty plays a significant potential role in risk stratification, preoperative shared decision making, and perioperative management. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021248424.
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Affiliation(s)
- Jinfeng Zhu
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China.,Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Xichenhui Qiu
- Health Science Center, Shenzhen University, Shenzhen, China
| | - Cuiling Ji
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Fang Wang
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - An Tao
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Lu Chen
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
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Evaluating pituitary adenomas using national research databases: systematic review of the quality of reporting based on the STROBE scale. Neurosurg Rev 2022; 45:3801-3815. [DOI: 10.1007/s10143-022-01888-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 04/26/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
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9
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Shahrestani S, Brown NJ, Nasrollahi TS, Strickland BA, Bakhsheshian J, Ruzevick JJ, Bove I, Lee A, Emeh UA, Carmichael JD, Zada G. Evaluating the predictive value of comorbidity indices in pituitary surgery: a mixed-effects modeling study using the Nationwide Readmissions Database. J Neurosurg 2022; 137:1443-1451. [PMID: 35303700 DOI: 10.3171/2022.1.jns22197] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 01/31/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although pituitary adenomas (PAs) are common intracranial tumors, literature evaluating the utility of comorbidity indices for predicting postoperative complications in patients undergoing pituitary surgery remains limited, thereby hindering the development of complex models that aim to identify high-risk patient populations. We utilized comparative modeling strategies to evaluate the predictive validity of various comorbidity indices and combinations thereof in predicting key pituitary surgery outcomes. METHODS The Nationwide Readmissions Database was used to identify patients who underwent pituitary tumor operations (n = 19,653) in 2016-2017. Patient frailty was assessed using the Johns Hopkins Adjusted Clinical Groups (ACG) System. The Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) were calculated for each patient. Five sets of generalized linear mixed-effects models were developed, using as the primary predictors 1) frailty, 2) CCI, 3) ECI, 4) frailty + CCI, or 5) frailty + ECI. Complications of interest investigated included inpatient mortality, nonroutine discharge (e.g., to locations other than home), length of stay (LOS) within the top quartile (Q1), cost within Q1, and 1-year readmission rates. RESULTS Postoperative mortality occurred in 73 patients (0.4%), 1-year readmission was reported in 2994 patients (15.2%), and nonroutine discharge occurred in 2176 patients (11.1%). The mean adjusted all-payer cost for the procedure was USD $25,553.85 ± $26,518.91 (Q1 $28,261.20), and the mean LOS was 4.8 ± 7.4 days (Q1 5.0 days). The model using frailty + ECI as the primary predictor consistently outperformed other models, with statistically significant p values as determined by comparing areas under the curve (AUCs) for most complications. For prediction of mortality, however, the frailty + ECI model (AUC 0.831) was not better than the ECI model alone (AUC 0.831; p = 0.95). For prediction of readmission, the frailty + ECI model (AUC 0.617) was not better than the frailty model alone (AUC 0.606; p = 0.10) or the frailty + CCI model (AUC 0.610; p = 0.29). CONCLUSIONS This investigation is to the authors' knowledge the first to implement mixed-effects modeling to study the utility of common comorbidity indices in a large, nationwide cohort of patients undergoing pituitary surgery. Knowledge gained from these models may help neurosurgeons identify high-risk patients who require additional clinical attention or resource utilization prior to surgical planning.
