Poor Preoperative Functional Status Research Articles

Long-term follow up of patients with WHO grade 2 oligodendroglioma

PurposeSince the introduction of the molecular definition of oligodendrogliomas based on isocitrate dehydrogenase (IDH)-status and the 1p19q-codeletion, it has become increasingly evident how this glioma entity differs much from other diffuse lower grade gliomas and stands out with longer survival and often better responsiveness to adjuvant therapy. Therefore, apart from using a molecular oligodendroglioma definition, an extended follow-up time is necessary to understand the nature of this slow growing, yet malignant condition. The aim of this study was to describe the long-term course of the oligodendroglioma disease in a population-based setting and to determine which factors affect outcome in terms of survival.MethodsAll adults with WHO-grade 2 oligodendrogliomas with known 1p19q-codeletion from five Scandinavian neurosurgical centers and with a follow-up time exceeding 5 years, were analyzed regarding survival and factors potentially affecting survival.Results126 patients diagnosed between 1998 and 2016 were identified. The median follow-up was 12.0 years, and the median survival was 17.8 years (95% CI 16.0–19.6).Factors associated with shorter survival in multivariable analysis were age (HR 1.05 per year; CI 1.02–1.08, p < 0.001), tumor diameter (HR 1.05 per millimeter; CI 1.02–1.08, p < 0.001) and poor preoperative functional status (KPS < 80) (HR 4.47; CI 1.70–11.78, p = 0.002). In our material, surgical strategy was not associated with survival.ConclusionIndividuals with molecularly defined oligodendrogliomas demonstrate long survival, also in a population-based setting. This is important to consider for optimal timing of therapies that may cause long-term side effects. Advanced age, large tumors and poor function before surgery are predictors of shorter survival.Graphical

Clinical profile and outcome of surgical management of intramedullary spinal cord tumours: A single center study in a developing country

ObjectiveThere is as yet a paucity of data on intramedullary spinal cord tumours (IMSCTs) in sub-Saharan Africa. This study aims to define the clinical profile and outcome of management of IMSCTs in a Nigerian tertiary hospital. MethodsThis is a retrospective study of all the patients who had surgery for IMSCTs in our hospital over a 14 year period. ResultsThere were 20 patients, 9 males, 11 females, in this study. The median age was 33 years (range = 7–78 years). The median duration of symptoms was 12 months (range = 1–120 months). Motor deficit was present in all but one (95%) of our patients. Only 25% of the patients presented in good functional status (McCormick grades I and II). The tumours were confined to the thoracic region in 10 patients (50%), while tumours in the thoracic region extending to the adjoining cervical and lumbar regions were seen in 6 patients (30%). Gross total tumour resection was achieved in 60% of the patients and subtotal resection in the remaining 40%. Astrocytoma and ependymoma were the most common tumours, each occurring in 35% of the cases. Six patients (30.0%) improved, 12 patients (60.0%) remained neurologically the same, while 2 patients (10.0%) deteriorated at the time of last follow up. The mortality rate was 15%. The preoperative functional status was a significant predictor of postoperative outcome (p = 0.03). ConclusionAstrocytoma and ependymoma were the most common histological tumour types among our patients. Late presentation and poor pre-operative functional status were prominent features of our patients’ cohort.

Functional outcomes correlate with sagittal spinal balance in degenerative lumbar spondylolisthesis surgery

