Rheumatoid arthritis and incident fracture in women: a case–control study

Background

To examine fracture incidence in women with rheumatoid arthritis (RA) for an entire geographical region of south-eastern Australia.

Methods

Women aged 35 years and older, resident in the Barwon Statistical Division (BSD) and clinically diagnosed with RA 1994–2001 were eligible for inclusion as cases (n?=?1,008). The control population (n?=?172,422) comprised the entire female BSD population aged 35 years and older, excluding those individuals identified as cases. Incident fractures were extracted from the prospective Geelong Osteoporosis Study Fracture Grid. We calculated rate ratios (RR) and 95% confidence intervals (CI) to compare the age-adjusted rate of fracture between the RA and non-RA populations, and used a chi-square test to compare proportions of fractures between women with and without RA, and a two-sided Mann–Whitney U-test to examine age-differences.

Results

Among 1,008 women with RA, 19 (1.9%) sustained a fracture, compared to 1,981 fractures sustained by the 172,422 women without RA (1.2%). Fracture rates showed a trend for being greater among women diagnosed with RA (age-adjusted RR 1.43, 95%CI 0.98-2.09, p?=?0.08). Women with RA sustained vertebral fractures at twice the expected frequency, whereas hip fractures were underrepresented in the RA population (p?<?0.001). RA status was not associated with the likelihood of sustaining a fracture at sites adjacent to joints most commonly affected by RA (p?=?0.22).

Conclusion

Given that women with RA have a greater risk of fracture compared to women without RA, these patients may be a suitable target population for anti-resorptive agents; however, larger studies are warranted.     

Porcelain Gallbladder: A Benign Process or Concern for Malignancy?

Background

Gallbladder wall calcifications, otherwise known as porcelain gallbladder, have received considerable attention due to its perceived association with gallbladder carcinoma. While the perception of a strong correlation persists, more recent reports raise conceivable doubts.

Study Design

A systematic literature search was conducted of human studies describing gallbladder wall calcification and its association with gallbladder malignancy.

Results

The 111 articles which met inclusion criteria identified 340 patients with gallbladder wall calcification. Of the 340 patients, 72 (21 %) were diagnosed with malignancy of the gallbladder. When examining a subgroup of 13 studies (n?=?124) without obvious selection bias, the rate of gallbladder malignancy was only 6 % (0–33 %) compared to 1 % (0–4 %) in a matched cohort of patients without gallbladder wall calcification (p?=?0.036, relative risk 8.0 (95%CI 1.0–63.0)). Multivariate analysis identified the presence of symptoms typical for gallbladder cancer (odds ratio 83.6, 95%CI 2.3–2979.1, p?=?0.015) and the presence of a gallbladder mass (odds ratio 3226.6, 95%CI 17.2–603884.8, p?=?0.003) as the only independent prognostic factors for harboring gallbladder malignancy.

Conclusions

The risk of harboring gallbladder cancer in patients with gallbladder wall calcifications is lower than recently anticipated. The risk factors identified have only limited clinical value, since they are stigmatic for advanced gallbladder cancer. In the absence of better risk stratification and in the presence of a relative low rate of associated malignancy, prophylactic cholecystectomy appears appropriate for otherwise healthy patients; whereas a non-operative approach should be considered in patients with significant co-morbidity.     

Simultaneous Versus Staged Bilateral Total Knee Arthroplasty

Background

An important source of debate in many orthopaedic practices is the choice of performing simultaneous or staged bilateral total knee arthroplasty.

Questions/Purpose

The objective of this meta-analysis is to compare simultaneous bilateral with staged bilateral total knee arthroplasty for peri-operative complication rates, infection rates and mortality outcomes.

Methods

All relevant citations were retrieved from MEDLINE, EMBASE, COCHRANE databases and the unpublished literature. Included studies were assessed for methodological quality and abstracted data was conducted independently by two reviewers. Data was categorized into subgroups and pooled using the DerSimonian and Laird’s random effects model.

