David Herz

Objective: The modified 5‐item frailty index (mFI‐5) is a comorbidity‐based risk stratification tool previously validated in patients undergoing facial plastic and reconstructive surgery. This retrospective US hospital database study investigates the association between mFI‐5 score and postoperative complications following zygomaticomaxillary complex (ZMC) fracture repair. Methods: The National Surgical Quality Improvement Program was queried for patients undergoing ZMC fracture repair between 2005 and 2020. The mFI‐5 score was calculated by assigning one point for each of the following comorbidities: diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and dependent functional status. Patients were stratified by mFI‐5 score. Univariate and multivariable analyses were performed to assess associations between frailty and postoperative complications. Results: A total of 2260 patients were included and stratified by mFI‐5 scores of 0 ( n = 1890), 1 ( n = 285), and 2 or greater ( n = 85). Higher mFI‐5 scores were associated with male sex, older age, higher American Society of Anesthesiologists classification, inpatient status, obesity, weight loss, bleeding disorders, and dependent functional status. Higher mFI‐5 was associated with increased rates of surgical complications, urinary tract infections, prolonged ventilation over 48 h, pneumonia, cumulative morbidity, and cumulative medical complications. On multivariable analysis, mFI‐5 scores of 1 ( p = 0.027) and 2 or greater ( p = 0.049) were independently associated with cumulative morbidity, and a score of 1 was associated with surgical complications ( p = 0.022). Conclusion: The mFI‐5 is associated with cumulative morbidity and surgical complications following ZMC fracture repair. Assessment of frailty may improve perioperative risk stratification in this population. Level of Evidence: 4.

Background: With implementation of early detection screening methods and advances in medical treatment, there have been improvement in outcomes for patients with breast cancer. Despite this, studies have suggested potential differences in outcomes amongst various racial and ethnic groups. To our knowledge, no study has evaluated if race and demographic characteristics impact survival outcomes in patients with breast cancer metastases to the bone. Aims: We sought to answer the following questions: (1) Does race, demographic, and tumor characteristics alter survival outcomes in patients with breast metastases to the bone? (2) When stratifying by income and treatment, does race influence survival outcomes in patients with breast metastases to the bone? Methods and Results: The surveillance, epidemiology, and end results (SEER) 2016 to 2021 database was reviewed for patients with a diagnosis of breast cancer with metastases to the bone N = 11 833. Patients with known primary breast cancer, known hormone receptor status, known metastasis to bone, known treatment regiment, and no additional cancer diagnoses were included. Using variables within the database, this study collected information on demographics and tumor characteristics. Multivariate analyses were conducted to determine associations between race and other demographic, clinical, and prognostic factors. Kaplan–Meier survival curves were utilized to evaluate outcome by race. Annual household income below $75 000 (hazard ratio 1.111 [95% confidence interval (CI): 1.047–1.178, p < 0.001]), age over 65 years old (hazard ratio 1.1150 [95% CI: 1.084–1.220, p < 0.001]), and race (black) (hazard ratio 1.256 [95% CI: 1.161–1.359, p < 0.001]) were independent risk factors for decreased survival likelihood. Surgery (hazard ratio 0.554 [95% CI: 0.507–0.606, p < 0.001]), chemotherapy (hazard ratio 0.421 [95% CI: 0.397–0.446, p < 0.001]), and radiation (hazard ratio 0.940 [95% CI: 0.885–0.998, p < 0.05]), were independent factors that increased survival. At 12‐month follow‐up (hazard ratio 1.211 [95% CI: 1.091–1.345, p < 0.001]) and 5‐year follow‐up (hazard ratio 1.256 [95% CI: 1.161–1.359, p < 0.001]) black women had decreased survival likelihood compared to all other races. When patients were stratified by annual household income greater than $75 000, regardless of treatment, black women had decreased survival likelihood in patients younger then 65 years old (hazard ratio 1.242 [95% CI: 1.117–1.381, p < 0.001]) and 65 years and older (hazard ratio 1.318 [95% CI: 1.121–1.550, p = 0.001]). Increasing age, race, and lower annual household income were significantly associated with higher mortality. When controlling for higher income and treatment variables, black women had significantly higher mortality rates at 5‐year follow up. Conclusion: Despite improved treatment methods, disparities among patients with metastatic breast cancer to bone exists. Our findings demonstrate that different sub‐groups experience different mortality rates. Further research must be conducted to understand the interplay between these socioeconomic variables and survival likelihood in metastatic breast cancer.

