Objective Measures Of Frailty Research Articles

The relationship between frailty, incontinence severity, and treatment decisions for men with post-prostatectomy stress urinary incontinence: a mixed methods analysis.

Frailty is common among urology patients in general as well as among men seeking evaluation for stress urinary incontinence (SUI), with 6.1% of men undergoing artificial urinary sphincter placement considered frail. It is unclear if and how patient views on frailty and incontinence severity impact decision-making with regards to SUI treatment. We undertook a mixed methods analysis to evaluate the intersection of frailty, incontinence severity, and treatment decision-making is presented. To do so, we utilized a previously published cohort of men undergoing evaluation for SUI at the University of California, San Francisco between 2015 and 2020, selecting those who had evaluation with timed up and go test (TUGT), objective measures of incontinence, and patient-reported outcome measures (PROMs). A subset of these participants had additionally undergone semi-structured interviews, and these interviews were re-examined to thematically code them with a focus on the impact of frailty and incontinence severity on SUI treatment decision-making. Among the original cohort of 130 patients, 72 had an objective measure of frailty and were included in our analysis; 18 of these individuals had corresponding qualitative interviews. Common themes identified included (I) impact of incontinence severity on decision-making; (II) the interaction between frailty and incontinence; (III) the impact of comorbidity on treatment decision-making; and (IV) age as a construct of frailty and impact on surgical choice and/or recovery. Direct quotations regarding each theme provides insight into patients' views and drivers of SUI treatment decision-making. The impact of frailty on treatment decision-making for patients with SUI is complex. This mixed methods study highlights the variety of patient views on frailty with regards to surgical intervention for male SUI. Urologists should make a concerted effort to personalize patient counseling for SUI management and take time to understand each patient's perspective in order to individualize SUI treatment decision-making. More research is needed to help identify factors that influence decision-making for frail male patients with SUI.

Psoas Muscle Area As A Prognostic Factor For Survival In Patients Undergoing EVAR Conversion

INTRODUCTION AND OBJECTIVES EVAR conversion (EVAR-c) is technically complex and physiologically demanding. Measures to quantify surgical frailty preoperatively may be useful prior to offering EVAR explant. There is data supporting psoas muscle area (PMA) as a prognostic factor in fenestrated endovascular and open AAA repairs. The purpose of this analysis was to use PMA as an objective measure of frailty and to determine its utility as a predictor of survival for EVAR-c. METHODS A retrospective single-center review of all AAA repairs was performed (2002-2019) and EVAR-c procedures were analyzed (n=153).Cross-sectional area of the psoas at the mid-body of the L3 vertebrae were measured. The lowest tertile of PMA in all patients was used as a cutoff value for low PMA and these patients were compared to “non-low” PMA. RESULTS Patients with low PMA tended to be older(77vs72,p=.002),less likely to be male(73%vs95%,p<.001),and have lower BMIs(26vs29%,p=.002). Time to conversion, total number of EVAR reinterventions and elective presentation as an indication for repair were similar, however; patients with low PMA had larger aneurysms(8.3vs7.5cm,p=.01)and increased post-EVAR sac growth(2.3vs1cm,p=.005). Inpatient mortality was significantly increased for those with low PMA(16%vs5%, p=.02)as well as the total number of complications (1.5±1.9vs0.9±1.5).Although MACE and need for inpatient dialysis were similar, those with low PMA had a four-fold increase in requiring dialysis at discharge(18%vs4%,p=.01).Long-term mortality was significantly reduced in those with low PMA at 68%,55%and 40% at 1,3 and 5 years, respectively, compared with 81%,69%and 69%(p=.049). CONCLUSIONS In patients with low PMA, higher complications, increased perioperative mortality and worse long-term survival may be expected. Time to conversion and endovascular remediation are equivalent but rates of sac growth and overall AAA diameter are increased. PMA evaluation offers a potential to stratify which patients may have worse short-term and late outcomes undergoing EVAR-c. EVAR conversion (EVAR-c) is technically complex and physiologically demanding. Measures to quantify surgical frailty preoperatively may be useful prior to offering EVAR explant. There is data supporting psoas muscle area (PMA) as a prognostic factor in fenestrated endovascular and open AAA repairs. The purpose of this analysis was to use PMA as an objective measure of frailty and to determine its utility as a predictor of survival for EVAR-c. A retrospective single-center review of all AAA repairs was performed (2002-2019) and EVAR-c procedures were analyzed (n=153).Cross-sectional area of the psoas at the mid-body of the L3 vertebrae were measured. The lowest tertile of PMA in all patients was used as a cutoff value for low PMA and these patients were compared to “non-low” PMA. Patients with low PMA tended to be older(77vs72,p=.002),less likely to be male(73%vs95%,p<.001),and have lower BMIs(26vs29%,p=.002). Time to conversion, total number of EVAR reinterventions and elective presentation as an indication for repair were similar, however; patients with low PMA had larger aneurysms(8.3vs7.5cm,p=.01)and increased post-EVAR sac growth(2.3vs1cm,p=.005). Inpatient mortality was significantly increased for those with low PMA(16%vs5%, p=.02)as well as the total number of complications (1.5±1.9vs0.9±1.5).Although MACE and need for inpatient dialysis were similar, those with low PMA had a four-fold increase in requiring dialysis at discharge(18%vs4%,p=.01).Long-term mortality was significantly reduced in those with low PMA at 68%,55%and 40% at 1,3 and 5 years, respectively, compared with 81%,69%and 69%(p=.049). In patients with low PMA, higher complications, increased perioperative mortality and worse long-term survival may be expected. Time to conversion and endovascular remediation are equivalent but rates of sac growth and overall AAA diameter are increased. PMA evaluation offers a potential to stratify which patients may have worse short-term and late outcomes undergoing EVAR-c.

