Case-Control Study of the Pathogenesis and Sequelae of Symptomatic Vertebral Fractures in Men

To investigate the pathogenesis and sequelae of symptomatic vertebral fractures (VF) in men, we have performed a case–control study, comparing 91 men with VF (median age 64 years, range 27–79 years) with 91 age-matched control subjects. Medical history, clinical examination and investigations were performed in all patients and control subjects, to identify potential causes of secondary osteoporosis, together with bone mineral density (BMD) measurements. BMD was lower at the lumbar spine and all sites in the hip in patients with VF than in control subjects (p<0.001). Potential underlying causes of secondary osteoporosis were found in 41% of men with VF, compared with 9% of control subjects (OR 7.1; 95% CI 3.1–16.4). Oral corticosteroid and anticonvulsant treatment were both associated with a significantly increased risk of VF (OR 6.1; 95% CI 1.3–28.4). Although hypogonadism was not associated with an increased risk of fracture, the level of sex hormone binding globulin was higher (p<0.001) and the free androgen index lower (p<0.001) in men with VF than control subjects. Other factors associated with a significantly increased risk of VF were family history of bone disease (OR 6.1; 95% CI 1.3–28.4), current smoking (OR 2.8; 95% CI 1.2–6.7) and alcohol consumption of more than 250 g/week (OR 3.8; 95% CI 1.7–8.7). Men with VF were more likely to complain of back pain (p<0.001) and greater loss of height (p<0.001) than control subjects, and had poorer (p<0.001) scores for the energy, pain, emotion, sleep and physical mobility domains of the Nottingham Health Profile. We conclude that symptomatic VF in men are associated with reduced BMD, underlying causes of secondary osteoporosis such as corticosteroid and anticonvulsant treatment, family history of bone disease, current smoking and high alcohol consumption, and that they impair the perceived health of the individual. Received: 23 February 1998 / Accepted: 13 May 1998     

Metacarpal Morphometry Using a Semi-automated Technique in the Assessment of Osteoporosis and Vertebral Fracture Risk

Metacarpal morphometry represents a potentially cheap and widely available non-invasive assessment of skeletal status. In two cross-sectional studies, we compared the performance characteristics of a semi-automated technique (the Teijin Bonalyzer) with an in-house manual measurement, and with measures of skeletal strength at other sites. The metacarpal cortical index (mCI) was measured on hand radiographs of 178 osteoporotic women using both the Teijin Bonalyzer and a digitizing tablet. Measurements on the latter were consistently lower than with the Bonalyzer except for mCI (0.443 ± 0.080 vs 0.364 ± 0.060, p<0.001), although correlation coefficients between these two methods were highly significant (r= 0.62–0.83, p<0.001). The reproducibility errors of metacarpal bone mineral density (mBMD) were constant (1.1–1.2%) whilst those for mCI showed a marked operator-dependency (2.0–7.9%). In 379 elderly community-dwelling women, Bonalyzer mCI and mBMD showed a significant decline with age (r=−0.30 and −0.27 respectively, p<0.05). Both mCI and mBMD correlated significantly with forearm BMD (r= 0.50 and 0.57 respectively, p<0.001) and hip BMD (r= 0.48 and 0.53 respectively, p<0.001). After adjustment for age and weight, hip BMD demonstrated the best discrimination for prevalent vertebral fractures as judged by the gradient of risk for a 1 SD decrease in measurement (odds ratio (OR) 2.17, 95% CI 1.56–3.01). Similar but smaller gradients of risk were shown by Bonalyzer mCI (OR 1.32, 95% CI 1.00–1.75), mBMD (OR 1.35, 95% CI 1.02–1.78) and forearm BMD (OR 1.39, 95% CI 1.08–1.80). MCI, and in particular mBMD, may be useful assessments of bone mass and fracture risk. In our study, it is comparable to peripheral assessment of skeletal status by forearm densitometry. Received: 22 February 2000 / Accepted: 6 June 2000     

Epigenetic Regulation of WNT Signaling Pathway Genes in Inflammatory Bowel Disease (IBD) Associated Neoplasia

