Elizabeth Leigh George

All Publications

• Association Between Patient Frailty and Postoperative Mortality Across Multiple Noncardiac Surgical Specialties. JAMA surgery George, E. L., Hall, D. E., Youk, A., Chen, R., Kashikar, A., Trickey, A. W., Varley, P. R., Shireman, P. K., Shinall, M. C., Massarweh, N. N., Johanning, J., Arya, S. 2020: e205152

  Abstract

  Importance: Frailty is an important risk factor for postoperative mortality. Whether the association between frailty and mortality is consistent across all surgical specialties, especially those predominantly performing lower stress procedures, remains unknown.Objective: To examine the association between frailty and postoperative mortality across surgical specialties.Design, Setting, and Participants: A cohort study was conducted across 9 noncardiac specialties in hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and Veterans Affairs Surgical Quality Improvement Program (VASQIP) from January 1, 2010, through December 31, 2014, using multivariable logistic regression to evaluate the association between frailty and postoperative mortality. Data analysis was conducted from September 15, 2019, to April 30, 2020. Patients 18 years or older undergoing noncardiac procedures were included.Exposures: Risk Analysis Index measuring preoperative frailty categorized patients as robust (Risk Analysis Index ≤20), normal (21-29), frail (30-39), or very frail (≥40). Operative Stress Score (OSS) categorized procedures as low (1-2), moderate (3), and high (4-5) stress. Specialties were categorized by case-mix as predominantly low intensity (>75% OSS 1-2), moderate intensity (50%-75%), or high intensity (<50%).Main Outcomes and Measures: Thirty-day (both measures) and 180-day (VASQIP only) postoperative mortality.Results: Of the patients evaluated in NSQIP (n=2 339 031), 1 309 795 were women (56.0%) and mean (SD) age was 56.49 (16.4) years. Of the patients evaluated in VASQIP (n=426 578), 395 761 (92.78%) were men and mean (SD) age was 61.1 (12.9) years. Overall, 30-day mortality was 1.2% in NSQIP and 1.0% in VASQIP, and 180-day mortality in VASQIP was 3.4%. Frailty and OSS distributions differed substantially across the 9 specialties. Patterns of 30-day mortality for frail and very frail patients were similar in NSQIP and VASQIP for low-, moderate-, and high-intensity specialties. Frailty was a consistent, independent risk factor for 30- and 180-day mortality across all specialties. For example, in NSQIP, for plastic surgery, a low-intensity specialty, the odds of 30-day mortality in very frail (adjusted odds ratio [aOR], 27.99; 95% CI, 14.67-53.39) and frail (aOR, 5.1; 95% CI, 3.03-8.58) patients were statistically significantly higher than for normal patients. This was also true in neurosurgery, a moderate-intensity specialty, for very frail (aOR, 9.8; 95% CI, 7.68-12.50) and frail (aOR, 4.18; 95% CI, 3.58-4.89) patients and in vascular surgery, a high-intensity specialty, for very frail (aOR, 10.85; 95% CI, 9.83-11.96) and frail (aOR, 3.42; 95% CI, 3.19-3.67) patients.Conclusions and Relevance: In this study, frailty was associated with postoperative mortality across all noncardiac surgical specialties regardless of case-mix. Preoperative frailty assessment could be implemented across all specialties to facilitate risk stratification and shared decision-making.

  View details for DOI 10.1001/jamasurg.2020.5152

  View details for PubMedID 33206156

• Association of Patient Frailty and Operative Stress with Postoperative Mortality: No Such Thing as Low-Risk Operations in Frail Adults Yan, Q., Hall, D. E., Shinall, M. C., Stitzenberg, K. B., Kao, L. S., George, E., Youk, A., Sharma, D., Wang, C., Shireman, P. K. ELSEVIER SCIENCE INC. 2020: S134–S135

  View details for Web of Science ID 000582792300237

• The Consequences of Delaying Elective Surgery: Surgical Perspective. Annals of surgery Fu, S. J., George, E. L., Maggio, P. M., Hawn, M., Nazerali, R. 2020; 272 (2): e79-e80

  View details for DOI 10.1097/SLA.0000000000003998

  View details for PubMedID 32675504

• Association of Preoperative Frailty and Operative Stress With Mortality After Elective vs Emergency Surgery. JAMA network open Shinall, M. C., Youk, A., Massarweh, N. N., Shireman, P. K., Arya, S., George, E. L., Hall, D. E. 2020; 3 (7): e2010358

  View details for DOI 10.1001/jamanetworkopen.2020.10358

  View details for PubMedID 32658284

• The Affordable Care Act Is Associated With Increased Coverage and Decreased Charges, but Limited Improvement in Access to Vascular Surgery for Medicaid Patients George, E. L., Kashikar, A., Barreto, N. B., Chen, R., Trickey, A. W., Arya, S. MOSBY-ELSEVIER. 2020: E247–E248

  View details for Web of Science ID 000544100700375

• Frailty Increases Reinterventions for Surgical Site Infections After Infrainguinal Bypass Procedures Kashikar, A., Barreto, N. B., George, E. L., Chen, R., Trickey, A. W., Arya, S. MOSBY-ELSEVIER. 2020: E152

  View details for Web of Science ID 000544100700232

• The Effect of Interfacility Transfer in Patients With Blunt Thoracic Aortic Injury Rothenberg, K. A., George, E. L., Ho, V., Barreto, N. B., Lee, J. T., Garcia-Toca, M., Stern, J. R. MOSBY-ELSEVIER. 2020: E167

  View details for Web of Science ID 000544100700255

• Intraoperative Heparin Use Is Associated With Reduced Inpatient Mortality After Thoracic Endovascular Aortic Repair for Blunt Aortic Injury Ho, V., Rothenberg, K. A., George, E. L., Lee, J. T., Garcia-Toca, M., Stern, J. R. MOSBY-ELSEVIER. 2020: E99

  View details for Web of Science ID 000544100700156

• Cost-effectiveness Analysis of Ankle-Brachial Index Screening in Patients With Coronary Artery Disease to Optimize Medical Management Minami, H., Itoga, N. K., George, E. L., Garcia-Toca, M. MOSBY-ELSEVIER. 2020: E250

