Frailty assessment has come to stay: Retrospective analysis pilot study of two frailty scales in oncological older patients undergoing colorectal surgery.

INTRODUCTION: Colorectal cancer is a disease of the elderly and its main treatment is surgery. Frailty, a clinical syndrome of decreased reserve, increases with age and has been recognized as a predictive factor for postoperative mortality. Our primary objective was to assess the association between two frailty scores and mortality within the first year after surgery, by retrospectively linking frailty scores to mortality data and comparing the strength of their association with mortality to that of the ASA Classification. The frailty scales used were: the Modified Frailty Index (MFI) and, the Risk Analysis Index-A (RAI-A) and the G8 screening test (G8). As secondary objectives, we assessed the relationship of the frailty scales with morbidity and compared all the scales with the ASA. MATERIAL AND METHODS: We retrospectively studied 172 patients aged 65 years and older who underwent laparoscopic colorectal surgery for cancer between January 2017 and June 2018, following them up for 1year after surgery. RESULTS: Both morbidity and mortality were significantly associated with all frailty scale scores (p<.001). The more frailty, the greater probability of prolonged hospital stay, complications, readmissions and emergency department visits. Using each scale, patients were categorized into two groups (frail and non-frail patients). The C-indexes for 1-year mortality with the RAI-A and, MFI and G8 were 0.89 and, 0.86 and 0.86 respectively. On the other hand, ASA status is not strongly associated with mortality, with a C-index of .63. DISCUSSION: Frailty scores should begin to influence medical and surgical strategies and further research is needed to develop guidelines for interventions in geriatric patients.

La evaluación de la fragilidad ha venido para quedarse: Estudio piloto retrospectivo de dos escalas de fragilidad en ancianos oncológicos intervenidos de cirugía colorrectal / Frailty assessment has come to stay: Retrospective analysis pilot study of two frailty scales in oncological older patients undergoing colorectal surgery

Introducción: El cáncer colorrectal es una enfermedad que habitualmente aparece en ancianos y su principal tratamiento continúa siendo quirúrgico. La fragilidad es síndrome clínico que se caracteriza por presentar una disminución de la reserva fisiológica, aumenta con la edad y ha sido reconocido como un factor predictivo de mortalidad postoperatoria. Nuestro objetivo primario ha sido evaluar la asociación entre dos escalas de fragilidad y la mortalidad a un año después de la cirugía, y comparando la fuerza de su asociación del poder predictivo de mortalidad de las escalas de fragilidad y la de la clasificación de la American Society of Anesthesiologists (ASA). Las escalas utilizadas fueron: Modified Frailty Index (MFI) y el Risk Analysis Index (RAI-A). Los objetivos secundarios han sido la evaluación de la relación de las escalas de fragilidad con la morbilidad y la comparación de estas con la clasificación ASA en cuanto a predicción de morbilidad. Material y métodos: Analizamos retrospectivamente 172 pacientes mayores de 65 años que fueron intervenidos de cirugía oncológica colorrectal laparoscópica desde enero de 2017 hasta junio de 2018 con un seguimiento de un año posterior a la cirugía. Resultados: La fragilidad esta significativamente asociada a la mortalidad y morbilidad (p < 0,001). A más fragilidad, mayor probabilidad de estancia hospitalaria, complicaciones, reingresos y visitas a urgencias. Los pacientes fueron categorizados en dos grupos (pacientes frágiles y no frágiles). Los C-index de la predicción a mortalidad a un año obtenidos con el RAI-A y el MFI fueron 0,89 y 0,86, respectivamente. Por otro lado, la clasificación ASA no se relaciona con mortalidad, su C-index fue del 0,63. Discusión: Las escalas de fragilidad deberían empezar a influenciar las intervenciones médicas y quirúrgicas, y se deberían implementar guías y protocolos que tuviesen en cuenta el grado de fragilidad de los pacientes geriátricos.(AU)