Introduction  WNT signaling pathway dysregulation is an important event in the pathogenesis of colorectal cancer (CRC) with APC mutations seen in more than 80% of sporadic CRC. However, such mutations in the WNT signaling pathway genes are rare in inflammatory bowel disease (IBD) associated neoplasia (dysplasia and cancer). This study examined the role of epigenetic silencing of WNT signaling pathway genes in the pathogenesis of IBD-associated neoplasia. Methods  Paraffin-embedded tissue samples were obtained and methylation of ten WNT signaling pathway genes, including APC1A, APC2, SFRP1, SFRP2, SFRP4, SFRP5, DKK1, DKK3, WIF1 and LKB1, was analyzed. Methylation analysis was performed on 41 IBD samples, 27 normal colon samples (NCs), and 24 sporadic CRC samples. Results  Methylation of WNT signaling pathway genes is a frequent and early event in IBD and IBD-associated neoplasia. A progressive increase in the percentage of methylated genes in the WNT signaling pathway from NCs (4.2%) to IBD colitis (39.7%) to IBD-associated neoplasia (63.4%) was seen (NCs vs. IBD colitis, p < 0.01; IBD colitis vs. IBD-associated neoplasia, p = 0.01). In the univariate logistic regression model, methylation of APC2 (OR 4.7, 95% CI: 1.1–20.63, p = 0.04), SFRP1 (OR 5.1, 95% CI: 1.1–31.9, p = 0.04), and SFRP2 (OR 5.1, 95% CI: 1.1–32.3, p = 0.04) was associated with progression from IBD colitis to IBD-associated neoplasia, while APC1A methylation was borderline significant (OR 4.1, 95% CI: 0.95–17.5, p = 0.06). In the multivariate logistic regression model, methylation of APC1A and APC2 was more likely to be associated with IBD-associated neoplasia than IBD colitis. (OR APC1A: 6.4, 95% CI: 1.1–37.7 p = 0.04; OR APC2 9.1, 95% CI: 1.3–61.7, p = 0.02). Summary  Methylation of the WNT signaling genes is an early event seen in patients with IBD colitis and there is a progressive increase in methylation of the WNT signaling genes during development of IBD-associated neoplasia. Moreover, methylation of APC1A, APC2, SFRP1, and SFRP2 appears to mark progression from IBD colitis to IBD-associated neoplasia, and these genes may serve as biomarkers for IBD-associated neoplasia.     

Comparative clinical outcomes between pediatric and young adult dialysis patients

Published data on the comparative achievement of The Kidney Disease Dialysis Outcome Quality Initative (KDOQI) recommended clinical performance targets between children and young adults on dialysis are scarce. To characterize the achievement of KDOQI targets among children (<18 years) and young adults (18–24 years) with prevalent end stage renal disease (ESRD), we performed a cross-sectional analysis of data collected by the Mid-Atlantic Renal Coalition, in conjunction with the 2007 and 2008 ESRD Clinical Performance Measures Projects. Data on all enrolled pediatric dialysis patients, categorized into three age groups (0–8, 9–12, 13–17 years), and on a random sample of 5% of patients ≥18 years in ESRD Network 5 were examined for two study periods: hemodialysis (HD) data were collected from October to December 2006 and from October to December 2007 and peritoneal dialysis (PD) data were collected from October 2006 to March 2007 and from October 2007 to March 2008. In total, 114 unique patients were enrolled the study, of whom 41.2% (47/114) were on HD and 58.8% (67/114) on PD. Compared to the pediatric patients, young adults were less likely to achieve the KDOQI recommended serum phosphorus levels and serum calcium × phosphorus product values, with less than one-quarter demonstrating values at or below each goal. Multivariate analysis revealed that both young adults and 13- to 17-year-olds were less likely to achieve target values for phosphorus [young adults: odds ratio (OR) 0.04, 95% confidence interval (95% CI) 0.01–0.19, p < 0.001; 13- to 17-year-olds: OR 0.17, 95% CI 0.04–0.77, p = 0.02] and calcium × phosphorus product (young adults: OR 0.01, 95% CI 0.002–0.09, p <  0.001; 13- to 17-year-olds: OR 0.09, 95% CI 0.02–0.56, p = 0.01) than younger children. In summary, there are significant differences in clinical indices between pediatric and young adult ESRD patients.     