BACKGROUND CONTEXTDegenerative lumbar spondylolisthesis (DLS) is a debilitating condition associated with poor preoperative functional status. Surgical intervention has been shown to improve functional outcomes in this population though the optimal surgical procedure remains controversial. The importance of maintaining and/or improving sagittal and pelvic spinal balance parameters has received increasing interest in the recent DLS literature. However, little is known about the radiographic parameters most associated with improved functional outcomes among patients undergoing surgery for DLS. PURPOSETo identify the effect of postoperative sagittal spinal alignment on functional outcome after DLS surgery. STUDY DESIGNRetrospective cohort study. PATIENT SAMPLETwo-hundred forty-three patients in the Canadian Spine Outcomes and Research Network (CSORN) prospective DLS study database. OUTCOME MEASURESBaseline and 1-year postoperative leg and back pain on the 10-point Numeric Rating Scale and baseline and 1-year postoperative disability on the Oswestry Disability Index (ODI). METHODSAll enrolled study patients had a DLS diagnosis and underwent decompression in isolation or with posterolateral or interbody fusion. Global and regional radiographic alignment parameters were measured at baseline and 1-year postoperatively including sagittal vertical axis (SVA), pelvic incidence and lumbar lordosis (LL). Both univariate and multiple linear regression was used to assess for the association between radiographic parameters and patient-reported functional outcomes with adjustment for possible confounding baseline patient factors. RESULTSTwo-hundred forty-three patients were available for analysis. Among participants, the mean age was 66 with 63% (153/243) female with the primary surgical indication of neurogenic claudication in 197/243 (81%) of patients. Worse pelvic incidence-LL mismatch was correlated with more severe disability [ODI, 0.134, p<.05), worse leg pain (0.143, p<.05) and worse back pain (0.189, p<.001) 1-year postoperatively. These associations were maintained after adjusting for age, BMI, gender, and preoperative presence of depression (ODI, R2 0.179, β, 0.25, 95% CI 0.08, 0.42, p=.004; back pain R2 0.152 (β, 0.05, 95% CI 0.022, 0.07, p<.001; leg pain score R2 0.059, β, 0.04, 95% CI 0.008, 0.07, p=.014). Likewise, reduction of LL was associated with worse disability (ODI, R2 0.168, β, 0.04, 95% CI -0.39, -0.02, p=.027) and worse back pain (R2 0.135, β, -0.04, 95% CI -0.06, -0.01, p=.007). Worsened SVA correlated with worse patient reported functional outcomes (ODI, R2 0.236, β, 0.12, 95% CI 0.05, 0.20, p=.001). Similarly, an increase (worsening) in SVA resulted in a worse NRS back pain (R2 0.136, β, 0.01, 95% CI .001, 0.02, p=.029) and worse NRS leg pain (R2 0.065, β, 0.02, 95% CI 0.002, 0.02, p=.018) scores regardless of surgery type. CONCLUSIONSPreoperative emphasis on regional and global spinal alignment parameters should be considered in order to optimize functional outcome in lumbar degenerative spondylolisthesis treatment.

Knee Arthrodesis: An Analysis of Surgical Risk Factors and Complications Using a National Database.

Knee arthrodesis is predominantly a salvage procedure. In present time, knee arthrodesis is mostly considered for cases of unreconstructable failed total knee arthroplasty after prosthetic joint infection or trauma. Knee arthrodesis has shown better functional outcomes than amputation for these patients but has a high complication rate. The purpose of this study was to characterize the acute surgical risk profile of patients undergoing a knee arthrodesis for any indication. The American College of Surgeons National Surgical Quality Improvement Program database was queried to determine 30-day outcomes after knee arthrodesis between 2005 and 2020. Demographics, clinical risk factors, and postoperative events were analyzed, along with reoperation and readmission rates. A total of 203 patients that underwent a knee arthrodesis were identified. Forty-eight percent of patients had at least 1 complication. The most common complication was acute surgical blood loss anemia requiring a blood transfusion (38.4%), followed by organ space surgical site infection (4.9%), superficial surgical site infection (2.5%), and deep vein thrombosis (2.5%). Smoking was associated with higher rates of reoperation and readmission (odds ratio 9, P < .01, and odds ratio 6, P < .05). Overall, knee arthrodesis is a salvage procedure that has a high rate of early postoperative complications and is most often performed in patients at higher risk. Early reoperation is strongly associated with a poor preoperative functional status. Smoking places patients at higher risk of early complications.

Impact of pre- and peri-operative risk factors on length of stay and hospital readmission following minimally-invasive partial nephrectomy

ObjectiveWe conducted an analysis of the American College of Surgeons National Surgical Quality Improvement Program database for minimally-invasive partial nephrectomy cases reported with the goal to identify pre- and peri-operative variables associated with length of stay (LOS) greater than 3 days and readmission within 30 days. MethodsRecords from 2008 to 2018 for “laparoscopy, surgical; partial nephrectomy” for prolonged LOS and readmission cohorts were compiled. Univariate analysis with Chi-square, t-tests, and multivariable logistic regression analysis with odds ratios (ORs), p-values, and 95% confidence intervals assessed statistical associations. ResultsTotally, 20 306 records for LOS greater than 3 days and 15 854 for readmission within 30 days were available. Univariate and multivariable analysis exhibited similar results. For LOS greater than 3 days, undergoing non-elective surgery (OR=5.247), transfusion of greater than four units within 72 h prior to surgery (OR=5.072), pre-operative renal failure or dialysis (OR=2.941), and poor pre-operative functional status (OR=2.540) exhibited the strongest statistically significant associations. For hospital readmission within 30 days, loss in body weight greater than 10% in 6 months prior to surgery (OR=2.227) and bleeding disorders (OR=2.081) exhibited strongest statistically significant associations. ConclusionMultiple pre- and peri-operative risk factors are independently associated with prolonged LOS and hospital readmission within 30 days of surgery using the American College of Surgeons National Surgical Quality Improvement Program data. Recognizing the risks factors that can potentially be improved prior to minimally-invasive partial nephrectomy is crucial to informing patient selection, optimization strategies, and patient education.

