The risk analysis index demonstrates exceptional discrimination in predicting frailty's impact on neurosurgical length of stay quality metrics.

BACKGROUND: Quality measures determine reimbursement rates and penalties in value-based payment models. Frailty impacts these quality metrics across surgical specialties. We compared the discriminatory thresholds for the risk analysis index (RAI), modified frailty index-5 (mFI-5) and increasing patient age for the outcomes of extended length of stay (LOS [eLOS]), prolonged LOS within 30 days (pLOS), and protracted LOS (LOS > 30). METHODS: Patients ≥18 years old who underwent neurosurgical procedures between 2012 and 2020 were queried from the ACS-NSQIP. We performed receiver operating characteristic analysis, and multivariable analyses to examine discriminatory thresholds and identify independent associations. RESULTS: There were 411,605 patients included, with a median age of 59 years (IQR, 48-69), 52.2% male patients, and a white majority 75.2%. For eLOS: RAI C-statistic 0.653 (95% CI: 0.652-0.655), versus mFI-5 C-statistic 0.552 (95% CI: 0.550-0.554) and increasing patient age C-statistic 0.573 (95% CI: 0.571-0.575). Similar trends were observed for pLOS- RAI: 0.718, mFI-5: 0.568, increasing patient age: 0.559, and for LOS>30- RAI: 0.714, mFI-5: 0.548, and increasing patient age: 0.506. Patients with major complications had eLOS 10.1%, pLOS 26.5%, and LOS >30 45.5%. RAI showed a larger effect for all three outcomes, and major complications in multivariable analyses. CONCLUSION: Increasing frailty was associated with three key quality metrics that is, eLOS, pLOS, LOS > 30 after neurosurgical procedures. The RAI demonstrated a higher discriminating threshold compared to both mFI-5 and increasing patient age. Preoperative frailty screening may improve quality metrics through risk mitigation strategies and better preoperative communication with patients and their families.

Frailty as a predictor of postoperative outcomes in neurosurgery: a systematic review.

INTRODUCTION: Baseline frailty status has been utilized to predict a wide range of outcomes and guide preoperative decision making in neurosurgery. This systematic review aims to analyze existing literature on the utilization of frailty as a predictor of neurosurgical outcomes. EVIDENCE ACQUISITION: We conducted a systematic review following PRISMA guidelines. Studies that utilized baseline frailty status to predict outcomes after a neurosurgical intervention were included in this systematic review. Studies that utilized sarcopenia as the sole measure of frailty were excluded. PubMed, EMBASE, and Cochrane library was searched from inception to March 1st, 2023, to identify relevant articles. EVIDENCE SYNTHESIS: Overall, 244 studies met the inclusion criteria. The 11-factor modified frailty index (mFI-11) was the most utilized frailty measure (N.=91, 37.2%) followed by the five-factor modified Frailty Index (mFI-5) (N.=80, 32.7%). Spine surgery was the most common subspecialty (N.=131, 53.7%), followed by intracranial tumor resection (N.=57, 23.3%), and post-operative complications were the most reported outcome (N.=130, 53.2%) in neurosurgical frailty studies. The USA and the Bowers author group published the greatest number of articles within the study period (N.=176, 72.1% and N.=37, 15.2%, respectively). CONCLUSIONS: Frailty literature has grown exponentially over the years and has been incorporated into neurosurgical decision making. Although a wide range of frailty indices exist, their utility may vary according to their ability to be incorporated in the outpatient clinical setting.

Frailty Is Associated With Decreased Survival in Adult Patients With Nonoperative and Operative Traumatic Subdural Hemorrhage: A Retrospective Cohort Study of 381,754 Patients.

Objective: We investigated frailty's impact on traumatic subdural hematoma (tSDH), examining its relationship with major complications, length of hospital stay (LOS), mortality, high level of care discharges, and survival probabilities following nonoperative and operative management. Background: Despite its frequency as a neurosurgical emergency, frailty's impact on tSDH remains underexplored. Frailty characterized by multisystem impairments significantly predicts poor outcomes, necessitating further investigation. Methods: A retrospective study examining tSDH patients ≥18 years and assigned an abbreviated injury scale score ≥3, and entered into ACS-TQIP between 2007 and 2020. We employed multivariable analyses for risk-adjusted associations of frailty and our outcomes, and Kaplan-Meier plots for survival probability. Results: Overall, 381,754 tSDH patients were identified by mFI-5 as robust-39.8%, normal-32.5%, frail-20.5%, and very frail-7.2%. There were 340,096 nonoperative and 41,658 operative patients. The median age was 70.0 (54.0-81.0) nonoperative, and 71.0 (57.0-80.0) operative cohorts. Cohorts were predominately male and White. Multivariable analyses showed a stepwise relationship with all outcomes P < 0.001; 7.1% nonoperative and 14.9% operative patients had an 20% to 46% increased risk of mortality, that is, nonoperative: very frail (HR: 1.20 [95% CI: 1.13-1.26]), and operative: very frail (HR: 1.46 [95% CI: 1.38-1.55]). There were precipitous reductions in survival probability across mFI-5 strata. Conclusion: Frailty was associated with major complications, LOS, mortality, and high level care discharges in a nationwide population of 381,754 patients. While timely surgery may be required for patients with tSDH, rapid deployment of point-of-care risk assessment for frailty creates an opportunity to equip physicians in allocating resources more precisely, possibly leading to better outcomes.

