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

The association between frailty and MRI features of cerebral small vessel disease

Abstract: Frailty is a common syndrome in older individuals that is associated with poor cognitive outcome. The underlying brain correlates of frailty are unclear. The aim of this study was to investigate the association between frailty and MRI features of cerebral small vessel disease in a group of non-demented older individuals. We included 170 participants who were classified as frail (n = 30), pre-frail (n = 85) or non-frail (n = 55). The association of frailty and white matter hyperintensity volume and shape features, lacunar infarcts and cerebral perfusion was investigated by regression analyses adjusted for age and sex. Frail and pre-frail participants were older, more often female and showed higher white matter hyperintensity volume (0.69 [95%-CI 0.08 to 1.31], p = 0.03 respectively 0.43 [95%-CI: 0.04 to 0.82], p = 0.03) compared to non-frail participants. Frail participants showed a non-significant trend, and pre-frail participants showed a more complex shape of white matter hyperintensities (concavity index: 0.04 [95%-CI: 0.03 to 0.08], p = 0.03; fractal dimensions: 0.07 [95%-CI: 0.00 to 0.15], p = 0.05) compared to non-frail participants. No between group differences were found in gray matter perfusion or in the presence of lacunar infarcts. In conclusion, increased white matter hyperintensity volume and a more complex white matter hyperintensity shape may be structural brain correlates of the frailty phenotype

Die Rolle des Nukleären Rezeptors Small Heterodimer Partner 1 (SHP1) in der Entstehung und Regulation des klarzelligen Nierenzellkarzinoms