Laparoscopic versus open approach for implantation of the peritoneal catheter during ventriculoperitoneal shunt placement

Background  Ventriculoperitoneal shunt (VPS) is the mainstay of therapy for hydrocephalus. The aim of this study is to compare outcomes of laparoscopic (LVPS) versus open (OVPS) techniques for placement of distal VPS catheters. Methods  All patients undergoing new VPS placement at a tertiary care center between January 2004 and August 2007 were included. Univariate analysis was performed. Wilcoxon rank-sum, chi-square, and Fisher’s exact tests were used to make comparisons between LVPS and OVPS groups. Stepwise backward logistic regression was performed to predict complications requiring operative intervention. A Kaplan–Meier estimate of the survival function was calculated for shunt survival. All data is presented as median and range unless otherwise specified. Results  Five hundred thirty-five consecutive patients underwent 579 VPS (258 LVPS, 321 OVPS). Median age (52.0 years) and American Society of Anesthesiologists (ASA) score (3) were similar in LVPS and OVPS groups. Body mass index (BMI) [27.8 (17.0–64.9) kg/m² versus 25.9 (12.3–44.4) kg/m², p = 0.007], previous operations [0.8 ± 0.9 versus 0.6 ± 0.7, p = 0.004 (mean ± standard deviation)], estimated blood loss (EBL) [20 (0–175) ml versus 25 (0–500) ml, p < 0.001], operating room (OR) time [37.5 (17.0–152.0) min versus 52.0 (20.0–197.0) min, p < 0.001], and length of stay (LOS) [11 (1–77) days versus 14 (1–225) days, p = 0.016] were statistically different between the LVPS and OVPS groups, respectively. LVPS abdominal complication rate of 5.8% and OVPS rate of 6.9% were similar (p = 0.611). Previous abdominal operation [odds ratio (OR) 1.673, 95% confidence interval (CI) 1.100–2.543, p = 0.016] and previous VPS (OR 1.929, 95% CI 1.147–3.243, p = 0.016) were significant predictors of complications requiring operative intervention. Kaplan–Meier analysis demonstrated no difference in survival between LVPS and OVPS groups (p = 0.538), with overall shunt survival of 86.4% at 6 months and 83.0% at 1 year. Conclusions  LVPS is associated with decreased OR time, less blood loss, and shorter LOS with no difference in complication rate when compared OVPS. The laparoscopic approach for VPS is a safe, effective, and readily reproducible alternative to the traditional open approach.     

The prevalence of radiographic vertebral fractures in Latin American countries: the Latin American Vertebral Osteoporosis Study (LAVOS)

Summary  In the first population-based study of vertebral fractures in Latin America, we found a 11.18 (95% CI 9.23–13.4) prevalence of radiographically ascertained vertebral fractures in a random sample of 1,922 women from cities within five different countries. These figures are similar to findings from studies in Beijing, China, some regions of Europe, and slightly lower than those found in the USA using the same standardized methodology. Introduction  We report the first study of radiographic vertebral fractures in Latin America. Methods  An age-stratified random sample of 1,922 women aged 50 years and older from Argentina, Brazil, Colombia, Mexico, and Puerto Rico were included. In all cases a standardized questionnaire and lateral X-rays of the lumbar and thoracic spine were obtained after informed consent. Results  A standardized prevalence of 11.18 (95% CI 9.23–13.4) was found. The prevalence was similar in all five countries, increasing from 6.9% (95% CI 4.6–9.1) in women aged 50–59 years to 27.8% (95% CI 23.1–32.4) in those 80 years and older (p for trend < 0.001). Among different risk factors, self-reported height loss OR = 1.63 (95% CI: 1.18–2.25), and previous history of fracture OR = 1.52 (95% CI: 1.14–2.03) were significantly (p < 0.003 and p < 0.04 respectably) associated with the presence of radiographic vertebral fractures in the multivariate analysis. In the bivariate analyses HRT was associated with a 35% lower risk OR = 0.65 (95% CI: 0.46–0.93) and physical activity with a 27% lower risk of having a vertebral fracture OR = 0.73 (95% CI: 0.55–0.98), but were not statistically significant in multivariate analyses Conclusion  We conclude that radiographically ascertained vertebral fractures are common in Latin America. Health authorities in the region should be aware and consider implementing measures to prevent vertebral fractures.     