Introduction: Colorectal cancer is a disease of the elderly and its main treatment is surgery. Frailty, a clinical syndrome of decreased reserve, increases with age and has been recognized as a predictive factor for postoperative mortality. Our primary objective was to assess the association between twohree frailty scores and mortality. within the first year after surgery, by retrospectively linking frailty scores to mortality data and comparing the strength of their association with mortality to that of the ASA Classification. The frailty scales used were: the Modified Frailty Index (MFI) and, the Risk Analysis Index-A (RAI-A) and the G8 screening test (G8). As secondary objectives, we assessed the relationship of the frailty scales with morbidity and compared all the scales with the ASA. Material and methods: We retrospectively studied 172 patients aged 65 years. and older who underwent laparoscopic colorectal surgery for cancer between January 2017 and June 2018, following them up for 1 year after surgery. Results: Both morbidity and mortality were significantly associated with all frailty scale scores (p < 0.001). The more frailty, the greater probability of prolonged hospital stay, complications, readmissions and emergency department visits. Using each scale, patients were categorized into two groups (frail and non-frail patients). The C-indexes for 1-year mortality with the RAI-A and, MFI and G8 were 0.89 and, 0.86 and 0.86 respectively. On the other hand, ASA status is not strongly associated with mortality, with a C-index of 0.63. Discussion: Frailty scores should begin to influence medical and surgical strategies and further research is needed to develop guidelines for interventions in geriatric patients.(AU)

Asociación de PCR plasmática y evolución del aneurisma de aorta infrarrenal / Association between C-reactive protein and the progression of the abdominal aortic aneurysm

OBJETIVO: Valorar la asociación entre las concentraciones plasmáticas de la proteína C reactiva (PCR) y la evolución de los aneurismas de aorta abdominal (AAA) infrarrenal, para verificar su validez como biomarcador de crecimiento aneurismático. MATERIAL Y MÉTODOS: Cohorte prospectiva de AAA asintomáticos seguidos en consultas externas desde 2008. Registramos: datos clínicos, mediciones seriadas del diámetro máximo de los AAA (mediante ecografía y angio-TAC) y determinaciones seriadas de PCR ultrasensible. El seguimiento fue anual para los AAA de 30-39 mm y semestral para aquellos ≥ 40 mm. Excluimos las determinaciones de PCR > 15 mg/L para evitar que posibles procesos agudos pudieran actuar como factor de confusión. Calculamos las tasas del crecimiento aórtico en cada periodo de seguimiento mediante la diferencia entre los diámetros aórticos en mediciones consecutivas y los clasificamos de forma dicotómica (progresión si el crecimiento fue > 2 mm, estabilidad si el crecimiento fue ≤ 2 mm). Empleamos para el análisis de datos la correlación de Pearson y los modelos mixtos lineales. RESULTADOS: Incluimos 218 AAA con un diámetro basal medio de 41,2 mm (desviación estándar [DE] 10,3 mm, intervalo 30-90 mm). El seguimiento medio fue 28,8 meses (DE 13,7; intervalo 4,8-62), y la concentración basal de PCR media fue 4,1 mg/L (DE 3,3; intervalo 0,5-15). Observamos una relación significativa entre los niveles basales de PCR y el diámetro basal (r = 0,23; p = 0,001), asociación que se mantuvo en las determinaciones seriadas a lo largo del seguimiento (p < 0,0001). No detectamos asociación significativa entre las concentraciones de PCR y las tasas de crecimiento aórtico medidas como variable continua (p = 0,10), pero concentraciones crecientes de PCR se asociaron a la progresión de los AAA, tomada la variable de forma dicotómica (OR = 1,008; IC 95%: 1,000-1,016; p = 0,04). CONCLUSIONES: Las concentraciones plasmáticas de PCR mantienen una asociación con el diámetro aneurismático a lo largo del seguimiento y se relacionan con la progresión de los AAA