Analysis of the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®) Database to Identify Factors Associated with Postoperative Mortality After Elective Non-cardiac Surgery

Various surgical risk assessment tools, including the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®) risk calculator, have been devised to predict postoperative mortality. However, the role of individual factors on mortality is unclear. We sought to identify patient characteristics from the database that were associated with postoperative mortality in patients undergoing elective, non-cardiac surgery. Data from the ACS NSQIP® database at a tertiary care academic medical center was analyzed from January 2011 to September 2016. Relevant patient-related variables were extracted from the database and univariable logistic regression was used to assess the association of each potential risk factor with 30-day mortality. A multivariable logistic regression model was then used to assess the adjusted effect of each potential risk factor on the outcome. A total of 5254 database patient records were identified and among the analyzed variables, American Society of Anesthesiologists (ASA) physical status III and IV (odds ratio and 95%CI: 16.75 [2.29, 122.69]), poor preoperative functional health status (odds ratio and 95%CI: 38.52 [2.46, 604.12]), and low serum albumin (odds ratio and 95%CI: 3.76 [1.35, 10.44]) were significant predictors of 30-day postoperative mortality. In a comprehensive analysis of the ACS NSQIP®database, spreading across multiple surgical specialties, we found an association between ASA physical status, preoperative albumin levels, and functional health status with 30-day mortality after elective non-cardiac surgery.

Preoperative Dependent Functional Status Is Associated With Poor Outcomes After Carotid Endarterectomy and Carotid Stenting in Both Symptomatic and Asymptomatic Patients

BackgroundBoth Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the most common procedures to treat patients with symptomatic, and asymptomatic high-grade carotid stenosis. Poor preoperative functional status (FS) is increasingly being recognized as predictor for postoperative outcomes. The purpose of this study is to determine the impact of preoperative functional status on the outcomes of patients who undergo CEA or CAS. MethodsData was obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from the years 2011–2018. All patients in the database who underwent CEA or CAS during this time period were identified. Patients were then further divided into 2 subgroups: FS-Independent and FS-dependent. Bivariate and multivariate analyses was performed for pre, intra and post-operative variables with functional status. Outcomes for treatment of symptomatic carotid disease were compared to those with asymptomatic disease among the cohort of functionally dependent patients. ResultsA total of 27,163 patients (61.2% Males, 38.8% Females) underwent CEA (n = 26,043) or CAS (n = 1,120) from 2011–2018. Overall, primary outcomes were as follows: mortality 0.77% (n = 210) and stroke 1.87% (n = 507).Risk adjusted multivariate analysis showed that FS-D patients undergoing CEA had higher mortality (AOR 3.06, CI 1.90–4.92, P < 0.001), longer operative times (AOR 1.36, CI 1.17–1.58, P< 0.001) higher incidence of unplanned reoperation (AOR 1.68, CI 1.19–2.37, P = 0.003), postoperative pneumonia (AOR 5.43, CI 1.62 – 18.11, P = 0.006) and ≥3 day LOS (AOR 3.05, CI 2.62–3.56, P < 0.001) as compared to FS-I patients. FS-D patients undergoing CAS had higher incidence of postoperative pneumonia (AOR 20.81, CI 1.66–261.54, P = 0.019) and higher incidence of LOS ≥3 days (AOR 2.18, CI 1.21–3.93, P < .01) as compared to FS-I patients. Survival analysis showed that the best 30-day survival was observed in FS-I patients undergoing CEA, followed by FS-I patients undergoing CAS, followed by FS-D patients undergoing CEA, followed by FS-D patients undergoing CAS. FS-D status increased mortality after CEA by 2.11%. When the outcomes of CAS and CEA were compared to each other for the cohort of FS-D patients, CAS was associated with higher incidence of stroke (AOR 3.46, CI 0.32–1.97, P= 0.046), shorter operative times (AOR 0.25, CI 0.12–0.52, P < 0.001) and higher incidence of pneumonia (AOR 11.29, CI 1.32–96.74, P = 0.027). Symptomatic patientsundergoing CEA had higher LOS as compared to symptomatic patients undergoing CAS, and asymptomatic patients undergoing CEA or CAS. ConclusionsFS-D patients, undergoing CEA have higher mortality as compared to FS-I patients undergoing CAS. FS-D patients undergoing CAS have higher incidence of postoperative pneumonia and longer LOS as compared to FS-I patients. For the cohort of FS-D patients undergoing either CEA or CAS, CAS was associated with higher risk of stroke and reduced operative times. Risk benefit ratio for any carotid intervention should be carefully assessed before offering it to FS-D patients.Preoperative Dependent Functional Status Is Associated with Poor Outcomes After Carotid Endarterectomy and Carotid Stenting in Both Symptomatic and Asymptomatic Patients