Risk factors for the association of intracranial and aortic aneurysms

Summary This study investigated the association of intracranial aneurysms and abdominal aortic aneurysms to elucidate the incidence and independent risk factors for this association. Ultrasonography of the abdominal aorta was performed in 181 patients with 224 intracranial aneurysms. Six patients had suffered subarachnoid haemorrhage and the others had chronic disease or no symptoms. Magnetic resonance angiography was performed for confirmation if abdominal aortic aneurysm was identified by ultrasonography. Thirteen patients (7.2%) with 23 intracranial aneurysms had abdominal aortic aneurysms. Univariate analysis demonstrated that age (p < 0.01), size of intracranial aneurysms (p < 0.001), male sex (p < 0.01), multiplicity of intracranial aneurysms (p < 0.001), history of cerebrovascular diseases (p < 0.05), and current smoking (p < 0.0001) were significantly different between patients with and without this association. Multiple logistic analysis indicated that age (odds ratio [OR] 1.27, 95% confidence interval 1.08–1.48, p < 0.01), multiplicity (OR 22.1, 95% confidence interval 1.83–266.3, p = 0.01), size of intracranial aneurysms (OR 1.30, 95% confidence interval 1.10–0.54, p < 0.01), and current smoking (OR 33.3, 95% confidence interval 2.43–456.7, p = 0.01) were independent risk factors for the association. Patients with intracranial aneurysms who are older males with multiple or large intracranial aneurysms, and current smokers should be examined for abdominal aortic aneurysms using ultrasonography.     

Clinical relevance of laparoscopically diagnosed hiatal hernia

Background  To determine the clinical relevance of a laparoscopically diagnosed hiatal hernia. Methods  Consecutive patients undergoing an elective laparoscopy were prospectively recruited. We assessed preoperative gastroesophageal reflux symptoms using a validated score, and documented the presence or absence of a hiatal hernia during laparoscopy. Results  Of the 95 evaluable patients, 42 (44%) had a hiatal hernia. The mean age was 49.8 years. Logistic regression analysis indicated that three features were significantly and independently associated with hiatal hernia: a higher reflux score (odds ratio [OR] 2.44; 95% confidence interval [CI] 1.48-4.05; p < 0.001), low body mass index (BMI) (OR 0.83; 95% CI 0.70–0.98; p = 0.029), and type of surgery (OR 0.34; 95% CI 0.14–0.92; p = 0.033). The diagnostic accuracy of a reflux score of more than 2 was 81%, with a sensitivity, specificity, positive predictive value, and negative predictive value of 76%, 85%, 80%, and 82%, respectively. The likelihood ratio for a positive result was 5.05. Conclusion  Hiatal hernia is common in this population of surgical patients undergoing an elective laparoscopy. Patients with reflux symptoms or a low BMI were more likely to have a hiatal hernia. With a reflux score of more than 2, the probability of finding a hiatal hernia during laparoscopy is 80%.     

Gender and vesico-ureteral reflux: a multivariate analysis

The aim of this retrospective cohort study was to describe the characteristics of patients with primary vesico-ureteral reflux (VUR) with special attention to gender-specific differences. Between 1970 and 2004, 735 patients were diagnosed with VUR and were systematically followed in a single tertiary renal unit. The following variables were analyzed: race, age at diagnosis, clinical presentation, weight and height Z-score, unilateral/bilateral reflux, VUR grade, renal damage, severity of renal damage, constipation, and dysfunctional voiding. Comparison of proportion between genders was assessed by the chi-square test with Yates’ correction. The logistic regression model was applied to identify independent variables associated with gender. A survival analysis was performed to evaluate VUR resolution. After adjustment, five variables remained independently associated with male gender at baseline: non-white race [Odds ratio (OR) = 1.98, 95% confidence interval (95% CI) 1.33–2.95, P=0.001], moderate/severe grade of reflux (OR=2.16, 95% CI 1.45–3.22, P<0.001), severe renal damage (OR=1.60, 95% CI 1.04–2.52, P=0.04), age at diagnosis <24 months (OR=1.79, 95% CI 1.23–2.60, P=0.002), and antenatal clinical presentation (OR=3.56, 95% CI 1.91–6.63, P<0.001). Follow-up data were available for 684 patients (93%). Median follow-up time was 69 months (range 6 months to 411 months). Girls had a greater risk of urinary tract infection (UTI) during follow-up than boys (OR=1.68, 95% CI 1.18–2.38, P=0.003). There was no difference in progression to chronic renal insufficiency (CRI) between boys (3.8%) and girls (2.4%) during this period of follow-up (OR=1.58, 95% CI 0.59–4.15, P=0.44). Gender as an isolated variable is a poor predictor of clinical outcome in an unselected series of primary reflux. Although boys had a more severe pattern at baseline, girls had a greater risk of dysfunctional voiding and recurrent UTI during follow-up.     