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Affiliation(s)
- Shane Shahrestani
- 1Department of Neurosurgery, University of Southern California, Los Angeles
- 2Department of Medical Engineering, California Institute of Technology, Pasadena
| | - Nolan J Brown
- 3Department of Neurosurgery, University of California, Irvine Medical Center, Irvine
| | - Tasha S Nasrollahi
- 4Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles; and
| | - Ben A Strickland
- 1Department of Neurosurgery, University of Southern California, Los Angeles
| | | | - Jacob J Ruzevick
- 1Department of Neurosurgery, University of Southern California, Los Angeles
| | - Ilaria Bove
- 1Department of Neurosurgery, University of Southern California, Los Angeles
| | - Ariel Lee
- 3Department of Neurosurgery, University of California, Irvine Medical Center, Irvine
| | - Ugochi A Emeh
- 5Department of Molecular and Cell Biology, University of California, Berkeley, California
| | - John D Carmichael
- 1Department of Neurosurgery, University of Southern California, Los Angeles
| | - Gabriel Zada
- 1Department of Neurosurgery, University of Southern California, Los Angeles
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10
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Utility of hospital frailty risk score for predicting postoperative outcomes in craniopharyngioma. J Neurooncol 2022; 159:185-193. [PMID: 35723816 DOI: 10.1007/s11060-022-04056-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/01/2022] [Indexed: 12/24/2022]
Abstract
OVERVIEW Frailty is an age-associated decline in functional status leading to increased vulnerability to otherwise innocuous stressors. In neurosurgical patients, frailty has been associated with postoperative complications, increased mortality, longer hospitalization, and increased care costs for a variety of conditions. This study seeks to determine the association between frailty and postoperative outcomes in patients undergoing surgery for craniopharyngioma. METHODS The Nationwide Inpatient Sample (NIS) database was queried for patients diagnosed with craniopharyngioma who underwent surgery via either craniotomy or transsphenoidal approach. Comorbid diagnoses were used to calculate the Hospital Frailty Risk Score (HFRS) and assign patients to low (< 5), intermediate (5-15), or high-risk (> 15) categories. Logistic regression was completed to determine whether the HFRS category was predictive of mortality, postoperative complication, extended hospitalization, or increased hospital costs compared to age. RESULTS Increased frailty score was predictive of increased length of stay, increased hospital costs, and non-home discharge in binary logistic regression with good discrimination on the ROC curve compared to age at admission. HFRS risk categories were significantly predictive of the development of any complication, with 100% of high-risk patients developing a complication compared to 76% of intermediate-risk and 63% of low-risk patients. HFRS risk categories were also predictive of the extended length of stay (71%, 49%, and 11% for high-, intermediate-, and low-risk, respectively) and non-home discharge (86%, 56%, and 17%). Regression analysis was unable to be performed for mortality due to the low number of deaths in the study group. CONCLUSION In patients undergoing any surgery for craniopharyngioma, frailty is predictive of increased hospital length of stay and overall care costs. HFRS failed to independently predict mortality because the incidence of mortality is too low in this population to analyze. The HFRS is a valuable tool to identify post-operative outcomes following surgery for craniopharyngioma.
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11
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Shahrestani S, Brown NJ, Strickland BA, Bakhsheshian J, Ghodsi SM, Nasrollahi T, Borrelli M, Gendreau J, Ruzevick JJ, Zada G. The role of frailty in the clinical management of neurofibromatosis type 1: a mixed-effects modeling study using the Nationwide Readmissions Database. Neurosurg Focus 2022; 52:E3. [DOI: 10.3171/2022.2.focus21782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/23/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Frailty embodies a state of increased medical vulnerability that is most often secondary to age-associated decline. Recent literature has highlighted the role of frailty and its association with significantly higher rates of morbidity and mortality in patients with CNS neoplasms. There is a paucity of research regarding the effects of frailty as it relates to neurocutaneous disorders, namely, neurofibromatosis type 1 (NF1). In this study, the authors evaluated the role of frailty in patients with NF1 and compared its predictive usefulness against the Elixhauser Comorbidity Index (ECI).
METHODS
Publicly available 2016–2017 data from the Nationwide Readmissions Database was used to identify patients with a diagnosis of NF1 who underwent neurosurgical resection of an intracranial tumor. Patient frailty was queried using the Johns Hopkins Adjusted Clinical Groups frailty-defining indicator. ECI scores were collected in patients for quantitative measurement of comorbidities. Propensity score matching was performed for age, sex, ECI, insurance type, and median income by zip code, which yielded 60 frail and 60 nonfrail patients. Receiver operating characteristic (ROC) curves were created for complications, including mortality, nonroutine discharge, financial costs, length of stay (LOS), and readmissions while using comorbidity indices as predictor values. The area under the curve (AUC) of each ROC served as a proxy for model performance.
RESULTS
After propensity matching of the groups, frail patients had an increased mean ± SD hospital cost ($85,441.67 ± $59,201.09) compared with nonfrail patients ($49,321.77 ± $50,705.80) (p = 0.010). Similar trends were also found in LOS between frail (23.1 ± 14.2 days) and nonfrail (10.7 ± 10.5 days) patients (p = 0.0020). For each complication of interest, ROC curves revealed that frailty scores, ECI scores, and a combination of frailty+ECI were similarly accurate predictors of variables (p > 0.05). Frailty+ECI (AUC 0.929) outperformed using only ECI for the variable of increased LOS (AUC 0.833) (p = 0.013). When considering 1-year readmission, frailty (AUC 0.642) was outperformed by both models using ECI (AUC 0.725, p = 0.039) and frailty+ECI (AUC 0.734, p = 0.038).
