Increased Frailty Associated with Higher Long-Term Mortality after Major Lower Extremity Amputation.

BACKGROUND: Frailty assessments have been incorporated into preoperative planning for surgery in the elderly population. Frailty in patients undergoing lower extremity amputation has been associated with increased short-term mortality. We compared 2 frailty scores, modified Frailty Index (mFI) and Risk Analysis Index (RAI), to evaluate the short- and long-term mortality stratified by frailty status after lower extremity amputation. METHODS: A retrospective review at a single Veterans Affairs Medical Center was performed for all patients with peripheral vascular disease that underwent an above or below the knee amputation from 2014 to 2019. Preoperative variables were obtained to calculate the mFI and RAI frailty scores. The frailty scoring systems were used to separate the patients into 3 cohorts: non-frail (mFI <0.45, RAI <20), frail (mFI 0.45-0.55; RAI 20-32), and very frail (mFI >0.55, RAI >32). The frailty groups with each scoring system were compared for 30-day outcomes (readmission, reoperation, adverse events, length of stay) and short- and long-term mortality. RESULTS: A total of 298 patients underwent lower extremity amputation. The number of non-frail patients was 98 (RAI) and 102 (mFI); frail patients 99 (RAI), and 123 (mFI); very frail patients 101 (RAI) and 73 (mFI). For the 30-day outcomes, only length of stay (mFI) was associated with increasing frailty. The short- and long-term mortality was associated with a worse survival with increasing frailty. At 1-year, the mortality by RAI was non-frail 8%; frail 24%, very frail 43% (P < 0.001); the mortality by mFI was non-frail 16%, frail 24%, very frail 41% (P < 0.001). CONCLUSIONS: Preoperative frailty scoring systems identify patients with worse short- and long-term mortality for lower extremity amputation. Frailty scoring should be considered as a screening tool for patients with peripheral vascular disease undergoing lower extremity amputation because of the high rate of frail and very frail patients. The frailty status may provide a more patient-centered approach to counsel patients and their families on the risks and benefits of amputation.

Predictive Accuracy of the American College of Surgeons Risk Calculator in Patients Undergoing Major Lower Extremity Amputation.

BACKGROUND: The American College of Surgeons Risk Calculator (ACS-RC) provides an assessment of a patient's risk of 30-day postoperative complications. The Surgeon Adjusted Risk (SAR) parameter of the calculator allows for ad hoc adjustment of risk based on risk factors not considered by the model. This study aims to evaluate the predictive accuracy of the ACS-RC in vascular surgery patients undergoing major lower-extremity amputation (LEA) and identify additional risk factors that warrant use of the SAR parameter. METHODS: This is a retrospective study of 298 sequential amputations at a single institution. At the population level, the mean of predicted 30-day outcomes from the ACS-RC with a SAR score of 1 (no adjustment necessary) and 2 (risk somewhat higher than estimate) were compared to the rate of observed outcomes. Predictive accuracy at the individual level was completed using receiver operating curve area under the curve (AUC). Logistic regression with respect to mortality was performed over variables not considered by the ACS-RC. Efficacy of selectively utilizing the SAR parameter in predicting mortality was analyzed with a stratified analysis in which patients with risk factors significant for mortality were assigned increased risk. RESULTS: At the population level, ACS-RC grossly underpredicted serious complications, SSI, VTE, and unplanned RTOR, while overpredicting mortality and cardiac complications. At the individual level, SAR1 was more predictive for serious complications (AUC = 0.624), SSI (AUC = 0.610), and unplanned RTOR (AUC = 0.541). Conversely, SAR2 was more predictive for mortality (AUC = 0.709), cardiac complications (AUC = 0.561), and VTE (AUC = 0.539). Logistic regression identified history of CVA with a residual deficit (OR = 4.61, P = 0.033) and ischemic rest pain without tissue loss (OR = 4.497, P = 0.047) as independent risk factors for postoperative mortality. Stratified analysis with utilization of the SAR2 based on the 2 independent risk factors improved AUC in predicting mortality (AUC 0.792 from 0.709). CONCLUSIONS: Major LEAs are associated with high perioperative morbidity and mortality. In a veteran population, the ACS-RC showed mixed predictability at the population level and fair predictability at the individual level with regards to postoperative outcomes. Rest pain without tissue loss and history of CVA with residual deficit were identified as risk factors for postoperative mortality. Although ad hoc adjustment with the subjective SAR modifier based on the presence of these 2 risk factors increased the calculator's accuracy, this study highlights some potential limitations of the ACS-RC when applied to vascular surgery patients undergoing major LEA.

Telemedicine at the VA: Examining smartphone connectivity rates to VA video connect and doximity dialer video.