OBJECTIVE: To assess the association between high sensitivity C-reactive protein (hs-CRP) plasma levels and the prospective progression of aortic abdominal aneurysm (AAA) in order to test its value as a biomarker. MATERIAL AND METHODS: Prospective cohort of asymptomatic AAA patients followed up in an outpatient clinic since 2008. Clinical data, serial maximum aneurysm diameter (ultrasound and CT) and hs-CRP plasma levels were recorded. Small AAA (30-39 mm) were followed up annually, and large AAA (≥ 40 mm) every 6 months. Hs-CRP levels > 15 mg/L were excluded from the study to avoid acute events acting as potential confounders. Aortic expansion rates were calculated in each follow up period, as well as the difference between aortic diameters in consecutive measurements. Aortic growth was also classified as a dichotomic variable (progression if the growth was > 2 mm, and stability if the growth was ≤ 2 mm). The Pearson correlation and mixed linear models were used for statistical analysis. RESULTS: The study included 218 AAA with a mean baseline diameter of 41.2 mm (SD 10.3 mm, range 30-90). The average follow up time was 28.8 months (SD 13.7, range 4.8-62) and the mean baseline hs-CRP level was 4.1 mg/dL (SD 3.3, range 0.5-15). A significant association was observed between hs-CRP levels and baseline AAA diameter (r = 0.23, P = .001), and this association was maintained over serial determinations throughout the follow-up (P < .0001). No statistically significant association was observed between hs-CRP concentrations and aortic growth rates, measured as a continuous variable (P = .10). However, increasing hs-CRP levels were associated with AAA progression [(OR = 1.008; 95% (1.000-1.016) P = .04)]. CONCLUSIONS: hs-CRP plasma levels are consistently associated with AAA diameter throughout the follow-up of the patients, and increased levels are associated with AAA progression

Determination of reference values for serum folate and vitamin B12 using three different immunoassays: is it worth making an effort to produce them in our laboratory?

BACKGROUND: Despite being a widely studied concept, the reference interval is the most widely used medical decision-making tool. As such, it is vital that these limits are correctly established and regularly reviewed in the clinical laboratory. METHODS: The reference population comprised 315 healthy individuals selected a priori from Bizkaia province. Blood and serum samples were sent for subsequent assay of vitamin B12 and folate using three immunochemical methods. Reference values were calculated using non-parametric methods. RESULTS: The reference values for serum vitamin B12 and folate were almost identical to those obtained previously using the same methods. Use of new reference values led to an increase in the kappa value despite the low agreement in the case of vitamin B12 (0.4 - 0.62). However, precision obtained for vitamin B12 (94.48 - 96.55%) and folate (95.77 - 97.18%) was very high. The intraclass correlation coefficient ranged from 0.723 to 0.894. Furthermore, a Passing-Bablok regression analysis gave acceptable correlation coefficients of 0.75 - 0.94 for vitamin B12 and 0.92 - 0.95 for folate. CONCLUSIONS: Vitamin B12 and folate deficiencies are currently being over-diagnosed leading to an increase in the number of unnecessary consultations. The main conclusion that can be drawn from our study has resulted in a change in reference values in our laboratory, with a subsequent increase in our ability to accurately detect possible deficiencies. Furthermore, as this study involved all methods currently in use in the Basque healthcare network, its conclusions can be extrapolated to the whole population covered by Osakidetza, thereby improving the rational use of healthcare funding.

[Fascia iliaca compartment block for analgesia following total hip replacement surgery]. / Bloqueo iliofascial para analgesia postoperatoria de prótesis total de cadera.

OBJECTIVE: The objective of this pilot study was to evaluate the effectiveness of the fascia iliaca compartment block to control pain following total hip replacement by assessing pain intensity 24 hours after surgery and recording the use of opiates for rescue analgesia. MATERIAL AND METHODS: We performed a prospective observational study of 41 patients undergoing total hip replacement surgery. The patients were divided into 2 groups: a group that received a fascia iliaca compartment block with 0.45% ropivacaine at a dosage of 0.3 mL/kg (maximum dose, 30 mL) and a control group in which no block was performed. Patients were enrolled consecutively as they entered the postanesthetic recovery unit. Postoperative pain was assessed on a visual analog scale (VAS) immediately after surgery and 24 hours later. Other variables recorded were opiate use for rescue analgesia and adverse effects due to the use of opiates. RESULTS: The VAS scores recorded in the postanesthetic recovery unit were significantly different in the 2 groups, with lower scores in the group receiving the fascia iliaca compartment block (P < .001). However, no significant between-group differences were observed in VAS scores recorded on the ward 24 hours after surgery (P = .57). CONCLUSIONS: A single-injection fascia iliaca compartment block was effective in controlling initial postoperative pain in a postanesthetic recovery unit. It was effective on the ward in the first few hours after surgery but not for the entire 24-hour period because of the limited duration of the block.

