Routine frailty assessment predicts postoperative complications in elderly patients across surgical disciplines – a retrospective observational study

BACKGROUND: Frailty is a frequent and underdiagnosed functional syndrome involving reduced physiological reserves and an increased vulnerability against stressors, with severe individual and socioeconomic consequences. A routine frailty assessment was implemented at our preoperative anaesthesia clinic to identify patients at risk. OBJECTIVE: This study examines the relationship between frailty status and the incidence of in-hospital postoperative complications in elderly surgical patients across several surgical disciplines. DESIGN: Retrospective observational analysis. SETTING: Single center, major tertiary care university hospital. Data collection took place between June 2016 and March 2017. PATIENTS: Patients 65 years old or older were evaluated for frailty using Fried's 5-point frailty assessment prior to elective non-cardiac surgery. Patients were classified into non-frail (0 criteria, reference group), pre-frail (1-2 positive criteria) and frail (3-5 positive criteria) groups. MAIN OUTCOME MEASURES: The incidence of postoperative complications was assessed until discharge from the hospital, using the roster from the National VA Surgical Quality Improvement Program. Propensity score matching and logistic regression analysis were performed. RESULTS: From 1186 elderly patients, 46.9% were classified as pre-frail (n = 556), and 11.4% as frail (n = 135). The rate of complications were significantly higher in the pre-frail (34.7%) and frail groups (47.4%), as compared to the non-frail group (27.5%). Similarly, length of stay (non-frail: 5.0 [3.0;7.0], pre-frail: 7.0 [3.0;9.0], frail 8.0 [4.5;12.0]; p < 0.001) and discharges to care facilities (non-frail:1.6%, pre-frail: 7.4%, frail: 17.8%); p < 0.001) were significantly associated with frailty status. After propensity score matching and logistic regression analysis, the risk for developing postoperative complications was approximately two-fold for pre-frail (OR 1.78; 95% CI 1.04-3.05) and frail (OR 2.08; 95% CI 1.21-3.60) patients. CONCLUSIONS: The preoperative frailty assessment of elderly patients identified pre-frail and frail subgroups to have the highest rate of postoperative complications, regardless of age, surgical discipline, and surgical risk. Significantly increased length of hospitalisation and discharges to care facilities were also observed. Implementation of routine frailty assessments appear to be an effective tool in identifying patients with increased risk. Now future studies are needed to investigate whether patients benefit from optimization of patient counselling, process planning, and risk reduction protocols based on the application of risk stratification

a comparison of two techniques

Einleitung: Perkutane Dilatationstracheotomien (PDT) stellen ein etabliertes Verfahren im Beatmungsregime kritisch kranker Patienten dar. Im Rahmen des intensivmedizinischen Gesamtkonzepts sind sie ein Standard zur Entwöhnung langzeitbeatmeter Patienten vom Respirator. Der Stellenwert der PDT, auch nach kardiochirurgischen Eingriffen, wurde in bisherigen Studien gut gesichert. Trotz des vermeintlich minimal-invasiven Routineeingriffs, stellt die Punktionstracheotomie eine Maßnahme am Atemweg kranker Patienten dar, die mit schwerwiegenden Komplikationen verbunden sein kann. Im Bestreben die PDT zu perfektionieren, setzt eine neue Technik überwiegend auf radiäre Dilatation mittels Ballon. Die primären Ziele der Studie waren bei Patienten einer kardio- und thoraxchirurgischen Intensivstation mit der Indikation zur Tracheotomie das Verfahren zur PDT mittels radiärer Ballondilatation (Ciaglia Blue Dolphin®) mit der etablierten Technik mittels gebogenem Dilatator (Ciaglia Blue Rhino®) in Bezug auf peri- und postoperative Komplikationen und die technische Durchführbarkeit zu vergleichen. Methoden: In einer prospektiven Kohortenstudie wurden alle Patienten der Intensivstation des Deutschen Herzzentrums Berlin untersucht, die von November 2007 bis Juni 2009 konsekutiv eine Dilatationstracheotomie mittels Dolphin- oder Rhino-Technik erhielten. Es wurden protokollbasiert Daten zur Demographie, Morbidität, peri- und postoperative Komplikationen, sowie zur technischen Durchführbarkeit der PDT erfasst. Ergebnisse: Es konnten von 219 durchgeführten PDT 213 Patienten in die Studie eingeschlossen werden (Dolphingruppe, n = 100; Rhinogruppe, n = 113), ohne dass zwischen den Patientengruppen ein signifikanter Unterschied bezüglich der demographischen Kennzahlen und der Morbidität bestand. Es zeigten sich keine signifikanten Unterschiede zwischen der Dolphin- und Rhinogruppe in Bezug auf die Summe der klinisch bedeutsamen und patientenrelevanten Gesamtkomplikationen (13% vs. 14,2 %), der Anzahl der Patienten mit 0, 1 oder ≥ 2 Komplikationen (p = 0,994), aller perioperativen (31 % vs. 32,7 %) oder postoperativen Komplikationen (6 % vs. 8,0 %) und der Anzahl der erforderlichen Dilatationsversuche bis zur erfolgreichen Platzierung der Trachealkanüle (p = 0,119). Die Dolphin-Technik erwies sich als die signifikant schneller durchführbare Methode (3,4 min vs. 4,3 min; p < 0,001). Schlussfolgerung: In der vorliegenden Studie konnte erstmals bei Patienten einer kardio- und thoraxchirurgischen Intensivstation gezeigt werden, dass das Verfahren zur PDT mittels radiärer Ballondilatation (Ciaglia Blue Dolphin®) im Vergleich mit der bisher etablierten Technik mittels gebogenem Dilatator (Ciaglia Blue Rhino®) keine klinisch relevanten Unterschiede in der Analyse von peri- und postoperativen Komplikationen und der technischen Durchführung aufwies. In vorliegender Arbeit ließ sich die PDT mit der Dolphin®-Technik signifikant schneller durchführen, was in Anbetracht insgesamt kurzer OP-Zeiten im klinischen Alltag nicht bedeutsam erscheint. Insgesamt ist die Rate an klinisch relevanten Gesamtkomplikationen niedrig und mit bisherigen Studien vergleichbar. Im Bestreben eine möglichst komplikationsarme und einfach handhabbare Technik bei der PDT anzuwenden, bleibt vorerst offen, welche Patienten von der Ballondilatation profitieren könnten.Introduction: Percutaneous dilatational tracheostomy (PDT) is an established procedure in modern intensive care medicine for patients undergoing prolonged intubation. The validity of the PDT after cardiosurgical intervention has been proven. In spite of presumed minimal tissue trauma by PDT, there are still serious and intermediate early and late complications. Efforts to perfect the PDT produced a balloon dilation technique, which uses predominantly radial force to widen the tracheostoma. The aim of this study was to compare the new Ciaglia Blue Dolphin® system with the established Ciaglia Blue Rhino® technique in cardiosurgical intensive care unit (ICU) patients according to early and late complications and practical feasibility. Methods: This prospective cohort study included every patient who consecutively received a PDT in the cardiosurgical ICU of the Deutsches Herzzentrum Berlin from November 2007 to June 2009. Patients’ baseline and clinical characteristics were collected. Early and late complications plus duration of the tracheostomy procedure and number of dilatation procedures needed to attain a safe airway passage were analyzed. This study was approved by the IRB, with waiver of need for patient consent. Results: During the study period, tracheostomy was indicated in 219 patients, 213 of whom were eligible for the study (Dolphin group, n = 100; Rhino group, n = 113). Baseline and clinical data showed no significant differences between the two groups. No differences were reported between the Dolphin and Rhino technique regarding clinically relevant early and late complications (13 % vs. 14.2 %), patients with one or more complications (p = 0.994), overall early (31 % vs. 32.7 %) or late (6 % vs. 8.0 %) complications and the number of dilatation procedures (p = 0.119). Median procedure time was significantly shorter in the Dolphin group (3.4 min vs. 4.3 min; p < 0.001). Discussion: This is the first study comparing the new Ciaglia Blue Dolphin® PDT technique with the Ciaglia Blue Rhino® technique in cardiosurgical ICU patients according to procedure-related early and late complications and practical feasibility. There were no clinically relevant differences between both groups. The advantages of a shorter time of intervention in the Dolphin group are not clinically relevant. The present study shows a low rate of clinically relevant early and late complications and corresponds to published data. Future efforts are needed to assess the advantages and limits of the Dolphin method in the presence of special patients