Results

A total of 18 articles were identified from 873 potentially relevant titles and selected for inclusion in the primary meta-analyses. The incidence of mortality was significantly higher in the simultaneous group at 30 days (RR [relative risk] 3.67, 95% confidence interval [CI] 1.68–8.02, p?=?0.001, I ²?=?59%, n?=?67,691 patients), 3 months (RR 2.45, 95% CI 2.15–2.79, p?<?0.00001, I ²?=?0%, n?=?66,142 patients) and 1 year (RR 1.85, 95% CI 1.66–2.06, p?<?0.001, I ²?=?0%, n?=?65,322 patients) after surgery. However, there were no significant differences between the two groups in regards to in-hospital mortality rates (R 1.18, 95% CI 0.74–1.88, p?=?0.48, I ²?=?0%, n?=?33,814 patients). In addition, there was no increased risk of deep vein thrombosis, cardiac complication, and pulmonary embolism or infection rates in either comparison group.

Conclusions

The results of the analysis suggest that simultaneous bilateral total knee arthroplasty has a significantly higher rate of mortality at 30 days, 3 months and 1 year after surgery, but similar infection and complication rates in comparison to staged bilateral total knee arthroplasty.     

Resection for Hilar Cholangiocarcinoma: Analysis of Prognostic Factors and the Impact of Systemic Inflammation on Long-term Outcome

Introduction

Resection for hilar cholangiocarcinoma is the single hope for long-term survival.

Methods

Ninety patients underwent curative intent surgery for hilar cholangiocarcinoma between 1996 and 2012. The potential prognostic factors were assessed by univariate (Kaplan–Meier curves and log-rank test) and multivariate analyses (Cox proportional hazards model).

Results

The median overall and disease-free survivals were 26 and 17 months, respectively. The multivariate analysis identified R0 resection (HR?=?0.03, 95 % CI 0–0.19, p?<?0.001), caudate lobe invasion (HR?=?6.33, 95 % CI 1.31–30.46, p?=?0.021), adjuvant gemcitabine-based chemotherapy (HR?=?0.38, 95 % CI 0.15–0.94, p?=?0.037), and the neutrophil-to-lymphocyte ratio (HR?=?0.78, 95 % CI 0.62–0.98, p?=?0.036) as independent prognostic factors for disease-free survival. The independent prognostic factors for overall survival were R0 resection (HR?=?0.03, 95 % CI 0–0.22, p?<?0.001), caudate lobe invasion (HR?=?11.75, 95 % CI 1.65–83.33, p?=?0.014), and adjuvant gemcitabine-based chemotherapy (HR?=?0.19, 95 % CI 0.06–0.56, p?=?0.003).

Conclusions

The negative resection margin represents the most important prognostic factor. Adjuvant gemcitabine-based chemotherapy appears to benefit survival. The neutrophil-to-lymphocyte ratio may potentially be used to stratify patients for future clinical trials.     

Refining the trauma triage algorithm at an Australian major trauma centre: derivation and internal validation of a triage risk score

Purpose

To derive and internally validate a clinical prediction rule for trauma triage.

Methods

Ambulance presentations requiring trauma team activation between 2007 and 2011 at a single inner city major trauma centre were analysed. The primary outcome was major trauma, defined as Injury Severity Score >15, intensive care unit admission or in-hospital death. Demographic details, vital signs on arrival at hospital, mechanism of injury and injured body regions were used in the modelling process. Multivariable logistic regression was used on a randomly selected derivation sample. Receiver operating characteristic (ROC) analysis and Hosmer–Lemeshow tests were used to assess the discrimination and calibration of the derived model. The model was further tested using bootstrapping cross-validation.

Results

A total of 3027 patients were identified. Predictors selected for the prediction model were age ≥65 years (OR 1.58, 95 %CI 1.08–2.32, p = 0.02), abnormal vital signs (OR 3.72, 95 %CI 2.64–5.25), Glasgow Coma Scale score ≤13 (OR 14, 95 %CI 9.23–23.34 p < 0.001), penetrating injury (OR 5.13, 95 %CI 2.76–9.54, p < 0.001), multiregion injury (OR 4.72 95 %CI 3.45–6.46, p < 0.001), falls (OR 1.51 95 %CI 1.06–2.15, p = 0.02) and motor vehicle crashes (OR 0.56, 95 %CI 0.35–0.90, p = 0.02). The ROC area under the curve (AUC) for the final model was 0.85 (95 %CI 0.83–0.87) with a Hosmer–Lemeshow test statistic p = 0.83. Bootstrapping cross-validation demonstrated an identical AUC.

Conclusion

We have derived and internally validated a trauma risk prediction rule using trauma registry data. This may assist with the formulation of revised local and regional trauma triage protocols. External validation is required before implementation.     