  View details for Web of Science ID 000544100700381

• The Consequences of Delaying Elective Surgery: Surgical Perspective. Annals of surgery Fu, S. J., George, E. L., Maggio, P. M., Hawn, M., Nazerali, R. 2020

  View details for DOI 10.1097/SLA.0000000000003998

  View details for PubMedID 32355120

• Frailty as measured by the Risk Analysis Index is associated with long-term death after carotid endarterectomy. Journal of vascular surgery Rothenberg, K. A., George, E. L., Barreto, N., Chen, R., Samson, K., Johanning, J. M., Trickey, A. W., Arya, S. 2020

  Abstract

  OBJECTIVE: The role of carotid endarterectomy (CEA) continues to be debated in the age of optimal medical therapy, particularly for patients with limited life expectancy. The Risk Analysis Index (RAI) measures frailty, a syndrome of decreased physiologic reserve, which increases vulnerability to adverse outcomes. The RAI better predicts surgical complications, nonhome discharge, and death than age or comorbidities alone. We sought to measure the association of frailty, as measured by the RAI, with postoperative in-hospital stroke, long-term stroke, and long-term survival after CEA. We also sought to determine how postoperative stroke interacts with frailty to alter survival trajectory after CEA.METHODS: We queried the Vascular Quality Initiative CEA procedure and long-term data sets (2003-2017) for elective CEAs with complete RAI case information. For all analyses, the cohort was divided into asymptomatic and symptomatic carotid stenosis. Scoring was defined as not frail (RAI<30), frail (RAI 30-34), and very frail (RAI ≥35). Mortality information through December 2017 was obtained from the Social Security Death Index. Multivariable models (logistic and Cox proportional hazards regressions) were used to study the association of frail and very frail patients with the outcomes of interest. In a post hoc analysis, we created Kaplan-Meier curves to analyze patient mortality after CEA as well as after postoperative stroke.RESULTS: Of the 42,869 included patients, 17,092 (39.9%) were female, and 38,395 (89.6%) were white. There were 25,673 (59.9%) patients assigned to the asymptomatic stenosis group and 17,196 (40.1%) patients in the symptomatic stenosis group. Frailty was not associated with perioperative or long-term postoperative stroke. The risk of long-term mortality was significantly higher for frail (hazard ratio, 1.9 [1.7-2.3]) and very frail (hazard ratio, 3.1 [2.6-3.7]) asymptomatic patients; symptomatic frail and very frail patients also had a two to three times increased risk of long-term mortality. Frail and very frail patients had two to three times the risk for long-term mortality compared with patients who were not frail. Postoperative stroke negatively affected the mortality trajectory for all patients in the cohort, regardless of frailty status.CONCLUSIONS: RAI score is not associated with postoperative stroke; however, frail and very frail status is associated with decreased long-term survival in an incremental fashion based on increasing RAI. RAI assessment should be considered in the preoperative decision-making for patients undergoing CEA to ensure long-term survival and optimal surgical outcomes vs medical management.

  View details for DOI 10.1016/j.jvs.2020.01.043

  View details for PubMedID 32169359

• Assessment of Risk Analysis Index for Prediction of Mortality, Major Complications and Length of Stay in Vascular Surgery Patients. Annals of vascular surgery Rothenberg, K. A., George, E. L., Trickey, A. W., Barreto, N. B., Johnson, T. M., Hall, D. E., Johanning, J. M., Arya, S. 2020

  Abstract

  INTRODUCTION: Frailty is a risk factor for adverse postoperative outcomes. We aimed to test the performance of a prospectively-validated frailty measure, the Risk Analysis Index (RAI) in vascular surgery patients and delineate the additive impact of procedure complexity on surgical outcomes.METHODS: We queried the 2007-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify six major elective vascular procedure categories (carotid revascularization, abdominal aortic aneurysm [AAA] repair, suprainguinal revascularization, infrainguinal revascularization, thoracic aortic aneurysm [TAA] repair, and thoracoabdominal aortic aneurysm [TAAA] repair). We trained and tested logistic regression models for 30-day mortality, major complications and prolonged length of stay (LOS). The first model, "RAI", used the RAI alone; "RAI-Procedure (RAI-P)" included procedure category (e.g., AAA repair) and procedure approach (e.g., endovascular); "RAI-Procedure Complexity (RAI-PC)" added outpatient versus inpatient surgery, general anesthesia use, work relative value units (RVUs), and operative time.RESULTS: The RAI model was a good predictor of mortality for vascular procedures overall (C-statistic 0.72). The C-statistic increased with the RAI-P (0.78), which further improved minimally, with the RAI-PC (0.79). When stratified by procedure category, the RAI predicted mortality well for infrainguinal (0.79) and suprainguinal (0.74) procedures, moderately well for AAA repairs (0.69) and carotid revascularizations (0.70), and poorly for TAAs (0.62) and TAAAs (0.54). For carotid, infrainguinal, and suprainguinal procedures, procedure complexity (RAI-PC) had little impact on model discrimination for mortality, did improve discrimination for AAAs (0.84), TAAs (0.73), and TAAAs (0.80). While the RAI model was not a good predictor for major complications or LOS, discrimination improved for both with the RAI-PC model.CONCLUSIONS: Frailty as measured by the RAI was a good predictor of mortality overall after vascular surgery procedures. While the RAI was not a strong predictor of major complications or prolonged LOS, the models improved with the addition of procedure characteristics like procedure category and approach.