Functional performance status and risk of cardiovascular events and mortality following endovascular repair of thoracic and abdominal aortic pathology.

To characterize the association of preoperative functional performance status based on Eastern Cooperative Oncology Group (ECOG) scoring with the risk of adverse cardiovascular events, vascular events, and mortality in patients undergoing EVAR and TEVAR. Retrospective review of the Society for Vascular Surgery Vascular Quality Initiative, a large, multi-center, registry database was performed. All individuals undergoing EVAR (n = 18,730) and TEVAR (n = 6595) for non-ruptured aortic pathologies between 2014 and 2018 were eligible for analysis. Multivariable logistic regression was used to determine the association of pre-procedure ECOG functional performance status on risk of in-hospital adverse cardiovascular events, vascular events, and mortality. The number of operations complicated by adverse cardiovascular and vascular events was 480 (2.6%) and 190 (1.0%) for EVAR and 733 (11.1%) and 219 (3.3%) for TEVAR, respectively. There were 118 (0.6%) and 240 (3.6%) in-hospital deaths following EVAR and TEVAR, respectively. Patients with ECOG grades 3 or 4 undergoing EVAR were at increased risk of cardiovascular events (OR = 1.62; 95% CI = 1.09, 2.41) and one-year mortality (HR = 2.62; 95% CI = 1.92, 3.57) compared to those with ECOG grade 0. Patients undergoing TEVAR with ECOG grade 3 or 4 were at increased risk for both inpatient death (OR = 2.77; 95% CI = 1.56, 4.9) and one-year mortality (HR = 3.27, 95% CI = 2.06, 5.21). ECOG status was not associated with an increased risk of adverse vascular events following either EVAR or TEVAR. Poor preoperative functional status as assessed by ECOG score is associated with an increased risk of adverse postoperative cardiovascular events following EVAR and a higher mortality risk following both EVAR and TEVAR. Functional status assessment may be useful for risk stratification and determining procedural candidacy prior to EVAR and TEVAR.

Functional Status May Serve as a Predictor of CABG Surgery Outcome in the Elderly Patient

Despite the growing number of elderly patients undergoing coronary artery bypass graft (CABG) surgery, no study addressing postoperative outcome from the perspective of preoperative functional status has been reported to date. The present investigation therefore undertook to determine, among elderly individuals matched for cardiac status, whether patients with poor functional status have a greater risk of mortality and morbidity following CABG surgery than those with good functional status. Retrospective preoperative and postoperative geriatric functional assessment using a standardized questionnaire was performed on 46 consecutive patients who had undergone CABG in 1994 at age 65 or older. Preoperative functional status was comprised of pre-anginal functional status (before angina limited physical activity) and anginal functional status (during which angina was a noticeable limiting factor). CABG outcome was recorded in terms of postoperative assessment of functional status, morbidity, and mortality. The results of statistical analysis revealed that both pre-anginal and anginal functional status were sensitive predictors of post-operative functional status (p &lt; 0.005 and p &lt; 0.001, respectively). In addition, the presence of comorbidities typically used in the screening of candidates was found to be a sensitive predictor of outcome (p &lt; 0.02). However, the presence of comorbidities was not significantly linked to poor preoperative functional status (p &gt; 0.05), indicating that these two predictors may screen for different elderly sub-populations at high risk for negative outcome of CABG. If confirmed by further studies of elderly patients undergoing CABG, these results suggest a new and important role for functional status as a predictor of CABG outcome in the elderly. Furthermore, these results may be useful toward the development of a reliable tool in screening for high risk of poor outcome among elderly candidates for CABG surgery.