Temporomandibular Joint Osteoarthritis: Regenerative Treatment by a Stem Cell Containing Advanced Therapy Medicinal Product (ATMP)—An In Vivo Animal Trial

Temporomandibular joint osteoarthritis (TMJ-OA) is a chronic degenerative disease that is often characterized by progressive impairment of the temporomandibular functional unit. The aim of this randomized controlled animal trial was a comparative analysis regarding the chondroregenerative potency of intra-articular stem/stromal cell therapy. Four weeks after combined mechanical and biochemical osteoarthritis induction in 28 rabbits, therapy was initiated by a single intra-articular injection, randomized into the following groups: Group 1: AB Serum (ABS); Group 2: Hyaluronic acid (HA); Group 3: Mesenchymal stromal cells (STx.); Group 4: Mesenchymal stromal cells in hyaluronic acid (HA + STx.). After another 4 weeks, the animals were euthanized, followed by histological examination of the removed joints. The histological analysis showed a significant increase in cartilage thickness in the stromal cell treated groups (HA + STx. vs. ABS, p = 0.028; HA + ST.x vs. HA, p = 0.042; STx. vs. ABS, p = 0.036). Scanning electron microscopy detected a similar heterogeneity of mineralization and tissue porosity in the subchondral zone in all groups. The single intra-articular injection of a stem cell containing, GMP-compliant advanced therapy medicinal product for the treatment of iatrogen induced osteoarthritis of the temporomandibular joint shows a chondroregenerative effect

The marine Devonian stratigraphy of Great Britain

Exposed marine Devonian rocks of Great Britain are in South-West England where successions together span most of the Devonian Period. The Geological Conservation Review (GCR) sites of the volume are located in Cornwall and Devon, the latter providing the historic stratotype of the Devonian System. Site stratigraphies are linked to basins of three sub-provinces. Those represent different, albeit largely penecontemporaneous, tectonosedimentary regimes of the differing settings of the Rhenohercynian Zone. The sites and their selection criteria based on their international and national importance in understanding Devonian geological history are listed. A History of Research section provides a detailed review of work on the Devonian rocks of the province from 1839, when Sedgwick and Murchison proposed establishment of the system, to the present and the recent recognition of the relationships between its numerous successions and their dependence upon, extensional and contractional tectonic structures and processes. Other sections detail the Stratigraphical Framework of Devonian strata; Devonian Chronostratigraphy, tracing development and refinement of the Series’ and Stages of the system; and Biostratigraphy, in relation to the faunal groups of the province and their relevance to biozone establishment and environmental discrimination. The chapter concludes with an explanation of current understanding of the evolution of the plate settings of the province that determined the nature of the marine Devonian and its stratigraphy in South-West England