External validation of a risk model for survival prediction in older patients with cancer undergoing elective abdominal surgery: a prospective cohort study.
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SUBMITTER: Liu KH
PROVIDER: S-EPMC9729892 | biostudies-literature | 2022
REPOSITORIES: biostudies-literature
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External validation of a risk model for survival prediction in older patients with cancer undergoing elective abdominal surgery: a prospective cohort study.
Liu Keng-Hao KH Hung Yu-Shin YS Lee Shu-Hui SH Lai Cheng-Chou CC Chen Shu-Chen SC Kao Wei-Ling WL Cheng Hui-Wen HW Hsu Mei-Hui MH Tsai Chun-Yi CY Hsueh Shun-Wen SW Hung Chia-Yen CY Lin Yung-Chang YC Chou Wen-Chi WC
American journal of cancer research 20221115 11
We previously developed a Chang Gung Memorial Hospital (CGMH) model to predict the 1-year postoperative mortality risk in patients with solid cancer undergoing cancer surgery. This study aimed to externally validate the CGMH score for survival outcome and surgical complication prediction in a prospective patient cohort. A total of 345 consecutive patients aged ≥65 years who underwent elective abdominal surgery for cancer treatment were prospectively enrolled. Patients were categorized into the l ...[more]
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Project description:ObjectiveThe benefit of prophylactic repair of abdominal aortic aneurysms (AAAs) is based on the risk of rupture exceeding the risk of death from other comorbidities. The purpose of this study was to validate a 5-year survival prediction model for patients undergoing elective repair of asymptomatic AAA <6.5 cm to assist in optimal selection of patients.MethodsAll patients undergoing elective repair for asymptomatic AAA <6.5 cm (open or endovascular) from 2002 to 2011 were identified from a single institutional database (validation group). We assessed the ability of a prior published Vascular Study Group of New England (VSGNE) model (derivation group) to predict survival in our cohort. The model was assessed for discrimination (concordance index), calibration (calibration slope and calibration in the large), and goodness of fit (score test).ResultsThe VSGNE derivation group consisted of 2367 patients (70% endovascular). Major factors associated with survival in the derivation group were age, coronary disease, chronic obstructive pulmonary disease, renal function, and antiplatelet and statin medication use. Our validation group consisted of 1038 patients (59% endovascular). The validation group was slightly older (74 vs 72 years; P < .01) and had a higher proportion of men (76% vs 68%; P < .01). In addition, the derivation group had higher rates of advanced cardiac disease, chronic obstructive pulmonary disease, and baseline creatinine concentration (1.2 vs 1.1 mg/dL; P < .01). Despite slight differences in preoperative patient factors, 5-year survival was similar between validation and derivation groups (75% vs 77%; P = .33). The concordance index of the validation group was identical between derivation and validation groups at 0.659 (95% confidence interval, 0.63-0.69). Our validation calibration in the large value was 1.02 (P = .62, closer to 1 indicating better calibration), calibration slope of 0.84 (95% confidence interval, 0.71-0.97), and score test of P = .57 (>.05 indicating goodness of fit).ConclusionsAcross different populations of patients, assessment of age and level of cardiac, pulmonary, and renal disease can accurately predict 5-year survival in patients with AAA <6.5 cm undergoing repair. This risk prediction model is a valid method to assess mortality risk in determining potential overall survival benefit from elective AAA repair.