Preoperative frailty risk in deep brain stimulation patients: Risk analysis index predicts Clavien-Dindo IV complications.

OBJECTIVE: Deep brain stimulation (DBS) improves patients' quality of life in multiple movement disorders and chronic neurodegenerative diseases. There are no published studies assessing frailty's impact on DBS outcomes. We evaluated frailty's impacts on DBS outcomes, comparing discriminative thresholds of the risk analysis index (RAI) to modified frailty index-5 (mFI-5) for predicting Clavien-Dindo complications (CDIV). METHODS: Patients who underwent DBS between 2015 and 2019 in the ACS-NSQIP registry were included. We employed receiver operating characteristic (ROC) curve to examine the discriminative thresholds of RAI and mFI-5 and multivariable analyses for postoperative outcomes. Our primary outcome was CDIV, and secondary outcomes were discharge to higher-level care facility, unplanned reoperation within 30 days, in any hospital, for any procedure related to the index procedure, and extended length of stay. RESULTS: A total of 3795 patients were included. In the ROC analysis for CDIV, RAI showed superior discriminative threshold (C-statistic = 0.70, 95% CI 0.61-0.80, <0.001) than mFI-5 (C-statistic = 0.60, 95% CI 0.49-0.70, P = 0.08). On multivariable analyses, frailty stratified by RAI, had independent associations with CDIV, i.e., pre-frail 2-fold increase OR 2.04 (95% CI: 1.94-2.14) p < 0.001, and frail 39% increase OR 1.39 (95% CI: 1.27-1.53), p < 0.001. CONCLUSION: Frailty was an independent risk-factor for CDIV. The RAI had superior discriminative thresholds than mFI-5 in predicting CDIV after DBS. Our ability to identify frail patients prior to DBS presents a novel clinical opportunity for quality improvement strategies to target this specific patient population. RAI may be a useful primary frailty screening modality for potential DBS candidates.

Postprocedural Complications of External Ventricular Drains: A Meta-Analysis Evaluating the Absolute Risk of Hemorrhages, Infections, and Revisions.

BACKGROUND: External ventricular drain (EVD) insertion is often a lifesaving procedure frequently used in neurosurgical emergencies. It is routinely done at the bedside in the neurocritical care unit or in the emergency room. However, there are infectious and noninfectious complications associated with this procedure. This meta-analysis sought to evaluate the absolute risk associated with EVD hemorrhages, infections, and revisions. The secondary purpose was to identify and characterize risk factors for EVD complications. METHODS: We searched the MEDLINE (PubMed) database for "external ventricular drain," "external ventricular drain" + "complications" or "Hemorrhage" or "Infection" or "Revision" irrespective of publication year. Estimates from individual studies were combined using a random effects model, and 95% confidence intervals (CIs) were calculated with maximum likelihood specification. To investigate heterogeneity, the t2 and I2 tests were utilized. To evaluate for publication bias, a funnel plot was developed. RESULTS: There were 260 total studies screened from our PubMed literature database search, with 176 studies selected for full-text review, and all of these 176 studies were included in the meta-analysis as they met the inclusion criteria. A total of 132,128 EVD insertions were reported, with a total of 130,609 participants having at least one EVD inserted. The pooled absolute risk (risk difference) and percentage of the total variability due to true heterogeneity (I2) for hemorrhagic complication was 1236/10,203 (risk difference: -0.63; 95% CI: -0.66 to -0.60; I2: 97.8%), infectious complication was 7278/125,909 (risk difference: -0.65; 95% CI: -0.67 to -0.64; I2: 99.7%), and EVD revision was 674/4416 (risk difference: -0.58; 95% CI: -0.65 to -0.51; I2: 98.5%). On funnel plot analysis, we had a variety of symmetrical plots, and asymmetrical plots, suggesting no bias in larger studies, and the lack of positive effects/methodological quality in smaller studies. CONCLUSIONS: In conclusion, these findings provide valuable information regarding the safety of one of the most important and most common neurosurgical procedures, EVD insertion. Implementing best-practice standards is recommended in order to reduce EVD-related complications. There is a need for more in-depth research into the independent risk factors associated with these complications, as well as confirmation of these findings by well-structured prospective studies.