A Novel Clinical Scoring System for Perioperative Morbidity in Metastatic Spinal Tumor Surgery: The Spine Oncology Morbidity Assessment Score.

Retrospective cohort study. To evaluate a scoring system to predict morbidity for patients undergoing metastatic spinal tumor surgery (MSTS). Multiple scoring systems exist to predict survival for patients with spinal metastasis. The potential benefits and risks of surgery need to be evaluated for patients with disseminated cancer and limited life expectancy. Few scoring systems exist to predict perioperative morbidity after MSTS. We reviewed records of patients who underwent MSTS at our institution between 2013 and 2019. All perioperative complications occurring within 30 days were recorded. A clinical scoring system consisting of five variables (age ≥ 70 yr, hypoalbuminemia, poor preoperative functional status [Karnofsky ≤ 40], Frankel Grade A-C, and multilevel disease ≥2 continuous vertebral bodies) was evaluated as a predictive tool for morbidity; every parameter was assigned a value of 0 if absent or 1 if present (total possible score = 5). The effect of the scoring system on morbidity was evaluated using stepwise multiple logistic regression. Model accuracy was calculated by receiver operating characteristic analysis. One hundred and five patients were identified, with a male prevalence of 58.1% and average age at surgery of 61 years. The overall 30-day complication rate was 36.2%. The perioperative morbidity was 4.6%, 30.0%, 53.9%, and 64.7% for patients with scores of 0, 1, 2, and ≥3 points, respectively (P < 0.001). On multiple logistic regression analysis controlling for covariates not present in the model, the scoring system was significantly associated with 30-day morbidity (OR 3.11; 95% CI, 1.72-5.59; P < 0.001). The model's accuracy was estimated at 0.75. Our proposed model was found to accurately predict perioperative morbidity after MSTS. The Spine Oncology Morbidity Assessment (SOMA) score may prove useful for risk stratification and possibly decision-making, though further validation is needed.Level of Evidence: 4.

Preoperative physical functional status affects the long-term outcomes of elderly patients with open abdomen.

The mortality rates among elderly patients with open abdomen (OA) are high, and pre-existing comorbidities could affect the outcomes. However, long-term prognosis remains uncertain. We examined long-term outcomes in elderly patients with OA, focusing on physical functional status. We undertook a retrospective cohort study between 2007 and 2017 at a single institution. Patients with OA who were aged ≥65years were categorized into two groups: "good preoperative functional status" group (GFG) and "poor preoperative functional status" group (PFG). The GFG was defined as Eastern Cooperative Oncology Group/World Health Organization performance status (PS) 0-1, whereas PFG was defined as PS 2-4. The primary outcomes were survival and PS 2years following the initial surgery. Of the 53 participants, 38 and 15 were assigned to the GFG and PFG, respectively. The PFG (median age, 81years) was older than the GFG (median age, 75.5years; P=0.040). The 2-year survival rate was 39.5% in GFG and 6.7% in PFG, and Kaplan-Meier analysis showed significant difference (P=0.022). Among all patients, the PS at 2years was worse than that at discharge (P=0.007). Preoperative PS was correlated with 2-year survival (P=0.003), whereas age and pre-existing comorbidities were not. The long-term outcomes of elderly patients with OA are affected by the preoperative physical functional status. Functional status deteriorates in a time-dependent manner. Therefore, surgery requiring OA must be carefully considered for elderly patients with PS 2 or higher.

Surgical Treatment of Intra- and Juxtamedullary Spinal Cord Tumors: A Population Based Observational Cohort Study.