Objective: To assess incidence, temporal trends, and risk factors for suicide among patients with HNC using Surveillance, Epidemiology, and End Results (SEER) data. Methods: A total of 222,222 patients were diagnosed with HNC from the SEER 17 registries between 2012 and 2021. Suicide deaths were identified using the SEER cause‐of‐death category “suicide and self‐inflicted injury.” We calculated age‐, sex‐, and race‐adjusted suicide incidence rates and standardized mortality ratios relative to the US general population. Risk factors analyzed included demographic variables, tumor site, disease stage, treatment modality, and time since diagnosis. Results: There were 298 suicides among patients with HNC over 1.9 million person‐years (33.53 per 100,000 person‐years; SMR, 1.90; 95% CI, 1.69–2.13). Suicide rates were highest among men (SMR, 2.23), unmarried individuals (SMR, 2.78), and patients with distant metastatic disease (SMR, 2.87). Site‐specific analysis showed elevated suicide risk for hypopharyngeal (SMR, 4.18) and laryngeal (SMR, 2.95) cancers. Radiation‐only treatment was associated with a higher suicide rate (SMR, 3.23), as was receiving no surgery or radiation (SMR, 5.39). Most suicides occurred within 5 years of diagnosis, particularly among patients with oral cavity and oropharyngeal cancers (SMR, 3.09). In some cancers, elevated suicide risk persisted beyond 10 years. Conclusion: While there was an observed reduction in SMR relative to earlier cohorts, this should be interpreted cautiously given rising general‐population suicide rates during the study period. High‐risk subgroups, including males, unmarried individuals, patients with cancer of the hypopharynx or larynx, and those receiving radiation alone or no definitive treatment, continue to face disproportionately elevated risk. Level of Evidence: 3.

Objective: Charlson–Deyo Comorbidity Index (CCI) predicts 10‐year mortality for a patient based on a range of comorbid conditions. Objective preoperative risk assessment tools inform physician decision making. Our study examines the relationship between CCI and overall survival (OS) following upfront laryngectomy for laryngeal squamous cell carcinoma (LSCC). Methods: A retrospective analysis of the 2004–2016 National Cancer Database (NCDB) was conducted to identify adult patients with pT1‐4 N0‐3 M0 LSCC undergoing upfront laryngectomy. Kaplan–Meier survival analysis and Cox proportional hazards modeling were performed to evaluate the association between CCI and OS. Results: Of the 25,720 patients satisfying inclusion criteria, 16,204 (63.0%) were CCI = 0, 6812 (26.5%) were CCI = 1, 1948 (7.6%) were CCI = 2, and 756 (2.9%) were CCI ≥ 3. On univariate analysis, CCI groups differed by age (65.1% were < 65 years old in CCI = 0 vs. 57.3%, 49.6%, and 48.9% in CCI = 1, 2, and ≥ 3; p < 0.001), sex ( p < 0.001), and race ( p < 0.001). Differences also existed across CCI groups in primary site, T‐stage, N‐stage, systemic therapy, and radiotherapy ( p < 0.001). On Kaplan–Meier analysis, 5‐year OS for CCI = 0, 1, 2, and ≥ 3 was 55.3%, 47.8%, 39.5%, and 34.0%, respectively ( p < 0.001). CCI = 1 (aHR 1.20, 95% CI 1.14–1.26, p < 0.001), CCI = 2 (aHR 1.57, 95% CI 1.45–1.71, p < 0.001), and CCI ≥ 3 (aHR 1.77, 95% CI 1.56–2.01, p < 0.001) were associated with worse OS than CCI = 0. Conclusion: In an adult cohort with pT1‐4 N0‐3 M0 LSCC undergoing upfront laryngectomy, increasing CCI was associated with worse OS. During perioperative counseling, CCI should be optimized and considered as a factor influencing survival outcomes. Level of Evidence: 4.