Bloqueo iliofascial para analgesia postoperatoria de prótesis totalde cadera / Fascia iliaca compartment block for analgesia following total hip replacement surgery

OBJETIVO: El objetivo de este estudio preliminar esmedir la efectividad del bloqueo iliofascial en el controldel dolor postoperatorio tras la colocación de prótesistotal de cadera, en cuanto a la intensidad del dolor 24horas tras la intervención y el consumo de opiáceos derescate.MATERIAL Y MÉTODOS: Estudio observacional, prospectivo,de cohortes, en el que se han incluido a 41 pacientesoperados de prótesis total de cadera, los cuales fuerondivididos en 2 grupos según se les practicara (grupo bloqueo)o no (grupo control) bloqueo iliofascial con ropivacaínaal 0,45%, 0,3 ml/kg (dosis máxima 30 ml). Se realizóun muestreo consecutivo simple según iban ingresandoen la Unidad de Recuperación Postanestésica. El dolorpostoperatorio se midió inmediatamente tras la intervencióny 24 horas después mediante una escala visual analógica.Otras variables de resultado evaluadas fueron elconsumo de opiáceos de rescate y la presencia de efectossecundarios derivados del uso de opiáceos.RESULTADOS: Se han encontrado diferencias estadísticamentesignificativas en las puntuaciones de la escalavisual analógica en la unidad de recuperación postanestésicaentre ambos grupos, obteniendo el grupo bloqueouna puntuación en la escala visual analógica menor queel grupo control (p < 0,001). Sin embargo, no hubo diferenciassignificativas entre ambos grupos respecto a laspuntuaciones de la escala visual analógica en la sala dehospitalización a las 24 horas (p = 0,57).CONCLUSIONES: El bloqueo iliofascial en inyecciónúnica es efectivo para el control del dolor postoperatorioinicial en la unidad de recuperación postanestésica. Posteriormenteen la sala es eficaz en las primeras horas deestancia, aunque no llega a cubrir las 24 horas por lalimitación de duración del bloqueo (AU)

OBJECTIVE: The objective of this pilot study was toevaluate the effectiveness of the fascia iliaca compartmentblock to control pain following total hip replacement byassessing pain intensity 24 hours after surgery andrecording the use of opiates for rescue analgesia.MATERIAL AND METHODS: We performed a prospectiveobservational study of 41 patients undergoing total hipreplacement surgery. The patients were divided into 2groups: a group that received a fascia iliaca compartmentblock with 0.45% ropivacaine at a dosage of 0.3 mL/kg(maximum dose, 30 mL) and a control group in which noblock was performed. Patients were enrolledconsecutively as they entered the postanesthetic recoveryunit. Postoperative pain was assessed on a visual analogscale (VAS) immediately after surgery and 24 hours later.Other variables recorded were opiate use for rescueanalgesia and adverse effects due to the use of opiates.RESULTS: The VAS scores recorded in thepostanesthetic recovery unit were significantly differentin the 2 groups, with lower scores in the group receivingthe fascia iliaca compartment block (P<.001). However,no significant between-group differences were observedin VAS scores recorded on the ward 24 hours aftersurgery (P=.57).CONCLUSIONS: A single-injection fascia iliacacompartment block was effective in controlling initialpostoperative pain in a postanesthetic recovery unit. Itwas effective on the ward in the first few hours aftersurgery but not for the entire 24-hour period because ofthe limited duration of the block (AU)

Evaluación de la proteína C reactiva, alfa1-antitripsina y lipoproteína(a) como potenciales marcadores biológicos asociados al crecimiento del aneurisma de aorta abdominal / Evaluation of C-Reactive protein, Alpha1-Antitrypsin and lipoprotein (a) as potential biomarkers associated with abdominal aortic aneuriysm growth