CONCLUSIONS
These findings suggest that frailty and ECI are useful in predicting key complications, including mortality, nonroutine discharge, readmission, LOS, and higher costs in NF1 patients undergoing intracranial tumor resection. Consideration of a patient’s frailty status is pertinent to guide appropriate inpatient management as well as resource allocation and discharge planning.
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Affiliation(s)
- Shane Shahrestani
- Department of Neurosurgery, University of Southern California, Los Angeles, California
- Department of Medical Engineering, California Institute of Technology, Pasadena, California
| | - Nolan J. Brown
- Department of Neurosurgery, UCI Medical Center, Irvine, California
| | - Ben A. Strickland
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Joshua Bakhsheshian
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | | | - Tasha Nasrollahi
- Cedars-Sinai Sinus Center of Excellence, Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Michela Borrelli
- Cedars-Sinai Sinus Center of Excellence, Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Julian Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland
| | - Jacob J. Ruzevick
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, California
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12
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Castle-Kirszbaum M, Wang YY, King J, Goldschlager T. Frailty does not preclude surgical success after endoscopic transsphenoidal surgery for pituitary adenomas. Pituitary 2021; 24:922-929. [PMID: 34173128 DOI: 10.1007/s11102-021-01166-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Frailty is a state of physiological vulnerability that negatively influences surgical outcomes. The effect of frailty on pituitary adenoma surgery, however, is not clear, and patients may be wrongly denied surgery because they are "too frail". We examined the effects of frailty on surgical outcome and quality-of-life (QoL) in patients undergoing endoscopic transsphenoidal resection of pituitary adenomas. METHODS A prospective, consecutive cohort of surgically managed pituitary adenoma was analysed. Frailty was defined by the 5-factor modified Frailty Index (mFI-5) and the Charlson Comorbidity Index (CCI). QoL was measured by the anterior skull base questionnaire (ASBQ) and sinonasal outcomes test (SNOT). RESULTS Of 304 patients with pituitary adenomas, 42 (13.8%) were frail (mFI5 of > 1). Frail patients tended to have smaller adenomas (p < 0.0001) with less suprasellar extension (p < 0.0001). Both overall (ASBQ) and sinonasal-specific (SNOT) QoL were not affected by frailty on multivariate analysis. Endocrine and visual outcomes were similarly not worsened by frailty. Overall, medical complications were uncommon, and perioperative morbidity or mortality was not significantly greater in the frail group. CONCLUSION Frail patients experience the same QoL benefits from surgery as their non-frail counterparts, and have equivalently successful visual and endocrine outcomes. Frailty should not be seen as a barrier to successful surgical management of pituitary adenomas.
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Affiliation(s)
- Mendel Castle-Kirszbaum
- Department of Neurosurgery, Monash Health, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia.