| S-EPMC6114131 | biostudies-literature
Project description:BackgroundPostoperative ileus is a major complication for persons undergoing abdominal surgery. Daikenchuto, a Japanese traditional medicine (Kampo), is a drug that may reduce postoperative ileus.ObjectivesTo assess the efficacy and safety of Daikenchuto for reducing prolonged postoperative ileus in persons undergoing elective abdominal surgery.Search methodsWe searched the following databases on 3 July 2017: CENTRAL, MEDLINE, Embase, ICHUSHI, WHO (World Health Organization) International Clinical Trials Registry Platform (ICTRP), EU Crinical Trials registry (EU-CTR), UMIN Clinical Trials Registry (UMIN-CTR), ClinicalTrials.gov, The Japan Society for Oriental Medicine (JSOM), American Society of Clinical Oncology (ASCO), Society of American Gastrointestinal and Endscopic Surgeons (SAGES). We set no limitations on language or date of publication.Selection criteriaWe included randomised controlled trials (RCTs) comparing Daikenchuto with any control condition in adults, 18 years of age or older, undergoing elective abdominal surgery.Data collection and analysisWe applied standard methodological procedures expected by Cochrane. Two review authors independently reviewed the articles identified by literature searches, extracted data, and assessed risk of bias of the included studies using the Cochrane software Review Manager 5.Main resultsWe included seven RCTs with a total of 1202 participants. Overall, we judged the risk of bias as low in four studies and high in three studies. We are uncertain whether Daikenchuto reduced time to first flatus (mean difference (MD) -11.32 hours, 95% confidence interval (CI) -17.45 to -5.19; two RCTs, 83 participants; very low-quality evidence), or time to first bowel movement (MD -9.44 hours, 95% CI -22.22 to 3.35; four RCTs, 500 participants; very low-quality evidence) following surgery. There was little or no difference in time to resumption of regular solid food following surgery (MD 3.64 hours, 95% CI -24.45 to 31.74; two RCTs, 258 participants; low-quality evidence). There were no adverse events in either arm of the five RCTs that reported on drug-related adverse events (risk difference (RD) 0.00, 95% CI -0.02 to 0.02, 568 participants, low-quality evidence). We are uncertain of the effect of Daikenchuto on patient satisfaction (MD 0.09, 95% CI -0.19 to 0.37; one RCT, 81 participants; very low-quality of evidence). There was little or no difference in the incidence of any re-interventions for postoperative ileus before leaving hospital (risk ratio (RR) 0.99, 95% CI 0.06 to 15.62; one RCT, 207 participants; moderate-quality evidence), or length of hospital stay (MD -0.49 days, 95% CI -1.21 to 0.22; three RCTs, 292 participants; low-quality evidence).Authors' conclusionsEvidence from current literature was unclear whether Daikenchuto reduced postoperative ileus in patients undergoing elective abdominal surgery, due to the small number of participants in the meta-analyses. Very low-quality evidence means we are uncertain whether Daikenchuto improved postoperative flatus or bowel movement. Further well-designed and adequately powered studies are needed to assess the efficacy of Daikenchuto.
| S-EPMC6494569 | biostudies-literature
Project description:BackgroundA proinflammatory state has been associated with several age-associated conditions; however, the inflammatory mechanisms of delirium remain poorly characterized.MethodsUsing the Successful Aging after Elective Surgery Study of adults age ≥70 undergoing major noncardiac surgery, 12 cytokines were measured at four timepoints: preoperative, postanesthesia care unit, postoperative day 2 (POD2) and 30 days later (POD1M). We conducted a nested, longitudinal matched (on age, sex, surgery type, baseline cognition, vascular comorbidity, and Apolipoprotein E genotype) case-control study: delirium cases and no-delirium controls were selected from the overall cohort (N = 566; 24% delirium). Analyses were independently conducted in discovery, replication, and pooled cohorts (39, 36, 75 matched pairs, respectively). Nonparametric signed-rank tests evaluating differences in cytokine levels between matched pairs were used to identify delirium-associated cytokines.ResultsIn the discovery and replication cohorts, matching variables were similar in cases and controls. Compared to controls, cases had (*p < .05, **p < .01) significantly higher interleukin-6 on POD2 in the discovery, replication, and pooled cohorts (median difference [pg/mL] 50.44**, 20.17*, 39.35**, respectively). In the pooled cohort, cases were higher than controls for interleukin-2 (0.99*, 0.77*, 1.07**, 0.73* at preoperative, postanesthesia care unit, POD2, POD1M, respectively), vascular endothelial growth factor (4.10* at POD2), and tumor necrosis factor-alpha (3.10* at POD1M), while cases had lower interleukin-12 at POD1M (-4.24*).ConclusionsIn this large, well-characterized cohort assessed at multiple timepoints, we observed an inflammatory signature of delirium involving elevated interleukin-6 at POD2, which may be an important disease marker for delirium. We also observed preliminary evidence for involvement of other cytokines.
