Frailty as a predictor of postoperative outcomes in neurosurgery: a systematic review.

INTRODUCTION: Baseline frailty status has been utilized to predict a wide range of outcomes and guide preoperative decision making in neurosurgery. This systematic review aims to analyze existing literature on the utilization of frailty as a predictor of neurosurgical outcomes. EVIDENCE ACQUISITION: We conducted a systematic review following PRISMA guidelines. Studies that utilized baseline frailty status to predict outcomes after a neurosurgical intervention were included in this systematic review. Studies that utilized sarcopenia as the sole measure of frailty were excluded. PubMed, EMBASE, and Cochrane library was searched from inception to March 1st, 2023, to identify relevant articles. EVIDENCE SYNTHESIS: Overall, 244 studies met the inclusion criteria. The 11-factor modified frailty index (mFI-11) was the most utilized frailty measure (N.=91, 37.2%) followed by the five-factor modified Frailty Index (mFI-5) (N.=80, 32.7%). Spine surgery was the most common subspecialty (N.=131, 53.7%), followed by intracranial tumor resection (N.=57, 23.3%), and post-operative complications were the most reported outcome (N.=130, 53.2%) in neurosurgical frailty studies. The USA and the Bowers author group published the greatest number of articles within the study period (N.=176, 72.1% and N.=37, 15.2%, respectively). CONCLUSIONS: Frailty literature has grown exponentially over the years and has been incorporated into neurosurgical decision making. Although a wide range of frailty indices exist, their utility may vary according to their ability to be incorporated in the outpatient clinical setting.

A completely fractured zotarolimus-eluting stent in an aortocoronary saphenous vein bypass graft.

Drug-eluting stents (DES) have significantly improved the rate of target vessel revascularization in comparison with bare metal stents. DES fracture was not reported in multicenter randomized clinical trials, but several case reports of DES fracture have been published, mostly with sirolimus-eluting stents. DES fracture is associated with stent restenosis and thrombosis. We report a zotarolimus-eluting stent fracture in an aortocoronary saphenous vein graft (SVG) bypass. The patient presented with chest pain and a non-ST-elevation myocardial infarction. He underwent cardiac catheterization that showed a complete fracture of a zotarolimus-eluting stent in the ostium of a sequential SVG to the diagonal and obtuse coronary arteries. His management included coronary angioplasty and retrieval of the proximal fractured segment. We discuss the potential causes for this stent fracture and suggest caution when using a DES in an ostial location of a SVG bypass, especially in a highly mobile vessel.

Lipid-lowering efficacy of red yeast rice in a population intolerant to statins.

Chinese red yeast rice is a dietary supplement containing monacolins, unsaturated fatty acids, and phytosterols capable of lowering low-density lipoprotein (LDL) cholesterol. Few studies have reported on its use in clinical practice or in statin-intolerant patients. We reviewed approximately 1,400 clinical charts and identified 25 patients treated with red yeast rice for > or =4 weeks. The patients were included if they had pre- and post-treatment lipid levels without simultaneous changes in other lipid-lowering medications. These patients had experienced myalgias (68%), gastrointestinal intolerance (16%), and/or elevated alanine aminotransferase levels (8%) with previous use of other lipid-lowering agents. The total cholesterol decreased 15% (-37 +/- 26 mg/dl, p <0.001) and LDL cholesterol decreased 21% (-35 +/- 25 mg/dl, p <0.001) during 74 +/- 39 days of treatment. Most (92%) patients tolerated the treatment, and many (56%) achieved their LDL cholesterol goal. In patients unable to tolerate daily statin use, the total cholesterol level decreased 13% (-33 +/- 10 mg/dl, p <0.001) and LDL cholesterol decreased 19% (-31 +/- 4 mg/dl, p <0.001). In conclusion, red yeast rice modestly decreased total and LDL cholesterol, was well-tolerated, and was an acceptable alternative in patients intolerant of other lipid-lowering medications.

A multicenter evaluation of a new post-processing method with depth-dependent collimator resolution applied to full-time and half-time acquisitions without and with simultaneously acquired attenuation correction.