| | - Yi Yuen Wang
- Department of Neurosurgery, St Vincent's Health, Melbourne, Australia
| | - James King
- Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia
- Department of Surgery, Monash University, Melbourne, Australia
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13
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Shahrestani S, Cardinal T, Micko A, Strickland BA, Pangal DJ, Kugener G, Weiss MH, Carmichael J, Zada G. Neural network modeling for prediction of recurrence, progression, and hormonal non-remission in patients following resection of functional pituitary adenomas. Pituitary 2021; 24:523-529. [PMID: 33528731 DOI: 10.1007/s11102-021-01128-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Functional pituitary adenomas (FPAs) cause severe neuro-endocrinopathies including Cushing's disease (CD) and acromegaly. While many are effectively cured following FPA resection, some encounter disease recurrence/progression or hormonal non-remission requiring adjuvant treatment. Identification of risk factors for suboptimal postoperative outcomes may guide initiation of adjuvant multimodal therapies. METHODS Patients undergoing endonasal transsphenoidal resection for CD, acromegaly, and mammosomatotroph adenomas between 1992 and 2019 were identified. Good outcomes were defined as hormonal remission without imaging/biochemical evidence of disease recurrence/progression, while suboptimal outcomes were defined as hormonal non-remission or MRI evidence of recurrence/progression despite adjuvant treatment. Multivariate regression modeling and multilayered neural networks (NN) were implemented. The training sets randomly sampled 60% of all FPA patients, and validation/testing sets were 20% samples each. RESULTS 348 patients with mean age of 41.7 years were identified. Eighty-one patients (23.3%) reported suboptimal outcomes. Variables predictive of suboptimal outcomes included: Requirement for additional surgery in patients who previously had surgery and continue to have functionally active tumor (p = 0.0069; OR = 1.51, 95%CI 1.12-2.04), Preoperative visual deficit not improved after surgery (p = 0.0033; OR = 1.12, 95%CI 1.04-1.20), Transient diabetes insipidus (p = 0.013; OR = 1.27, 95%CI 1.05-1.52), Higher MIB-1/Ki-67 labeling index (p = 0.038; OR = 1.08, 95%CI 1.01-1.15), and preoperative low cortisol axis (p = 0.040; OR = 2.72, 95%CI 1.06-7.01). The NN had overall accuracy of 87.1%, sensitivity of 89.5%, specificity of 76.9%, positive predictive value of 94.4%, and negative predictive value of 62.5%. NNs for all FPAs were more robust than for CD or acromegaly/mammosomatotroph alone. CONCLUSION We demonstrate capability of predicting suboptimal postoperative outcomes with high accuracy. NNs may aid in stratifying patients for risk of suboptimal outcomes, thereby guiding implementation of adjuvant treatment in high-risk patients.
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Affiliation(s)
- Shane Shahrestani
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA.
| | - Tyler Cardinal
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alexander Micko
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Dhiraj J Pangal
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Guillaume Kugener
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Martin H Weiss
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - John Carmichael
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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14
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Khalafallah AM, Shah PP, Huq S, Jimenez AE, Patel PP, London NR, Hamrahian AH, Salvatori R, Gallia GL, Rowan NR, Mukherjee D. The 5-factor modified frailty index predicts health burden following surgery for pituitary adenomas. Pituitary 2020; 23:630-640. [PMID: 32725418 DOI: 10.1007/s11102-020-01069-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Frailty is known to influence cost-related surgical outcomes in neurosurgery, but quantifying frailty is often challenging. Therefore, we investigated the predictive value of the 5-factor modified frailty index (mFI-5) on total hospital charges, LOS, and 90-day readmission for patients undergoing pituitary surgery. METHODS The medical records of all patients undergoing endoscopic endonasal resection of pituitary adenomas at an academic medical center between January 2017 and December 2018 were retrospectively reviewed. Bivariate statistical analyses were conducted using Fisher's exact test, chi-square test, and independent samples t-test. Linear and logistic regression models were used for multivariate analysis. RESULTS Our cohort (n = 234) had a mean age of 53.8 years (standard deviation 14.6 years). Sex distributions were equal, and most patients were Caucasian (59%). On multivariate linear regression, with each one-point increase in mFI-5, total LOS increased by 0.64 days in the overall cohort (p < 0.001), 1.08 days in the Cushing disease cohort (p = 0.045), and 0.59 days in non-functioning tumors cohort (p = 0.004). Total charges increased by $3954 in the whole cohort (p < 0.001), $10,652 in the Cushing disease cohort (p = 0.033), and $2902 in the non-functioning tumors cohort (p = 0.007) with each one-point increase in mFI-5. Greater mFI-5 scores were associated with greater odds of 90-day readmission in both overall and Cushing disease cohorts, but these associations did not reach statistical significance. CONCLUSION A patient's mFI-5 score is significantly associated with increased length of stay and hospital charges for patients undergoing pituitary surgery. The mFI-5 may hold peri-operative value in patient counseling for pituitary adenoma surgery.
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Affiliation(s)
- Adham M Khalafallah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Pavan P Shah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Sakibul Huq
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Adrian E Jimenez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Palak P Patel
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Nyall R London
- Department of Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
- Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Amir H Hamrahian
- Division of Endocrinology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
- Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Roberto Salvatori
- Division of Endocrinology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
- Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
- Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Nicholas R Rowan
- Department of Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
- Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA.
- Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA.
- Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD, 21287, USA.
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