Association of baseline frailty and age with postoperative outcomes in metastatic brain tumor patients.

BACKGROUND: The impact of baseline frailty status versus that of chronological age on surgical outcomes of metastatic brain tumor patients remains largely unknown. The present study aimed to evaluate this relationship for preoperative risk stratification using a large national database. METHODS: The National Surgical Quality Improvement Program database was queried to extract data of metastatic brain tumor patients who underwent surgery between 2015 and 2019 (n=5,943). Univariate and multivariate analyses were performed to assess the effect of age and modified frailty index-5 (mFI-5) on mortality, major complications, unplanned readmission and reoperation, extended length of stay (eLOS), and non-home discharge. RESULTS: Both univariate and multivariate analyses demonstrated that frailty status was significantly predictive of 30-day mortality, major complications, eLOS, and non-home discharge. Although increasing age was also a significant predictor of eLOS and discharge to non-home destination, effect sizes were smaller compared with frailty. CONCLUSIONS: The present study, based on analysis of data from a large national registry, shows that frailty, when compared with age, is a superior predictor of postoperative outcomes in metastatic brain tumor patients. A future prospective study, namely a randomized controlled trial, would be beneficial in helping to corroborate the findings of this retrospective study.

Frailty is a risk factor for intracranial abscess and is associated with longer length of stay: a retrospective single institution case-control study.

BACKGROUND: Intracranial abscess (IA) causes significant morbidity and mortality. The impact of baseline frailty status on post-operative outcomes of IA patients remains largely unknown. The present study evaluated if frailty status can be used to prognosticate outcomes in IA patients. METHODS: We retrospectively reviewed all IA patients undergoing craniotomy at our institution from 2011 to 2018 (n =18). These IA patients were age and gender matched with patients undergoing craniotomy for intracranial tumor (IT), an internal control for comparison. Demographic and clinical data were collected to measure frailty, using the modified frailty index-11 (mFI-11), pre-operative American Society of Anesthesiologists Physical Status Classification System (ASA), and study their association with post-operative complications, as measured by the Clavien-Dindo Grade (CDG). RESULTS: No significant difference in mFI-11 or ASA score was observed between the IA and IT groups (p = 0.058 and p = 0.131, respectively). IA patients had significantly higher CDG as compared with the control IT patients (p < 0.001). There was a trend towards increasing LOS in the IA group as compared to the IT group (p = 0.053). Increasing mFI and ASA were significant predictors of LOS by multiple linear regression in the IA group (p = 0.006 and p = 0.001, respectively), but not in the control IT group. Neither mFI-11 nor ASA were found to be predictors for CDG in either group. Within this case-control group of patients, we found an increase for odds of having IA with increasing mFI (OR 1.838, CI 95% 1.016-3.362, p = 0.044). CONCLUSIONS: Frail IA patients tend to have more severe postoperative complications. The mFI-11 seems to predict increased resource utilization in the form of LOS. This study provides the initial retrospective data of another neurosurgical pathology where frailty leads to significantly worse outcomes. We also found that mFI may serve as a potential risk factor for severe disease.

Intraoperative navigation in surgical management of traumatic spine injury: a propensity score matching analysis.

BACKGROUND: Traumatic spinal injury (TSI) can lead to severe morbidity and significant health care resource utilization. Intraoperative navigation (ION) systems have been shown to improve outcomes in some populations. However, controversy about the benefit of ION remains. To our knowledge, there is no large database analysis studying the outcomes of ION on TSI patients. Here we hope to compare complications and outcomes in patients with TSI undergoing spinal fusion of 3 or more levels with or without the use of ION. METHODS: The 2015-2019 National Surgical Quality Improvement Program (NSQIP) database was queried for cases of posterior spinal instrumentation of 3 or more levels. This population was then selected for postoperative diagnosis consistent with TSI. The effect of prolonged operative time was analyzed for all patients. Propensity score matching analysis was performed to create ION case and non-ION control groups. Baseline demographic characteristics, complications, and outcome data were collected and compared between ION and non-ION groups. RESULTS: A total of 1,034 patients were included in the propensity matched analysis. Among comorbidities, only obesity was significantly more likely in the non-ION group. There was no difference in case complexity between the two groups. ION was associated with higher incidence of prolonged operative time but was a negative independent predictor for sepsis. Prolonged operative time was a significant independent predictor for pulmonary embolism and requirement of transfusion in all patients. Discharge to home, readmission, and reoperation rates did not differ between TSI patients with or without ION. CONCLUSIONS: Use of ION during posterior spinal fusion of 3 or more levels in TSI patients is not associated with worse outcomes. Prolonged operative time, rather than ION, appears to have a higher influence on the rate of complications in this population. Evaluation of ION in the context of specific populations and pathology is warranted to optimize its use.