| S-EPMC4817082 | biostudies-literature
Project description:BackgroundFrailty predicts an increased risk of postoperative morbidity and mortality. Comparison of the predictive performance between two deficit accumulation models of frailty, the modified frailty index (mFI) and the revised-Risk Analysis Index (RAI-rev), is poorly understood. This study compared the predictive abilities of the above two frailty indices in predicting life-threatening morbidity and mortality among older patients following elective high-risk abdominal surgery.MethodsThis retrospective cohort study extracted perioperative data of older patients (age ≥65 years) undergoing elective high-risk abdominal surgery at a single institution between January 2018 and December 2020. Preoperative frailty was screened by mFI and RAI-rev scoring systems. The primary outcome was the composite of postoperative life-threatening morbidity and mortality during hospitalization. Multivariable logistic regression analyses were performed to investigate the association of the two frailty indices with the primary outcome. Receiver-operating characteristic (ROC) curve was employed to test the predictive performances of the two frailty instruments in predicting the composite primary outcome. The difference between the area under the curves (AUCs) was assessed by DeLong's test.Results1,132 older patients (mean age, 73.4 ± 6.2 years; 63.9% male) were included. Of these, 107 (9.5%) developed postoperative life-threatening morbidity and mortality. In multivariable logistic regression analyses, rising continuous frailty scores (mFI: adjusted OR 1.319 per 0.09-point increase in score, 95% CI 1.151-1.511, p < 0.001; RAI-rev: adjusted OR 1.052 per 1-point increase in score, 95% CI 1.018-1.087, p = 0.002) as well as dichotomized frailty measures (mFI ≥0.27: adjusted OR 2.059, 95% CI 1.328-3.193, p = 0.001; RAI-rev ≥45: adjusted OR 1.862, 95% CI 1.188-2.919, p = 0.007) were associated with increased odds of the primary outcome separately. ROC curve analysis showed that the discrimination of mFI and RAI-rev scores for the life-threatening morbidity and mortality was poor and comparable (AUC: 0.598 [95% CI 0.569-0.627] vs. 0.613 [95% CI 0.583-0.641]; DeLong's test: Z = 0.375, p = 0.7075).ConclusionHigh mFI and RAI-rev scores were associated with an increased risk of life-threatening morbidity and mortality in older patients undergoing elective high-risk abdominal surgery. However, both frailty indices displayed poor discrimination for postoperative life-threatening morbidity and mortality.
| S-EPMC10113537 | biostudies-literature
Project description:ObjectivesValued life activities are those activities an individual deems particularly important or meaningful. Surgery in older adults can affect their ability to perform valued activities, but data are lacking. We characterized these activities and assessed performance of them following surgery.DesignRetrospective observational study.SettingPreoperative program for older adults undergoing elective surgery at an academic hospital.ParticipantsOlder adults (N = 194) in the program from February 2015 to February 2018.MeasurementsA preoperative written questionnaire asked, "What are the activities that are most important to you to be able to do when you return home from surgery?" Participants could list up to three activities. Content analysis was used to develop domains of valued life activities and categorize responses. Postoperative questionnaires and medical records were used to determine ability to perform activities 6 months after surgery.ResultsOf 194 participants (mean age = 74.9 ± 9.1 y), 57.7% were female; 33.5% had more than two comorbid conditions. We elicited 510 valued activities, with a mean of 2.6 (± .7) activities per participant. Content analysis revealed five categories: (1) recreational activities (28.9%); (2) mobility (24.9%); (3) activities of daily living (ADLs; 17.5%); (4) instrumental activities of daily living (IADLs; 16.9%); and (5) social activities (12.0%). Ultimately, 154 participants had surgery, of which 27.3% were unable to perform one of their valued activities at 6 months. Performance varied between activity categories; 91.9% of mobility activities, 90.8% of ADLs, 80.3% of IADLs, 77.3% of social activities, and 65.5% of recreational activities were able to be performed after surgery.ConclusionOlder adults expressed a wide range of valued life activities. More than one-quarter were unable to engage in at least one valued life activity after surgery, with recreation the most commonly affected. Assessment of valued life activities should be incorporated into the perioperative management of older adults. J Am Geriatr Soc 67:2305-2310, 2019.
| S-EPMC6910083 | biostudies-literature
Project description:Prehabilitation has emerged as a strategy to prepare patients for elective abdominal cancer surgery with documented improvements in postoperative outcomes. The aim of this study was to assess the evidence for prehabilitation interventions of relevance to the older adult. Systematic searches were conducted using MEDLINE, Web of Science, Scopus, CINAHL and PsychINFO. Studies of preoperative intervention (prehabilitation) in patients undergoing abdominal cancer surgery reporting postoperative outcomes were included. Age limits were not set as preliminary searches revealed this would be too restrictive. Articles were screened and selected based on PRISMA guidelines, and assessment of bias was performed. Qualitative, quantitative and meta-analyses of data were conducted as appropriate. Thirty-three studies (3962 patients) were included. Interventions included exercise, nutrition, psychological input, comprehensive geriatric assessment and optimization, smoking cessation and multimodal (two or more interventions). Nine studies purposely selected high-risk, frail or older patients. Thirty studies were at moderate or high risk of bias. Ten studies individually reported benefits in complication rates, with meta-analyses for overall complications demonstrating significant benefit: multimodal (risk difference -0·1 (95 per cent c.i. -0·18 to -0·02); P = 0·01, I2 = 18 per cent) and nutrition (risk difference -0·18 (-0·26 to -0·10); P < 0·001, I2 = 0 per cent). Seven studies reported reductions in length of hospital stay, with no differences on meta-analysis. The conclusions of this review are limited by the quality of the included studies, and the heterogeneity of interventions and outcome measures reported. Exercise, nutritional and multimodal prehabilitation may reduce morbidity after abdominal surgery, but data specific to older patients are sparse.