Introducción. Actualmente, la valoración del aneurisma de aorta abdominal (AAA) infrarrenal asintomáticose realiza únicamente con pruebas de imagen seriadas. Buscamos un marcador plasmático útil como indicador de la actividaddel AAA y potencial valor pronóstico. Pacientes y métodos. Obtuvimos muestras de sangre periférica de 35 pacientescon AAA (13 AAA 30-39 mm; 11 40-49 mm; 11 >= 50 mm) y 35 controles. Determinamos la concentración plasmáticade proteína C reactiva (PCR), alfa1-antitripsina y lipoproteína(a). Registramos: datos clínicos, diámetro aórtico(ecografía/TC) en el momento de la extracción y crecimiento del AAA en el año previo. Analizamos la correlación entrecada proteína y el diámetro y crecimiento aórticos con los tests de Mann-Whitney, Kruskal-Wallis, Spearman y regresiónlineal. Resultados. Los pacientes eran mayoritariamente varones (n =33; 94,3%), con edad 71 ± 6,8 (54-83) años. El diámetrodel AAA (n = 35) era 45 ± 12 (30-71) mm, con crecimiento (n = 25) 3,1 ± 3,1 (0-10) mm/año previo. Las tres proteínaspresentaban concentraciones mayores en los pacientes que los controles: PCR 4,1 (1,9-7,3) frente a 1,9 (0,5-4,9)mg/L (p = 0,026); alfa1-antitripsina 147 (131-168) frente a 125,5 (113,8-135,5) mg/dL (p < 0,0001); lipoproteína(a) 47(20-117,5) frente a 27 (9-47) mg/dL (p = 0,022). Encontramos correlaciones positivas PCR-diámetro AAA (r = 0,46; p =0,007) y alfa1-antitripsina-crecimiento AAA (r = 0,55; p = 0,004), sin correlación entre lipoproteína(a)-diámetro/crecimientoAAA (p > 0,52). Las concentraciones de PCR estaban influidas por la toma de estatinas (p = 0,036). No existíancorrelaciones en los controles para ninguno de los marcadores (p > 0,22). Conclusiones. La alfa1-antitripsina pareceprometedora como marcador biológico de la actividad del AAA. La PCR muestra correlación con el tamaño del AAA, perose ve influida por las estatinas. Se descarta la utilidad de la lipoproteína(a)(AU)

Introduction. Current assessment of asymptomatic infrarenal abdominal aortic aneurysms (AAA) is donesolely with serial image techniques. We try to find a useful serological biomarker of AAA activity with potentialprognostic value. Patients and methods.We obtained peripheral blood samples from 35 AAA patients (13 3-3.9 cm AAA;11 4-4.9 cm AAA; 11 >= 5 cm AAA) and 35 controls. We quantified the serum concentration of C-reactive protein(CRP), alpha1-antitrypsin and lipoprotein(a). We registered: clinical data, aortic diameter (ultrasound/CT) at the timeof blood sample harvest, and AAA growth in the previous 12 months. We analysed the correlation between each proteinand the aortic diameter and growth, using Mann-Whitney, Kruskal-Wallis and Spearman’s tests and linear regression.Results. The AAA patients were mostly male (n = 33; 94.3%) and aged 71 ± 6.8 (54-83) years. The AAA diameter (n =35) was 45 ± 12 (30-71) mm, with expansion (n = 25) 3,1 ± 3,1 (0-10) mm/previous year. The levels of the three proteinswere significantly higher in the AAA patients compared to the controls: CRP 4.1 (1.9-7.3) v. 1.9 (0.5-5) mg/L (p = 0.026);alpha1-antitrypsin 147 (131-168) v. 125.5 (114-135.5) mg/dL (p < 0.0001); lipoprotein(a) 47 (20-117.5) v. 27 (9-47)mg/dL (p = 0.022). We found positive correlations CRP-AAA diameter (r = 0.46; p = 0.007) and alpha1-antitrypsin-AAAgrowth (r = 0,55; p = 0,004), but no association between lipoprotein(a) and AAA diameter or expansion (p > 0.52). CRPconcentrations were influenced by statin intake (p = 0.036). There were no correlations for any of the proteins in thecontrol group (p > 0.22). Conclusions. Alpha1-antitrypsin seems promising as a biomarker of AAA activity. CRP showscorrelation with AAA size, but is influenced by statin intake. Lipoprotein(a) has not proved useful(AU)