Provider Perception of Frailty Is Associated with Dialysis Decision Making in Patients with Advanced CKD.

Frailty is common in patients with CKD. Little is known about the prevalence of frailty and its effect on prognosis and decisions surrounding dialysis modalities in patients with advanced CKD (eGFR<30 ml/min per 1.73 m2). Our objective was to determine the agreement between different frailty measures and physical function and their association with dialysis modality choice (home based versus in-center) and all-cause mortality in patients with advanced CKD. Our study was a prospective, multicenter, cohort study. In 603 patients with advanced CKD, we collected demographics, comorbidities, and laboratory results in addition to objective (Fried frailty criteria) and subjective measures of frailty (physician and nurse impressions) and physical function (Short Physical Performance Battery). Logistic regression and Cox proportional hazards models were used to evaluate the association of frailty with dialysis modality choice and all-cause mortality, respectively. The prevalence of frailty varied with assessment tool used (Fried frailty criteria, 34%; Short Physical Performance Battery, 55%; physician impression, 44%; nurse impression, 36%). The agreement between all frailty and physical function measures was poor. We had 227 patients reach kidney failure and decide on a dialysis therapy, and 226 patients died during a mean follow-up of 1455 days. After adjusting for age, sex, and comorbid conditions, the Fried criteria and Short Physical Performance Battery were associated with a two-fold higher risk of all-cause mortality (hazard ratio, 1.96; 95% confidence interval, 1.47 to 2.61 and hazard ratio, 1.96; 95% confidence interval,1.42 to 2.76, respectively). Patients deemed as frail by physician and nurse frailty impressions were three to four times more likely to choose in-center dialysis (odds ratio, 3.41; 95% confidence interval, 1.56 to 7.44; odds ratio, 3.87; 95% confidence interval, 1.76 to 8.51, respectively). We found that the agreement between objective and subjective measures of frailty and physical function was poor. Objective measures of frailty and physical function were associated with mortality, and subjective measures of frailty were associated with dialysis modality choice.

