Frailty Index (mFI-5) Predicts Resource Utilization after Nonruptured Endovascular Aneurysm Repair.

INTRODUCTION: The 5- factor frailty index (mFI-5) has reliably predicted outcomes after vascular surgeries. The purpose of this study was to determine the performance of this index in aortic endovascular surgery ( endovascular aneurysm repair [EVAR]) MATERIALS AND METHODS: The American College of Surgeons' National Surgical Quality Improvement Program Database (NSQIP) was retrospectively analyzed for patients undergoing nonruptured EVAR between 2015 and 2019. Outcomes were assessed using bivariate analysis (Mann Whitney U test, chi-squared test, and t-test) and multivariate logistic regression analysis. RESULTS: 10,450 patients were identified with a mean age of 73.59 (SD 8.93) y. 8222 (78.7%) were performed for large diameter with the remaining indications including dissection, symptomatic, and embolization/thrombosis. 30-d mortality was 1.3%. Univariate analysis showed that mFI-5≥0.6 was associated with higher rates of prolonged hospital stay (18.8% versus 5.7%, P < 0.001, reference mFI-5 = 0), readmission (12.3% versus 5.9%, P < 0.001), mortality (3.6 % versus 1.2%, P = 0.01), intensive care unit (ICU) length of stay more than 3 d (7.2% versus 2.7%, P < 0.001). Female gender higher age, indication for surgery, and mFI-5 were all associated with increased mortality. Multivariate logistic regression showed that mFI-5 remained as a significant predictor with mFI-5≥0.6 predicting a close to 3 times higher odds for 30-d mortality (odds ratio OR 2.83, P = 0.003), ICU length of stay >3 d (OR 2.48, P < 0.001), >7 d hospital stay (OR 3.94, P < 0.001), readmission (OR 2.16, P < 0.001), and pneumonia (OR 4.2, P < 0.001) CONCLUSIONS: The modified frailty index (mFI-5) is a good predictor for postoperative complications and hospital resource utilization after nonruptured EVAR.

Performance of the Emergency Surgery Score in Nonelective Lower-Extremity Endovascular Procedures.

INTRODUCTION: Multiple studies have validated the Emergency Surgery Score (ESS) as a tool which reliably predicts outcomes after emergency general surgery. The purpose of this study was to assess the performance of the ESS for lower-extremity endovascular procedures in nonelective setting (neLEE). METHODS: The American College of Surgeons' National Surgical Quality Improvement Program database was retrospectively analyzed for patients undergoing neLEE between 2015 and 2019. The performance of the ESS in predicting mortality in each procedure was assessed using receiver operating characteristic analyses. RESULTS: Four thousand five hundred and eighty three patients underwent neLEE with median age 68 (±12.3 SD), with 1802 females (39.3%). The ESS correlated with 30-day mortality (area under the curve [AUC] was 0.729), discharge to rehab (AUC 0.638), renal failure (AUC 0.667), postintervention ventilation requirement (AUC 0.680), and stroke (AUC 0.656). The predictive ability of the ESS decreased with increasing age, with the ESS performing best for patients between 60 and 69 y in age (AUC 0.735) and worst for patients above 80 y (AUC 0.650). A Cochran-Armitage test showed linear trend towards increased 30-day mortality among the quartiles with increasing ESS (P < 0.001), with patients with ESS ≥10 having 10 times odds of increased 30-day mortality compared to reference quartile of patients with ESS ≤4 on multivariate analysis. CONCLUSIONS: The ESS score is associated with 30-day mortality and other complications after neLEE procedures. It can potentially be used as a predictive tool for preoperative risk stratification and can also be used for equitably evaluating standards and outcomes after lower extremity endovascular procedures.

Matrix regeneration proteins in the hypoxia-triggered exosomes of shoulder tenocytes and adipose-derived mesenchymal stem cells.

