Associations of body size with all-cause and cause-specific mortality in healthy older adults.

In the general population, body mass index (BMI) and waist circumference are recognized risk factors for several chronic diseases and all-cause mortality. However, whether these associations are the same for older adults is less clear. The association of baseline BMI and waist circumference with all-cause and cause-specific mortality was investigated in 18,209 Australian and US participants (mean age: 75.1 ± 4.5 years) from the ASPirin in Reducing Events in the Elderly (ASPREE) study, followed up for a median of 6.9 years (IQR: 5.7, 8.0). There were substantially different relationships observed in men and women. In men, the lowest risk of all-cause and cardiovascular mortality was observed with a BMI in the range 25.0-29.9 kg/m2 [HR25-29.9 vs 21-24.9 kg/m2: 0.85; 95% CI, 0.73-1.00] while the highest risk was in those who were underweight [HRBMI <21 kg/m2 vs BMI 21-24.9 kg/m2: 1.82; 95% CI 1.30-2.55], leading to a clear U-shaped relationship. In women, all-cause mortality was highest in those with the lowest BMI leading to a J-shaped relationship (HRBMI <21 kg/m2 vs BMI 21-24.9 kg/m2: 1.64; 95% CI 1.26-2.14). Waist circumference showed a weaker relationship with all-cause mortality in both men and women. There was little evidence of a relationship between either index of body size and subsequent cancer mortality in men or women, while non-cardiovascular non-cancer mortality was higher in underweight participants. For older men, being overweight was found to be associated with a lower risk of all-cause mortality, while among both men and women, a BMI in the underweight category was associated with a higher risk. Waist circumference alone had little association with all-cause or cause-specific mortality risk.Trial registration ASPREE https://ClinicalTrials.gov number NCT01038583.

GFR Variability, Survival, and Cardiovascular Events in Older Adults.

Rationale & Objective: Variability in estimated glomerular filtration rate (eGFR) over time is often observed, but it is unknown whether this variation is clinically important. We investigated the association between eGFR variability and survival free of dementia or persistent physical disability (disability-free survival) and cardiovascular disease (CVD) events (myocardial infarction, stroke, hospitalization for heart failure, or CVD death). Study Design: Post hoc analysis. Setting & Participants: 12,549 participants of the ASPirin in Reducing Events in the Elderly trial. Participants were without documented dementia, major physical disability, previous CVD, and major life-limiting illness at enrollment. Predictors: eGFR variability. Outcomes: Disability-free survival and CVD events. Analytical Approach: eGFR variability was estimated using the standard deviation of eGFR measurements obtained from participants' baseline, first, and second annual visits. Associations between tertiles of eGFR variability with disability-free survival and CVD events occurring after the eGFR variability estimation period were examined. Results: During median follow-up of 2.7 years after the second annual visit, 838 participants died, developed dementia, or acquired a persistent physical disability; 379 had a CVD event. The highest tertile of eGFR variability had an increased risk of death/dementia/disability (HR, 1.35; 95% CI, 1.14-1.59) and CVD events (HR, 1.37; 95% CI, 1.06-1.77) compared with the lowest tertile after covariate adjustment. These associations were present in patients with and without chronic kidney disease at baseline. Limitations: Limited representation of diverse demographics. Conclusions: In older, generally healthy adults, higher variability in eGFR over time predicts increased risk of future death/dementia/disability and CVD events.

Test-Retest Reliability and Minimal Detectable Change of Four Cognitive Tests in Community-Dwelling Older Adults.