Der Nukleäre Rezeptor SHP1 ist ein zentrales Stellglied zahlreicher biologischer Prozesse. So reguliert SHP1 über direkte Protein-Protein-Interaktion mit Nukleären Rezeptoren Stoffwechselwege, wie den Gallensäure-, Cholesterin- und Lipidmetabolismus sowie die Glucosehomöostase und den Arzneimittelstoffwechsel. Erweiternd konnte kürzlich ein tumorsupprimierender Effekt des SHP1 gezeigt werden. So wurde die Entwicklung eines Hepatozellulären Karzinoms im Mausmodell in Abwesenheit des SHP1 beschrieben. Es ist bekannt, dass SHP1 nicht nur in hepatischem Gewebe, sondern auch in Lunge, Herz, Milz, Dünndarm, Pankreas, Niere, Nebenniere und Hirn exprimiert ist. In einer orientierenden Expressionsanalyse konnten wir eine verminderte SHP1 Expression in Tumorentitäten der Organe Niere, Lunge und Magen zeigen. Diese Ergebnisse konnten in den Proben einer Kohorte von an einem klarzelligen Nierenzellkarzinom erkrankten Patienten verifiziert werden. Es zeigte sich eine signifikant verminderte SHP1 Expression im klarzelligen Nierenzellkarzinom (RCC) im Vergleich zu Nierengewebe. Nachfolgend konnten wir mittels adenoviral vermittelter Überexpression des SHP1 in einem Zellmodell des RCC einen antiproliferativen Effekt des SHP1 im RCC zeigen. Bisher wurde die Vermittlung dieser antiproliferativen Komponente über eine Hemmung des CyclinD1 durch SHP1 vermutet. Zwar konnten wir im Einklang hiermit eine verminderte CyclinD1 Expression im RCC gegenüber Niere detektieren, nach Überexpression des SHP1 zeigte sich jedoch keine Suppression des CyclinD1, so dass davon auszugehen ist, dass die antiproliferative Wirkung des SHP1 im RCC über andere Zielstrukturen vermittelt wird. Da sich das RCC durch eine hohe Chemotherapieresistenz auszeichnet und SHP1 in den Arzneimittelstoffwechsel involviert ist, untersuchten wir den Einfluss des SHP1 auf die Chemosensitivität des RCC. Hier konnten wir zunächst keinen Einfluss des SHP1 auf die Viabilität des zellulären Modells des RCC durch die Substanzen Vinblastin, Temsirolimus und Sunitinib zeigen. Dennoch ist ein Einfluss des SHP1 auf die Proliferationshemmung durch diese Substanzen nicht auszuschließen. Abschließend untersuchten wir Ursachen für die verminderte SHP1 Expression im RCC. Hier zeigte sich, dass sowohl eine verminderte Expression von Aktivatoren des SHP1 als auch genetischen Varianten in der Promotorregion des SHP1 zunächst nicht ursächlich für die Minderexpression im RCC zu sein scheinen. Zusammenfassend konnten wir den Nukleären Rezeptor SHP1 als Tumorsuppressorgen des klarzelligen Nierenzellkarzinoms, dessen Pathogenese nach dem heutigen Wissensstand nicht geklärt ist, identifizieren. Basierend auf der antiproliferativen Wirkung könnte der SHP1 zukünftig ein Zielmolekül einer pharmakologischen Therapie des RCC darstellen.Mammalian nuclear receptors (NRs) are transcription factors regulating the expression of target genes that play an important role in drug metabolism, transport, and cellular signaling pathways. The orphan and structurally unique receptor small heterodimer partner 1 (also known as NR0B2) is not only known for its modulation of drug response, but has also been reported to be involved in hepatocellular carcinogenesis. Previous studies show that NR0B2 is downregulated in human hepatocellular carcinoma, suggesting that NR0B2 acts as a tumor suppressor via inhibition of cellular growth, and activation of apoptosis in this tumor entity. It is known that SHP1 is not only expressed in hepatic tissue but also in the lungs, heart, spleen, small intestine, pancreas, kidney, adrenal glands and brain. In an expression analysis, we were able to show a reduced expression of SHP1 in tumor entities of the kidney, lungs, and stomach. These results could be verified in the samples of a patient cohort suffering from clear cell renal cell carcinoma (RCC). There was a significantly reduced SHP1 expression in RCC compared to adjacent nonmalignant transformed tissue. Subsequently, we were able to show an antiproliferative effect of SHP1 in RCC, using an adenoviral-mediated overexpression of SHP1 in a cellular model of RCC. Up to this point, the mediation of this antiproliferative effect was described as CyclinD1 inhibition by SHP1. Although we were able to detect a reduced CyclinD1 expression in RCC compared to renal tissue, no further suppression of cyclinD1 was seen after overexpression of SHP1, so that the antiproliferative effect of SHP1 in RCC must be mediated by other targets. Since RCC is characterized by a high chemotherapeutic drug resistance, and SHP1 is involved in drug metabolism, we investigated the influence of SHP1 overexpression on the chemosensitivity of RCC. Here, SHP1 overexpression had no influence on the viability of cellular model of RCC to the substances vinblastine, temsirolimus, or sunitinib. Nevertheless, the influence of SHP1 on proliferation inhibition by these substances cannot be ruled out. Finally, we investigated the causes of reduced SHP1 expression in RCC. It was shown that neither a reduced expression of SHP1 activators, nor genetic variants in the promoter region of the SHP1 are the source for the reduced expression in RCC. In summary, we were able to identify the mammalian nuclear receptor SHP1 as a tumor suppressor gene of clear cell renal cell carcinoma, whose pathogenesis is currently unknown. Based on antiproliferative effects, SHP1 could become a suitable target molecule for a pharmacological therapy of RCC

Light-Induced Opening and Closing of the Intramolecular Hydrogen Bond in Glyoxylic Acid

The isomerization process of glyoxylic acid (GA) conformers and their complexes with a water molecule were studied in a low temperature argon matrix. The research target was to understand how starting conformation and complexation affects the near-IR (NIR) induced conformer interconversion. The most stable GA conformer (Tc) is characterized by an intramolecular hydrogen bond, and it is found to undergo light-induced conformer interconversion slower than the open (Tt) conformer. Upon complexation with water, the isomerization processes slow down in the case of the Tc conformer, whereas for the Tt-based complex the influence of water is negligible on the isomerization process