Association between iron overload and osteoporosis in patients with hereditary hemochromatosis

Summary  In 87 patients with hereditary hemochromatosis, osteoporosis was detected in 25%, and osteopenia in 41%. Bone mineral density was independently associated with BMI, ALP levels, hypogonadism/menopause, and the amount of iron removed to reach depletion, but not with cirrhosis. Osteoporosis is influenced by iron overload in hemochromatosis. Introduction  To analyze prevalence, clinical characteristics and genetic background associated with osteoporosis in a retrospective study in Italian patients with hereditary hemochromatosis (HHC). Methods  In 87 consecutive patients with HHC, bone mineral density was systematically evaluated by dual energy x-ray absorptiometry of the lumbar spine (n = 87) and femoral neck (n = 66). Results  Osteoporosis was detected in 22 (25.3%), and osteopenia in 36 (41.4%) patients. Mean Z scores were −0.92 ± 1.42 at lumbar spine and −0.35 ± 1.41 at femoral neck. Lumbar spine T-score was independently associated with total ALP (p = 0.002), hypogonadism/menopause (p = 0.026), and iron overload (p = 0.033 for ferritin and p = 0.017 for iron removed). We observed a borderline significance for BMI (p = 0.069) and smoking status (p = 0.086). Lumbar spine osteoporosis was independently associated with lower BMI (OR 0.73, 95% CI 0.54–0.94), total ALP (OR 1.17, 95% CI 1–1.39 per 10 unit increase) and the amount of iron removed (OR 1.53, 95% CI 1–2.5 per 5 g increase). HFE genotypes did not differ between patients with and without osteoporosis. Conclusions  Osteoporosis is observed in a quarter of unselected patients with HHC, independently of the genetic background, and is associated with ALP, hypogonadism, body weight, and severity of iron overload.     

Umbilical Herniorrhapy in Cirrhosis: Improved Outcomes with Elective Repair

Objective This study was undertaken to examine the effect of cirrhosis on elective and emergent umbilical herniorrhapy outcomes. Methods Procedures were identified from the Veterans’ Affairs National Surgical Quality Improvement Program at 16 hospitals. Medical records and operative reports were physician abstracted to obtain preoperative and intraoperative variables. Results Of the 1,421 cases reviewed, 127 (8.9%) had cirrhosis. Cirrhotics were more likely to undergo emergent repair (26.0% vs. 4.8%, p < 0.0001), concomitant bowel resection (8.7% vs. 0.8%, p < 0.0001), return to operating room (7.9% vs. 2.5%, p = 0.0006), and increased postoperative length of stay (4.0 vs. 2.0 days, p = 0.01). Best-fit regression models found cirrhosis was not a significant predictor of postoperative complications. Significant predictors of complications were emergent case (OR 5.4; 95% CI 3.1–9.4), diabetes (OR 2.1; 95% CI 1.2–3.8), congestive heart failure (OR 4.0; 95% CI 1.4–11.4), and chronic obstructive pulmonary disease (OR 2.0; 95% CI 1.1–3.6). Among emergent repairs, cirrhosis (OR 4.4; 95% CI 1.3–14.3) was strongly associated with postoperative complications. Conclusion Elective repair in cirrhotics is associated with similar outcomes as in patients without cirrhosis. Emergent repair in cirrhotics is associated with worse outcomes. Early elective repair may improve the overall outcomes for patients with cirrhosis.     

