Evaluation of Agreement Among Frailty Assessment Tools in Head and Neck Surgery.

OBJECTIVE: To evaluate intertest agreement among hand grip strength (HGS), the modified Frailty Index (mFI), and the Edmonton Frail Scale (EFS) in patients presenting for presurgical assessment in a head and neck surgery clinic. STUDY DESIGN: Prospective observational study. SETTING: Academic tertiary medical center. METHODS: Prospective data relating to 3 frailty measurements were collected for 96 consecutive adults presenting for presurgical counseling at a single high-volume head and neck surgical oncology clinic. Frailty was determined with previously validated thresholds for the mFI (≥3) and EFS (>7). The highest of 2 HGS measurements performed for the dominant hand was used to determine frail status based on previously validated sex- and body mass index-specific thresholds. Baseline characteristics were identified to determine the association of such variables to each tool. Agreement among frailty assessment tools was examined. RESULTS: The frequency of frailty in the cohort varied among tools, ranging from 29.2% (28/96) for HGS to 12.5% (12/96) for the mFI and 4.2% (4/96) for the EFS. The overall agreement among the 3 frailty tools via the Fleiss index was poor (kappa, 0.088; 95% CI, -0.028 to 0.203). CONCLUSION: Assessment of frailty is complex, and established frailty assessment tools may not agree on which patients are frail. When assessing a patient as frail, clinicians must be vigilant to the influence of frailty assessment tools on such determinations, which may contribute critical input during shared decision making for patients considering head and neck surgery or nonsurgical alternatives.

Long-term survival outcomes associated with robotic-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer.

BACKGROUND: Minimally Invasive esophagectomy for esophageal cancer is associated with less morbidity compared to open approach. Whether robotic-assisted minimally invasive esophagectomy (RAMIE) results in better long-term survival compared with open esophagectomy (OE) and minimally invasive esophagectomy (MIE) is unclear. METHODS: We analyzed data from the National Cancer Database (NCDB) for patients with primary esophageal cancers who underwent esophagectomy in 2010-2017. Those with unknown staging, distant metastasis, or diagnosed with another cancer were excluded. Patients were stratified by RAMIE, MIE, and OE operative techniques. The Kaplan-Meier method and associated log-rank test were employed to compare unadjusted survival outcomes by surgical technique, our primary outcome. Multivariable Cox proportional hazards regression model was employed to discern factors independently contributing to survival. RESULTS: A total of 5170 patients who underwent esophagectomy were included in the analysis; 428 underwent RAMIE, 1417 underwent MIE, and 3325 underwent OE. Overall median survival was 42 months. In comparison to RAMIE, there was an increased risk of death for those that underwent either MIE [Hazard Ratio (HR) = 1.19; 95% Confidence Interval (CI): > 1.00 to 1.41; P < 0.047)] or OE (HR = 1.22; 95% CI: 1.04 to 1.43; P < 0.017). Academic vs community program facility type was associated with decreased risk of death (HR = 0.84; 95% CI: 0.76 to 0.93; P < 0.001). In general, males from areas of lower income with advanced stages of cancer who received neoadjuvant chemotherapy or radiation were at increased risk of death. Factors that were not associated with survival included race and ethnicity, Charlson-Devo Score, type of health insurance, zipcode level education, and population density. CONCLUSIONS: Overall survival was significantly longer in patients with esophageal cancers that underwent RAMIE in comparison to either MIE or OE in a 7-year NCDB cohort study.

Comparative antiplatelet effects of chlorthalidone and hydrochlorothiazide.

Chlorthalidone (CTD) may be superior to hydrochlorothiazide (HCTZ) in the reduction of adverse cardiovascular events in hypertensive patients. The mechanism of the potential benefit of CTD could be related to antiplatelet effects. The objective of this study was to determine if CTD or HCTZ have antiplatelet effects. This study was a prospective, double-blind, randomized, three-way crossover comparison evaluating the antiplatelet effects of CTD, HCTZ, and aspirin (ASA) in healthy volunteers. The effects of these treatments on platelet activation and aggregation were assessed using a well-established method with five standard platelet agonists. Thirty-four patients completed the three-way crossover comparing pre- and post-treatment changes in platelet activation and aggregation studies. There were statistically significant antiplatelet effects with ASA but not with CTD or HCTZ. Hypokalemia occurred in 0 (0%), 10 (30%), and 6 (18%) of the ASA, CTD, and HCTZ patients, respectively. The results of our study suggest that the benefits of CTD and HCTZ in reducing adverse cardiovascular events in patients with hypertension is not a result of an antiplatelet effect. In our study, hypokalemia with CTD was more prevalent than that reported in a large outcome trial in patients with hypertension. The clinical relevance of this finding is uncertain.

