Is Preoperative Serum Albumin Predictive of Adverse Surgical Outcomes in Maxillofacial Fracture Repair?

PURPOSE: Malnutrition has been recognized as a predictor of postoperative adverse outcomes across many surgical subspecialties. The purpose of this study was to evaluate the relationship between serum albumin and adverse outcomes in patients undergoing operative repair of maxillofacial fractures. METHODS: The authors utilized the 2011 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases to identify patients with facial fractures undergoing operative repair. The primary predictor variable was preoperative serum albumin level. Outcome variables included complications and other adverse outcomes occurring within 30 days of the index operation. Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between serum albumin and adverse outcomes. RESULTS: During the study period 1211 subjects underwent operative repair of a facial fracture and had a documented serum albumin level. Of these subjects, 1037 (85.6%) had normal albumin levels and 174 (14.4%) had hypoalbuminemia. A total of 90 subjects experienced a complication (7.43%), although albumin level was not associated with surgical complications or any complication. In bivariate analysis, subjects with hypoalbuminemia were significantly more likely to have an extended length of stay (P ≤ .001), adverse discharge disposition (P ≤ .001), and be readmitted (P = .002). In multivariate analysis, hypoalbuminemia was an independent predictor of an extended length of stay (P ≤ .001, 95% CI 2.50 to 7.62), adverse discharge disposition (P = .048, 95% CI 1.01 to 3.75), and readmission (P = .041, 95% CI 1.03 to 3.47). CONCLUSIONS: Serum albumin was not an independent predictor of complications after maxillofacial trauma repair. However, it was an independent predictor of other adverse outcomes including extended length of stay, adverse discharge disposition, and readmission. Targeted nutritional optimization may represent an opportunity to improve outcomes in this demographic.

Does the Modified Frailty Index (mFI-5) Predict Adverse Outcomes in Maxillofacial Fracture Repair?

PURPOSE: Frailty has been recognized as a predictor of postoperative adverse outcomes in many surgical subspecialties. The purpose of this study was to evaluate the relationship between frailty and complications in patients undergoing operative repair of facial fractures. METHODS: The authors utilized the 2011 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases to identify patients with facial fractures undergoing operative repair. The primary predictor variable was frailty as measured by the 5-Factor Modified Frailty Index (mFI-5). The primary outcome variable was the postoperative complication rate. Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between frailty and complications. RESULTS: During the study period, 4,290 subjects underwent operative repair of a facial fracture. Of these subjects, 4,086 (83.0%) were classified as nonfrail, 626 (12.7%) as moderately frail, and 208 (4.20%) as severely frail. A total of 237 subjects experienced a complication (4.82%), and the incidence of complications increased in a stepwise manner with increasing frailty (P ≤ .001). In multivariate regression, age (P = .050, 95% CI = 1.00 to 1.02), Native Hawaiian/Pacific Islander race (P = .018, 95% CI = 1.23 to 8.63), classification as moderately frail (P = .010, 95% CI = 1.15 to 2.66), classification as severely frail (P = .032, 95% CI = 1.06 to 3.70), mandibular fractures (P = .004, 95% CI = 1.24 to 2.98), and wound classification as contaminated (P ≤ .001, 95% CI = 1.53 to 4.57) or dirty/infected (P = .020, 95% CI = 1.16 to 5.55) were independent predictors of complications. Severely frail subjects also had greater length of hospital admission (P ≤ .001) and higher 30-day readmission rates (P ≤ .001). CONCLUSIONS: Frailty is an independent predictor of complications following facial fracture repair and is associated with greater length of hospital admission and 30-day readmission rates.

Females Have Worse Overall and Disease-Specific Survival in Human Papillomavirus-Negative Oropharyngeal Squamous Cell Carcinoma.