Regenerative functions of exosomes rely on their contents which are influenced by pathological stimuli, including hypoxia, in rotator cuff tendon injuries (RCTI). The hypoxic environment triggers tenocytes and adjacent adipose-derived mesenchymal stem cells (ADMSCs) to release regenerative mediators to the ECM via the exosomes which elicit autocrine/paracrine responses to protect the tendon matrix from injury. We investigated the exosomal protein contents from tenocytes and subcutaneous ADMSCs from the shoulder of Yucatan microswine cultured under hypoxic conditions (2% O2). The exosomal proteins were detected using high-resolution mass spectrometry nano-LC-MS/MS Tribrid system and were compiled using 'Scaffold' software. Hypoxic exosomes from tenocytes and ADMSCs carried 199 and 65 proteins, respectively. The key proteins identified by mass spectrometry and associated with ECM homeostasis from hypoxic ADMSCs included MMP2, COL6A, CTSD and TN-C and those from hypoxic tenocytes were THSB1, NSEP1, ITIH4 and TN-C. These findings were confirmed at the mRNA and protein level in the hypoxic ADMSCs and tenocytes. These proteins are involved in multiple signaling pathways of ECM repair/regeneration. This warrants further investigations for their translational significance in the management of RCTI.

Modified frailty index as an indicator for outcomes after lower extremity endovascular revascularization.

BACKGROUND: The 5-factor frailty index is associated with adverse outcomes after various procedures. This study aimed to evaluate the performance of the 5-factor frailty index after lower extremity endovascular revascularization. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program Database as retrospectively analyzed for patients undergoing lower extremity endovascular revascularization between 2015 and 2019. Outcomes were assessed using bivariate analyses and multivariate logistic regression analyses. RESULTS: In the study, 11,947 lower extremity endovascular revascularization performed between 2015 and 2019 were identified from National Surgical Quality Improvement Program Database. Median age was 69 (standard deviation 11.44) years, 4,727 (39.6%) were female, and 7,570 (63.4%) were White. In addition, 7,541 (62.9%) were performed for chronic limb threatening ischemia. Thirty-day mortality was 1.7%. Bivariate analysis demonstrated that a 5-factor frailty index score greater than 0.6 was associated with higher rates of discharge to SNF (28.6% vs 8.2%, P < .001, reference 5-factor frailty index = 0), cardiopulmonary arrest (2.0% vs 0.1%, P < .001), readmission (21.1% vs 10.8%, P < .001), reintubation (2.8% vs 0.3%, P < .001), and 30-day mortality (5.1% vs 0.7%, P < .001). Beta blocker use, higher age, chronic limb threatening ischemia indication, and 5-factor frailty index were all associated with increased 30-day mortality. Multivariate logistic regression showed that 5-factor frailty index >0.6 predicted 3 times higher odds for 30-day mortality (odds ratio, 2.988; P = .013), with physiologic high risk (odds ratio, 2.118; P < .001), chronic limb threatening ischemia indication (odds ratio, 2.157; P < .001), and inpatient procedures (odds ratio, 3.409; P < .001) also showing increased risk for mortality. CONCLUSION: For patients undergoing lower extremity endovascular revascularization, higher 5-factor frailty index was associated with increased hospital resource utilization and 30-day mortality. The 5-factor frailty index may be useful for preoperative risk stratification and predicting adverse outcomes in patients undergoing lower extremity endovascular revascularization.

Performance of the Emergency Surgery Score (ESS) for nonelective infrainguinal open revascularization procedures (NEIOR).