BACKGROUND: The field of nuclear cardiology is limited by image quality and length of procedure. The use of depth-dependent resolution recovery algorithms in conjunction with iterative reconstruction holds promise to improve image quality and reduce acquisition time. This study compared the Astonish algorithm employing depth-dependent resolution recovery and iterative reconstruction to filtered backprojection (FBP) using both full-time (FTA) and half-time (HTA) data. Attenuation correction including scatter correction in conjunction with the Astonish algorithm was also evaluated. METHODS: We studied 187 consecutive patients (132 with cardiac catheterization and 55 with low likelihood for CAD) from three nuclear cardiology laboratories who had previously undergone clinically indicated rest/stress Tc-99m sestamibi or tetrofosmin SPECT. Acquisition followed ASNC guidelines (64 projections, 20-25 seconds). Processing of the full-time data sets included FBP and Astonish (FTA). A total of 32 projection data sets were created by stripping the full-time data sets and processing with Astonish (HTA). Attenuation correction was applied to both full-time and half-time Astonish-processed images (FTA-AC and HTA-AC, respectively). A consensus interpretation of three blinded readers was performed for image quality, interpretative certainty, and diagnostic accuracy, as well as severity and reversibility of perfusion and functional parameters. RESULTS: Full-time and half-time Astonish processing resulted in a significant improvement in image quality in comparison with FBP. Stress and rest perfusion image quality (excellent or good) were 85%/80% (FBP), 98%/95% (FTA), and 95%/92% (HTA), respectively (p < 0.001). Interpretative certainty and diagnostic accuracy were similar with FBP, FTA, and HTA. Left ventricular functional data were not different despite a slight reduction in half-time gated image quality. Application of attenuation correction resulted in similar image quality and improved normalcy (FTA vs. FTA-AC: 76% vs. 95%; HTA vs. HTA-AC: 76% vs. 100%) and specificity (FTA vs. FTA-AC: 62% vs. 78%; HTA vs. HTA-AC: 63% vs. 84%) (p < 0.01 for all comparisons). CONCLUSION: Astonish processing, which incorporates depth-dependent resolution recovery, improves image quality without sacrificing interpretative certainty or diagnostic accuracy. Application of simultaneously acquired attenuation correction, which includes scatter correction, to full-time and half-time images processed with this method, improves specificity and normalcy while maintaining high image quality.

A history of medical reports on the Boston Marathon: 112 years and still running.

INTRODUCTION/METHODS: We performed a systematic search for medical reports on the Boston Marathon, run annually since April 19, 1897 and studied medically since 1899. RESULTS: We identified 66 articles: 25 were related to cardiology; 10, exercise physiology; 8, metabolism; 5, neurology; 4, gastroenterology; 3, hematology; 3, several disciplines; and 8, nephrology, orthopedics, and general topics. The predominance of cardiology articles reflects concerns about the cardiac risks of exercise present in the early 20th century and persistent to this day. The authors and contributors included luminaries from the medical and exercise community including Drs. Paul Dudley White, Samuel Levine, Kenneth Cooper, Paul Zoll, Ellsworth Buskirk, and David Costill. The articles identified or confirmed many of the presently accepted principles of marathon medicine. CONCLUSIONS: Medical studies on the Boston Marathon not only provide lessons applicable to managing modern athletes but also demonstrate the interests and concerns of researchers who have used the event to study the physiology of prolonged exercise for more than a century.

Managing statin myopathy.

Approximately 10% of patients treated with statins experience some form of muscle-related side effects in clinical practice. These can range from asymptomatic creatine kinase (CK) elevation, to muscle pain, weakness, and its most severe form, rhabdomyolysis. Higher risk patients for statin myopathy are those older than 80, with a small body frame, on higher statin doses, on other medications, or with other systemic diseases including hepatic or renal diseases, diabetes mellitus, or hypothyroidism. The cause of statin myopathy is presumed to be the same for its variable presentation but has not been defined. In patients with myopathic symptoms, their symptoms and CK levels determine whether statin therapy can be continued or must be stopped.

A history of medical reports on the Boston Marathon: 112 years and still running.