Adherence to antiretroviral therapy for HIV in sub‐Saharan Africa and Asia: a comparative analysis of two regional cohorts

Introduction : Our understanding of how to achieve optimal long‐term adherence to antiretroviral therapy (ART) in settings where the burden of HIV disease is highest remains limited. We compared levels and determinants of adherence over time between HIV‐positive persons receiving ART who were enrolled in a bi‐regional cohort in sub‐Saharan Africa and Asia. Methods : This multicentre prospective study of adults starting first‐line ART assessed patient‐reported adherence at follow‐up clinic visits using a 30‐day visual analogue scale. Determinants of suboptimal adherence (<95%) were assessed for six‐month intervals, using generalized estimating equations multivariable logistic regression with multiple imputations. Region of residence (Africa vs. Asia) was assessed as a potential effect modifier. Results : Of 13,001 adherence assessments in 3934 participants during the first 24 months of ART, 6.4% (837) were suboptimal, with 7.3% (619/8484) in the African cohort versus 4.8% (218/4517) in the Asian cohort (p < 0.001). In the African cohort, determinants of suboptimal adherence were male sex (odds ratio (OR) 1.27, 95% confidence interval (CI) 1.06–1.53; p = 0.009), younger age (OR 0.8 per 10 year increase; 0.8–0.9; p = 0.003), use of concomitant medication (OR 1.8, 1.0–3.2; p = 0.044) and attending a public facility (OR 1.3, 95% CI 1.1–1.7; p = 0.004). In the Asian cohort, adherence was higher in men who have sex with men (OR for suboptimal adherence 0.6, 95% CI 0.4–0.9; p = 0.029) and lower in injecting drug users (OR for suboptimal adherence 1.6, 95% CI 0.9–2.6; p = 0.075), compared to heterosexuals. Risk of suboptimal adherence decreased with longer ART duration in both regions. Participants in low‐ and lower‐middle‐income countries had a higher risk of suboptimal adherence (OR 1.6, 1.3–2.0; p < 0.001), compared to those in upper‐middle or high‐income countries. Suboptimal adherence was strongly associated with virological failure, in Africa (OR 5.8, 95% CI 4.3–7.7; p < 0.001) and Asia (OR 9.0, 95% CI 5.0–16.2; p < 0.001). Patient‐reported adherence barriers among African participants included scheduling demands, drug stockouts, forgetfulness, sickness or adverse events, stigma or depression, regimen complexity and pill burden. Conclusions : Psychosocial factors and health system resources may explain regional differences. Adherence‐enhancing interventions should address patient‐reported barriers tailored to local settings, prioritizing the first years of ART.     

Disparities in Gastric Cancer Outcomes Among Asian Ethnicities in the USA

Background  Survival for gastric cancer is reportedly higher in Asians than for other races. It is unclear whether differences in outcome exist among Asian ethnicities. Our objective was to assess gastric cancer survival in Asian ethnic groups in a large heterogeneous population. Methods  Asian-Americans treated for gastric adenocarcinoma between 1988 and 2006 were identified from the Los Angeles County Cancer Surveillance Program. Patients were stratified and compared by ethnicity (Korean, Japanese, Chinese, Vietnamese or Filipino). Results  Of the 1,817 Asian-Americans in the study cohort, 45% (n = 810) were Korean, 25% (n = 462) were Chinese, 11% (n = 193) were Japanese, 10% (n = 188) were Filipino, and 9% (n = 164) were Vietnamese. For the entire cohort Koreans and Filipinos had the longest and shortest median survival (MS), respectively (22.4 and 10.3 months, respectively; P < 0.001). Multivariate analysis demonstrated that Japanese and Filipino ethnicity independently predicted worse survival compared with Korean ethnicity [hazard ratio (HR) 1.37, 95% confidence interval (CI) 1.08–1.73, P = 0.008; and HR 1.71, 95% CI 1.37–2.13, P < 0.001, respectively]. In the surgical cohort, Koreans and Filipinos had the longest and shortest survival, respectively (MS of 57.8 and 21.7 months, respectively; P < 0.001). Multivariate analysis of the surgical cohort also demonstrated that Japanese and Filipino ethnicity independently predicted worse survival compared with Korean ethnicity (HR 1.61, 95% CI 1.22–2.13, P < 0.001; and HR 1.66, 95% CI 1.24–2.22, P < 0.001, respectively). Conclusion  There are differences in gastric cancer survival among Asian ethnicities. Future studies addressing varying environmental exposures and molecular expression patterns in gastric cancer are warranted to better understand these disparities in outcome. This study was presented at the Society of Surgical Oncology’s 62nd Annual Cancer Symposium on March 7, 2009.     