The association between low pre-operative step count and adverse post-operative outcomes in older patients undergoing colorectal cancer surgery

BackgroundMultiple tools exist estimating perioperative risk. With an ageing surgical demographic, frailty is becoming an increasingly important concept in perioperative medicine due to its association with adverse post-operative outcomes. Reduced physical activity is a hallmark of frailty, and we postulate that a low pre-operative step count may be an objective measure of frailty. This study aimed to determine the association between low pre-operative step count and post-operative outcomes in patients undergoing elective colorectal cancer surgery.MethodsA prospective analysis of 85 older patients undergoing major elective colorectal surgery was performed at a tertiary centre between October 2017 and October 2018. Patients aged 65 years and over who met inclusion criteria were provided with an activity tracker to wear for 14 days prior to planned surgery. Their median daily step count was measured and a cut-off of < 2500 steps/day was used to define a reduced step count. Primary outcomes included length of stay and 30-day post-operative complication rate. Multivariable logistic regression analyses were used to analyze the influence of low pre-operative step count and other preoperative variables, on post-operative outcomes including mortality, prolonged hospital admission, and complication rates.ResultsOf 85 patients, 17 (20%) were identified as having a low pre-operative step count. A low pre-operative step count was associated with a significantly increased length of stay (14 vs. 6 days, IRR 2.09, 95% CI 1.55–2.83, p ≤ 0.01) and rate of major post-operative complications (29.4% vs. 8.8%, OR 3.34, 95% CI 1.03–14.3, p = 0.04). It was also associated with significantly increased rates of discharge to care facilities (p < 0.01) and requiring support on discharge (p = 0.03).ConclusionLow pre-operative step count (< 2500 steps/day) is predictive of an increased risk of post-operative morbidity in patients undergoing elective colorectal surgery. Accurate preoperative identification may allow for treatment modification and tailored perioperative care. The possibility of using a wearable activity tracker as a simple but powerful pre-habilitation tool is raised as an important avenue for future study.Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12618000045213).

P0197CLINICAL FRAILTY SCORING IN PATIENTS WITH END STAGE RENAL DISEASE: A PREDICTOR OF DECLINING HEALTH?

Abstract Background and Aims The incidence of frailty increases as GFR decreases. In the end stage renal disease (ESRD) population frailty is associated with early mortality, increased hospitalisations, and significant symptom burden. We examined the use of formal frailty scoring and its role in identifying deteriorating patients with advanced renal disease. Method The Rockwood Clinical Frailty Scale (CFS) has high inter-rater reliability and correlates well with objective measures of frailty. We introduced routine recording of the CFS from January 2018 in the renal electronic record for patients on hospital haemodialysis therapy and those undergoing renal replacement therapy (RRT) planning. Based on CFS scoring patients were divided into ‘frail’ (CFS≥6) or ‘robust’ based (CFS&amp;lt;6) and patient demographics are described. The association of being ‘frail’ or a decline in score with mortality at seven months were described using adjusted logistic regression analyses. Results A total of 1663 scores were recorded in 800 patients. 57.3% of patients were male. The median age at entry date was 66 (IQR 55,75) years. The median CFS score was 4 (IQR 3,5). At follow-up 74 (9.3%) had died. The median score prior to death was 5.5. 182 (22.8%) were ‘frail’. During the study period 469 patients had more than one score documented. Death at follow-up was more common in those who were ‘frail’, 20.9 vs 5.8%, p&amp;lt;0.001. Patients who were deceased at follow-up were more likely to have had a deterioration in frailty score, 51.9% vs 24.4%, p=0.002. Being ‘frail’ or having a deteriorating frailty score was associated with death at seven-month follow-up independent of age, sex or diabetic nephropathy status. Conclusion The presence of ‘frailty’ as measured by CFS, or deterioration in CFS is associated with death at follow-up, independent of age, sex or diabetic nephropathy. Routine monitoring of frailty using the CFS provides a simple method to identify patients who are deteriorating and at risk of death. High or deteriorating CFS score should trigger clinical review and anticipatory care planning where appropriate.

Association Between Sarcopenia and Functional Status in Liver Transplant Patients.