Skeletal findings in the first 12 months following initiation of glucocorticoid therapy for pediatric nephrotic syndrome

Summary

Incident vertebral fractures and lumbar spine bone mineral density (BMD) were assessed in the 12 months following glucocorticoid initiation in 65 children with nephrotic syndrome. The incidence of vertebral fractures was low at 12 months (6 %) and most patients demonstrated recovery in BMD Z-scores by this time point.

Introduction

Vertebral fracture (VF) incidence following glucocorticoid (GC) initiation has not been previously reported in pediatric nephrotic syndrome.

Methods

VF was assessed on radiographs (Genant method); lumbar spine bone mineral density (LS BMD) was evaluated by dual-energy X-ray absorptiometry.

Results

Sixty-five children were followed to 12 months post-GC initiation (median age, 5.4 years; range, 2.3–17.9). Three of 54 children with radiographs (6 %; 95 % confidence interval (CI), 2–15 %) had incident VF at 1 year. The mean LS BMD Z-score was below the healthy average at baseline (mean ± standard deviation (SD), ?0.5?±?1.1; p?=?0.001) and at 3 months (?0.6?±?1.1; p?<?0.001), but not at 6 months (?0.3?±?1.3; p?=?0.066) or 12 months (?0.3?±?1.2; p?=?0.066). Mixed effect modeling showed a significant increase in LS BMD Z-scores between 3 and 12 months (0.22 SD; 95 % CI, 0.08 to 0.36; p?=?0.003). A subgroup (N?=?16; 25 %) had LS BMD Z-scores that were ≤?1.0 at 12 months. In these children, each additional 1,000 mg/m² of GC received in the first 3 months was associated with a decrease in LS BMD Z-score by 0.39 at 12 months (95 % CI, ?0.71 to ?0.07; p?=?0.017).

Conclusions

The incidence of VF at 1 year was low and LS BMD Z-scores improved by 12 months in the majority. Twenty-five percent of children had LS BMD Z-scores ≤?1.0 at 12 months. In these children, LS BMD Z-scores were inversely associated with early GC exposure, despite similar GC exposure compared to the rest of the cohort.     

Impact of Mucinous Histology on the Prognosis of Stage I–III Adenocarcinomas of the Appendix: a Population-Based,Propensity Score-Matched Analysis

Background

Whereas the poor prognosis of signet ring cell adenocarcinomas of the appendix is well known, the significance of mucinous histology remains unclear. The aim of this population-based study was to evaluate if mucinous histology is an independent prognostic factor in appendiceal adenocarcinomas.

Methods

Patients with stage I–III adenocarcinoma of the appendix who underwent surgery between 2004 and 2012 were identified in the Surveillance, Epidemiology, and End Results database. Overall survival (OS) and cancer-specific survival (CSS) were assessed using risk-adjusted Cox proportional hazards regression models and propensity score methods.

Results

Overall, 980 patients with appendix cancer were included, of which 449 (45.8 %) had a mucinous histology. In an unadjusted analysis, the 5-year OS and CSS in patients with a mucinous adenocarcinoma (MC) was 76.8 % (95 % confidence interval (95 %CI): 72.1–81.7 %) and 81.0 % (95 %CI: 76.6–85.6 %), respectively, compared with 70.0 % (95 %CI: 65.1–75.3 %) and 76.2 % (95 %CI: 71.5–81.2 %) in patients with non-mucinous adenocarcinoma (NMC) (P?=?0.082 and P?=?0.368). In multivariable analysis, no impact on survival was observed for OS (HR?=?1.22, 95 %CI: 0.89–1.68, P?=?0.208) and CSS (HR?=?1.21, 95 %CI: 0.84–1.74, P?=?0.296). After propensity score matching, nearly identical survival rates were observed (OS: HR?=?1.03, 95 %CI: 0.71–1.49, P?=?0.881 and CSS: HR?=?1.05, 95 %CI: 0.70–1.59, P?=?0.803).

Conclusions

The present population-based, propensity score matched analysis shows that mucinous histology does not affect survival in stage I–III appendiceal adenocarcinoma patients. Therefore, the same treatment strategies can be applied for patients with NMC and MC of the appendix.

     

Risk factors for permanent stoma after low anterior resection for rectal cancer

Purpose

This study evaluated the risk factors influencing permanent stoma after curative resection of rectal cancer and compared the long-term survival of patients according to the stoma state.