INTRODUCTION/METHODS: We performed a systematic search for medical reports on the Boston Marathon, run annually since April 19, 1897 and studied medically since 1899. RESULTS: We identified 66 articles: 25 were related to cardiology; 10, exercise physiology; 8, metabolism; 5, neurology; 4, gastroenterology; 3, hematology; 3, several disciplines; and 8, nephrology, orthopedics, and general topics. The predominance of cardiology articles reflects concerns about the cardiac risks of exercise present in the early 20th century and persistent to this day. The authors and contributors included luminaries from the medical and exercise community including Drs. Paul Dudley White, Samuel Levine, Kenneth Cooper, Paul Zoll, Ellsworth Buskirk, and David Costill. The articles identified or confirmed many of the presently accepted principles of marathon medicine. CONCLUSIONS: Medical studies on the Boston Marathon not only provide lessons applicable to managing modern athletes but also demonstrate the interests and concerns of researchers who have used the event to study the physiology of prolonged exercise for more than a century.

Effectiveness of thrice weekly ezetimibe.

Ezetimibe is usually dosed daily, but its 22-hour elimination half-life permits significant cholesterol reduction with less frequent dosing. The aim of this study was to examine lipid changes in 33 patients treated with thrice-weekly ezetimibe for > or =1 month, who had pre- and postezetimibe lipid levels and no other concurrent changes in their lipid treatment. Ninety-four percent of the patients were treated with ezetimibe because they experienced myalgias, elevated transaminase levels, or gastrointestinal intolerance with higher doses of other lipid-lowering agents. Total cholesterol decreased by 15% (-36 +/- 28 mg/dl, p <0.001) and low-density lipoprotein cholesterol by 20% (-30 +/- 25 mg/dl, p <0.001) during 58 +/- 50 days of treatment. Most patients (85%) tolerated the treatment, and many (48%) achieved their low-density lipoprotein cholesterol goals. In conclusion, thrice-weekly ezetimibe decreases total and low-density lipoprotein cholesterol and is well tolerated. It is a viable treatment for patients intolerant of other lipid-lowering medications.

Effectiveness and tolerability of every-other-day rosuvastatin dosing in patients with prior statin intolerance.

BACKGROUND: Statins are generally well tolerated, but some patients discontinue therapy secondary to adverse effects. Dosing a statin (rosuvastatin) every other day (EOD) may provide significant lipoprotein changes while avoiding common adverse effects in this statin-intolerant population. OBJECTIVE: To determine the effect and tolerance of EOD rosuvastatin in patients previously intolerant to statin therapy. METHODS: We performed a retrospective analysis of patients treated with EOD rosuvastatin at 2 lipid specialty clinics: the University of Kansas Lipid, Atherosclerosis, and LDL-Apheresis Center and the Hartford Hospital Cholesterol Management Center. Approximately 2600 charts were reviewed to identify patients receiving rosuvastatin EOD who previously had experienced statin intolerance. Fifty-one patients were eligible for the analysis, which evaluated changes in the lipid profile, the number achieving their low-density lipoprotein cholesterol (LDL-C) goals, and the percent tolerating rosuvastatin EOD. Laboratory data were assessed immediately prior to rosuvastatin EOD therapy and at the first follow-up. RESULTS: Myalgias (76.5%) and increased transaminase levels (19.5%) were the most common causes of prior statin intolerance, but 72.5% (37/51) of patients were able to tolerate the EOD therapy (mean dose 5.6 mg) regimen for 4 +/- 2.9 (mean +/- SD) months. Mean LDL-C decreased 34.5% (p < 0.001) in the patients who tolerated the regimen, enabling approximately 50% to achieve their LDL-C goal. All patients who were considered to be intolerant to rosuvastatin EOD therapy (27.5%; 14/51) re-experienced the symptoms of their prior statin intolerance. CONCLUSIONS: Treating patients intolerant to statins with rosuvastatin EOD was tolerated by the majority of patients and reduced LDL-C in our study. This dosing strategy may be useful in patients intolerant to once-daily statin dosing, although such an approach has not been documented to reduce cardiovascular events.