A growing body of evidence shows that frailty and functional performance predict liver transplant outcomes. The Organ Procurement and Transplant Network uses the Karnofsky Performance Status scale to adjust for transplant center case mix in assessing quality measures. This study explores the strength of the relationship between Karnofsky Performance Status scores and objective measures of frailty. This observational study includes 136 adult, first-time liver transplant recipients at UMass Memorial (2006-2015) who had 2 abdominal computed tomography scans available (at ≤ 90 days pretransplant and ≥ 7 days before that). We analyzed the relationship between Karnofsky Performance Status and muscle wasting using absolute and change in psoas muscle size and quality pretransplant. The mean age was 55 years, mean Model for End-Stage Liver Disease was 22, and 34% of patients were women. In the study group, 50% of patients had sarcopenia pretransplant and 71.3% demonstrated declined lean psoas area at an average rate of 11% per month. Patients who experienced muscle wasting at a rate of ≥ 1% per month had 2.83 times the risk (95% confidence interval, 1.18-6.80) of being severely impaired/disabled pretransplant. The risk increased by 2.32-fold (95% confidence interval, 1.44-3.75) for every standard deviation decrease in pretransplant lean psoas area. Provider-assessed physical health status moderately correlates with objective measures of frailty.

CAN YOU SEE FRAILTY? AN EXPLORATORY STUDY OF THE USE OF A PATIENT PHOTOGRAPH IN THE TRANSCATHETER AORTIC VALVE IMPLANTATION PROGRAM

Frailty is a multisystem clinical syndrome characterized by the loss of physiological reserves and accumulation of physical deficits. The measurement of frailty is an important assessment to inform treatment decision, peri-procedure planning, post-operative care, and transition home. This is of pivotal importance in the management of elderly patients referred for transcatheter aortic valve implantation (TAVI). To this end, frailty is routinely measured in our centre at the time of assessment using the Essential Frailty Toolset (EFT), while a patient photograph is taken to document overall health status. Documentation of frailty is used as an adjunctive source of information to augment multimodality assessment. We sought to understand how the standardized use of a patient photograph is associated with an objective measure of frailty, and how clinicians use the photograph to form impressions about patients considered for TAVI. We conducted a mixed methods exploratory study to (1) examine the relationship between the EFT, a validated and sensitive frailty score, and health care providers’ (HCPs) assessment of frailty as determined by the patient’s photograph, and (2) investigate how clinicians use patient photographs to form impressions about frailty and clinical care. To this end, we prospectively recruited patients and HCPs. HCPs rated a set of patient photographs between 0 (not frail) and 6 (very frail); median HCP scores were compared to the objective EFT score, across all disciplines, and between nurses and physicians. Using content analysis informed by an interpretive description approach, we conducted semi-structured interviews with HCPs directly involved in TAVI treatment decisions to explore how they form impressions of frailty. We recruited 40 patients who agreed to have their photograph included in the study; their EFT score ranged from 0 to 6. Individual variations in photo ratings were observed; median ratings were higher than EFT scores. Patients’ use of a mobility aid was associated with higher ratings. Nursing and physician ratings were generally aligned. HCPs’ impressions were informed by patients’ visible attributes, the inferences made, and the cautious clinical conclusions drawn. The routine use of a patient photograph augments multimodality assessment but requires recommendations for use to inform clinical care. Cardiovascular nurses can play a pivotal role in the development of a nursing protocol to document patients’ photograph and provide leadership for the multidisciplinary team to critically examine its use in practice.

Estimated glomerular filtration rate and functional status among older people: A systematic review

BackgroundThe association between chronic kidney disease (CKD) and functional status may change as a function of the equation used to estimate glomerular filtration rate (eGFR). We reviewed the predictive value of different eGFR equations in regard to frailty and disability outcomes. MethodsWe searched Pubmed from inception to March 2018 for studies investigating the association between eGFR and self-reported and/or objective measures of frailty or disability. Cross-sectional and longitudinal studies were separately analysed. ResultsWe included 16 studies, one of which reporting both cross-sectional and longitudinal data. Three out of 7 cross-sectional studies compared different eGFR equations in regard to their association with functional status: two studies showed that cystatin C-based, but not creatinine-based eGFR may be associated with hand-grip strength or frailty; another study showed that two different creatinine-based eGFR equations may be similarly associated with disability. Four out of 10 longitudinal studies provided comparative data: two studies reported similar association with disability for different creatinine-based eGFR equations; one study showed that creatinine-based eGFR was not associated with frailty, but a not significant trend for association was observed with cystatin C-based eGFR; one study showed that cystatin C-based but not creatinine-based eGFR may predict incident mobility disability, while both methods may predict gait speed decline. High heterogeneity was observed in regard to confounders included in reviewed studies. None of them included the most recently published equations. ConclusionAvailable data do not support the superiority of one of the eGFR equations in terms of measuring or predicting functional decline.