Methods

From January 2004 to December 2010, 895 consecutive rectal cancer patients with histological-confirmed adenocarcinoma who received low anterior resection with curative intent at the Department of Colon and Rectal Surgery, Chonnam National University Hwasun Hospital, were evaluated retrospectively. Patient demographics, times of stoma reversal, and number/reason of permanent stoma were evaluated.

Results

Three hundred fifteen patients (35.2 %) had a diverting stoma of temporary intent among 895 rectal adenocarcinoma patients. Loop ileostomy was performed in 271 patients (86.0 %). A total of 256 (81.3 %) of 315 stoma patients received stoma closure. The mean period between primary surgery and stoma closure was 5.6 months (range, 1–44 months). Seventy-three patients (23.2 %) were confirmed with permanent stoma. Multivariate analysis showed stage IV (hazard ratio (HR), 3.380; 95 % confidence interval (CI), 1.192–18.023; p?=?0.027), anastomosis-related complication (HR, 3.299; 95 % CI, 1.397–7.787; p?=?0.006), colostomy type (HR, 7.276, 95 % CI, 2.454–21.574; p?=?0.000), systemic metastasis (HR, 2.698; 95 % CI, 1.1.288–5.653; p?=?0.009), and local recurrence (HR, 4.231; 95 % CI, 1.724–10.383; p?=?0.002) were independent risk factors for permanent stoma.

Conclusions

On postoperative follow-up, in patients with anastomotic complication, tumor progression with local recurrences and systemic metastasis may cause permanent stoma.     

Preoperative therapy of esophagogastric cancer: the problem of nonresponding patients

Introduction

Preoperative treatment is nowadays standard for locally advanced esophagogastric cancer in Europe. Surprisingly, little attention has been paid to nonresponders so far. The aim of our retrospective exploratory study was the comparison of responder, nonresponder, and primary resected patients in respect of outcome considering the tumor entity.

Patients and methods

From 2001–2011, 607 patients with locally advanced esophagogastric carcinoma (adenocarcinoma of the esophagogastric junction (AEG), n?=?293; squamous cell cancer (SCC), n?=?111; gastric cancer, n?=?203) after preoperative treatment (n?=?281) or primary resection (n?=?326) were included. Histopathological response evaluation (Becker criteria) was available for 263.

Results

A total of 76/263 (28.9 %) were responders (<10 % residual tumor). There was an association of response with increased R0 resections (p?<?0.001) but also with a higher complication rate (p?=?0.008) compared to nonresponse and primary surgery. Mortality was not influenced. Increased R0 resections after response were confirmed in every tumor entity (AEG, p?=?0.010; SCC, p?=?0.023; gastric cancer, p?=?0.006). Median survival was best for responders with 43.5 months [95 % confidence interval (CI), 27.9–59.1], followed by nonresponders with 24.3 months (95 % CI, 21.6–27.0) and primary resected patients with 20.8 months (95 % CI, 17.7–23.9; p?=?0.002). AEG (p?=?0.012) and gastric cancer (p?=?0.017) revealed identical results, but in the subgroup of SCC, the survival of nonresponders (median, 11.6 months; 95 % CI, 6.9–16.3) was even worse than for primary resected patients (median, 23.8 months; 95 % CI, 1.7–46.0; p?=?0.012).

Conclusion

The histopathological response rate was low. Generally, nonresponding patients with AEG or gastric cancer seem not to have a disadvantage compared to primary resected patients, but nonresponders with SCC have a worse prognosis, which strengthens the demand for a critical patient selection in surgery for this tumor entity.     

Liver Resection in the Elderly: Significance of Comorbidities and Blood Loss

Objective

Liver resection is increasingly performed in elderly patients who are suspected of increased postoperative morbidity (PM) and reduced overall survival (OS). Patient selection based on the identification of age-adjusted risk factors may help to decrease PM and OS.

Design and Participants

Prospectively collected data of 879 patients undergoing elective hepatic resection were analyzed. This population was stratified into three age cohorts: >70 years (n?=?228; 26 %), 60–69 years (n?=?309; 35 %), and <60 years (n?=?342; 39 %). Multivariate survival analysis was performed.