Primary Site and Other Prognostic Factors for Fibrosarcoma: An Analysis of the National Cancer Database.

PURPOSE: Fibrosarcoma (FS) is a rare and malignant tumor that can occur in a variety of anatomic sites. The goal of this study is to use the National Cancer Database (NCDB) to analyze various factors affecting overall survival in FS and to be one of the rare studies to characterize the significance of the primary anatomic sites. METHODS: The study cohort included 2,278 patients diagnosed with fibrosarcoma who received surgery from the NCDB. Kaplan-Meier curves, log-rank tests, and a multivariable Cox proportional hazard model were used to analyze the significance of factors affecting overall survival. RESULTS: The head, face, and neck (HR = 1.44; 95% CI: 1.01-2.05; P = 0.046) and thorax anatomical sites (HR = 1.33; 95% CI: 1.02-1.73; P = 0.035) had a higher increased risk of death in comparison to the lower limb and hip. Compared to patients with private insurance, patients without insurance (HR = 1.99; 95% CI: 1.22 to 3.25; P = 0.006) and patients with Medicaid (HR = 1.99; 95% CI: 1.37 to 2.90; P < 0.001) had decreased overall survival. Patients associated with a zip code-level median household income ≥ $63,000 had a decreased risk of mortality when compared to lower income groups. CONCLUSION: In general, older patients with comorbidities, advanced-stage disease, and larger tumors who did not have private insurance and were from areas associated with lower income levels had poorer overall survival. No significant difference in overall survival was associated with receipt of neoadjuvant chemotherapy or neoadjuvant radiation.

Bamlanivimab use in mild-to-moderate COVID-19 disease: A matched cohort design.

STUDY OBJECTIVE: Our objective was to determine if bamlanivimab (LY-CoV555; BAM), a monoclonal antibody for mild-to-moderate Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-Co-V-2, prevented emergency department (ED) visits, hospitalizations for SARS-CoV-2, or death within 60 days of a positive SARS-CoV-2 viral test. DESIGN: Patient propensity matching was performed for BAM administration to get two discrete groups of patients; those who received BAM (N = 117) and those who did not (N = 117). SETTING: Outpatients (N = 2107) eligible to receive BAM from November 1 to December 31, 2020, were identified. PATIENTS: A total of 144 of 2107 patients with mild-to-moderate SARS-CoV-2 received BAM INTERVENTION: Eligible patients had mild-to-moderate SARS-CoV-2 disease, a positive SARS-CoV-2 test, and risk factor(s) for progression to severe SARS-CoV-2 infection. All patients were reviewed for subsequent ED visits, subsequent hospitalization, and death. MEASUREMENTS AND MAIN RESULTS: Patients (N = 234) were matched, 117 in each group. Median (interquartile range) age was 72 (65-80) years. Forty-seven percent of patients were male. Twenty-one patients who received BAM were subsequently seen in the ED compared to 34 untreated patients (18.0% vs. 29.1%; p = 0.045). Fourteen BAM-treated patients were subsequently hospitalized post-BAM infusion compared to 27 untreated patients (12.0% vs. 23.1%; p = 0.025). Finally, there were no mortalities in the BAM group, however, eleven patients in the untreated group died (0.0% vs. 9.4%; p < 0.001). The number needed to treat (NNT) is 11 patients to prevent one mortality event. CONCLUSIONS: BAM infusion for mild-to-moderate SARS-CoV-2 infection in outpatients significantly prevented subsequent ED visits, hospitalizations, and death from SARS-CoV-2.

A systematic review and individual patient data meta-analysis of heart failure as a rare complication of traumatic arteriovenous fistulas.