Sarcopenia increases risk of long-term mortality in elderly patients undergoing emergency abdominal surgery.

Frailty is associated with poor surgical outcomes in elderly patients but is difficult to measure in the emergency setting. Sarcopenia, or the loss of lean muscle mass, is a surrogate for frailty and can be measured using cross-sectional imaging. We sought to determine the impact of sarcopenia on 1-year mortality after emergency abdominal surgery in elderly patients. Sarcopenia was assessed in patients 70 years or older who underwent emergency abdominal surgery at a single hospital from 2006 to 2011. Average bilateral psoas muscle cross-sectional area at L3, normalized for height (Total Psoas Index [TPI]), was calculated using computed tomography. Sarcopenia was defined as TPI in the lowest sex-specific quartile. Primary outcome was mortality at 1 year. Secondary outcomes were in-hospital mortality and mortality at 30, 90, and 180 days. The association of sarcopenia with mortality was assessed using Cox proportional hazards regression and model performance judged using Harrell's C-statistic. Two hundred ninety-seven of 390 emergency abdominal surgery patients had preoperative imaging and height. The median age was 79 years, and 1-year mortality was 32%. Sarcopenic and nonsarcopenic patients were comparable in age, sex, race, comorbidities, American Society of Anesthesiologists classification, procedure urgency and type, operative severity, and need for discharge to a nursing facility. Sarcopenic patients had lower body mass index, greater need for intensive care, and longer hospital length of stay (p < 0.05). Sarcopenia was independently associated with increased in-hospital mortality (risk ratio, 2.6; 95% confidence interval [CI], 1.6-3.7) and mortality at 30 days (hazard ratio [HR], 3.7; 95% CI, 1.9-7.4), 90 days (HR, 3.3; 95% CI, 1.8-6.0), 180 days (HR, 2.5; 95% CI, 1.4-4.4), and 1 year (HR, 2.4; 95% CI, 1.4-3.9). Sarcopenia is associated with increased risk of mortality over 1 year in elderly patients undergoing emergency abdominal surgery. Sarcopenia defined by TPI is a simple and objective measure of frailty that identifies vulnerable patients for improved preoperative counseling, setting realistic goals of care, and consideration of less invasive approaches. Prognostic study, level III.

Sarcopenia: Preoperative assessment of muscle mass to predict surgical complications and prognosis in patients with endometrial cancer

Background Sarcopenia or loss of skeletal muscle mass is an objective measure of frailty associated with functional impairment and disability. This study aimed to examine the impact of sarcopenia on surgical complications and survival outcomes in patients with endometrial cancer.

Frailty Measurements and Dysphagia in the Outpatient Setting

Deconditioning and frailty may contribute to dysphagia and aspiration. Early identification of patients at risk of aspiration is important. Aspiration prevention would lead to reduced morbidity and health care costs. We therefore wondered whether objective measurements of frailty could help identify patients at risk for dysphagia and aspiration. Consecutive patients (n = 183) were enrolled. Patient characteristics and objective measures of frailty were recorded prospectively. Variables tested included age, body mass index, grip strength, and 5 meter walk pace. Statistical analysis tested for association between these parameters and dysphagia or aspiration, diagnosed by instrumental swallowing examination. Of variables tested for association with grip strength, only age category (P = .003) and ambulatory status (P < .001) were significantly associated with grip strength in linear regression models. Whereas walk speed was not associated with dysphagia or aspiration, ambulatory status was significantly associated with dysphagia and aspiration in multivariable model building. Nonambulatory status is a predictor of aspiration and should be included in risk assessments for dysphagia. The relationship between frailty and dysphagia deserves further investigation. Frailty assessments may help identify those at risk for complications of dysphagia.

