Does neoadjuvant therapy for esophageal cancer increase postoperative morbidity or mortality?

Neoadjuvant therapy has proven to be effective in the reduction of locoregional recurrence and mortality for esophageal cancer. However, induction treatment has been reported to be associated with increased risk of postoperative complications. We therefore compared outcomes after esophagectomy for esophageal cancer for patients who underwent neoadjuvant therapy and patients treated with surgery alone. Using the American College of Surgeons National Surgical Quality Improvement Program database (2005–2011), we identified 1939 patients who underwent esophagectomy for esophageal cancer. Seven hundred and eight (36.5%) received neoadjuvant therapy, while 1231 (63.5%) received no neoadjuvant therapy within 90 days prior to surgery. Primary outcome was 30‐day mortality, and secondary outcomes included overall and serious morbidity, length of stay, and operative time. Patients who underwent neoadjuvant treatment were younger (62.3 vs. 64.7, P < 0.001), were more likely to have experienced recent weight loss (29.4% vs. 15.9%, P < 0.001), and had worse preoperative hematological cell counts (white blood cells <4.5 or >11 × 10⁹/L: 29.3% vs. 15.0%, P < 0.001; hematocrit <36%: 49.7% vs. 30.0%, P < 0.001). On unadjusted analysis, 30‐day mortality, overall, and serious morbidity were comparable between the two groups, with the exception of the individual complications of venous thromboembolic events and bleeding transfusion, which were significantly lower in the surgery‐only patients (5.71% vs. 8.27%, P = 0.027; 6.89% vs. 10.57%, P = 0.004; respectively). Multivariable and matched analysis confirmed that 30‐day mortality, overall, and serious morbidity, as well as prolonged length of stay, were comparable between the two groups of patients. An increasing trend of preoperative neoadjuvant therapy for esophageal cancer was observed through the study years (from 29.0% in 2005–2006 to 44.0% in 2011, P < 0.001). According to our analysis, preoperative neoadjuvant therapy for esophageal cancer does not increase 30‐day mortality or the overall risk of postoperative complications after esophagectomy.     

Does acromegaly enhance mortality?

The increased mortality associated with acromegaly was first demonstrated in early epidemiological studies. Since the seminal paper by Wright et al. in 1970, nearly 20 studies have analyzed mortality rates in over 5,000 patients with acromegaly. Overall standardized mortality rates are approximately two times higher than in the general population, relating to an average reduction in life expectancy of around 10 years. The excess deaths are due predominantly to cardiovascular, cerebrovascular and respiratory disease. Malignancy deaths have been high in some studies but not others; in the largest series looking at cancer mortality in acromegaly, overall cancer deaths were not increased, but colon cancer mortality was higher than expected. In 1993, Bates et al. first demonstrated that outcome was related to the latest measurable growth hormone (GH), and treatment to reduce GH levels led to improved outcomes. Other factors predicting poor outcome include the presence of hypertension and diabetes. On the basis of current evidence, a latest GH of less than 2–2.5 μg/L is a better predictor of good outcome than a normal insulin-like growth factor-1 (IGF-1), possibly due to discrepancy between GH and IGF-1 at low GH levels. There is some evidence to suggest a more stringent GH cut-off (less than 1 μg/L) may yield additional benefit but further studies are required to investigate any added risk of increased mortality from hypopituitarism. Radiotherapy has been linked specifically to cerebrovascular mortality and its use in patients with acromegaly must involve a careful risk–benefit analysis in each case.     

Does the preoperative mild renal dysfunction effect mortality and morbidity following valve cardiac surgery?

AimsThe objective of this study was to investigate the effect of preoperative mild renal dysfunction (RD), not requiring dialysis, on mortality and morbidity after valve cardiac surgery (VCS).PopulationWe studied 340 consecutive patients (2008–2012), who underwent VCS with or without coronary artery bypass graft (CABG).MethodsPreoperative RD was calculated with the abbreviated Modification of Diet in Renal Disease formula and was defined as a glomerular filtration rate <60 ml/min/1.73 m². Logistic regression analysis was used to assess the effect of preoperative renal dysfunction (RD) on operative and adverse outcomes.Results80 patients (30%) had preoperative mild RD. Patients with preoperative RD were older, had a higher rate of preoperative anemia (43% vs. 25%, p < 0.001), and more comorbidities. Patients with preoperative RD had worse outcomes with more reoperation (6.8% vs. 2.3%, p < 0.001).ConclusionPreoperative RD was significantly and independently associated with more red blood cell transfusions and longer hospital stay (median 9 vs. 8 days, p < 0.001). Mortality was similar in both groups (3.4% vs. 2.3%, p = 0.43). Preoperative mild RD in patients undergoing cardiac valve surgery is an independent marker of postoperative morbidity.     