PURPOSE: Although sex (male vs female) has been identified as an independent prognostic factor in human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC), the role of sex in HPV-negative OPSCC is less understood. The purpose of this study is to measure the association between sex and HPV-negative OPSCC disease-specific survival (DSS) and overall survival (OS). METHODS: This longitudinal, retrospective study examined cases of HPV-negative OPSCC diagnosed in the United States between 2013 and 2016 from the Surveillance, Epidemiology, and End Results database. Patients with primary OPSCC and known HPV-negative status were included. Those with HPV-positive or unknown status and primary lesions located outside the oropharynx were excluded. The primary predictor variable was patient sex (male vs female). Primary outcome variables of interest included DSS and OS. The following patient-level covariates were also assessed: age, race, insurance status, primary anatomical site and histological type of lesion, histologic grade and stage, and disease outcome. A survival analysis was conducted using univariate and multivariate analyses via a cox proportional hazard regression model. An α value less than 0.05 was considered statistically significant. RESULTS: The study sample consisted of 2,565 cases (25.1% female) of HPV-negative OPSCC. Females presented with lower histologic grade (P = .015) and earlier stage (P = .003). Females demonstrated worse DSS (P < .001) and OS (P < .001). After multivariate adjustment, female sex (hazard ratio [HR] = 1.38; 95% confidence interval [CI], 1.13 to 1.67; P = .002), advanced age (HR = 1.672; 95% CI, 1.07 to 2.60; P = .023), advanced overall stage (HR = 4.69; 95% CI, 1.54 to 14.267; P = .006), TNM stage (T4: HR = 5.74; 95% CI, 3.86 to 8.55, P < .001, N3: HR = 3.48; 95% CI, 2.17 to 5.58; P < .001, and M1: HR = 2.80; 95% CI, 2.09 to 3.74; P < .001), subjects residing in counties with the highest rates of smoking (HR = 1.29; 95% CI, 1.01 to 1.65; P = .044), and the lack of surgical treatment in patients treated with radiation and/or chemotherapy (HR = 1.44; 95% CI, 1.08 to 1.91; P = .012) were correlated with poorer DSS and OS. CONCLUSION: Females with HPV-negative OPSCC demonstrated worse DSS and OS despite better typical prognostic signs such as histologic grade and clinical stage.

Effects of racial residential segregation on oral squamous cell carcinoma prognosis and survival.

OBJECTIVES: The objective of this study is to evaluate the impact of racial residential segregation on disease prognosis and overall survival in Black patients diagnosed with oral squamous cell carcinoma (OSCC), relative to White patients. MATERIALS AND METHODS: This retrospective cohort study identified individuals diagnosed with OSCC between 2005 and 2015 using the Surveillance, Epidemiology and End Results Database. Patients were included with cancers diagnosed in the following locations: lip, tongue, gum, floor of mouth, palate, and other/unspecified. Tumors located at the base of tongue, tonsils, and oropharynx were excluded. The primary predictor variable was the degree of residential segregation. The primary outcome was overall survival. A Kaplan Meier survival analysis and univariate/multivariate analyses were performed to account for potential confounders of survival. RESULTS: A total of 35,769 patients met inclusion criteria. At the time of initial diagnosis, Black patients presented with OSCC of higher grades and more advanced stages (p < 0.001). A greater number of Black subjects were dead by the time of last follow-up compared to White subjects (p < 0.001). Across the entire spectrum of residential segregation, cumulative survival was worse among Black patients compared to Whites (p < 0.001). Multivariate analysis identified highly segregated counties, advanced age, higher grade/advanced stage at time of diagnosis, lack of surgery, and no chemotherapy treatment as poor prognostic factors for survival among Black individuals. CONCLUSION: Racial residential segregation results in poorer long-term cancer survival among Black patients. Understanding the links between residential segregation and inequities in cancer outcomes will allow policymakers to better implement targeted, population-based interventions in treating various cancers.

Rural patients with oral squamous cell carcinoma experience better prognosis and long-term survival.

OBJECTIVES: No studies have attempted to examine the role of geographic location on oral squamous cell carcinoma (OSCC) disease progression in the United States (US). The purpose of this study is to analyze rural-urban differences in prognosis and long-term survival in patients with OSCC. MATERIALS AND METHODS: This retrospective cohort study utilizes the National Cancer Institute's (NCI) Surveillance, Epidemiology and End Results (SEER) database to examine primary OSCC diagnoses from 1990 to 2015 in the US. The primary predictor variable was patient Rural-Urban Continuum Code (RUCC) (rural vs. urban). The primary outcome variable consisted of overall survival time after initial diagnosis. Additional variables assessed include patient demographics, primary anatomical site of the cancer, histological diagnosis, stage/grade at time of diagnosis, and disease outcome. Descriptive statistics were calculated, and categorical variables were compared. Additional cumulative survival and univariate/multivariate analyses were performed. RESULTS: 46,678 cases of OSCC between 1990 and 2015 were identified. The rural subgroup was more likely to present at the time of diagnosis with a lower grade (p < 0.001) and an earlier stage (p < 0.001). Rural populations demonstrated superior overall survival (p < 0.001), whereas urban populations were more likely to die as a result of their OSCC (p < 0.001). After adjusting for all patient-specific factors, urban status still yielded a poorer disease prognosis. CONCLUSION: Living in rural areas is associated with better prognosis and long-term survival in patients with OSCC. Further studies are needed to better elucidate the mechanisms underlying these findings.