Results

The incidence of severe (p?<?0.01) and non-surgical (p?<?0.001) postoperative complications was higher in older compared to younger patients. Major estimated blood loss (EBL; p?=?0.039) and comorbidities (p?=?0.002) independently increased PM. EBL was comparable between all age cohorts. However, preexisting comorbidities, major EBL, and postoperative complications markedly decreased OS in contrast to younger patients. Adjusted for age, independent predictors of OS were comorbidities (HR?=?1.51; p?=?0.001), major hepatectomy (HR?=?1.33; p?=?0.025), increased EBL (HR?=?1.32; p?=?0.031), and postoperative complications (HR?=?1.64; p?<?0.001).

Conclusion

Although increased age should not be a contraindication for liver resection, this study accents the avoidance of major blood loss in elderly patients and a stringent patient selection based on preexisting comorbidities.     

Does inadequate diet during childhood explain the higher high fracture rates in the Southern United States?

Summary

Southern states have the highest age-adjusted hip fracture rates among older adults in the United States. Regional hip fracture rates in the United States in 1986–1993 correlate with death rates from rickets in the 1940s. Historical patterns of bone nutrition early in life might explain contemporary geographic patterns in bone fragility.

Introduction

State of residence early in life is a better predictor of the risk of hip fracture after age 65 than state of current residence. Therefore, the geography of rickets mortality in the United States before 1950 was compared with the geography of hip fracture rates among older adults in the United States during 1986–1993.

Methods

Vital statistics data for the US white population for 1942–1948 allowed calculation of the ratio of deaths from rickets to live births for each geographic division of the USA. These ratios were correlated with previously published, standardized hip fracture rates among whites 65–89 years old during 1986–1993 by census division.

Results

During 1942–1948, the rickets mortality ratio among whites was 3.11 in the South, 1.91 in the Northeast, 1.75 in the Midwest, and 1.04 in the West. The correlation of mortality with risk of hip fracture was 0.71 (p?=?0.03) for both sexes combined and 0.86 (p?=?0.01) for women.

Conclusions

Inadequate nutrition during skeletal formation early in life might explain the higher incidence of hip fracture among older adults in the South.     

The epidemiology of transient synovitis in Liverpool,UK

Background

The epidemiology of transient synovitis is poorly understood, and the aetiology is unknown, although a suggestion of a viral association predominates.

Purpose

This population-based study investigated the epidemiology in order to formulate aetiological theories of pathogenesis.

Patient and methods

Cases in Merseyside were identified between 2004 and 2009. Incidence rates were determined and analysed by age, sex, season and region of residence. Socioeconomic deprivation scores were generated using the Index of Multiple Deprivation, allocated by postcode. Poisson confidence intervals were calculated and Poisson regression was used to check for trends.

Results

Two hundred and fifty-nine cases were identified over 5.5 years. The annual incidence was 25.1 (95 % CI 22.1–28.5) per 100,000 0–14 year-olds. Male to female ratio was 3.2:1 (p < 0.001). Mean age at presentation was 5.4 years (95 % CI 5.0–5.8), which demonstrated a near-normal distribution. No relationship was identified between seasonality and incidence (p = 0.64). A correlation was identified with socioeconomic deprivation in Merseyside: incidence rate ratio 1.16 (95 % CI 1.06–1.26, p < 0.001), although further analysis within the subregion of Liverpool did not confirm this finding (p = 0.35).

Conclusions

The normal distribution for age at disease presentation suggests a specific disease entity. The absence of seasonality casts some doubt on the popular theory of a viral aetiology. The absence of a consistent socioeconomic gradient in both Merseyside and Liverpool challenges a previous suggestion of an association with Perthes’ disease. This paper provides ecological evidence that may challenge existing aetiological theories, though transient synovitis remains an enigma.     

SHBG levels are associated with bone loss and vertebral fractures in patients with prostate cancer

Summary

Fractures are increased among prostate cancer patients. No data have been reported in patients with prostate cancer about the relation between serum sex hormone-binding globulin (SHBG) and bone metabolism. We found that SHBG levels were inversely related to bone mass and vertebral fractures in this population.

Introduction

Fractures are increased among prostate cancer patients, especially those on androgen deprivation therapy (ADT), but few data are available on the role of SHBG in their bone status. Our objective was to analyze the relation between serum SHBG and bone metabolism in prostate cancer patients.

Methods

This is a cross-sectional study including 91 subjects with prostate cancer (54 % with ADT). We measured serum levels of SHBG and sex steroids, bone mineral density (BMD) by dual-energy X-ray absorptiometry, and prevalent radiographic vertebral fractures.