| S-EPMC7709363 | biostudies-literature
Project description:BACKGROUND:Enhanced recovery programs (ERPs) in colorectal surgery have demonstrated beneficial effects on postoperative complications, return of bowel function, length of stay, and costs, without increasing readmissions or mortality. However, ERPs were not specifically designed for older patients and feasibility in older patients has been questioned. AIM:The aim of this study was to assess ERP adherence and outcomes in older patients and to identify risk factors for postoperative complications and prolonged length of stay. METHOD:Retrospective analysis of consecutive patients (≥70 years) undergoing elective colorectal resection in a tertiary referral hospital in 2017. RESULTS:Ninety-six patients were included. Adherence rates were above 80% in 18 of 21 ERP interventions considered. The lowest adherence rates were noted for preoperative carbohydrate loading and cessation of intravenous fluids. Postoperative complications (Clavien-Dindo ≥2) and prolonged postoperative length of stay (>75th percentile) were observed in 39.6% and 26.3%, respectively. Median length of stay was 7 days. The 30-day mortality, readmission and reoperation rates were 2.1%, 12.6% and 8.3%, respectively. Multivariable analysis indicated that polypharmacy and site of surgery were independent risk factors for postoperative complications, while higher age, American Society of Anesthesiologists class and preoperative radiotherapy were independent risk factors for prolonged postoperative length of stay. CONCLUSION:ERP adherence in older patients undergoing colorectal resection is high and ERP is therefore considered feasible. Postoperative complications and prolonged postoperative length of stay are common, so at risk patients should be targeted with tailored geriatric interventions.
| S-EPMC7209103 | biostudies-literature
Project description:BackgroundPrehabilitation optimizes colorectal cancer patients' health during the preoperative waiting period, by increasing functional capacity, reducing postoperative complications, and speeding recovery. However, challenges in implementation include patients' willingness to attend multiple hospital visits, and hospitals needing trained personnel, facilities, and financial resources. An app-based prehabilitation program could address these issues by allowing patients to participate from home with remote support from healthcare professionals.ObjectiveTo develop and evaluate the feasibility of a digital application to offer multimodal home-based prehabilitation for older patients undergoing surgery for colorectal cancer.Materials and methodsThis single-center prospective cohort study at Northwest Clinics (Alkmaar and Den Helder, The Netherlands) included patients scheduled for elective surgery for the curative treatment of colorectal cancer. The Patient Journey App was used to deliver prehabilitation. The primary outcome was the number of patients who downloaded and activated the app. Secondary outcomes included usage information, videos viewed, questionnaires answered, and signals triggered.ResultsNinety-seven patients were included in the study (age 72.1 [SD 0.8], 62.9% male). All patients used the app daily for a median of 29 days (IQR 23-28). Exercise videos were viewed most. Ninety-five patients activated daily exercise and protein shake reminders. Patients provided 1367 answers, triggering 79 signals related to smoking cessation, nutrition, and exercise. Response rates to in-app questionnaires were high, up to 90.5%.ConclusionsHome-based prehabilitation via an app for older colorectal cancer surgery patients is feasible. Given the effectiveness of prehabilitation programs, the scarcity of healthcare professionals, and patients' reluctance for frequent in-person visits, home-based prehabilitation programs via an app could become a valuable added modality for offering these programs.Trial registration2020.0600 (VU University Medical Center).