  View details for DOI 10.1016/j.avsg.2020.01.015

  View details for PubMedID 31935435

• Real-World Outcomes of EKOS Ultrasound-Enhanced Catheter-Directed Thrombolysis for Acute Limb Ischemia. Annals of vascular surgery George, E. L., Colvard, B., Ho, V., Rothenberg, K. A., Lee, J. T., Stern, J. R. 2020

  Abstract

  OBJECTIVES: Ultrasound-enhanced catheter-directed thrombolysis (UET) using the EKOS device for acute, peripheral arterial ischemia has been purported in clinical trials to accelerate the fibrinolytic process in order to reduce treatment time and lytic dosage. We aim to describe outcomes of UET in a real-world clinical setting.METHODS: We performed a retrospective review of all patients undergoing UET for acute limb ischemia at a single institution. Data collected included patient demographics, procedural details, and 30-day and 1-year outcomes. The primary endpoints for analysis were major adverse limb events (MALE; reintervention and/or amputation) and mortality within 30-days and 1-year. Secondary endpoints included technical success, use of adjunctive therapies, and postoperative complications.RESULTS: 32 patients (mean age 67.4 ± 14.9 years; 25% female) underwent UET for acute limb ischemia between 2014-2018. Rutherford Acute Limb Ischemia Classification was R1 in 56.3%, R2a in 31.3%, and R2b in 12.5%. Etiology was thrombosis of native artery in 12.5% of patients, prosthetic bypass in 31.3%, autogenous bypass in 6.3%, and stented native vessel in 50.0%. Mean duration of thrombolytic therapy was 22.2 ± 11.3 hours, and mean tissue plasminogen activator dose was 24.5 ± 15.3 mg. Major adverse limb events occurred in 16.7% of patients within the first 30-days and 38.9% experienced a MALE by 1-year. Limb salvage at 30-days and 1-year was 93.8% and 87.5%, respectively. Ipsilateral reintervention was required in 12.5% of patients within 30 days and 37.5% of patients within 1 year. Overall mortality was 6.2% at 30-days and 13.5% at 1-year. In-line flow to the foot was re-established in 90.6% of patients, with a significant improvement in pre- to post-op ABI (0.31+0.29 vs. 0.78+0.34, p<0.001) and number of patent tibial runoff vessels (1.31+1.20 vs. 1.96+0.86, p <0.001). There was no significant difference in revascularization success between occluded vessel types. All but one patient required adjunctive therapy such as further thromboaspiration, stenting, or balloon angioplasty. Major bleeding complications occurred in 3 patients (9.4%), including 1 intracranial hemorrhage (3.1%).CONCLUSIONS: UET with the EKOS device demonstrates acceptable real-world outcomes in the treatment of acute limb ischemia. UET is generally safe and effective at re-establishing in line flow to yield high limb salvage rates. However, UET is associated with a high rate of reintervention. Further investigation is needed into specific predictors of limb salvage and need for reintervention, as well as cost-efficacy of this technology compared to traditional methods.

  View details for DOI 10.1016/j.avsg.2019.12.026

  View details for PubMedID 31917220

• Contemporary Practices and Complications of Surgery for Thoracic Outlet Syndrome in the United States. Annals of vascular surgery George, E. L., Arya, S. n., Rothenberg, K. A., Hernandez-Broussard, T. n., Ho, V. T., Stern, J. R., Gelabert, H. A., Lee, J. T. 2020

  Abstract

  Thoracic outlet syndrome (TOS) surgery is relatively rare and controversial given the challenges in diagnosis as well as wide variation in symptomatic and functional recovery. Our aims were to measure trends in utilization of TOS surgery, complications, and mortality rates in a nationally representative cohort and compare higher- versus lower-volume centers.The National Inpatient Sample was queried using ICD-9 codes for rib resection and scalenectomy paired with axillo-subclavian aneurysm [arterial (aTOS)], subclavian DVT [venous (vTOS)], or brachial plexus lesions [neurogenic (nTOS)]. Basic descriptive statistics, non-parametric tests for trend, and multivariable hierarchical regression models with random intercept for center were used to compare outcomes for TOS types, trends over time, and higher- and lower-volume hospitals, respectively.There were 3,547 TOS operations (for an estimated 18,210 TOS operations nationally) performed between 2010-2015 (89.2% nTOS, 9.9% vTOS, 0.9% aTOS) with annual case volume increasing significantly over time (p=0.03). Higher-volume centers (≥10 cases/year) represented 5.2% of hospitals and 37.0% of cases, and these centers achieved significantly lower overall major complication (defined as neurologic injury, arterial or venous injury, vascular graft complication, pneumothorax, hemorrhage/hematoma or lymphatic leak) rates [adjusted Odds Ratio (OR) 0.71 (95% confidence interval 0.52-0.98); p=0.04], but no difference in neurologic complications such as brachial plexus injury (aOR 0.69 (0.20-2.43); p=0.56) or vascular injuries/graft complications [aOR 0.71 (0.0.33=1.54); p=0.39]. Overall mortality was 0.6%, neurologic injury was rare (0.3%), and the proportion of patients experiencing complications decreased over time (p=0.03). However, vTOS & aTOS had >2.5 times the odds of major complication compared to nTOS [OR 2.68 (1.88-3.82) & aOR 4.26 (1.78-10.17); p<0.001], and ∼10 times the odds of a vascular complication [aOR 10.37 (5.33-20.19) & aOR 12.93 (3.54-47.37); p<0.001], respectively. As the number of complications decreased, average hospital charges also significantly decreased over time (p<0.001). Total hospital charges were on average higher when surgery was performed in lower-volume centers (< 10 cases/year) compared to higher-volume centers [mean $65,634 (standard deviation 98,796) vs. $45,850 (59,285), p<0.001].The annual number of TOS operations have increased in the United States from 2010-2015, while complications and average hospital charges have decreased. Mortality and neurologic injury remain rare. Higher-volume centers delivered higher-value care: less or similar operative morbidity with lower total hospital charges.

  View details for DOI 10.1016/j.avsg.2020.10.046

  View details for PubMedID 33340669

• Improving Outcomes After Surgery-An Old Medication With Unexpected Benefits. JAMA surgery George, E. L., Wren, S. M. 2020: e200417

  View details for DOI 10.1001/jamasurg.2020.0417

  View details for PubMedID 32267486

• Racial and Sex Disparities in Catheter Use and Dialysis Access in the United States Medicare Population. Journal of the American Society of Nephrology : JASN Arya, S. n., Melanson, T. A., George, E. L., Rothenberg, K. A., Kurella Tamura, M. n., Patzer, R. E., Hockenberry, J. M. 2020