Results

SHBG levels were inversely related to BMD (femoral neck: r?=??0.299, p?=?0.00; total hip: r?=??0.259, p?=?0.019). Subjects with osteoporosis had higher SHBG concentrations than patients without osteoporosis (60.97?±?39.56 vs 44.45?±?23.32 nmol/l, p?=?0.022). Patients with SHBG levels in the first quartile (>57.6 nmol/l) had an odds ratio (OR) for osteoporosis of 2.59 (95 % CI, 1.30–5.12; p?=?0.009) compared with patients with lower SHBG levels. In patients with SHBG >57.6 nmol/l, the OR for vertebral fractures was 2.34 (95 % CI, 1.15–4.78; p?=?0.034). The calculated OR was higher after adjustment for age (OR, 5.16; 95 % CI, 1.09–24.49; p?=?0.039), estrogens (OR, 6.45; 95 % CI, 1.44–28.95; p?=?0.023), and androgens (OR, 5.51; 95 % CI, 1.36–22.37; p?=?0.017).

Conclusions

In prostate cancer patients, SHBG levels were inversely related to bone mass and vertebral fractures. Determination of the serum SHBG level may constitute a useful and straightforward marker for predicting the severity of osteoporosis in these patients.     

Pulmonary Function Testing and Complications of Laparoscopic Bariatric Surgery

Background

Obesity is associated with respiratory symptoms and impaired pulmonary function, which could increase the risk of complications after bariatric surgery. The purpose of this study is to assess the relationship between pulmonary function parameters before, and the risk of complications after, laparoscopic bariatric surgery.

Methods

This prospective study included patients (age 18–60, BMI >35 kg/m²), who were eligible for bariatric surgery. Spirometry was performed in all patients. Complications up to 30 days after bariatric surgery were recorded.

Results

Four hundred eighty-five patients were included (304 laparoscopic sleeve gastrectomy, 181 laparoscopic gastric bypass). There were 53 complications (8 pulmonary, 27 surgical, 14 infectious, 4 other) in 50 patients (10 %). There were 35 re-admissions (7.2 %), and 17 re-laparoscopies (3.5 %). Subjects with and without complications did not differ significantly with respect to demographics, weight, BMI, abdominal circumference or fat percentage. Subjects with complications had a significantly lower mean FEV₁ (mean 86.9 % predicted) and FVC (95.6 % predicted) compared to patients without complications (95.9 % predicted, p?=?0.005, and 100.1 % predicted, p?=?0.045, respectively). After adjustment for age, gender, BMI, and smoking, abnormal spirometry value remained the single predictive covariable of postoperative complications: FEV₁/FVC <70 % adjusted OR 3.1 (95%CI 1.4–6.8, p?=?0.006) and ΔFEV₁ ≥12 % adjusted OR 2.9 (95 %CI 1.3–6.6, p?=?0.010).

Conclusions

The risk of pulmonary complications after laparoscopic bariatric surgery is low. However, subjects with abnormal spirometry test results have a threefold risk of complications after laparoscopic bariatric surgery. Preoperative pulmonary function testing might be useful to predict the risk of complications of laparoscopic bariatric surgery.     

Perioperative Outcomes of Pancreaticoduodenectomy Compared to Total Pancreatectomy for Neoplasia

Purpose

Total pancreatectomy (TP) eliminates the risk and morbidity of pancreatic leak after pancreaticoduodenectomy (PD). However, TP is a more extensive procedure with guaranteed endocrine and exocrine insufficiency. Previous studies conflict on the net benefit of TP.

Methodology

A comparison of patients undergoing non-emergent, curative-intent TP or PD for pancreatic neoplasia using the National Surgical Quality Improvement Project data from 2005–2011 was done. Main outcome measures were mortality and major and minor morbidities.

Results

Of the 6,314 (97 %) who underwent PD and the 198 (3 %) who underwent TP, malignancy was present in 84 % of patients. The two groups were comparable at baseline. Mortality was higher after TP (6.1 %) than DP (3.1 %), p?=?0.02. Adjusting for differences on multivariable analysis, TP carried increased mortality (OR 2.64, 95 % CI 1.3–5.2, p?=?0.005). TP was also associated with increased rates of major morbidity (38 vs. 30 %, p?=?0.02) and blood transfusion (16 vs. 10 %, p?=?0.01). Infectious and septic complications occurred equally in both groups.