BACKGROUND: Cognitive test-retest reliability measures can be used to evaluate meaningful changes in scores. OBJECTIVE: This analysis aimed to develop a comprehensive set of test-retest reliability values and minimal detectable change (MDC) values for a cognitive battery for community-dwelling older individuals in Australia and the U.S., for use in clinical practice. METHODS: Cognitive scores collected at baseline and year 1, in the ASPirin in Reducing Events in the Elderly clinical trial were used to calculate intraclass correlation coefficients (ICC) for four tests: Modified Mini-Mental State examination (3MS), Hopkins Verbal Learning Test-Revised (HVLT-R), single-letter Controlled Oral Word Association Test (COWAT-F), and Symbol Digit Modalities Test (SDMT). 16,956 participants aged 70 years and over (65 years and over for U.S. minorities) were included. ICCs were used to calculate MDC values for eight education and ethno-racial subgroups. RESULTS: All four cognitive tests had moderate (ICC > 0.5) to good (ICC > 0.7) test-retest reliability. ICCs ranged from 0.53 to 0.63 (3MS), 0.68 to 0.77 (SDMT), 0.56 to 0.64 (COWAT-F), 0.57 to 0.69 (HVLT-R total recall), and 0.57 to 0.70 (HVLT-R delayed recall) across the subgroups. MDC values ranged from 6.60 to 9.95 (3MS), 12.42 to 15.61 (SDMT), 6.34 to 8.34 (COWAT-F), 8.13 to 10.85 (HVLT-R total recall), and 4.00 to 5.62 (HVLT-R delayed recall). CONCLUSION: This large cohort of older individuals provides test-retest reliability and MDC values for four widely employed tests of cognitive function. These results can aid interpretation of cognitive scores and decline instead of relying on cross-sectional normative data alone.

Long-Term Blood Pressure Variability and Kidney Function in Participants of the ASPREE Trial.

BACKGROUND: Whether long-term blood pressure variability (BPV) predicts kidney function decline in generally healthy older adults is unknown. We investigated this association in ASPirin in Reducing Events in the Elderly (ASPREE) trial participants. METHODS: Between 2010 and 2014, Australian and US individuals aged ≥70 years (≥65 if US minority) were recruited and followed with annual study visits for a median of 4.7 years. Time-to-event analyses and linear mixed effects models were used to examine associations between incident chronic kidney disease (CKD), and trajectories of estimated glomerular filtration rate (eGFR) and log albumin-creatinine ratio (log ACR) with systolic BPV as a continuous measure, and, by tertile of SD of systolic blood pressure (BP). BPV was estimated using systolic BP measures from baseline through the second annual visit, and kidney outcomes were assessed following this period. RESULTS: Incident CKD occurred in 1,829 of 6,759 participants (27.2%), and more commonly in BPV tertiles 2 (27.4%) and 3 (28.3%) than tertile 1 (25.5%); however, the risk was not significantly increased after covariate adjustment (tertile 3 hazard ratio = 1.02; 95% confidence interval: 0.91-1.14). Analysis of eGFR (n = 16,193) and log ACR trajectories (n = 15,213) showed individuals in the highest BPV tertile having the lowest eGFR and highest log ACR, cross-sectionally. However, the trajectories of eGFR and log ACR did not differ across BPV tertiles. CONCLUSIONS: CKD and markers of reduced kidney function occur more commonly in individuals with higher BPV; however, BPV does not influence trajectory of decline in kidney function over time in older adults who are in generally good health. CLINICAL TRIALS REGISTRATION: Trial Number NCT01038583 and ISRCTN83772183.

Patient-Reported Outcomes of Split-Thickness Skin Grafts for Floor of Mouth Cancer Reconstruction.