  Abstract

  Despite efforts to increase arteriovenous fistula and graft use, 80% of patients in the United States start hemodialysis on a central venous catheter (CVC).To better understand in incident hemodialysis patients how sex and race/ethnicity are associated with time on a central venous catheter and transition to an arteriovenous fistula and graft, our observational cohort study analyzed US Renal Data System data for patients with incident ESKD aged ≥66 years who started hemodialysis on a CVC in July 2010 through 2013.At 1 year, 32.7% of 74,194 patients transitioned to an arteriovenous fistula, 10.8% transitioned to an arteriovenous graft, 32.1% stayed on a CVC, and 24.5% died. Women spent a significantly longer time on a CVC than men. Compared with white patients, patients who were black, Hispanic, or of another racial/ethnicity minority spent significantly more days on a CVC. In competing risk regression, women were significantly less likely than men to transition to a fistula and more likely to transition to a graft. Compared with white patients, blacks were significantly less likely to transition to a fistula but more likely to transition to a graft, Hispanics were significantly more likely to transition to a fistula, and other races/ethnicities were significantly more likely to transition to either a fistula or a graft.Female patients spend a longer time on a CVC and are less likely to transition to permanent access. Compared with white patients, minorities also spend longer time on a CVC, but are more likely to eventually transition to permanent access. Strategies to speed transition to permanent access should target groups that currently lag in this area.

  View details for DOI 10.1681/ASN.2019030274

  View details for PubMedID 31941721

• Simplifying Hospital Quality Comparisons for Vascular Surgery Using Center-Level Frailty Burden Rather than Comorbidities George, E. L., Rothenberg, K., Barreto, N. L., Chen, R., Trickey, A. W., Arya, S. ELSEVIER SCIENCE INC. 2019: S163–S164

  View details for Web of Science ID 000492740900304

• Cost-Effectiveness Analysis of Routine Repeat CT Head Scan in Patients on Novel Anticoagulation after Trauma Cohan, C., Beattie, G., George, E. L., Rothenberg, K., Dominguez, D. A., Victorino, G. P. ELSEVIER SCIENCE INC. 2019: E223

  View details for Web of Science ID 000492749600534

• Delayed Fasciotomy Is Associated with Higher Risk of Major Amputation in Patients with Acute Limb Ischemia ANNALS OF VASCULAR SURGERY Rothenberg, K. A., George, E. L., Trickey, A. W., Chandra, V., Stern, J. R. 2019; 59: 195–201

  View details for DOI 10.1016/j.avsg.2019.01.028

  View details for Web of Science ID 000479186900025

• Cost-Effectiveness Analysis of Fenestrated Endovascular Aneurysm Repair Compared With Open Surgical Repair for Patients With Juxtarenal Abdominal Aortic Aneurysms George, E. L., Nardacci, L., Sinawang, P., Rao, I., Owens, D. K., Garcia-Toca, M. MOSBY-ELSEVIER. 2019: E244–E245

  View details for DOI 10.1016/j.jvs.2019.04.367

  View details for Web of Science ID 000469220300359

• The Impact of Frailty on Failure to Rescue Following Elective Abdominal Aortic Aneurysm Repair George, E. L., Rothenberg, K. A., Barreto, N., Chen, R., Trickey, A., Johanning, J., Hockenberry, J., Arya, S. MOSBY-ELSEVIER. 2019: E124–E125

  View details for DOI 10.1016/j.jvs.2019.04.150

  View details for Web of Science ID 000469220300147

• Frailty as Measured by the Risk Analysis Index Predicts Long-Term Death After Carotid Endarterectomy Rothenberg, K. A., George, E., Barreto, N., Chen, R., Samson, K. K., Johanning, J. M., Trickey, A., Arya, S. MOSBY-ELSEVIER. 2019: E62

  View details for DOI 10.1016/j.jvs.2019.04.034

  View details for Web of Science ID 000469220300036

• Real-World Outcomes of EKOS Ultrasound-Enhanced Catheter-Directed Thrombolysis for Acute Limb Ischemia George, E. L., Colvard, B., Ho, V. T., Rothenberg, K. A., Lee, J. T., Stern, J. R. MOSBY-ELSEVIER. 2019: E170–E171

  View details for DOI 10.1016/j.jvs.2019.04.236

  View details for Web of Science ID 000469220300232

• Factors Affecting Intervention Rates and Time to Intervention for Lower Extremity Venous Disease in the Private Insurance Market Itoga, N. K., Rothenberg, K. A., George, E. L., Deslarzes-Dubuis, C., Rapanos, T., Harris, E. J. MOSBY-ELSEVIER. 2019: E255–E256

  View details for DOI 10.1016/j.jvs.2019.04.386

  View details for Web of Science ID 000469220300378

• Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery. JAMA network open Rothenberg, K. A., Stern, J. R., George, E. L., Trickey, A. W., Morris, A. M., Hall, D. E., Johanning, J. M., Hawn, M. T., Arya, S. 2019; 2 (5): e194330

  Abstract

  Importance: Ambulatory surgery in geriatric populations is increasingly prevalent. Prior studies have demonstrated the association between frailty and readmissions in the inpatient setting. However, few data exist regarding the association between frailty and readmissions after outpatient procedures.Objective: To examine the association between frailty and 30-day unplanned readmissions after elective outpatient surgical procedures as well as the potential mediation of surgical complications.Design, Setting, and Participants: In this retrospective cohort study of elective outpatient procedures from 2012 and 2013 in the National Surgical Quality Improvement Program (NSQIP) database, 417 840 patients who underwent elective outpatient procedures were stratified into cohorts of individuals with a length of stay (LOS) of 0 days (LOS=0) and those with a LOS of 1 or more days (LOS≥1). Statistical analysis was performed from June 1, 2018, to March 31, 2019.Exposure: Frailty, as measured by the Risk Analysis Index.Main Outcomes and Measures: The main outcome was 30-day unplanned readmission.Results: Of the 417 840 patients in this study, 59.2% were women and unplanned readmission occurred in 2.3% of the cohort overall (LOS=0, 2.0%; LOS≥1, 3.4%). Frail patients (mean [SD] age, 64.9 [15.5] years) were more likely than nonfrail patients (mean [SD] age, 35.0 [15.8] years) to have an unplanned readmission in both LOS cohorts (LOS=0, 8.3% vs 1.9%; LOS≥1, 8.5% vs 3.2%; P<.001). Frail patients were also more likely than nonfrail patients to experience complications in both cohorts (LOS=0, 6.9% vs 2.5%; LOS≥1, 9.8% vs 4.6%; P<.001). In multivariate analysis, frailty doubled the risk of unplanned readmission (LOS=0: adjusted relative risk [RR], 2.1; 95% CI, 2.0-2.3; LOS≥1: adjusted RR, 1.8; 95% CI, 1.6-2.1). Complications occurred in 3.1% of the entire cohort, and frailty was associated with increased risk of complications (unadjusted RR, 2.6; 95% CI, 2.4-2.8). Mediation analysis confirmed that complications are a significant mediator in the association between frailty and readmissions; however, it also indicated that the association of frailty with readmission was only partially mediated by complications (LOS=0, 22.8%; LOS≥1, 29.3%).Conclusions and Relevance: These findings suggest that frailty is a significant risk factor for unplanned readmission after elective outpatient surgery both independently and when partially mediated through increased complications. Screening for frailty might inform the development of interventions to decrease unplanned readmissions, including those for outpatient procedures.