Background: Telemedicine usage has accelerated as a result of the COVID-19 pandemic, raising concerns those without the necessary technology and digital literacy to participate may face increasing health disparities. In this study, we examined the rates at which veterans are able to connect to two common telemedicine applications: VA Video Connect (VVC) and Doximity Dialer Video (DV). Methods: Participants were selected from a pool of vascular surgery patients seen from August 2020 to October 2021 at a single Veterans Affairs medical center. Participants had to be >50 years old and not previously participated in a video visit. Eligible veterans were asked their interest participating in video visits and if they owned a smartphone. Those who met the eligibility requirements were tested on their ability to connect to both VVC and DV with minimal assistance. The connectivity rate for both platforms was recorded, and basic demographic and medical history information was collected. Results: One-hundred-four veterans participated in the study, with an average age of 70 ± 7 years. Seventy-four participants (71%) expressed interest in video visits, and 52 (70%) owned a smartphone. Forty-five smartphone owners (87%) successfully connected to DV, whereas 19 (37%) successfully connected to VVC (p < 0.001). VVC connectivity decreased with increasing age-group: 50-59 = 80%, 60-69 = 44%, ≥70 = 18% (p = 0.02). Conclusions: Older veterans demonstrate difficulty connecting to VVC. The VHA is taking important steps to streamline usability of VVC, however continued expansion of support programs is necessary to improve access and reduce healthcare disparities in this population.

Surgical risk calculators in veterans following lower extremity amputation.

OBJECTIVE: To evaluate the accuracy of multiple risk calculators for 30-day mortality on patients undergoing major lower extremity amputation. METHODS: The actual 30-day mortality at a single Veterans Affairs institution was compared to the predicted outcome from the following risk calculators: ACS-NSQIP, VASQIP, amputation scoring tool (AST), and POTTER elective. RESULTS: The overall calculated 30-day mortality was similar to the actual mortality with the VASQIP and POTTER elective risk calculators, while the NSQIP and AST over-estimated the 30-day mortality. The predictive accuracy of the POTTER and NSQIP risk calculators were moderate (AUC >0.7), and fair for the VASQIP and AST. CONCLUSION: Risk assessment tools can provide adjunctive data on predicted 30-day mortality in patients undergoing major lower extremity amputation. In our study, there were differences in predictability of the risk calculators for lower extremity amputation that should be considered when utilizing a risk assessment tool to improve physician-patient shared decision-making.

Simulation in Perioperative Liver Transplant Anesthesia: A Systematic Review.

Due to the complexity of liver transplant patients and the variability in exposure to transplantation by anesthesia trainees, simulation is often required as an adjunct to clinical experience. This systematic review identifies current simulation models in the literature that pertain to perioperative liver transplant anesthesia. Data were collected by performing an electronic search of the PubMed and Scopus databases for articles describing simulation in transplant anesthesia. Abstracts were screened using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Three reviewers analyzed 16 abstracts found in the search and agreed upon articles that met the inclusion criteria for the systematic review. A total of five publications met the inclusion criteria; they could be grouped as cognitive skills and technical skills simulators. Cognitive skills simulators utilized high-fidelity mannequins and animal models combined with traditional educational material to enhance pattern recognition of critical complications during liver transplantation. One manuscript focused on a technical skills acquisition by utilizing transesophageal echocardiography (TEE) to identify intraoperative pathologies. There is a heterogeneity in the exposure to liver transplant care during anesthesia training. Simulation provides low-stakes exposure to the high-stakes skills required in the operating room. Hence, it can be used as an adjunct to improve both cognitive and technical skill acquisition for perioperative transplant anesthesia. The goal of these simulation programs is to improve patient outcomes and produce more capable anesthesiologists.

What Is the Utility of Restaging Imaging for Patients With Clinical Stage II/III Rectal Cancer After Completion of Neoadjuvant Chemoradiation and Prior to Proctectomy?

BACKGROUND: In the United States, patients with clinical stage II or III rectal cancer typically receive neoadjuvant chemoradiation therapy (chemo/XRT) over a 5-6 week period followed by a 6-10 week break prior to proctectomy. In the current study, we evaluate the utilization of restaging studies performed and detection of disease progression during this window. METHODS: A retrospective review of patients with clinical stage II/III rectal cancer was performed. Medical records were analyzed to collect clinicopathologic data and the performance and results of preoperative, early postoperative, and first surveillance CT and/or PET/CT in patients completing long course neoadjuvant chemo/XRT and undergoing proctectomy. RESULTS: Between 2005 and 2017, 176 patients with clinical stage II or III rectal adenocarcinoma completed neoadjuvant chemo/XRT and underwent proctectomy. Preoperative restaging with CT CAP and/or CT/PET was performed in 72 (40.9%) patients with no detection of disease progression. Of the 104 patients without preoperative restaging, 1 had intraoperative detection of liver metastases and 31 had early postoperative reimaging (within 30 days of proctectomy) of which 2 had detection of new pulmonary metastases. Among 72 patients with no preoperative or early postoperative reimaging, first surveillance imaging was available in 47 and detected new metastases in 8 (17%). DISCUSSION: In patients with clinical stage II/III rectal cancer who undergo long course neoadjuvant chemo/XRT, perioperative reimaging with CT CAP and/or PET/CT detects new metastases in a small percentage of patients. A multi-institutional, prospective analysis using standardized staging protocols is warranted to better determine the value of preoperative restaging in these patients.