MP39-02 CORE MUSCLE SIZE PREDICTS 6-MONTH MORTALITY IN PATIENTS UNDERGOING RADICAL CYSTECTOMY

You have accessJournal of UrologyBladder Cancer: Basic Research IV1 Apr 2014MP39-02 CORE MUSCLE SIZE PREDICTS 6-MONTH MORTALITY IN PATIENTS UNDERGOING RADICAL CYSTECTOMY Hailey Allen, E Jason Abel, Daniel D. Shapiro, Fangfang Shi, Aaron Potretzke, David F. Jarrard, Timothy J. Ziemiewicz, and Tracy M. Downs Hailey AllenHailey Allen More articles by this author , E Jason AbelE Jason Abel More articles by this author , Daniel D. ShapiroDaniel D. Shapiro More articles by this author , Fangfang ShiFangfang Shi More articles by this author , Aaron PotretzkeAaron Potretzke More articles by this author , David F. JarrardDavid F. Jarrard More articles by this author , Timothy J. ZiemiewiczTimothy J. Ziemiewicz More articles by this author , and Tracy M. DownsTracy M. Downs More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1317AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Loss of skeletal muscle mass, termed sarcopenia, is a reproducible marker of overall frailty and is closely linked to surgical outcomes. Core muscle size seems to represent a unique domain of preoperative surgical risk assessment to identify patient’s who may not benefit from curative oncologic surgery. The objective of this study was to evaluate the ability of total psoas muscle area (TPA) to predict mortality in patients undergoing radical cystectomy (RC). METHODS Preoperative computed tomographic (CT) studies were retrospectively analyzed in 128 of the 145 patients who underwent RC for urothelial carcinoma between January 2009 and May 2013. Cross-sectional area in mm2 was measured of the left and right psoas muscles at the level of the L4 transverse processes. The left and right psoas muscle areas were summed to obtain a total psoas muscle area (TPA). Patients were divided into tertiles of TPA, with the high TPA group serving as the reference group for the analysis. Outcomes measured included 6-month mortality. RESULTS 98 patients (76.5%) were male and 30 patients (23.4%) were female. Median follow-up 25.4 months. Median age was 68 years old (IQR 58-76.5), median BMI 28.1 (IQR 24.8-30.9), and median preoperative albumin was 3.7 g/dl (IQR 3.5-4.2). Median TPA was 2321.5 mm2 (IQR 1908.6-2785.2) On univariate analysis overall survival was significantly worse for the low TPA group compared to the high TPA group - HR 2.85 (CI 1.4-5.7). 6-month mortality (p=0.01) rates were significantly higher in the low TPA group compared to the high TPA group. CONCLUSIONS Additional measures to improve preoperative risk assessment are necessary for patients undergoing radical cystectomy. Core muscle size, an objective measure of frailty was correlated with early mortality following RC in this study. Multicenter studies in larger cohorts are necessary to valid these findings. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e426 Peer Review Report Advertisement Copyright & Permissions© 2014MetricsAuthor Information Hailey Allen More articles by this author E Jason Abel More articles by this author Daniel D. Shapiro More articles by this author Fangfang Shi More articles by this author Aaron Potretzke More articles by this author David F. Jarrard More articles by this author Timothy J. Ziemiewicz More articles by this author Tracy M. Downs More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The effect of free health care on polypharmacy: a comparison of propensity score methods and multivariable regression to account for confounding

Differing healthcare access has implications for public health. In Ireland, eligibility for free public health care is means tested. Here, we examine the association between healthcare access and polypharmacy while accounting for underlying socio-economic and health status differences. Self-reported regular medication use, history of diagnosed health conditions, disability, socio-demographics, and objective measures of depression and anxiety for adults aged 50-69 years (n = 5796) were ascertained from the population-representative Irish Longitudinal Study on Ageing. Objective measures of frailty, cognition, hypertension, and body mass index were also assessed for 4241 participants. The associations between free healthcare access and polypharmacy and use of 15 medication classes were estimated using multivariable modified Poisson regression, adjustment for the propensity score, and inverse probability of treatment weighting by the propensity score. Polypharmacy was reported by 22% and 7% of the 1932 and 3864 participants with and without public healthcare coverage. Public patients had a 21-38% greater risk of polypharmacy depending on the method used to account for confounding. Results were less robust using propensity score weighting. There was evidence that classes of cardiovascular drugs, drugs for acid-related disorders, and analgesics were used more commonly in public patients. Associations were mostly unaffected after also accounting for objective health measures but were significantly attenuated after accounting for frequency of healthcare visits. Publically funded health care in Ireland leads to greater medication use in people aged 50-69 years. This may reflect over-prescribing to public patients or restricted use among those who pay out of pocket.