  View details for DOI 10.1001/jamanetworkopen.2019.4330

  View details for PubMedID 31125103

• The Importance of Incorporating Frailty Screening Into Surgical Clinical Workflow JAMA NETWORK OPEN George, E. L., Arya, S. 2019; 2 (5)

  View details for DOI 10.1001/jamanetworkopen.2019.3538

  View details for Web of Science ID 000476806200034

• Delayed Fasciotomy is Associated with Higher Risk of Major Amputation in Patients with Acute Limb Ischemia. Annals of vascular surgery Rothenberg, K. A., George, E. L., Trickey, A. W., Chandra, V. n., Stern, J. R. 2019

  Abstract

  Compartment syndrome (CS) is a feared complication after revascularization for acute limb ischemia (ALI), and patients often undergo prophylactic 4-compartment fasciotomy at the time of revascularization to avoid developing CS and its associated complications. However, fasciotomy carries its own morbidity and surgeons may opt against this initially. The subsequent development of CS would mandate fasciotomy in a delayed fashion. We sought to investigate relationships between fasciotomy timing and patient outcomes.Patients who underwent lower extremity revascularization for ALI from 2005-2017 were retrospectively identified from an institutional database. Fasciotomy was classified as either prophylactic (occurring with revascularization) or delayed. Associations between patient characteristics, comorbidities, fasciotomy timing and patient outcomes were evaluated.A total of 138 patients met study inclusion criteria. Forty-two patients (30.4%) underwent fasciotomy, and of these, 8 (19%) were delayed. Patients with higher Rutherford acute limb ischemia classification were more likely to undergo fasciotomy (I 4.2%, IIA 13.2%, IIB 53.3%, p<0.001), and patients with coronary artery disease were less likely (16.1% vs. 83.9% fasciotomy, p=0.003). Ischemia time > 6 hours was noted in 66.7% of patients, though this was not significantly associated with fasciotomy occurrence (≤6 hours 21.7% fasciotomy vs. >6 hours 34.8% fasciotomy, p=0.17). Patients undergoing delayed fasciotomy were more likely to require major amputation within 30 days (50% vs. 5.9%, p=0.002).The decision to perform prophylactic fasciotomy in the setting of ALI is complex. When not performed, the subsequent development of CS requiring delayed fasciotomy appears to be associated with increased risk of major amputation at 30 days. This suggests that a liberal approach to prophylactic fasciotomy at the time of revascularization may improve limb salvage rates.

  View details for PubMedID 31034949

• Comparison of Surgeon Assessment to Frailty Measurement in Abdominal Aortic Aneurysm Repair. The Journal of surgical research George, E. L., Kashikar, A. n., Rothenberg, K. A., Barreto, N. L., Chen, R. n., Trickey, A. W., Arya, S. n. 2019; 248: 38–44

  Abstract

  Endovascular abdominal aortic aneurysm repair (EVAR) allows us to intervene on patients otherwise considered poor candidates for open repair. Despite its importance in determining operative approach, no comparison has been made between the subjective "eyeball test" and an objective measurement of preoperative frailty for EVAR patients.Patients undergoing elective EVAR were identified in the Vascular Quality Initiative (VQI) database (2003-2017). Patients were classified "unfit" based on a surgeon-reported variable. Frailty was defined using the VQI-derived Risk Analysis Index, which includes sex, age, BMI, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. The association between fitness and/or frailty and adverse outcomes was determined by logistic regression.A total of 11,694 patients undergoing elective EVAR were included of which only 18.1% were "unfit," whereas 34.6% were "frail" and overall 43.6% "unfit or frail." Patients deemed "unfit" or "frail" had significantly increased odds of mortality, complications, and nonhome discharge (P < 0.001), and both frailty and unfitness generated negative predictive values for these outcomes greater than 93%. In adjusted logistic regression, the addition of objective frailty significantly improved model performance in predicting nonhome discharge (C-statistic 0.65 versus 0.71, P < 0.001) and complications (0.59 versus 0.61, P = 0.01), but similarly predicted mortality (0.74 versus 0.73, P = 0.99).Preoperative frailty assessment provides a useful objective measure of risk stratification as an adjunct to a physician's clinical intuition. The addition of frailty expands the pool of high-risk patients who are more likely to experience adverse postoperative events after elective EVAR and may benefit from uniquely tailored perioperative interventions.

