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Title: An investigation into the measurement and management of frailty in surgical patients
Author: Trotter, John Martin
ISNI:       0000 0004 9356 586X
Awarding Body: University of Hull and the University of York
Current Institution: University of Hull
Date of Award: 2019
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Aims: This thesis intends to investigate a method of identification of frailty in the surgical population, CT defined sarcopenia, and a possible method to attenuate its effects in the preoperative period, prehabilitation. Methods: 845 patients that underwent emergency laparotomy in 4 acute hospitals were screened for sarcopenia by review of CT scans assessing sarcopenia by psoas density (PD) and area (PA). Primary outcomes were 30 day and 1 year mortality. A pilot RCT was undertaken to assess the acceptability and achievability of walking- based prehabilitation monitored by wearable technology. Participants were randomised to either normal activity or a walking based exercise programme. Results: Sarcopenia measured by PD was associated with increased mortality compared to non-sarcopenic patients at 30-days (23.2% vs. 9.6% p<0.0001 OR=2.84 (95% CI 1.88-4.30)) and 1-year (37% vs. 19.2% p<0.0001 OR=2.46 (95% CI 1.75-3.47)). Increased mortality was seen in sarcopenic patients measured by PA at 30-days (16.3% vs. 7.8% p=0.001 OR=2.31 (95% CI 1.38-3.88)) and 1-year (32% vs. 18.7% p=<0.0001 OR=2.25 (95% CI 1.52-3.34)). For the RCT 45 patients were approached to recruit 40 participants. The median time in study was 12.5days (IQR 6-18). Mean compliance to the exercise programme was 58%. Mean distance change between initial and pre-operative assessment for the exercise and normal-activity groups was +16.4m and -13.6m respectively, p=0.013. Mean distance change between initial and 3-month postoperative assessment was - 11.4m and -40m p=0.11. Conclusion: Sarcopenia assessed by PD and PA on CT is associated with increased mortality following emergency laparotomy. The use of sarcopenia as a predictive tool may be useful to direct geriatric input and guide expectations in emergency surgery. This pilot study confirms that acceptable compliance can be achieved using a user- friendly pedometer and that this is associated with measurable improvements in fitness. Further work is required to establish whether this translates into improved patient outcomes after surgery.
Supervisor: McNaught, Clare ; MacFie, John ; Hartley, John Edward Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: Medicine