Conclusion

The morbidity of a pancreatic fistula can be eliminated by TP. However, based on our findings, TP is associated with increased major morbidity and mortality. TP cannot be routinely recommended for to reduce perioperative morbidity when pancreaticoduodenectomy is an appropriate surgical option.     

End-to-End Cervical Esophagogastric Anastomoses Are Associated with a Higher Number of Strictures Compared with End-to-Side Anastomoses

Background

Leakage and benign strictures occur frequently after esophagectomy. The objective of this study was to analyze the outcome of hand-sewn end-to-end versus end-to-side cervical esophagogastric anastomoses.

Methods

A series of 390 consecutive patients who underwent esophagectomy with gastric conduit reconstruction was analyzed.

Results

The end-to-end technique was performed in 112 (29 %) patients and the end-to-side in 278 (71 %) patients. Anastomotic leakage occurred in 20 (18 %) patients with an end-to-end anastomosis versus 58 (21 %) patients with an end-to-side anastomosis (p?=?0.50). A higher incidence in anastomotic strictures was seen in end-to-end anastomoses (48 (43 %)) compared with end-to-side anastomoses (89 (32 %); p?=?0.04). Moreover, a median of 11 (7–17) dilations was necessary in patients with a benign anastomotic stricture in the end-to-end group compared with four (2–8) dilations in patients with a benign anastomotic stricture in the end-to-end group (p?<?0.036). After multivariate analysis, the difference in anastomotic leakage rates remained nonsignificant (p?=?0.74), whereas anastomotic stricture rate and number of dilations were higher in the end-to-end group (p?=?0.03 and p?=?0.01, respectively).

Conclusion

The technique of anastomosis is not significantly related to anastomotic leakage rate. However, patients with end-to-end anastomoses develop postoperative strictures more frequently, requiring a higher number of dilations compared to end-to-side anastomoses.     

Training the novice to become cardiac surgeon: does the “early learning curve” training compromise surgical outcomes?

Objective

It is unclear whether novice trainees can be taught safely to perform adult cardiac surgery without any impact on early or late outcomes.

Methods

All patients (n = 1305) data were obtained from an externally validated, mandatory institutional database (2003–2010). ‘Novice’ is defined as a trainee who required substantial assistance or supervision to perform part or whole of the specified procedure (Intercollegiate Surgical Curriculum Programme UK, Competency Level ≤2). Outcome measures were in-hospital mortality, composite score of in-hospital mortality-morbidities, mid-term survival and revascularisation rate after CABG. Follow-up up to 7 years (median 3.2 years) was determined.

Results

Some 39 % (n = 510) of the cases involved novice (28 %-part, 11 %-whole procedure), 12 % (n = 157) competent trainees and 49 % (n = 638) consultant. Median EuroSCORE was higher in consultant group (p < 0.001). Without risk adjustment, composite outcome score and mid-term mortality were higher in consultant group (p = 0.03). With adjustment using EuroSCORE and propensity scores, EuroSCORE was significantly predictive of in-hospital mortality [odd ratio (OR) 1.38, 95 %CI 1.20–1.57, p < 0.001], composite outcome (OR 1.26, 95 %CI 1.15–1.37, p < 0.001) and mid-term mortality (HR 1.24, 95 %CI 1.18–1.31, p < 0.001) but not the operator categories. Further analysis of subcohort undergoing first-time, isolated CABG (n = 1070) showed that EuroSCORE remained predictive of adjusted in-hospital mortality (OR 1.39, 95 %CI 1.13–1.71, p = 0.002), composite outcome (OR 1.33, 95 %CI 1.19–1.49, p < 0.001) and mid-term mortality (HR 1.22, 95 %CI 1.10–1.35, p < 0.001). The operator categories were not associated with adjusted outcome measures including revascularisation rate after CABG.

Conclusion

Supervised training in adult cardiac surgery can be achieved safely at the early learning curve phase without compromising both early and mid-term clinical outcomes.     

Trends in subtrochanteric, diaphyseal, and distal femur fractures, 1984–2007

Summary

The incidence of non-hip femur fractures increased between 1984 and 2007, with an increase in the rates for women after 1996.

Introduction

Recent reports have suggested that non-hip femur fractures may be decreasing over time, similar to proximal femur fractures.

Methods

Incidence rates for non-hip femur fractures among Olmsted County, Minnesota, residents were assessed before and after 1995 when the oral bisphosphonate, alendronate, was approved in the USA.