Gender Differences in Self- versus Clinician-Rated Global Health Status among Liver Transplant Candidates

Purpose: Gender differences in liver transplant outcomes exist: females experience higher rates of wait-list mortality and, among hepatitis C-infected (HCV) recipients, have higher rates of acute rejection and posttransplant mortality. We hypothesized that patient- or clinician-perceived health status may be contributing to these outcomes. The aim of this study was to explore gender differences in perceived health status. Methods: All outpatients ≥18 years listed for LT with model for end-stage liver disease (MELD)≥12 at a single center underwent a structured assessment of global functional status (“Frailty Score”) [Fried Instrument; range: 0-5] at baseline. Patients (self-assessment) and their clinicians (MD-assessment) were then asked to grade the patient's global health status on a range of excellent (0) to fair (3), to very poor (5) without knowledge of the frailty score. Correlations were assessed by the Pearson's correlation coefficient (r). Results: One hundred sixty-two listed LT outpatients with MELD≥12 had a mean [standard deviation(SD)] age of 57 years (10), 57% were White, 52% had HCV, and 20% had hepatocellular carcinoma (HCC). Mean (SD) MELD was 17 (5), frailty score was 1.5 (1.1). Compared to the 115 (71%) males (M), the 47 (29%) females (F) were older (59 vs. 56; p=0.03), but were similar by % HCV, % HCC, and MELD score. F vs. M were more frail by frailty score (1.9 vs. 1.4; p<0.01) and MD-assessment scores (2.7 vs. 2.2; p=0.04), but self-assessment scores were similar (3.5 vs. 3.3; p=0.25). The correlation between MD-assessment and frailty score among M was weak (r=0.27; p<0.01), but stronger among F (r=0.47; p<0.01). The correlation between self-assessment and frailty scores among M (r=0.46; p<0.01) and F (r=0.41; p<0.01) was similar. The correlation between MD-assessment and self-assessment was weak for both M (r=0.34; p<0.01) and F (r=0.30; p<0.01). Conclusion: Female LT candidates are more frail than males by an objective measure of frailty. Despite this difference, self-rated global health status was similar by gender. Clinician-rated global health status was more strongly correlated for female than male LT candidates. Whether these gender differences in patient- and clinician-perceived global health status contribute to outcomes in liver transplantation warrant further study.

Impact of Sarcopenia on Outcomes Following Intra-arterial Therapy of Hepatic Malignancies

BackgroundAssessment of patient performance status is often subjective. Sarcopenia—measurement of muscle wasting—may be a more objective means to assess performance status and therefore mortality risk following intra-arterial therapy (IAT). MethodsTotal psoas area (TPA) was measured on cross-sectional imaging in 216 patients undergoing IAT of hepatic malignancies between 2002 and 2012. Sarcopenia was defined as TPA in the lowest sex-specific quartile. Impact of sarcopenia was assessed relative to other clinicopathological factors. ResultsIndications for IAT included hepatocellular carcinoma (51 %), intrahepatic cholangiocarcinoma (13 %), colorectal liver metastasis (7 %), or other metastatic disease (30 %). Median TPA among men (568 mm2/m2) was greater than women (413 mm2/m2). IAT involved conventional chemoembolization (54 %), drug-eluting beads (40 %), or yttrium-90 (6 %). Median tumor size was 5.8 cm; most patients had multiple lesions (74 %). Ninety-day mortality was 9.3 %; 3-year survival was 39 %. Factors associated with risk of death were tumor size (HR = 1.84) and Child's score (HR = 2.15) (all P < 0.05). On multivariate analysis, sarcopenia remained independently associated with increased risk of death (lowest vs. highest TPA quartile, HR = 1.84; P = 0.04). Sarcopenic patients had a 3-year survival of 28 vs. 44 % for non-sarcopenic patients. ConclusionsSarcopenia was an independent predictor of mortality following IAT with sarcopenic patients having a twofold increased risk of death. Sarcopenia is an objective measure of frailty that can help clinical decision-making regarding IAT for hepatic malignancies.