  View details for DOI 10.1016/j.jss.2019.11.005

  View details for PubMedID 31841735

• Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms. Journal of vascular surgery George, E. L., Chen, R. n., Trickey, A. W., Brooke, B. S., Kraiss, L. n., Mell, M. W., Goodney, P. P., Johanning, J. n., Hockenberry, J. n., Arya, S. n. 2019

  Abstract

  Frailty is increasingly recognized as a key determinant in predicting postoperative outcomes. Centers that see more frail patients may not be captured in risk adjustment, potentially accounting for poorer outcomes in hospital comparisons. We aimed to (1) determine the effect of frailty on long-term mortality in patients undergoing elective abdominal aortic aneurysm (AAA) repair and (2) evaluate the variability in frailty burden among centers in the Vascular Quality Initiative (VQI) database.Patients undergoing elective open and endovascular AAA repair (2003-2017) were identified, and those with complete data on component variables of the VQI-derived Risk Analysis Index (VQI-RAI) and centers with ≥10 AAA repairs were included. VQI-RAI characteristics are sex, age, body mass index, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. Frailty was defined as VQI-RAI ≥35 based on prior work in surgical patients using other quality improvement databases. This corresponds to the top 12% of patients at risk in the VQI. Center-level VQI-RAI differences were assessed by analysis of variance test. Relationships between frailty and survival were compared by Kaplan-Meier analysis and the log-rank test for open and endovascular procedures. Multivariable hierarchical Cox proportional hazards regression models were calculated with random intercepts for center, controlling for frailty, race, insurance, AAA diameter, procedure type, AAA case mix, and year.A total of 15,803 patients from 185 centers were included. Mean VQI-RAI scores were 27.6 (standard deviation, 5.9; range, 4-56) and varied significantly across centers (F = 2.41, P < .001). The percentage of frail patients per center ranged from 0% to 40.0%. In multivariable analysis, frailty was independently associated with long-term mortality (hazard ratio, 2.88; 95% confidence interval, 2.6-3.2) after accounting for covariates and center-level variance. Open AAA repair was not associated with long-term mortality after adjusting for frailty (hazard ratio, 0.98; 95% confidence interval, 0.86-1.13). There was a statistically significant difference in the percentage of frail patients compared with nonfrail patients who were discharged to a rehabilitation facility or nursing home after both open (40.5% vs 17.8%; P < .0001) and endovascular repair (17.7% vs 4.6%; P < .0001).There is considerable variability of preoperative frailty among VQI centers performing elective AAA repair. Adjusting for center-level variation, frailty but not procedure type had a significant association with long-term mortality; however, frailty and procedure type were both associated with nonhome discharge. Routine measurement of frailty preoperatively by centers to identify high-risk patients may help mitigate procedural and long-term outcomes and improve shared decision-making regarding AAA repair.

  View details for DOI 10.1016/j.jvs.2019.01.074

  View details for PubMedID 31147116

• The Importance of Incorporating Frailty Screening Into Surgical Clinical Workflow. JAMA network open George, E. L., Arya, S. n. 2019; 2 (5): e193538

  View details for PubMedID 31074807

• Incidence and Risk Factors for Deep Vein Thrombosis after Radiofrequency and Laser Ablation of the Lower Extremity Veins. Annals of vascular surgery Itoga, N. K., Rothenberg, K. A., Deslarzes-Dubuis, C. n., George, E. L., Chandra, V. n., Harris, E. J. 2019

  Abstract

  The rates of thromboembolic complications such as deep venous thrombosis (DVT) after venous ablation procedures for symptomatic superficial venous insufficiency are controversial. We sought to describe the risk factors for, and incidence of DVT after radiofrequency ablation (RFA) and laser ablation (LA).We queried the Truven Health Marketscan Database from 2007-16 for patients who underwent RFA or LA and had a follow-up duplex ultrasound within 30 days of the ablation procedure. The primary outcome was DVT at 7- and 30-days identified by ICD-9 and ICD-10 codes. Multivariable regression was used to evaluate the patient and procedural variables associated with a DVT at 30-days, expressed as odds ratios with a 95% confidence interval (OR 95%CI). Patients and procedures with a previous DVT diagnosis were excluded.A total of 256,999 patients underwent 433,286 ablation procedures: 192,195 (44.4%) RFA and 241,091 LA. Of these, 8,203 (1.9%) had a newly diagnosed DVT within 7-days and 13,347 (3.1%) within 30-days of the procedure. The incidence of DVT decreased over the study period. LA (2.8%) demonstrated a lower incidence of DVT at 30-days compared to RFA (3.4%), p<0.001. On multivariable regression, LA (OR 0.82, 95%CI 0.80-0.85) was again associated with a decreased risk for 30-day DVT, as was female gender (OR 0.74, 95%CI 0.71-0.77) and sclerotherapy performed on the same day (OR 0.91, 95%CI 0.85-0.98). A diagnosis of peripheral artery disease (OR 1.23, 95%CI 1.16-1.31) and concomitant stab phlebectomy (OR 1.43, 95%CI 1.37-1.49) was associated with an increased risk of DVT within 30-days.The incidence of newly diagnosed DVT within 30-days of an ablation procedure was 3.2%. The risk for DVT decreased in recent years and LA was associated with a 18% decreased risk compared to RFA.

  View details for DOI 10.1016/j.avsg.2019.04.008

  View details for PubMedID 31201974

• Early Real-World Experience with Endoanchors by Indication. Annals of vascular surgery Ho, V. T., George, E. L., Dua, A. n., Lavingia, K. S., Sgroi, M. D., Dake, M. D., Lee, J. T. 2019

  Abstract

  The Heli-Fx Endoanchor system is a transmural aortic fixation device with Federal Drug Administration (FDA) approval for treatment of endoleaks, endograft migration, or high-risk seal zones. Published data is primarily from industry-sponsored registries highlighting safety and efficacy. Our objective is to evaluate real-world outcomes of Endoanchor usage after FDA approval across a variety of stent-grafts and indications at a single institution.We retrospectively reviewed our prospectively maintained aneurysm database for patients undergoing endovascular aortic repair with Heli-Fx Endoanchors (EAs). Technical success was defined as successful EA deployment, while procedural success was defined as absence of endoleak on completion aortogram. Cohorts were divided by indication and outcomes assessed via review of clinical and radiographic data.From 2016-2018, 37 patients underwent EA fixation. We divided the cohort by indication: Group A (Prior EVAR with endoleak), B (intraoperative type 1A endoleak), C (high-risk seal zone), and D (TEVAR). In Group A (n=11), all endoleaks were type 1A and a mean of 10 EAs were deployed with 100% technical and 45.4% procedural success. Two perioperative re-interventions were performed (translumbar coil embolization; proximal graft extension with bilateral renal artery stents). At a mean 10.6 months follow-up, 45.4% of patients had persistent endoleaks, with 100% aortic related survival. In Group B (n=10), a mean of 8.7 EAs were used with 100% technical and procedural success. One immediate adverse event occurred (right iliac dissection from wire manipulation, treated with a covered stent). At 13.6 month mean follow-up, there was significant sac regression (mean 9.75 mm) with no type 1A endoleaks. In Group C (n=10), a mean of 9.5 EAs were deployed with 100% technical and procedural success. At 11.2 month mean follow-up, there were no residual endoleaks and significant sac regression (mean 3.4 mm). Overall survival was 100%. In Group-D (n=6), a mean of 8.3 EAs were used with 83.3% technical and 66.6% procedural success. One immediate adverse event occurred, in which an EA embolized to the left renal artery. At 9.4 month mean follow-up, overall survival was 83.3% with a mean 2.2 mm increase in sac diameter.Early experience suggests EAs effectively treat intraoperative type-1A endoleaks and high-risk seal zones, with significant sac regression and no proximal endoleaks on follow-up. In patients treated for prior EVAR with postoperative type-1A endoleaks, fewer than half resolved after EA attempted repair. Further experience and longer-term followup will be necessary to determine which patients most benefit from postoperative EA fixation.