Can morbidity and mortality of SLE be improved?

Systemic lupus erythematosus (SLE) is the second most common autoimmune disorder (after thyroid disease) in women of childbearing age. Lupus is increasingly being recognized throughout the world's population. The incidence and prevalence of SLE varies among racial and ethnic groups. Lupus patient survival has significantly improved over the past five decades, but a three- to fivefold increased risk of death remains compared with the general population. As lupus patients survive longer, these individuals face a range of complications from the disease itself or consequent to its treatment. Emerging data from epidemiological studies underscore the importance of incorporating race and ethnicity in understanding the risk factors leading to the significant burden of mortality and morbidity associated with this disease. This chapter describes the epidemiology of lupus with a focus on racial and ethnic differences, reviews the mortality associated with the disease, discusses selected complications associated with morbidity related to the disease and highlights areas where we can improve mortality and morbidity.     

Can pharmacologic gradient reduction decrease mortality in hypertrophic cardiomyopathy?

Pharmacologic therapy is the first line approach to relieve symptoms in obstructive hypertrophic cardiomyopathy. There are no randomized trials to evaluate their effect on prognosis. Gradient reduction by surgical septal myectomy is associated with excellent prognosis, but not all patients have symptoms severe enough to require surgery; and, guidelines recommend operation only for patients with high gradients and symptoms unresponsive to pharmacologic therapy. The combination of disopyramide and beta-blockade is effective in reducing resting gradients (though not to the extent of surgery). This review examines the question of whether pharmacologic reduction of gradient in asymptomatic patients or those with milder symptoms might decrease HCM-related mortality.     

Does reducing malaria improve household living standards?

Living in malaria-endemic regions places an economic burden on households even if they do not actually suffer an episode of malaria. Households living in endemic malarial regions are less likely to have access to economic opportunities and may have to modify agricultural practices and other household behaviour to adapt to their disease environment. Data from Vietnam demonstrate that reductions in malaria incidence through government-financed malaria control programmes can contribute to higher household income for all households in endemic areas. Empirically, the roughly 60% decline in malaria cases over the 1990s in Vietnam translated to a dollars 12.60 average improvement in annual consumption of all households, or a roughly dollars 180 million annual economic benefit in the form of improved living standards.     

Does EBV alter the pathogenesis of malaria?

Plasmodium falciparum infections have been implicated in immune deficiencies resulting in ineffective control of Epstein–Barr virus, thereby increasing the risk of endemic Burkitt lymphoma in children. However, the impact of Epstein–Barr virus infections on the development of immunity to P. falciparum has not been studied in depth. In this review, we examine novel findings from animal co‐infection models and human immuno‐epidemiologic studies to speculate on the impact of acute gammaherpesvirus co‐infection on malarial disease severity. Children are often concurrently or sequentially infected with multiple pathogens, and this has implications for understanding the development of protective immunity as well as in the evaluation of vaccine efficacy.     

Does anemia matter? Anemia, morbidity, and mortality in older adults: need for greater recognition

Anemia is common and under recognized in older adults and associated with increased morbidity and mortality. Estimates of prevalence of anemia in older adults vary considerably based on the setting, gender, age and definition used and likely to increase further based on aging trends. Rather than simply a consequence of aging, anemia is a marker of underlying disease, requiring investigation for an etiology. A cause is discernible in at least two-thirds of cases; management involves addressing the underlying disease process, replacement of deficient nutrients or the use of erythropoietic factors.     

Why is left ventricular hypertrophy so predictive of morbidity and mortality?

The prevalence, prognosis, and predictors of left ventricular hypertrophy (LVH) are reviewed, and theories of the pathogenesis of the relation between LVH and poor prognosis are summarized to highlight controversies in the field. In the Framingham Heart Study, which consists largely of white people, echocardiographic LVH has a prevalence of 14% in men and 18% in women. The prevalence of LVH is reported to be elevated in African Americans compared with whites, although the higher prevalence has been attributed to the increased prevalence of hypertension and obesity. Echocardiographic LVH is independently associated with a variety of cardiovascular endpoints, including coronary heart disease and stroke. Furthermore, after adjusting for other cardiovascular disease risk factors, LVH is associated with a doubling in mortality in both white and African American cohorts. Despite the intensive investigation of LVH, there remain many unanswered questions: To what extent do genetic or other factors account for the large portion of the variance in LVH that remains unexplained? What is the prognosis of LVH and left ventricular geometry in a population-based African American cohort? How does the development and progression of LVH relate to other risk factors and their treatment? What is the relation of LVH to poor prognosis? The proposed Jackson Heart Study will help address many important unanswered questions regarding LVH.