Objective: Intramedullary spinal cord tumors (IMSCT) are rare entities and high-level evidence regarding optimal treatment is lacking. We aim to describe the demographics, histopathological distribution, onset symptoms, treatment strategies, and functional outcome for patients surgically treated for IMSCT.Methods: We performed a retrospective review of a consecutive population-based cohort of 95 patients who underwent surgery for intra- or juxtamedullary tumors at a single institution during the period 2004–2017.Results: When gross total resection (GTR) was achieved, we found no case of local tumor recurrence even in the absence of adjuvant radio- or chemotherapy. Meanwhile, we found a 50% progression rate on long-term MRI follow-up in patients where only a partial resection was possible. At long-term follow-up, there was no significant alteration in functional status, while a significant reduction in share of patients reporting pain, compared to preoperative status, was identified. Poor preoperative functional status and postoperative tumor remnant were identified as individual risk factors for further functional decline.Conclusion: Gross total resection, with minimal post-operative neurological deterioration, is possible in the majority of the cases, especially in the presence of an identifiable resection plane between tumor and healthy spinal cord. Since long-term progression-free survival could be achieved by GTR without additional adjuvant treatment, we emphasize that low-grade tumors should not be subject to radiotherapy. Treatment of high-grade or diffusely infiltrating tumors, tumor remnants, or metastases should be individualized.

Incidence and Predictors of Hardware Failure After Instrumentation for Spine Metastasis: A Single-Institutional Series

We report a retrospective analysis of hardware failure in patients requiring instrumentation for spinal metastasis. In a retrospective study at a single institution, we identified 58 patients who underwent spinal instrumentation for metastasis from 2012 to 2018. Hardware failure was defined as screw pullout/loosening, cage migration, progressive kyphosis, or an otherwise-noticeable instrumentation deficit detectable on imaging. Risk factors for hardware failure with a P < 0.05 in in univariate were included in multivariate logistic regression models controlled for age, sex, and previously identified risk factors for hardware failure. In total, 58 patients required instrumentation for metastatic spine disease. Median age was 60.2 years (interquartile range 49.0-66.3), 38 patients (65.5%) were male, and median follow-up was 8.1 months (interquartile range 3.1-20.7). Eight patients (13.8%) developed signs of hardware failure during follow-up, of whom 2 patients (3.4%) underwent operative revision. In univariate analysis, Eastern Cooperative Oncology Group performance status >2 (P= 0.049) and multiple myeloma lesions (P= 0.010) were significant predictors of failure. Both factors maintained significance in a multivariate logistic regression model controlled for age, sex, history of spine radiation, and number of fused levels with P= 0.047; odds ratio 12.7 (95% confidence interval 1.03-156.4) for Eastern Cooperative Oncology Group performance status over 2 and P= 0.012; odds ratio 31.5 (95% confidence interval 2.2-460.0) for multiple myeloma lesions. The rate of hardware failure in this cohort was 13.8%, although operative revision rate was 3.4%. Spinal instrumentation in patients with poor preoperative functional status or multiple myeloma may be more likely to develop instrumentation failure.

Risk Factors and Outcomes Associated With Sepsis After Coronary Artery Bypass and Open Heart Valve Surgeries.

Sepsis causes significant morbidity and mortality after cardiac surgery and carries a significant burden on health care costs. There is a general association of increased risk of post-cardiac surgery sepsis in patients with postoperative complications. We sought to investigate significant patient and procedural risk factors and outcomes associated with sepsis after cardiac surgery. In this retrospective study, we analyzed 531 coronary artery bypass grafting and open heart valve surgery cases that developed postoperative sepsis in the National Surgical Quality Improvement Program database between 2007 and 2014. Patient-based and surgery-based parameters were analyzed for risk factors and outcomes reported in the 30 days postoperatively. The association between sepsis and patient outcomes was assessed in a propensity-matched cohort using univariable logistic regression. Modifiable and nonmodifiable patient characteristics, including age >80, poor preoperative functional status, chronic diseases such as diabetes mellitus, congestive heart failure, chronic kidney disease with serum creatinine ⩾1.5, as well as serum albumin <3.5 and emergent nature of the case were associated with post-cardiac surgery sepsis. Surgical outcomes associated with sepsis included mortality (15.4% vs 4.5%), unplanned intubation (29.8% vs 8.2%), transfusion (53.4% vs 48.4%), acute kidney injury (7.1% vs 1.4%), postoperative dialysis (18.8% vs 3.5%), and return to the operating room (29.8% vs 8.2%). We identified multiple patient and surgical characteristics as well as postoperative outcomes associated with postoperative sepsis development in the high-risk population of patients undergoing cardiac surgery. Early identification of patients who are at high risk for postoperative sepsis can facilitate early treatment interventions.

Quality of Life After Craniovertebral Junction Meningioma Resection: Shaping the Real Neurologic and Functional Expectancies About These Surgeries in a Contemporary Large Multicenter Experience.