Early-Onset Network Hyperexcitability in Presymptomatic Alzheimer's Disease Transgenic Mice Is Suppressed by Passive Immunization with Anti-Human APP/Aß Antibody and by mGluR5 Blockade.

Cortical and hippocampal network hyperexcitability appears to be an early event in Alzheimer's disease (AD) pathogenesis, and may contribute to memory impairment. It remains unclear if network hyperexcitability precedes memory impairment in mouse models of AD and what are the underlying cellular mechanisms. We thus evaluated seizure susceptibility and hippocampal network hyperexcitability at ~3 weeks of age [prior to amyloid beta (Aß) plaque deposition, neurofibrillary pathology, and cognitive impairment] in a triple transgenic mouse model of familial AD (3xTg-AD mouse) that harbors mutated human Aß precursor protein (APP), tau and presenilin 1 (PS1) genes. Audiogenic seizures were elicited in a higher proportion of 3xTg-AD mice compared with wild type (WT) controls. Seizure susceptibility in 3xTg-AD mice was attenuated either by passive immunization with anti-human APP/Aß antibody (6E10) or by blockade of metabotropic glutamate receptor 5 (mGluR5) with the selective antagonist, 2-methyl-6-(phenylethynyl)pyridine hydrochloride (MPEP). In in vitro hippocampal slices, suppression of synaptic inhibition with the GABAA receptor antagonist, bicuculline, induced prolonged epileptiform (>1.5 s in duration) ictal-like discharges in the CA3 neuronal network in the majority of the slices from 3xTg-AD mice. In contrast, only short epileptiform (<1.5 s in duration) interictal-like discharges were observed following bicuculline application in the CA3 region of WT slices. The ictal-like activity in CA3 region of the hippocampus was significantly reduced in the 6E10-immunized compared to the saline-treated 3xTg-AD mice. MPEP acutely suppressed the ictal-like discharges in 3xTg-AD slices. Remarkably, epileptiform discharge duration positively correlated with intraneuronal human (transgenic) APP/Aß expression in the CA3 region of the hippocampus. Our data suggest that in a mouse model of familial AD, hypersynchronous network activity underlying seizure susceptibility precedes Aß plaque pathology and memory impairment. This early-onset network hyperexcitability can be suppressed by passive immunization with an anti-human APP/Aß antibody and by mGluR5 blockade in 3xTg-AD mice.

Attitudes towards genetic diagnosis in Pakistan: a survey of medical and legal communities and parents of thalassemic children.

OBJECTIVES: It was the aim of this study to assess the attitudes of doctors, medical students, lawyers, parliament members and parents of thalassemic children towards genetic diagnosis in Pakistan. STUDY DESIGN: A cross-sectional descriptive survey was conducted among representative samples. RESULTS: Five hundred and seventy doctors, 49 lawyers, 178 medical students, 89 parents of thalassemic children and 16 members of parliament (MPs) were included in the survey. The groups showed considerable difference in their attitudes towards different aspects of the issue. A large proportion (88.5%) agreed to the idea of genetic diagnostic screening, especially the parents of thalassemic patients. Premarital carrier screening was favored by 77% of the respondents. Prenatal screening was most favored by the parents of thalassemic children (94.4%). Likewise, a majority of parents of thalassemic children were in favor of abortion in case of an affected fetus. Genetic self-screening was also favored most by the parents of thalassemic patients (78.2%). Only 24% of the doctors favored making genetic screening mandatory, whereas 63% of the parents agreed to the idea. CONCLUSION: Attitudes regarding genetic diagnosis are markedly different among various societal groups in Pakistan. The parents of the affected children strongly favor genetic screening as does the medical community, though not as strongly as the parents. The legislative groups, particularly the MPs, are reserved in their support. Genetic diagnosis can help decrease the disease burden in the future. However, it raises a number of ethical issues, which need to be addressed. It is important to educate the population about potential benefits as well as ethical dilemmas involved so that the general public is able to make the right decisions for themselves and their families.