| S-EPMC11822823 | biostudies-literature
Project description:ImportanceDelirium is a common, serious, and potentially preventable problem for older adults, associated with adverse outcomes. Coupled with its preventable nature, these adverse sequelae make delirium a significant public health concern; understanding its economic costs is important for policy makers and health care leaders to prioritize care.ObjectiveTo evaluate current 1-year health care costs attributable to postoperative delirium in older patients undergoing elective surgery.Design, setting, and participantsThis prospective cohort study included 497 patients from the Successful Aging after Elective Surgery (SAGES) study, an ongoing cohort study of older adults undergoing major elective surgery. Patients were enrolled from June 18, 2010, to August 8, 2013. Eligible patients were 70 years or older, English-speaking, able to communicate verbally, and scheduled to undergo major surgery at 1 of 2 Harvard-affiliated hospitals with an anticipated length of stay of at least 3 days. Eligible surgical procedures included total hip or knee replacement; lumbar, cervical, or sacral laminectomy; lower extremity arterial bypass surgery; open abdominal aortic aneurysm repair; and open or laparoscopic colectomy. Data were analyzed from October 15, 2019, to September 15, 2020.ExposuresMajor elective surgery and hospitalization.Main outcomes and measuresCumulative and period-specific costs (index hospitalization, 30-day, 90-day, and 1-year follow-up) were examined using Medicare claims and extensive clinical data. Total inflation-adjusted health care costs were determined using data from Medicare administrative claims files for the 2010 to 2014 period. Delirium was rated using the Confusion Assessment Method. We also examined whether increasing delirium severity was associated with higher cumulative and period-specific costs. Delirium severity was measured with the Confusion Assessment Method-Severity long form. Regression models were used to determine costs associated with delirium after adjusting for patient demographic and clinical characteristics.ResultsOf the 566 patients who were eligible for the study, a total of 497 patients (mean [SD] age, 76.8 [5.1] years; 281 women [57%]; 461 White participants [93%]) were enrolled after exclusion criteria were applied. During the index hospitalization, 122 patients (25%) developed postoperative delirium, whereas 375 (75%) did not. Patients with delirium had significantly higher unadjusted health care costs than patients without delirium (mean [SD] cost, $146 358 [$140 469] vs $94 609 [$80 648]). After adjusting for relevant confounders, the cumulative health care costs attributable to delirium were $44 291 (95% CI, $34 554-$56 673) per patient per year, with the majority of costs coming from the first 90 days: index hospitalization ($20 327), subsequent rehospitalizations ($27 797), and postacute rehabilitation stays ($2803). Health care costs increased directly and significantly with level of delirium severity (none-mild, $83 534; moderate, $99 756; severe, $140 008), suggesting an exposure-response relationship. The adjusted mean cumulative costs attributable to severe delirium were $56 474 (95% CI, $40 927-$77 440) per patient per year. Extrapolating nationally, the health care costs attributable to postoperative delirium were estimated at $32.9 billion (95% CI, $25.7 billion-$42.2 billion) per year.Conclusions and relevanceThese findings suggest that the economic outcomes of delirium and severe delirium after elective surgery are substantial, rivaling costs associated with cardiovascular disease and diabetes. These results highlight the need for policy imperatives to address delirium as a large-scale public health issue.
| S-EPMC7905699 | biostudies-literature
Project description:BackgroundPerioperative cognitive maintenance and protection in older adults is an important patient safety imperative. In addition to foundational care, one area of growing interest is integrating cognitive prehabilitation into the surgical trajectory. This review aimed to evaluate the effectiveness and safety of cognitive prehabilitation on cognitive functional capacity and postoperative cognitive outcomes among older adults undergoing elective surgery.MethodsThe MEDLINE, Embase, CENTRAL, CINAHL, PsycINFO, PEDro, CBM, CNKI, WANFANG, and VIP databases were systematically searched up to September 5, 2024, to identify randomized controlled trials published for English or Chinese. Two authors independently completed the study selection process, data extraction process and methodological quality assessment. The Patient, Intervention, Comparison, Outcome, Study design framework was used to construct the search strategy. The predefined primary outcomes of interest included the incidence of postoperative delirium (POD) and the incidence of delayed neurocognitive recovery (dNCR). The quality of the studies was evaluated by the PEDro scale. Owing to the small number of trials and clinical and methodological diversity, a narrative synthesis was undertaken in accordance with the Synthesis Without Meta-analysis guidelines. This study was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation system.ResultsSix studies were analysed. These trials involved 645 total participants, with 316 in the intervention group (mean age, 66.0-73.8 years; 38.4-77.8% male) and 329 in the comparator group (mean age, 67.5-72.6 years; 31.8-88.9% male). The effects of preoperative cognitive training on reducing the incidence of dNCR, the incidence of POD, the length of hospital stay and the incidence of postsurgical complications as well as improving postoperative global cognitive function and activities of daily living are quite uncertain. The results of this study should be interpreted with caution owing to the limited number of trials and low to very low certainty of evidence.ConclusionCurrent evidence on the effectiveness and safety of cognitive prehabilitation on cognitive and noncognitive outcomes in older patients undergoing elective surgery is limited and unclear.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=277191, Identifier CRD42021277191.
| S-EPMC11486734 | biostudies-literature