The Range and Reproducibility of the Liver Frailty Index.

The Liver Frailty Index (LFI), composed of 3 performance-based tests (grip strength, chair stands, and balance), is a tool specifically developed in patients with cirrhosis to objectively measure physical function, a critical determinant of health outcomes. We aimed to (1) determine the range of LFI scores in adults with chronic liver disease but without cirrhosis, (2) determine the range of LFI scores in adults without known liver disease, and (3) evaluate reproducibility of the LFI in adults with cirrhosis listed for liver transplantation. Intraclass correlation coefficient (ICC) assessed interrater reliability of the LFI. Included were 91 adults with chronic liver disease, 109 adults without known liver disease, and 166 adults with cirrhosis with median Model for End-Stage Liver Disease-sodium of 16. Median (interquartile range) LFI was 3.6 (3.1-4.1) in adults with cirrhosis, 3.1 (2.5-3.7) in adults with chronic liver disease but not cirrhosis, and 2.7 (2.2-3.2) in adults without liver disease (P < 0.001). Using established LFI cutoffs for robust, prefrail, and frail categories, adults with cirrhosis or chronic liver disease were less likely to be robust (29% versus 53% versus 77%) and more likely to be prefrail (57% versus 42% versus 22%) or frail (14% versus 5% versus 1%) when compared with adults without liver disease (P < 0.001). The LFI had excellent reliability with ICC of 0.93 (95% confidence interval, 0.91-0.95). In conclusion, the LFI has external validity in noncirrhotic populations and is highly reproducible among different raters. This objective assessment tool can be implemented in outpatient clinical practice or research to operationalize the concept of physical frailty.

Association of Cardiac Abnormalities to the Frail Phenotype in Cirrhotic Patients on the Waitlist: From the Functional Assessment in Liver Transplantation Study.

BACKGROUND: Frailty is a syndrome of decreased physiologic reserve that results from compromise of multiple physiologic systems including cardiovascular system. We aimed to determine the association between the frail phenotype and cardiac abnormalities in liver transplant (LT) candidates through evaluation of transthoracic echocardiography (TTE) indices. METHODS: Included were consecutive outpatients listed for LT who underwent a frailty assessment from January 1, 2014, to June 30, 2016 (using the Liver Frailty Index) and a 2-dimensional/Doppler TTE examination. Patients were categorized as robust, intermediate frail, or frail by the Liver Frailty Index based on scores of less than 3.2, between 3.2 and 4.5, or 4.5 or greater. Linear regression assessed associations between the Liver Frailty Index and TTE indices. RESULTS: Of 335 patients, 19% were robust, 65% intermediate frail, and 16% frail. TTE indices of left atrial (LA) dilatation differed significantly by frailty status: median LA dimension (P = 0.03), LA volume index (LAVI mL/m; P < 0.001) and %LAVI > 34 mL/m (P = 0.001). In linear regression adjusted for age, sex, hypertension, and diabetes, the Liver Frailty Index was positively associated with LA dimension (coeff, 0.20; 95% confidence interval [CI], 0.07-0.34), LAVI mL/m (coeff, 0.01; 95% CI, 0.005-0.02), ejection fraction (coeff, 1.59; 95% CI, 0.32-2.85), and pulmonary artery systolic pressure (coeff, 0.01; 95% CI, 0.003-0.02), and negatively associated with LV hypertrophy (coeff, -0.22; 95% CI, -0.37 to -0.06). CONCLUSIONS: In LT candidates, frailty is associated with cardiac structural and functional changes, independent of known risk factors. Our study provides evidence to support that measures of frailty in cirrhotic patients encompass abnormalities of the cardiovascular system and may inform assessments of cardiovascular reserve in this population.

The Effect of California's Breast Density Notification Legislation on Breast Cancer Screening.

PURPOSE: Half of US states mandate women be notified if they have dense breasts on their mammogram, yet guidelines and data on supplemental screening modalities are limited. Breast density (BD) refers to the extent that breast tissue appears radiographically dense on mammograms. High BD reduces the sensitivity of screening mammography and increases breast cancer risk. The aim of this study was to determine the potential impact of California's 2013 BD notification legislation on breast cancer screening patterns. METHODS: We conducted a cohort study of women aged 40 to 74 years who were members of a large Northern California integrated health plan (approximately 3.9 million members) in 2011-2015. We calculated pre- and post-legislation rates of screening mammography and magnetic resonance imaging (MRI). We also examined whether women with dense breasts (defined as BI-RADS density c or d) had higher MRI rates than women with nondense breasts (defined as BI-RADS density a or b). RESULTS: After adjustment for race/ethnicity, age, body mass index, medical facility, neighborhood median income, and cancer history, there was a relative 6.6% decrease (relative risk [RR] 0.934, confidence interval [CI] 0.92-0.95) in the rate of screening mammography, largely driven by a decrease among women <50 years. While infrequent, there was a relative 16% increase (RR 1.16, CI 1.07-1.25) in the rate of screening MRI, with the greatest increase among the youngest women. In the postlegislation period, women with extremely dense breasts (BI-RADS d) had 2.77 times (CI 1.93-3.95) the odds of a MRI within 9 months of a screening mammogram compared with women with nondense breasts (BI-RADS b). CONCLUSIONS: In this setting, MRI rates increased in the postlegislation period. In addition, women with higher BD were more likely to have supplementary MRI. The decrease in mammography rates seen primarily among younger women may have been due to changes in national screening guidelines.

Femur fracture classification in women with a history of breast cancer.

PURPOSE: Women with breast cancer are at increased risk for femur fracture. Contributing factors include estrogen deficiency, cancer-related therapies, or direct bone involvement. This study examines fracture subtypes in women with prior breast cancer experiencing a femur fracture. METHODS: Women age ≥50 years old with a history of invasive breast cancer who experienced a femur fracture were identified during 2005-2012. Fracture site was classified by hospital diagnosis (for hip) and/or radiologic findings (for femoral diaphysis), with subtype classification as pathologic, atypical or fragility fracture. Clinical characteristics were ascertained using health plan databases and disease registries. RESULTS: There were 802 women with prior breast cancer who experienced a femur fracture. The mean age at fracture was 80.5±9.6 years, with most fractures (93.8%) occurring in the hip and only 6.2% in the femoral diaphysis. However, diaphyseal fractures accounted for 23.6% of fractures in younger women (age ≤65 years). Pathologic fractures comprised 9.6% of total fractures (56.0% of diaphyseal fractures) and accounted for half the fractures in younger women. An atypical fracture pattern was seen in 1% of all femur fractures and 16.0% of diaphyseal fractures, with prior bisphosphonate exposure in all atypical fracture cases. CONCLUSION: Most femur fractures in women with prior breast cancer occurred in the hip. Among younger women and those experiencing diaphyseal fractures, a larger proportion were pathologic and some were found to be atypical. Further studies should examine risk factors for femur fracture in women with breast cancer with specific attention to fracture subtype and pharmacologic exposures.