Functional assessment of genetic variants located in the promoter of SHP1 (NR0B2)

Small heterodimer partner 1 (SHP1, NR0B2) is a member of the superfamily of nuclear receptors (NRs). Even if this orphan receptor, unlike other NRs, lacks the DNA-binding domain, it is capable of regulating transcription by repressing the activity of other NRs by direct protein-protein interaction. Accordingly, SHP1 is part of negative feedback loops of the transcriptional regulation of genes involved in drug metabolism and various metabolic pathways including bile acid and glucose homeostasis. Although it is known that several interacting partners of SHP1 also modulate its expression, there is little information about genetic variability of this regulatory mechanism. Our study aimed to identify genetic variants in the NR0B2 promoter region and to determine their impact on NR0B2 transcription. For this, DNA samples originating from 119 participants of the population-based cohort Study of Health in Pomerania were analyzed by Sanger sequencing revealing four genetic variants: NR0B2:c.-594T&gt;C (rs71636795), NR0B2:c.-414G&gt;C (newly identified), NR0B2:c.-423C&gt;T (rs78182695), and NR0B2:c.-224delCTGA (rs145613139) localized in the 5' untranslated region of NR0B2. The impact of these variants on transactivation of the NR0B2 promoter by NRs known to be regulators of SHP1 expression (hepatocyte nuclear factor 4α, liver receptor homolog-1, and farnesoid X receptor) was assessed in a cell-based reporter gene assay, showing that transactivation by hepatocyte nuclear factor 4α and liver receptor homolog-1 was significantly decreased in the presence of the genetic variant NR0B2:c.-594T&gt;C, even though this effect was cell specific. However, SHP1 mRNA expression in a small collection of human kidney samples was not affected by these genetic variants

Modulation of expression of the nuclear receptor NR0B2 (small heterodimer partner 1) and its impact on proliferation of renal carcinoma cells

Mammalian nuclear receptors (NRs) are transcription factors regulating the expression of target genes that play an important role in drug metabolism, transport, and cellular signaling pathways. The orphan and structurally unique receptor small heterodimer partner 1 (syn NR0B2) is not only known for its modulation of drug response, but has also been reported to be involved in hepatocellular carcinogenesis. Indeed, previous studies show that NR0B2 is downregulated in human hepatocellular carcinoma, suggesting that NR0B2 acts as a tumor suppressor via inhibition of cellular growth and activation of apoptosis in this tumor entity. The aim of our study was to elucidate whether NR0B2 may also play a role in other tumor entities. Comparing NR0B2 expression in renal cell carcinoma and adjacent nonmalignant transformed tissue revealed significant downregulation in vivo. Additionally, the impact of heterologous expression of NR0B2 on cell cycle progression and proliferation in cells of renal origin was characterized. Monitoring fluorescence intensity of resazurin turnover in RCC-EW cells revealed no significant differences in metabolic activity in the presence of NR0B2. However, there was a significant decrease of cellular proliferation in cells overexpressing this NR, and NR0B2 was more efficient than currently used antiproliferative agents. Furthermore, flow cytometry analysis showed that heterologous overexpression of NR0B2 significantly reduced the amount of cells passing the G1 phase, while on the other hand, more cells in S/G2 phase were detected. Taken together, our data suggest that downregulation of NR0B2 may also play a role in renal cell carcinoma development and progression

Relevance of peripheral cholinesterase activity on postoperative delirium in adult surgical patients (CESARO)