Craniovertebral junction (CVJ) meningiomas are one of the most surgically complex conditions in neuro-oncologic surgery. The aim of this work is to correlate our data with clinical outcome to outline factors leading to a worse functional prognosis. We analyzed sex, age, clinical presentation, topography, surgical approach, Simpson grade resection, postoperative lower cranial nerve deficits, consistency, histology, site of origin, presence of a capsule, and radiologic and clinical follow-up at 1, 6, and 12 months of 61 patients affected by CVJ meningiomas, operated on in our institution from 1992 to2014. 78.7% of patients were women (mean age, 52.85 years); the onset symptom was pain in 65.5% of cases. The mean preoperative Nurick grade of the sample was 3.78; the most frequent histologic type was endotheliomatous (42.8%). We treated 22 patients with a posterior median approach (5 with lateral and 17 with posterolateral axial topography); in 39 cases (30 anterolateral and 9 anterior) we performed a posterolateral approach. Gross total removal was achieved in 85.2% of cases. We recorded a final follow-up step overall neurologic improvement in the cohort (average preoperative Nurick grade, 3.81, and at 12 months, 2.13). Twenty-nine patients presented with lower cranial nerve deficit (permanent or transient) and no statistically significant association was found between surgical approach and temporary or permanent postoperative complications. We selected, in our experience, some predictors of worse outcome: preoperative sphincter impairment, absence of a capsule, cranial site of origin, a poor preoperative functional status, and firm consistency of the tumor.

Effect of Preoperative Leg Length Discrepancy on Functional Outcome and Patient Satisfaction After Total Hip Arthroplasty in Cases of Osteonecrosis of the Femoral Head

BackgroundSevere preoperative leg length discrepancy (LLD) can lead to poor preoperative functional status in patients with extensive osteonecrosis of the femoral head (ONFH). This study aimed to assess the effect of preoperative LLD on functional outcomes and patient satisfaction post-total hip arthroplasty (THA) in ONFH patients. MethodsTwenty-two patients with severe LLD (≥15 mm) and 44 patients with mild LLD (<15 mm) on preoperative radiographs were enrolled as the study group and control group, respectively. All 66 patients were diagnosed with unilateral ONFH. Patients' functional outcomes (Harris Hip Score [HHS], Oxford Hip Score [OHS], patient-perceived LLD, Visual Analogue Scale [VAS] pain score, and Limping Assessment]) and satisfaction (self-administered patient satisfaction scale) were evaluated at 3 and 12 months after THA. ResultsAt 3 months after THA, the study group had poorer outcomes in terms of the HHS (P = .002) and OHS (P = .002), a higher prevalence of patient-perceived LLD (P = .002), and worse limping (P < .001) than the control group, but the self-administered patient satisfaction scale and VAS pain scores did not differ. However, improvements in the HHS and OHS from preoperative assessment to 3 months were comparable in both groups. At 12 months after THA, there were no significant differences in functional outcomes or self-satisfaction, and the study group showed significantly greater improvements from preoperative assessment to 12 months (P < .05). ConclusionPatients with severe LLD experienced similar improvement at 3 months after THA as those with mild LLD in terms of the HHS and OHS but showed greater improvement at 12 months postoperatively than patients with mild LLD.

Abstract TP177: Preoperative Functional Status and Type of Surgery Influences Postoperative Stroke Risk: analysis from the Nationwide Surgical Quality Initiative Program