Endarterectomía ilíaca: una técnica en peligro de extinción / Iliac endarterectomy: A technique in danger of extincion

Introducción. La tromboendarterectomía ilíaca ha sido desplazada primero por los bypass y, posteriormente,por las técnicas endovasculares. Objetivo. Revisar los resultados a corto y largo plazo de la tromboendarterectomía retrógraday abierta, y su indicación terapéutica actual. Pacientes y métodos. Incluimos todos los pacientes con patologíaoclusiva del sector ilíaco, independientemente de la afectación fémoropopliteodistal. Recogimos el sexo, la edad, los factoresde riesgo cardiovascular y la comorbilidad. Clasificamos a los pacientes en grupo I: tromboendarterectomía retrógrada,y grupo II: tromboendarterectomía abierta. De cada procedimiento analizamos la indicación quirúrgica, la clasificaciónde la lesión oclusiva ilíaca según la clasificación TASC II, la sutura arterial, la asociación con revascularizacióninfrainguinal y el número de reintervenciones. Analizamos la permeabilidad primaria, primaria-asistida, secundaria y elsalvamento de la extremidad de la serie completa y de cada grupo. Resultados. Intervinimos 101 pacientes con una edadmedia de 61 ± 10,6 años (38-86). El seguimiento medio fue de 87,2 ± 61,1 meses. Las permeabilidades de la serie completafueron: primaria: al mes, año, 5 y 10 años 93,6, 84, 72,2 y 68,2%; primaria-asistida: 99, 92,9, 88,4 y 71,8%; secundaria:99, 94,2, 90,2 y 84,4%. El salvamento de la extremidad fue del 96,3, 90,6, 85,6 y 81,9% y la supervivencia del 98,2,90,6, 73,5 y 47,9%. Al comparar ambos procedimientos observamos que el grupo I estaba constituido por pacientes deedad más avanzada (p = 0,048) y las lesiones tratadas según la clasificación TASC II eran menos complejas (p < 0,001).Conclusiones. La endarterectomía ilíaca presenta buenas permeabilidades tardías y de salvamento de la extremidad, quepueden constituir un buen recurso terapéutico en pacientes seleccionados(AU)

Introduction. Iliac thromboendarterectomies have been largely replaced, first, by bypasses and, later, by endovasculartechniques. Aim. To review short- and long-term outcomes of retrograde and open thromboendarterectomies,and the current therapeutic indication of these techniques. Patients and methods. We include all patients with anocclusive pathology of the iliac sector, regardless of femoral-popliteal-distal involvement. Data collected included sex,age, cardiovascular risk factors and comorbidity. Patients were classified into group I: retrograde thromboendarterectomy,and group II: open thromboendarterectomy. For each procedure, we analysed the surgical indication, the classificationof the iliac occlusive lesion according to the TASC II classification, the arterial suturing, the association withinfrainguinal revascularisation and the number of reinterventions. We also analysed the primary, assisted-primary andsecondary patency and limb salvage of the complete series and in each group. Results. Surgery was performed on 101patients, whose mean age was 61 ± 10.6 years (38-86). The mean follow-up time was 87.2 ± 61.1 months. The patenciesof the complete series were: primary: at one month, one year, 5 and 10 years 93.6, 84, 72.2, 68.2%; assisted-primary:99, 92.9, 88.4 and 71.8%; secondary: 99, 94.2, 90.2 and 84.4%. Limb salvage was 96.3, 90.6, 85.6 and 81.9%, andsurvival rate was 98.2, 90.6, 73.5 and 47.9%. On comparing the two procedures, it was observed that group I was madeup of patients of a more advanced age (p = 0.048) and the lesions treated, according to the TASC II classification, wereless complex (p < 0.001). Conclusions. Iliac endarterectomy offers good late patencies and limb salvage rates, and canconstitute a good therapeutic resource in selected patients(AU)