BACKGROUND The cholinergic system is considered to play a key role in the development of postoperative delirium (POD), which is a common complication after surgery. OBJECTIVES To determine whether peri-operative acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE) activities are associated with the development of POD in in-hospital surgical patients, and raise hypotheses on cholinergic regulatory mechanisms in POD. DESIGN A prospective multicentre observational study by the Peripheral Cholinesterase-activity on Neurocognitive Dysfunctions in Surgical Patients (CESARO) study group. SETTING Nine German hospitals. PATIENTS Patients of at least 18 years of age scheduled for inpatient elective surgery for a variety of surgical procedures. A total of 650 patients (mean age 61.5 years, 52.8% male) were included. METHODS Clinical variables, and peripheral AChE and BuChE activities, were assessed throughout the peri-operative period using bedside point-of-care measurements (one pre-operative and two postoperative measurements). POD screening was conducted postoperatively for at least 24 h and up to the third postoperative day using a validated screening tool (nursing delirium screening scale). RESULTS In all, 179 patients (27.5%) developedPODwithin the early postoperative phase. There was a lower BuChE activity in patients with delirium compared with patients without delirium pre-operatively (Cohen's r = 0.07, P = 0.091), on postoperative day 1 (Cohen's r = 0.12, P = 0.003) and on postoperative day 2 (Cohen's r = 0.12, P = 0.002). In contrast, there was a significantly higher AChE activity in patients with delirium compared with patients without delirium preoperatively (Cohen's r = 0.10, P = 0.012), on postoperative day 1 (Cohen's r = 0.11, P = 0.004) and on postoperative day 2 (Cohen's r = 0.13, P = 0.002). After adjusting for covariates in multiple logistic regression, a significant association between both BuChE and AChE activities and POD was not found. However, in the multivariable analysis using the Generalized Estimating Equation, cholinesterase activities showed that a decrease of BuChE activity by 100UL(-1) increased the risk of a delirium by approximately 2.1% (95% CI 1.6 to 2.8%) and for each 1Ug(-1) of haemoglobin increase in AChE activity, there was a 1.4% (95% CI 0.6 to 2.2%) increased risk of POD. CONCLUSION Peri-operative peripheral cholinesterase activities may be related to the development of POD, but the clinical implications remain unclear. Further studies, in homogeneous patient groups with a strict protocol for measurement time points, are needed to investigate the relationship between cholinesterase activities and POD

Frequency of microsatellite instability (MSI) in upper tract urothelial carcinoma: comparison of the Bethesda panel and the Idylla MSI assay in a consecutively collected, multi-institutional cohort

AIMS: Upper tract urothelial carcinoma (UTUC) is a rare malignancy with a poor prognosis which occurs sporadically or in few cases results from a genetic disorder called Lynch syndrome. Recently, examination of microsatellite instability (MSI) has gained importance as a biomarker: MSI tumours are associated with a better response to immunomodulative therapies. Limited data are known about the prevalence of MSI in UTUC. New detection methods using the fully automated Idylla MSI Assay facilitate analysis of increased patient numbers. METHODS: We investigated the frequency of MSI in a multi-institutional cohort of 243 consecutively collected UTUC samples using standard methodology (Bethesda panel), along with immunohistochemistry of mismatch repair (MMR) proteins. The same tumour cohort was retested using the Idylla MSI Assay by Biocartis. RESULTS: Using standard methodology, 230/243 tumours were detected as microsatellite stable (MSS), 4/243 tumours as MSI and 9/243 samples as invalid. In comparison, the Idylla MSI Assay identified four additional tumours as MSS, equalling 234/243 tumours; 4/243 were classified as MSI and only 5/243 cases as invalid. At the immunohistochemical level, MSI results were supported in all available cases with a loss in MMR proteins. The overall concordance between the standard and the Idylla MSI Assay was 98.35%. Time to result differed between 3 hours for Idylla MSI Assay and 2 days with the standard methodology. CONCLUSION: Our data indicate a low incidence rate of MSI tumours in patients with UTUC. Furthermore, our findings highlight that Idylla MSI Assay can be applied as an alternative method of MSI analysis for UTUC