Objective: To analyze Medicare reimbursement and utilization trends of Zenker's diverticulectomy from 2000 to 2024. Study Design: Retrospective cross‐sectional study. Setting: Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule (2000–2024) and Part B Medicare Fee‐For‐Service National Summary Data (2000–2022). Methods: Utilization and payment trends for open (Current Procedural Terminology [CPT] code 43130) and endoscopic (CPT code 43180, introduced in 2015) repair of Zenker's diverticulum were analyzed, with reimbursement rates adjusted for inflation using the Consumer Price Index (CPI). Linear regression analysis was performed to assess the relationship between reimbursement rates and time. Results: From 2000 to 2022, the total number of Zenker's diverticulectomy procedures decreased by 14.8% (1775–1513), with a 72.1% decrease (1775–495) for open approach. There was a 22.5% increase (831–1018) in endoscopic approach from 2015 to 2022. By 2022, endoscopic procedures accounted for 67.3% of all Zenker's diverticulectomies, compared to 32.7% for the open approach. From 2000 to 2024, inflation‐adjusted reimbursement for open procedures declined by 49.96% ($1586.26–$670.41), with an annual decrease of 2.08%. Endoscopic procedures, tracked separately from 2015 to 2024, saw a 29.32% decline ($773.24–$547.13) and an annual decrease of 3.26%. Unadjusted reimbursement for both approaches combined declined by an average of 0.88% per year, while inflation‐adjusted rates decreased by 3.45% annually ( p < 0.001). Conclusion: There has been a downward trend in the Medicare reimbursement of Zenker's diverticulectomy, with an average adjusted decline of 3.45% annually. This trend raises concerns about the sustainability of such specialized procedures, potentially limiting access for elderly patients reliant on Medicare coverage. Level of Evidence: 4.

Objectives: Objective preoperative risk assessment tools inform physician and patient decision making. Our study examines the relationship between the Charlson–Deyo comorbidity index ( CCI ) and overall survival ( OS ) following surgery for sinonasal squamous cell carcinoma ( SNSCC ). Methods: In a retrospective cohort study, the 2004–2016 National Cancer Database was used to extract adult patients with pT1 ‐4 N0 ‐3 M0 SNSCC undergoing surgery. Kaplan–Meier survival analysis and Cox‐proportional hazards modeling were used to analyze the impact of CCI on OS . Results: Of the 3307 patients satisfying inclusion criteria, 2613 (79.0%) were CCI = 0, 533 (16.1%) were CCI = 1, and 161 (4.9%) were CCI = 2+. On univariate analysis, CCI groups differed by age (42.8% were ≥ 65 years old in CCI = 0 vs. 53.3% and 64.0% in CCI groups 1 and 2+, respectively, p < 0.001) and race ( p < 0.001). There was no significant difference between CCI groups in sex, T‐stage, N‐stage, margin status, primary site, radiation therapy, or systemic therapy. On Kaplan–Meier analysis, 5‐year OS for CCI = 0, CCI = 1, and CCI = 2+ was 58.6%, 48.0%, and 42.9%, respectively ( p < 0.001). CCI = 1 ( HR 1.20, 95% CI 0.99–1.45, p = 0.069) was not associated with worse OS than CCI = 0. CCI = 2+ ( HR 1.43, 95% CI 1.05–1.96, p = 0.025) was associated with worse OS than CCI = 0. Conclusions: In a cohort of adult patients with SNSCC undergoing surgery, higher CCI was independently associated with worse OS . These findings support the use of CCI as a predictor of postoperative outcomes in SNSCC patients. Future studies should explore how comorbidity burden interacts with frailty and other prognostic factors to refine risk stratification tools. Level of Evidence: 4