INTRODUCTION: Patient-reported outcome measures (PROM) on quality of life (QOL) for early-stage floor of mouth carcinoma (FOM-CA) undergoing surgical resection and split-thickness skin graft (STSG) reconstruction have not been established. We have performed a cross-sectional QOL analysis of such patients to define functional postoperative outcomes. METHODS: Patients with pathologic stage T1/T2 FOM-CA who underwent resection and STSG reconstruction at a tertiary academic cancer center reported outcomes with the University of Washington QOL (v4) questionnaire after at least 6 months since surgery. RESULTS: Twenty-four out of 49 eligible patients completed questionnaires with a mean follow-up of 41 months (range: 6-88). Subsites of tumor involvement/resection included the following: (1) lateral FOM (L-FOM) (n = 17), (2) anterior FOM (A-FOM) (n = 4), and (3) alveolar ridge with FOM, all of whom underwent lateral marginal mandibulectomy (MM-FOM) (n = 3). All patients reported swallowing scores of 70 ("I cannot swallow certain solid foods") or better. Ninety-six percent (23/24) reported speech of 70 ("difficulty saying some words, but I can be understood over the phone") or better. A-FOM patients reported worse chewing than L-FOM patients (mean: 50.0 vs. 85.3; p = 0.01). All 4 A-FOM patients reported a low chewing score of 50 ("I can eat soft solids but cannot chew some foods"). Otherwise, there were no significant differences between subsite groups in swallowing, speech, or taste. CONCLUSION: STSG reconstructions for pathologic T1-T2 FOM-CA appear to result in acceptable PROM QOL outcomes with the exception of A-FOM tumors having worse chewing outcomes.

Patient-Reported Quality of Life After Resection With Primary Closure for Oral Tongue Carcinoma.

OBJECTIVES/HYPOTHESIS: For early-stage oral tongue carcinoma and carcinoma in situ (ESOTCCIS), we evaluated patient-reported quality-of-life (QOL) outcomes following resection with primary closure (R-PC). STUDY DESIGN: Retrospective review at an academic cancer center. METHODS: Thirty-nine ESOTCCIS patients (Tis, T1, T2) who underwent R-PC without radiation completed the University of Washington Quality of Life Questionnaire Version 4 (UW-QOL) at least 6 months since R-PC (mean = 2.39 years; range = 0.5-6.7 years). We compared UW-QOL scores for pain, swallowing, chewing, speech, and taste to established normative population scores. Multivariable regression analysis evaluated factors associated with QOL impairment. RESULTS: ESOTCCIS patients who underwent R-PC in comparison to the normative population reported significantly worse mean speech (87.7 vs. 98, P < .001) and taste (85.6 vs. 95, P = .002) scores and no significant differences in mean pain (91.7 vs. 86, P = .96), swallowing (100 vs. 98, P = .98), chewing (97.4 vs. 94, P = .98) scores. For speech and taste, 59% (23/39) reported no postoperative change from baseline, whereas 41% (16/39) and 35.9% (14/39) reported mild impairment, respectively. Overall, postoperative QOL was reported as good, very good, or outstanding by 87.2% (34/39). Higher American Society of Anesthesiologists class, cT1 compared to CIS, and ventral tongue involvement were independently associated with worse speech. Age < 60 years was independently associated with worse taste. CONCLUSIONS: ESOTCCIS patients who undergo R-PC without radiation can expect long-term swallowing, chewing, and pain to be in the normative range. Although a majority of patients can expect to achieve normative speech and taste outcomes, R-PC carries the risks of mild speech and/or taste impairments. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:312-318, 2021.

Influences of Age, Gender, and Body Mass Index on the Depth of the Superficial Fascia of the Arm and Thigh.

BACKGROUND: Nonsurgical skin-tightening procedures are increasing in popularity because of their noninvasiveness as the energy is transdermally applied to the subcutaneous tissues. OBJECTIVE: To provide precise data on the depth of the superficial fascia for potentially safer and better targeted treatments of arms and thighs. METHODS: One hundred fifty Caucasian individuals were investigated with an equal distribution of men and women (each n = 75) and a balanced distribution of age (n = 30 per decade). Ultrasound-based measurements were conducted, measuring the distance between skin and the superficial fascia in the posterior arm and the anterior, medial, and posterior thigh. RESULTS: Deep to the skin, 5 layers were consistently and bilaterally identified in both sexes: skin, superficial fat, superficial fascia, deep fat, and deep fascia. The overall mean distance between the skin surface and the superficial fascia was for the posterior arm 4.38 ± 0.9 mm; range (2.60-6.70), for the anterior thigh 7.90 ± 2.3 mm range (3.50-13.20), for the medial thigh 5.74 ± 1.2 mm range (3.10-8.20), and for the posterior thigh 7.77 ± 3.2 mm range (3.60-14.50). CONCLUSION: Knowing the precise depth of the superficial fascia for nonsurgical skin-tightening procedures could potentially guide practitioners toward safer and more effective outcomes.