  View details for DOI 10.1016/j.avsg.2019.05.006

  View details for PubMedID 31201976

• Disparities as Predictors of Non-Healing in Lower Extremity Wounds George, E. L., Trang, K., Dua, A., Parsley, J. D., Robertson, R., Fukaya, E., Sen, S. K., Gurtner, G. C., Chandra, V. ELSEVIER SCIENCE INC. 2018: E248

  View details for DOI 10.1016/j.jamcollsurg.2018.08.675

  View details for Web of Science ID 000447772500607

• Open versus endovascular aneurysm repair trial review SURGERY Weinkauf, C., George, E., Zhou, W. 2017; 162 (5): 974–78

  Abstract

  The Open versus Endovascular Aneurysm Repair trial is the only randomized controlled trial that is funded by the federal government to evaluate the treatment outcomes of infrarenal abdominal aortic aneurysms. Since the initial publication, multiple post-hoc analyses have become available. This review summarizes these data, focusing on the primary outcome measures (ie, overall survival) and several key secondary outcomes including aneurysm-related death, age consideration, secondary procedures, and endoleaks. Cost-effectiveness of each treatment modality and the limitations of OVER trial also are discussed critically in this review.

  View details for PubMedID 28602492

• Institutional Retrospective Review of Ultrasound-Accelerated Arterial and Venous Thrombolysis Howe, K. L., George, E. L., Lee, A., Chandra, V., Mell, M. W. MOSBY-ELSEVIER. 2017: 105S

  View details for DOI 10.1016/j.jvs.2017.03.196

  View details for Web of Science ID 000403108000185

• Duodenal adenocarcinoma: Advances in diagnosis and surgical management. World journal of gastrointestinal surgery Cloyd, J. M., George, E., Visser, B. C. 2016; 8 (3): 212-221

  Abstract

  Duodenal adenocarcinoma is a rare but aggressive malignancy. Given its rarity, previous studies have traditionally combined duodenal adenocarcinoma (DA) with either other periampullary cancers or small bowel adenocarcinomas, limiting the available data to guide treatment decisions. Nevertheless, management primarily involves complete surgical resection when technically feasible. Surgery may require pancreaticoduodenectomy or segmental duodenal resection; either are acceptable options as long as negative margins are achievable and an adequate lymphadenectomy can be performed. Adjuvant chemotherapy and radiation are important components of multi-modality treatment for patients at high risk of recurrence. Further research would benefit from multi-institutional trials that do not combine DA with other periampullary or small bowel malignancies. The purpose of this article is to perform a comprehensive review of DA with special focus on the surgical management and principles.

  View details for DOI 10.4240/wjgs.v8.i3.212

  View details for PubMedID 27022448

• Incidence and Risk Factors for Turf Toe Injuries in Intercollegiate Football: Data From the National Collegiate Athletic Association Injury Surveillance System FOOT & ANKLE INTERNATIONAL George, E., Harris, A. H., Dragoo, J. L., Hunt, K. J. 2014; 35 (2): 108-115

  Abstract

  Turf toe is the general term for a sprain of the first metatarsophalangeal (MTP) joint complex. Previously attributed to shoe design and artificial turf, the incidence of turf toe injury has been thought to decline with the advent of newer turf designs. However, the current incidence and epidemiology remain unknown as the majority of the literature consists of small series and addresses diagnosis and treatment rather than epidemiology and prevention.We examined data from the NCAA's Injury Surveillance System (ISS) for 5 football seasons (2004-2005 through 2008-2009), including all preseason, regular season, and postseason practice and competition data. The incidence, epidemiology, and risk factors for turf toe injury, defined as injury to the connective tissue of the first MTP joint, plantar plate complex, and/or sesamoid fracture, were determined.The overall incidence of turf toe injuries in NCAA football players was 0.062 per 1000 athlete-exposures (A-Es; 95% CI 0.052, 0.072). Athletes were nearly 14 times more likely to sustain the injury during games compared to practice, with a mean days lost due to injury of 10.1 (7.9, 12.4). Fewer than 2% of turf toe injuries required operative intervention. There was a significantly higher injury rate on third-generation artificial surfaces compared to natural grass (0.087 per 1000 A-E [0.067, 0.11] vs 0.047 per 1000 A-E [0.036, 0.059]). The majority of injuries occurred as a result of contact with the playing surface (35.4%) or contact with another player (32.7%), and running backs and quarterbacks were the most common positions to suffer turf toe injury.Our data suggest a significantly higher incidence of turf toe injuries during games, a greater susceptibility among running backs and quarterbacks, and a significant contribution of playing surface to risk of injury. Though turf toe injuries may be less common that previously reported in elite football players, these injuries warrant appropriate acute and long-term management to prevent long-term dysfunction.Level IV, case series.