Introduction: Post-operative stroke (POS) is associated with vascular and cardiac surgery, but this finding has mainly been reported among populations receiving vascular and cardiac procedures. We investigated the association between type of surgery and risk of POS in a large, generalizable inpatient cohort from the American College of Surgeons National Surgical Quality Initiative Program (NSQIP) database. Hypothesis: Cardiac and vascular procedures are associated with an increased risk of POS. Methods: We identified patients that underwent surgery between the years of 2000 and 2010. Our primary outcome was POS within 30 days of surgery. Using a hierarchical model adjusted for age, race, sex, medical comorbidities and dichotomized functional status, we assessed for clustering between type of surgery and POS. We then determined risk factors for POS while adjusting for clustering. Each surgical type was compared against all other surgical types. Results: We identified 729,886 patients, of whom 2,703 (0.3%) developed POS. In the hierarchical analysis, cardiac surgery (incidence rate ratio (IRR) 6.38, 95%CI 5.37-7.55), vascular surgery (IRR 4.41, 95%CI 4.08-4.76), and neurosurgery (IRR 2.05, 95%CI 1.69-2.48) were associated with increased risk of POS. The only patient-level factor associated with surgery type was poor preoperative functional status. Accounting for clustering, patients with poor pre-operative functional status (OR 4.11, 95%CI 3.60-4.69), history of stroke (OR 2.35 95%CI 2.06-2.69), history of transient ischemic attack (OR 2.49 95%CI 2.19-2.83), active smoking (OR 1.20, 95%CI 1.08-1.32), and COPD (OR 1.39 95%CI 1.21-1.59) were at higher risk of POS. There was no interaction between preoperative functional status and type of surgery. Conclusions: In a large cohort of surgical inpatients, we found that the risk of POS was significantly associated with cardiac, vascular, and neurosurgical procedures. Certain patient populations, such as those with a dependent pre-operative functional status, may be at a higher risk of POS and may be more likely to undergo cardiac, vascular, or neurosurgical procedures. Further studies are needed to elucidate the relationship between pre-surgical functional status and type of surgery.

Associations between preoperative functional status and functional outcomes of total joint replacement in the Dominican Republic

In developed countries, the functional status scores of patients with poor preoperative scores undergoing total joint replacement (TJR) improve more following TJR than those for patients with better preoperative scores. However, those with better preoperative scores achieve the best postoperative functional outcomes. We determined whether similar associations exist in a developing country. Dominican patients undergoing total hip or knee replacement completed WOMAC and SF-36 surveys preoperatively and at 12-month follow-up. Patients were stratified into low-, medium- and high-scoring preoperative groups based on their preoperative WOMAC function scores. We examined the associations between the baseline functional status of these groups and two outcomes-improvement in functional status over 12 months and functional status at 12 months-using analysis of variance with multivariable linear regression. Patients who scored the lowest preoperatively made the greatest gains in function and pain relief following their TJRs. However, there were no significant differences in pain or function at 12-month follow-up between patients who scored low and those who scored high on preoperative WOMAC and SF-36 surveys. Patients with poor preoperative functional status had greater improvement but similar 12-month functional outcomes compared with patients who had a higher level of function before surgery. These results suggest that a policy of focusing scarce resources on patients with worse functional status in developing countries may optimize improvement following TJR without threatening functional outcome. Additional research is needed to confirm these findings in other developing countries and to understand why these associations vary between patients in the Dominican Republic and patients from developed countries.

Factors associated with survival for patients with glioblastoma with poor pre-operative functional status

Patients with glioblastoma (GB) are known to have poor prognoses, and among these patients, those with poor neurological function have an even poorer prognosis. Consequently, aggressive surgeries and adjuvant therapies are often withheld because of this dismal outlook. The effects of aggressive therapies in this small subset of patients remain unknown. The goal of this study was to evaluate outcomes and factors associated with survival for poor functioning patients who underwent aggressive resection of their GB. Adult patients who underwent surgical resection of an intracranial primary GB at an academic tertiary-care institution between 1997 and 2007 were retrospectively reviewed. Patients with a Karnofsky Performance Scale (KPS) score of ⩽60 were included. A total of 100 patients with primary GB met the inclusion criteria. The average age (±standard deviation) and KPS score of this cohort were 54±15years and 53±12, respectively. No patient (0%) experienced perioperative mortality, and 0 (0%), 10 (10%), and 3 (3%) of patients incurred a new or increasing language, motor, and visual deficit, respectively. At last follow-up, 88 (88%) patients died with a median survival of 6.6months. The factors associated with improved survival were age <65year (p=0.005), tumor size >2cm (p=0.01), radical tumor resection (p=0.01), and temozolomide (p=0.001). This study identifies a subset of patients with poor functional status who may benefit from aggressive surgical resection.

Outcomes of Mitral Valve Surgery in the Elderly

As the US population ages, the burden of mitral valve disease has become an increasingly important and controversial issue. Traditionally, elderly patients have been denied surgical intervention due to poor preoperative functional status and higher risk for postoperative morbidity and mortality. Over the last decade, as the field has evolved, more elderly patients are being considered for surgical management. In this review, we examine the literature surrounding the safety of mitral valve surgery in the elderly, the type of procedure these patients should undergo, and the survival and quality of life associated with these interventions. Additionally, we examine some of the new technologies and advancements in the field that may allow for surgical intervention in patients who would otherwise be denied this treatment.