OBJECTIVE: Traumatic arteriovenous fistulas (AVFs) are rare. The vast majority occur secondary to penetrating injuries. High-output cardiac failure is a well-recognized serious complication of AVFs, associated with high morbidity and mortality. The objective of the present study was to identify predictors of heart failure (HF) in patients with traumatic AVF. METHODS: Both PubMed/MEDLINE (Ovid) and CINAHL were searched (up to June 2019) for studies reporting individual patient data on the clinical and demographic characteristics of patients with AVF secondary to penetrating trauma. Exclusion criteria were age <18 years, no specification of symptoms, a cranial, spinal, or cardiac AVF location, and an iatrogenic mechanism of injury. The present study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. RESULTS: A total of 274 AVF patients from 15 case series and 177 case reports were included. The median age at presentation was 32 years (interquartile range, 24-43 years), 90% were men. The most frequent mechanisms of injury were stab wounds (43%) and gunshot wounds (32%). The AVF location was the abdomen (n = 86; 31%), lower limb (n = 79; 29%), neck (n = 61; 22%), thorax (n = 38; 14%), and upper limb (n = 10; 4%). Of the 274 patients, 35 (13%) had presented with HF and 239 (87%) with other symptoms. The risk of HF increased with an increased feeding artery diameter (P < .001). On univariate analysis, HF was significantly associated with a longer median time from injury to presentation with AVF (11.2 years vs 0.1 years; P < .001), older median age at presentation (43 years vs 31 years; P = .002), involvement of a large feeding artery (ie, aorta, pulmonary artery, subclavian artery, external iliac artery; 40% vs 13%; P < .001), shrapnel injuries (11% vs 2%; P = .011), and injuries to the trunk or lower limb (94% vs 71%; P = .004). After adjusting for clinical and demographic patient characteristics, involvement of a large feeding artery (odds ratio, 3.25; 95% confidence interval, 1.26-8.42; P = .015) and every 6 years of delay to presentation (odds ratio, 1.30; 95% confidence interval, 1.03-1.63; P = .026) remained independent predictors for HF. CONCLUSIONS: HF occurs in a small but important fraction of traumatic AVF patients and develops after highly variable latency periods. Large feeding arteries and delayed presentation independently predicted HF in this cohort.

Evidence for the Efficacy of an Opioid-Sparing Effect of Intravenous Acetaminophen in the Surgery Patient: A Systematic Review.

BACKGROUND: Intravenous (IV) acetaminophen is used in multimodal analgesia to reduce the amount and duration of opioid use in the postoperative setting. METHODS: A systematic review of published randomized controlled trials was conducted to define the opioid-sparing effect of IV acetaminophen in different types of surgeries. Eligible studies included prospective, randomized, double-blind trials of IV acetaminophen compared with either a placebo- or active-treatment group in adult (age ≥18 years) patients undergoing surgery. Trials had to be published in English in a peer-reviewed journal. RESULTS: A total of 44 treatment cohorts included in 37 studies were included in the systematic analysis. Compared with active- or placebo-control treatments, IV acetaminophen produced a statistically significant opioid-sparing effect in 14 of 44 cohorts (32%). An opioid-sparing effect was more common in placebo-controlled comparisons. Of the 28 placebo treatment comparisons, IV acetaminophen produced an opioid-sparing effect in 13 (46%). IV acetaminophen produced an opioid-sparing effect in only 6% (one out of 16) of the active-control groups. Among the 16 active-control groups, opioid consumption was significantly greater with IV acetaminophen than the active comparator in seven cohorts and not significantly different than the active comparator in eight cohorts. CONCLUSIONS: The results of this systematic analysis demonstrate that IV acetaminophen is not effective in reducing opioid consumption compared with other adjuvant analgesic agents in the postoperative patient. In patients where other adjuvant analgesic agents are contraindicated, IV acetaminophen may be an option.

Treatment Facility: An Important Prognostic Factor for Dedifferentiated Liposarcoma Survival.

A National Cancer Database study of on survival outcomes for patients with dedifferentiated liposarcomas found that insurance status, median household income, and treatment facility were associated with differences in median survival and 5- and 10-year survival probabilities.

Inflammatory and other breast cancer incidence rate trends by estrogen receptor status in the Surveillance, Epidemiology, and End Results database (2001-2015).

PURPOSE: Inflammatory breast cancer (IBC) rates increased in the United States before the turn of the twenty-first century. We examine trends by estrogen receptor (ER) status since then. METHODS: Using data from the Surveillance, Epidemiology, and End Results (SEER) program for years 2001-2015, we calculated age-adjusted incidence rates for IBC (defined by AJCC TNM category T4d, extent of disease codes, and morphology code 8530) by ER status, which was imputed if unknown, among women aged 25-84 years. For comparison, we included other locally advanced breast cancer and other breast cancers partitioned into localized and regional/distant/unstaged. We fit joinpoint log-linear models to annual rates to calculate annual percentage change (APC) and average annual percentage change (AAPC). RESULTS: The rate of increase in ER+ IBC rates among women aged 25-44 (AAPC = 0.5) was similar to other advanced tumor types, but declines among women aged 45-84 (AAPC = - 2.2) were more rapid. Declines in ER- IBC rates for women aged 25-84 (AAPC = - 3.7) were more rapid than for other tumor types. CONCLUSIONS: Our results show a reversal of the rising rates of IBC overall reported at the end of the twentieth century. Direction of trends for IBC is consistent with other breast cancer types, except for ER+ localized breast cancer in older women. Decreasing parity and rising prevalence of older age at first birth may contribute to declining rates of ER- IBC. Otherwise, patterns of changing risk factors are inconsistent with the trends we observed. Further studies of IBC are necessary to identify additional risk factors and possible preventive strategies.