Treating the Lips and Its Anatomical Correlate in Respect to Vascular Compromise.

Treating the lips to increase facial attractiveness and youthfulness is challenging when trying to consider ethnic differences in an increasingly more diverse society. Multiple injection techniques are currently available for treating lip contour and volume, but a validation in the cadaveric model under the aspects of safety has not been performed yet. The injection techniques presented in this study are based on the experience and personal selection of the authors. The authors have assessed, treated, and evaluated for more than 20 years patients from the Middle East and Central Europe. Cadaveric verification was performed for each of the presented techniques to identify the positioning of the injected product inside the lips and its relation to the superior/inferior labial arteries. The results of the anatomic analyses revealed that in 58.3% of the performed injections, the product was placed close to the superior/inferior labial arteries. In 60.0% of the cases, applications using a needle placed the injected product in endangered locations, whereas 57.1% of the cases using cannulas placed the product in endangered locations (i.e., in the vicinity of the superior/inferior labial arteries). This anatomic study revealed that injected material into the lips is frequently placed in close proximity to labial arteries representing a high risk for intra-arterial applications, leading to tissue loss (necrosis) and potential end-arterial embolism (potential blindness). Nevertheless, treatment of the lips should be a multistep approach focusing first on the far (upper and middle face) and close (labiomandibular and labiomental) perioral regions.

Influence of Age, Sex, and Body Mass Index on the Depth of the Superficial Fascia in the Face and Neck.

BACKGROUND: Nonsurgical skin-tightening procedures are increasing in popularity, as patients seek aesthetic interventions that are safe with minimal downtime. OBJECTIVE: This study was designed to provide precise data on the depth of the superficial fascia-the structure of action-of the face and neck. METHODS: One hundred fifty Caucasian individuals (75 men and 75 women) were investigated with a balanced distribution of age (n = 30 per decade: 20-29, 30-39, 40-49, 50-59, and 60-69 years) and body mass index (BMI) (n = 50 per group: BMI ≤ 24.9 kg/m, BMI between 25.0 and 29.9 kg/m, and BMI ≥ 30 kg/m). The distance between skin surface and the superficial fascia was measured through ultrasound in the buccal region, premasseteric region, and lateral neck. RESULTS: The mean distance between skin surface and superficial fascia was for the buccal region 4.82 ± 0.9 mm, range (2.60-6.90); for the premasseteric region 4.25 ± 0.6 mm, range (2.60-5.80); and for the lateral neck 3.71 ± 0.5 mm, range (2.0-5.0). The depth of the superficial fascia increased with increasing BMI, whereas it decreased with advanced age. CONCLUSION: Knowing the precise depth of the superficial fascia for nonsurgical skin-tightening procedures will guide practitioners toward safer and more effective outcomes.

Arterial Wall Penetration Forces in Needles versus Cannulas.