BACKGROUND: The Emergency Surgery Score has been previously validated as a reliable; tool to predict postoperative outcomes in emergency general surgery. The purpose of this study was to assess the performance of the Emergency Surgery Score for infrainguinal open revascularization procedures in the nonelective setting. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program database was retrospectively analyzed for patients undergoing infrainguinal open revascularization procedures in the nonelective setting between 2015 and 2019. The performance of the Emergency Surgery Score in predicting mortality in each procedure was assessed using receiver operating characteristic analyses. RESULTS: A total of 5,027 patients underwent infrainguinal open revascularization procedures in the nonelective setting with median age 68 (±11.66 standard deviation), with 1,666 females (33.1%). The 30-day mortality rate was 2.7%. The Emergency Surgery Score correlated with 30-day mortality (area under the curve was 0.738). The Emergency Surgery Score also predicted risk of death/discharge to hospice (area under the curve 0.756), discharge to rehab (area under the curve 0.643), renal failure (area under the curve 0.741), postintervention ventilation requirement (0.684), stroke (0.717), cardiopulmonary arrest (0.657), and septic shock (0.697). A cumulative frequency table of mortality with Emergency Surgery Score was used to partition patients into quartiles of Emergency Surgery Score ≤5, Emergency Surgery Score of 6, Emergency Surgery Score of 7 or 8, and Emergency Surgery Score ≥9. A Cochran-Armitage test showed linear trend toward increased 30-day mortality among the quartiles with increasing Emergency Surgery Score (P < .001), with quartile 4 (Emergency Surgery Score ≥10) having 13 times odds of increased 30-day mortality compared to reference quartile 1 (Emergency Surgery Score ≤4). CONCLUSION: Emergency Surgery Score performance accurately predicts mortality for infrainguinal open revascularization procedures in the nonelective setting procedures. It may be useful for preoperative risk stratification and for national benchmarking after nonelective open lower extremity procedures.

Hybrid interpenetrating hydrogel network favoring the bidirectional migration of tenocytes for rotator cuff tendon regeneration.

Replenishment of tenocytes to the injury site is an ideal strategy to improve healing response and accelerate the tendon ECM regeneration. The present study focused on the synthesis and characterization of a hybrid hydrogel scaffold system poly(propylene-fumarate)-alginate-polyvinyl alcohol-acrylic acid (PAPA) using poly(propylene-fumarate) (PPF), alginate, polyvinyl alcohol (PVA) and acrylic acid and the in vitro investigation of bidirectional mobility of swine shoulder tenocytes (SST) for its potential application in rotator-cuff tendon regeneration. IR analysis revealed the presence of alginate, PPF and PVA segments on the surface, SEM and AFM analyses revealed the porous and nano-topographical features of PAPA, respectively, swelling was 712.6 ± 84.21% with the EWC (%) of 87.59 ± 1.26 having the diffusional exponent and swelling constant 0.551 and 1.8, respectively. PAPA was biodegradable, cytocompatible and supported long-term survival of SSTs. SEM imaging revealed the adhesion, colonization, and sheet formation of SSTs within the PAPA hydrogel network. The SSTs seeded on the PAPA scaffolds were peculiar for their bidirectional migration as the anterograde movement was completed in 9 days whereas the retrograde infiltration occurred up to the depth of 198 µm. These findings suggest the promising translational potential of PAPA scaffold system in the management of rotator cuff tendon injury.

Amplification of Mitochondrial Activity in the Healing Response Following Rotator Cuff Tendon Injury.

Mitochondrial function following rotator cuff tendon injury (RCI) influences the tendon healing. We examined the mitochondrial morphology and function under hypoxia in the shoulder tendon tissue from surgically-induced tenotomy-RCI rat model and cultured swine tenocytes. The tendon tissue was collected post-injury on 3-5 (Group-A), 10-12 (Group-B), and 22-24 (Group-C), days and the corresponding contralateral tendons were used as control for each group. There was higher protein expression of citrate synthase (P < 0.0001) [10.22 MFI (mean fluorescent intensity)] and complex-1 (P = 0.0008) (7.86 MFI) in Group-A and Group-B that decreased in Group-C [(P = 0.0201) (5.78 MFI and (P = 0.7915) (2.32 MFI), respectively] compared to control tendons. The ratio of BAX:Bcl2 (Bcl2 associated x protein:B cell lymphoma 2) in RCI tendons increased by 50.5% (Group-A) and 68.4% (Group-B) and decreased by 25.8% (Group-C) compared to normoxic controls. Hypoxia increased ß-tubulin expression (P = 0067) and reduced PGC1-α (P = 0412) expression in the isolated swine tenocytes with no effect on the protein expression of Complex-1 (P = 7409) and citrate synthase (P = 0.3290). Also, the hypoxic tenocytes exhibited about 4-fold increase in mitochondrial superoxide (P < 0.0001), altered morphology and mitochondrial pore integrity, and increase in mitochondrial density compared to normoxic controls. These findings suggest the critical role of mitochondria in the RCI healing response.