  View details for DOI 10.1177/1071100713514038

  View details for PubMedID 24334272

• Epidemiology of syndesmosis injuries in intercollegiate football: incidence and risk factors from National Collegiate Athletic Association injury surveillance system data from 2004-2005 to 2008-2009. Clinical journal of sport medicine Hunt, K. J., George, E., Harris, A. H., Dragoo, J. L. 2013; 23 (4): 278-282

  Abstract

  OBJECTIVE:: To describe the incidence and risk factors for high ankle sprains (ie, syndesmosis injuries) among National Collegiate Athletic Association (NCAA) football players. DESIGN:: Descriptive epidemiologic study. SETTING:: Data were examined from the NCAA's Injury Surveillance System (ISS) for 5 football seasons (from 2004-2005 to 2008-2009). PARTICIPANTS:: All NCAA men's football programs participating in the ISS. ASSESSMENT OF RISK FACTORS:: No additional risk factors were introduced as a result of this analysis. MAIN OUTCOME MEASURES:: For partial and complete syndesmosis injuries, outcome measures included incidence, time lost from participation, and requirement for surgical repair. RESULTS:: The overall incidence of high ankle sprains in NCAA football players was 0.24 per 1000 athlete exposures, accounting for 24.6% of all ankle sprains. Athletes were nearly 14 times more likely to sustain the injury during games compared with practice; complete syndesmosis injuries resulted in significantly greater time lost compared with partial injuries (31.3 vs 15.8 days). Less than 3% of syndesmosis injuries required surgical intervention. There was a significantly higher injury incidence on artificial surfaces compared with natural grass. The majority of injuries (75.2%) occurred during contact with another player. CONCLUSIONS:: Our data suggest a significantly higher incidence of syndesmosis injuries during games, during running plays, and to running backs and interior defensive linemen. The wide range in time lost from participation for complete syndesmosis injuries underscores the need for improved understanding of injury mechanism and classification of injury severity such that prevention, safe return to play protocols, and outcomes can be further improved.

  View details for DOI 10.1097/JSM.0b013e31827ee829

  View details for PubMedID 23339895

• Increased efficiency of the GABAA and GABAB receptor-mediated neurotransmission in the Ts65Dn mouse model of Down syndrome NEUROBIOLOGY OF DISEASE Kleschevnikov, A. M., Belichenko, P. V., Gall, J., George, L., Nosheny, R., Maloney, M. T., Salehi, A., Mobley, W. C. 2012; 45 (2): 683-691

  Abstract

  Cognitive impairment in Down syndrome (DS) involves the hippocampus. In the Ts65Dn mouse model of DS, deficits in hippocampus-dependent learning and synaptic plasticity were linked to enhanced inhibition. However, the mechanistic basis of changes in inhibitory efficiency remains largely unexplored, and efficiency of the GABAergic synaptic neurotransmission has not yet been investigated in direct electrophysiological experiments. To investigate this important feature of neurobiology of DS, we examined synaptic and molecular properties of the GABAergic system in the dentate gyrus (DG) of adult Ts65Dn mice. Both GABAA and GABAB receptor-mediated components of evoked inhibitory postsynaptic currents (IPSCs) were significantly increased in Ts65Dn vs. control (2N) DG granule cells. These changes were unaccompanied by alterations in hippocampal levels of GABAA (α1, α2, α3, α5 and γ2) or GABAB (Gbr1a and Gbr1b) receptor subunits. Immunoreactivity for GAD65, a marker for GABAergic terminals, was also unchanged. In contrast, there was a marked change in functional parameters of GABAergic synapses. Paired stimulations showed reduced paired-pulse ratios of both GABAA and GABAB receptor-mediated IPSC components (IPSC2/IPSC1), suggesting an increase in presynaptic release of GABA. Consistent with increased gene dose, the level of the Kir3.2 subunit of potassium channels, effectors for postsynaptic GABAB receptors, was increased. This change was associated with enhanced postsynaptic GABAB/Kir3.2 signaling following application of the GABAB receptor agonist baclofen. Thus, both GABAA and GABAB receptor-mediated synaptic efficiency is increased in the Ts65Dn DG, thus likely contributing to deficient synaptic plasticity and poor learning in DS.

  View details for DOI 10.1016/j.nbd.2011.10.009

  View details for Web of Science ID 000299500200003

  View details for PubMedID 22062771

  View details for PubMedCentralID PMC3259223

• Restoration of disk height through non- surgical spinal decompression is associated with decreased discogenic low back pain: a retrospective cohort study BMC MUSCULOSKELETAL DISORDERS Apfel, C. C., Cakmakkaya, O. S., Martin, W., Richmond, C., Macario, A., George, E., Schaefer, M., Pergolizzi, J. V. 2010; 11

  Abstract

  Because previous studies have suggested that motorized non-surgical spinal decompression can reduce chronic low back pain (LBP) due to disc degeneration (discogenic low back pain) and disc herniation, it has accordingly been hypothesized that the reduction of pressure on affected discs will facilitate their regeneration. The goal of this study was to determine if changes in LBP, as measured on a verbal rating scale, before and after a 6-week treatment period with non-surgical spinal decompression, correlate with changes in lumbar disc height, as measured on computed tomography (CT) scans.A retrospective cohort study of adults with chronic LBP attributed to disc herniation and/or discogenic LBP who underwent a 6-week treatment protocol of motorized non-surgical spinal decompression via the DRX9000 with CT scans before and after treatment. The main outcomes were changes in pain as measured on a verbal rating scale from 0 to 10 during a flexion-extension range of motion evaluation and changes in disc height as measured on CT scans. Paired t-test or linear regression was used as appropriate with p < 0.05 considered to be statistically significant.We identified 30 patients with lumbar disc herniation with an average age of 65 years, body mass index of 29 kg/m2, 21 females and 9 males, and an average duration of LBP of 12.5 weeks. During treatment, low back pain decreased from 6.2 (SD 2.2) to 1.6 (2.3, p < 0.001) and disc height increased from 7.5 (1.7) mm to 8.8 (1.7) mm (p < 0.001). Increase in disc height and reduction in pain were significantly correlated (r = 0.36, p = 0.044).Non-surgical spinal decompression was associated with a reduction in pain and an increase in disc height. The correlation of these variables suggests that pain reduction may be mediated, at least in part, through a restoration of disc height. A randomized controlled trial is needed to confirm these promising results.NCT00828880.

  View details for DOI 10.1186/1471-2474-11-155

  View details for Web of Science ID 000280834100001

  View details for PubMedID 20615252

  View details for PubMedCentralID PMC2912793