BACKGROUND: If safety is defined as the diminished ability to penetrate facial arteries, the goal of this study was to investigate whether different-sized cannulas are safer than correspondingly sized needles for the application of facial soft-tissue fillers. METHODS: Two hundred ninety-four penetration procedures of the facial and superficial temporal arteries were performed in four fresh frozen cephalic specimens using both needles (20-, 22-, 25-, and 27-gauge) and cannulas (22-, 25-, and 27-gauge). Continuously increasing force was applied and measured until intraarterial penetration occurred. RESULTS: No statistically significant differences were detected when comparing forces required to penetrate the facial arterial vasculature between different sexes, arteries, or sides of the face (all p > 0.05). Forces needed to penetrate significantly (p < 0.001) decreased with smaller diameter needles (20-gauge, 1.12 ± 0.29 N; 22-gauge, 1.08 ± 0.25 N; 25-gauge, 0.69 ± 0.24 N; and 27-gauge, 0.70 ± 0.29 N) and in cannulas (22-gauge, 1.50 ± 0.31 N; 25-gauge, 1.04 ± 0.36 N; and 27-gauge, 0.78 ± 0.35 N). Comparing 27-gauge injectors, no statistically significant difference was detected between needles and cannulas; an artery could be penetrated with a similar force independent of whether the injector was a needle or a cannula (0.70 ± 0.29 N versus 0.78 ± 0.35 N; p = 0.558). CONCLUSIONS: Cannulas, in all measured sizes except 27-gauge, required greater forces for intraarterial penetration compared with correspondingly sized needles, confirming the safety of 22- and 25-gauge cannulas; 27-gauge cannulas, however, required similar forces as 27-gauge needles, indicating that 27-gauge cannulas are not safer than 27-gauge needles. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

The posterior temporal supraSMAS minimally invasive lifting technique using soft-tissue fillers.

BACKGROUND: To investigate the effectiveness of the posterior temporal supraSMAS minimally invasive lifting technique and compared it to experiments performed in fresh human body donors by applying skin vector displacement measurement technology. MATERIALS AND METHODS: A total of 15 patients (14 females/1 male) with a mean age of 37.1 ± 9.4 years and a mean body mass index of 21.4 ± 3.3 kg/m2 were included into this observational analysis. The injection procedure was additionally performed in 2 male and 1 female fresh body donors with a mean age of 85.67 ± 9.7 years and a mean body mass index of 23.83 ± 4.7 kg/m2 . Different grades of skin laxity, variable amounts of product, and the application with and without subcision were tested and measured via three-dimensional reconstructions and surface displacement vectors using Vectra software with VAM module. RESULTS: Esthetic outcome was rated by an independent professional observer and by the patient immediately after the treatment (76.67% ± 17.6% vs 66.67% ± 18.1%) (P = 0.001) and after 1 month (80.00% ± 14.0% vs 75.00% ± 21.1%) (P = 0.19). Skin laxity, subcision, and the application of more than 1.0 cc per side resulted in our experimental setting in a smaller magnitude of skin displacement vectors indicating a reduced lifting effect. CONCLUSION: The posterior temporal supraSMAS minimally invasive lifting procedure seems to be a valid technique to treat temporal volume loss and to reduce the signs of age-related changes in the middle and lower face, ie "marionett line" and jowl deformity.

The layered anatomy of the jawline.

BACKGROUND: To investigate the layered anatomy of the jawline and to provide anatomic background for the formation of the labiomandibular sulcus, the jowl deformity, and the "double-chin" for safe and effective minimally invasive procedures. MATERIALS AND METHODS: Seventy-two fresh-frozen human cephalic cadavers (32 males, 40 females; mean age 75.2 ± 10.9 years, BMI 24.2 ± 6.6 kg/m2 , 99% Caucasian ethnicity) were investigated by layer-by-layer anatomical dissection. Magnet resonance and computed tomographic imaging was additionally carried out to support the anatomical findings. RESULTS: No major neuro-vascular structures were found to run in the subdermal plane or in the subcutaneous fat. The jowl deformity was identified to be caused by the loose adherence of the platysma to the mandible, which occurs posterior (but not anterior) to the mandibular ligament. The formation of the submental sulcus was identified to be caused by the submental septum, an osteo-cutaneous adhesion spanning all facial layers in the submental area. The formation of the labiomandibular sulcus was caused by the change in the subcutaneous fibro-connective arrangement rather than by an underlying adhesion or ligament. CONCLUSION: The layered arrangement of the jawline predisposes this region for subdermal and subcutaneous treatment options located superficial to the platysma. Subdermal subcision procedures might have a beneficial effect on the labiomandibular sulcus as the boundary between the different types of subcutaneous arrangement, which form the sulcus, is being smoothened.