Results

From 1984 to 2007, 727 non-hip femur fractures were observed in 690 Olmsted County residents (51% female [median age, 71.6?years] and 49% male [21.4?years]). Altogether, 20% of the fractures were subtrochanteric, 51% were diaphyseal, and 29% involved the distal femur. Causes included severe trauma in 51%, minimal to moderate trauma in 34%, and pathologic causes in 15%. The overall age- and sex-adjusted annual incidence of first non-hip femur fracture was 26.7 per 100,000 (25.0 per 100,000 for women and 26.6 per 100,000 for men). Incidence rates increased with age and were greater in women than men. Between 1984–1995 and 1996–2007, age-adjusted rates increased significantly for women (20.4 vs. 28.7 per 100,000; p?=?0.002) but not for men (22.4 vs. 29.5 per 100,000; p?=?0.202).

Conclusion

The incidence of first non-hip femur fractures rose between 1984 and 2007, with an increase in the rates for women after 1995.     

Postoperative morbidity is an additional prognostic factor after potentially curative pancreaticoduodenectomy for primary duodenal adenocarcinoma

Purpose

The aims of this paper were to evaluate the clinical features of patients with primary duodenal adenocarcinoma and to address the prognostic relevance of different surgical and pathological variables after potentially curative pancreaticoduodenectomy.

Methods

Patients with primary duodenal adenocarcinoma observed from 2000 through 2009 were identified from a single-institution electronic database. Univariate and multivariate analyses were performed to identify factors associated with survival.

Results

The study population consisted of 37 patients. Of these, 25 underwent pancreaticoduodenectomy, while the remaining 12 were not amenable to resection and underwent bypass operations or were given best supportive care. Overall survival after radical resection (R0) was significantly longer than after palliative surgery (180 versus 35 months, p?=?0.013). On multivariate analysis, tumor grade (hazard ratio (HR)?=?1.345, 95% CI?=?1.28–1.91, p?=?0.03) and the occurrence of postoperative or abdominal complications (HR?=?1.781, 95% CI?=?1.10–2.89, p?=?0.037; HR?=?1.878, 95% CI?=?1.21–3.08, p?=?0.029) were found to be significant prognostic factors for survival in patients undergoing potentially curative resection. In particular, median survival was 180 months in patients with an uneventful postoperative course and 52 months in those with abdominal complications. The 5-year overall survival rates were 100 and 60 %, respectively.

Conclusions

According to the present findings, the development of postoperative complications may be an additional prognostic factor after potentially curative pancreaticoduodenectomy for primary duodenal adenocarcinoma. This emphasizes the need for centralization to high-volume centers where an appropriate postoperative care can be delivered.     

Value of Geriatric Frailty and Nutritional Status Assessment in Predicting Postoperative Mortality in Gastric Cancer Surgery

Objectives

This study seeks to evaluate assessment of geriatric frailty and nutritional status in predicting postoperative mortality in gastric cancer surgery.

Methods

Preoperatively, patients operated for gastric adenocarcinoma underwent assessment of Groningen Frailty Indicator (GFI) and Short Nutritional Assessment Questionnaire (SNAQ). We studied retrospectively whether these scores were associated with in-hospital mortality.

Results

From 2005 to September 2012 180 patients underwent surgery with an overall mortality of 8.3 %. Patients with a GFI?≥?3 (n?=?30, 24 %) had a mortality rate of 23.3 % versus 5.2 % in the lower GFI group (OR 4.0, 95%CI 1.1–14.1, P?=?0.03). For patients who underwent surgery with curative intent (n?=?125), this was 27.3 % for patients with GFI?≥?3 (n?=?22, 18 %) versus 5.7 % with GFI?<?3 (OR 4.6, 95 % CI 1.0–20.9, P?=?0.05). SNAQ?≥?1 (n?=?98, 61 %) was associated with a mortality rate of 13.3 % versus 3.2 % in patients with SNAQ?=?0 (OR 5.1, 95 % CI 1.1–23.8, P?=?0.04). Given odds ratios are corrected in multivariate analyses for age, neoadjuvant chemotherapy, type of surgery, tumor stage and ASA classification.

Conclusions

This study shows a significant relationship between gastric cancer surgical mortality and geriatric frailty as well as nutritional status using a simple questionnaire. This may have implications in preoperative decision making in selecting patients who optimally benefit from surgery.