Sarcopenia as a Prognostic Factor among Patients with Stage III Melanoma

Several hypotheses proposed to explain the worse prognosis for older melanoma patients include different tumor biology and diminished host response. If the latter were true, then biologic frailty, and not age, should be an independent prognostic factor in melanoma. Our prospective institutional review board (IRB)-approved database was queried for stage III patients with computed tomography (CT) scans at time of lymph node dissection (LND). Psoas area (PA) and density (PD) were determined in semi-automated fashion. Kaplan-Meier (K-M) survival estimates and Cox proportional-hazard models were used to determine PA and PD impact on survival and surgical complications. Among 101 stage III patients, PD was significantly associated with both disease-free survival (DFS) (P = 0.04) and distant disease-free survival (DDFS) (P = 0.0002). Cox multivariate modeling incorporating thickness, age, ulceration, and N stage showed highly significant association with PD and both DFS and DDFS. DDFS was significantly associated with Breslow thickness (P = 0.04), number of positive nodes (P = 0.001), ulceration (P = 0.04), and decreasing muscle density (P = 0.01), with hazard ratio of 0.55 [95% confidence interval (CI) 0.35-0.87]. PD also correlated with surgical complications, with odds ratio (OR) of 1.081 [95% CI 1.016-1.150, P = 0.01]. Decreased psoas muscle density on CT, an objective measure of frailty, was as important a predictor of outcome as tumor factors in a cohort of stage III melanoma patients. On multivariate analysis, frailty, not age, was associated with decreased disease-free survival and distant disease-free survival, and higher rate of surgical complications.

Frailty, core muscle size, and mortality in patients undergoing open abdominal aortic aneurysm repair

Determining operative risk in patients undergoing aortic surgery is a difficult process, as multiple variables converge to affect overall mortality. Patient frailty is certainly a contributing factor, but is difficult to measure, with surgeons often relying on subjective or intuitive influences. We sought to use core muscle size as an objective measure of frailty, and determine its utility as a predictor of survival after abdominal aortic aneurysm (AAA) repair. Four hundred seventy-nine patients underwent elective open AAA repair between 2000 and 2008. Two hundred sixty-two patients (54.7%) had preoperative computed tomography (CT) scans available for analysis. Cross-sectional areas of the psoas muscles at the level of the L4 vertebra were measured. The covariate-adjusted effect of psoas area on postoperative mortality was assessed using Cox regression. Of the 262 patients, there were 55 deaths and the mean length of follow-up was 2.3 years. Cox regression revealed a significant association between psoas area and postoperative mortality (P = .003). The effect of psoas area was found to decrease significantly as follow-up time increased (P = .008). Among all covariates included in the Cox models (including predictors of mortality such as American Society of Anesthesiologists [ASA] score), the psoas area was the most significant. Core muscle size, an objective measure of frailty, correlates strongly with mortality after elective AAA repair. A better understanding of the role of frailty and core muscle size may aid in risk stratification and impact timing of surgical repair, especially in more complex aortic operations.

Central Sarcopenia and Post-Liver Transplant Mortality

Introduction: Surgeons frequently struggle with determining which patients will benefit from liver transplantation. This is especially true in the case of frail patients. Until now, there were no quantitative and objective measures of frailty among transplant patients. With this work, we introduce the concept of central sarcopenia as a proxy measure for patient frailty and as a powerful predictor of post-liver transplant mortality. Methods: We identified n=207 deceased-donor liver recipients transplanted at the University of Michigan between 01/01/2002 and 12/31/2008 who had a CT scan of the abdomen in the peri-transplant period.