Predictive Factors for Morbidity and Mortality in Patients Undergoing Laparoscopic Paraesophageal Hernia Repair: Age,ASA Score and Operation Type Influence Morbidity

Background  Patients undergoing laparoscopic paraesophageal hernia (PEH) repair risk substantial morbidity. The aim of the present study was to analyze predictive factors for postoperative morbidity and mortality. Methods  A total of 354 laparoscopic PEH repairs were analyzed from the database of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS). Age (<70 and ≥70 years) and risk (low: American Society of Anesthesiologists (ASA) scores 1 + 2; high ASA scores 3 + 4) groups were defined and multivariate logistic regression was conducted. Results  In patients ≥70 years of age postoperative morbidity (24.4% versus 10.1%; p = 0.001) and mortality (2.4% versus 0%; p = 0.045) were significantly higher than in patients <70 years of age. In patients with gastropexy, this significant age difference was again present (38.8% versus 10.5%; p = 0.001) whereas in patients with fundoplication no difference between age groups occurred (11.9% versus 10.1%; p = 0.65). Mortality did not differ. High-risk patients had a significantly higher morbidity (26.0% versus 11.2%; p = 0.001) but not mortality (2.1% versus 0.4%; p = 0.18). The multivariate logistic regression identified the following variables as influencing postoperative morbidity: Age ≥70 years (Odds Ratio [OR] 1.99 [95% CI 1.06 to 3.74], p = 0.033); ASA 3 + 4 (OR 2.29 [95% Confidence Interval (CI) 1.22 to 4.3]; p = 0.010); type of operation (gastropexy) (OR 2.36 [95% CI 1.27 to 4.37]; p = 0.006). Conclusions  In patients undergoing laparoscopic paraesophageal hernia repair age, ASA score, and type of operation significantly influence postoperative morbidity and mortality. Morbidity is substantial among elderly patients and those with co-morbidity, questioning the paradigm for surgery in all patients. The indication for surgery must be carefully balanced against the individual patient’s co-morbidities, age, and symptoms, and the potentially life threatening complications. H. J. Larusson and U. Zingg equally contributed as first authors.     

Tumour-infiltrating lymphocytes in non-invasive breast cancer: A systematic review and meta-analysis

BackgroundThe role of tumour infiltrating lymphocytes (TILs) as a biomarker in non-invasive breast cancer is unclear. This meta-analysis assessed the prognostic impact of TIL levels in patients with non-invasive breast cancer.MethodsSystematic literature search was performed to identify studies assessing local recurrence in patients with non-invasive breast cancer according to TIL levels (high vs. low). Subgroup analyses per local recurrence (invasive and non-invasive) were performed. Secondary objectives were the association between TIL levels and non-invasive breast cancer subtypes, age, grade and necrosis. Odds ratios (ORs) and 95% confidence intervals (CI) were extracted from each study and a pooled analysis was conducted with random-effect model.ResultsSeven studies (N = 3437) were included in the present meta-analysis. High-TILs were associated with a higher likelihood of local recurrence (invasive or non-invasive, N = 2941; OR 2.05; 95%CI, 1.03–4.08; p = 0.042), although with a lower likelihood of invasive local recurrence (N = 1722; OR 0.69; 95%CI, 0.49–0.99; p = 0.042). High-TIL levels were associated with triple-negative (OR 3.84; 95%CI, 2.23–6.61; p < 0.001) and HER2-positive (OR 6.27; 95%CI, 4.93–7.97; p < 0.001) subtypes, high grade (OR 5.15; 95%CI, 3.69–7.19; p < 0.001) and necrosis (OR 3.09; 95%CI, 2.33–4.10; p < 0.001).ConclusionsHigh-TIL levels were associated with more aggressive tumours, a higher likelihood of local recurrence (invasive or non-invasive) but a lower likelihood of invasive local recurrence in patients with non-invasive breast cancer.     

Anastomotic Leakage is Associated with Poor Long-Term Outcome in Patients After Curative Colorectal Resection for Malignancy

The impact of anastomotic leakage on long-term outcomes after curative surgery for colorectal cancer has not been well documented. This study aimed to investigate the effect of anastomotic leakage on survival and tumor recurrence in patients who underwent curative resection for colorectal cancer. Prospectively collected data of the 1,580 patients (904 men) of a median age of 70 years (range: 24–94), who underwent potentially curative resection for colorectal cancer between 1996 and 2004, were reviewed. Cancer-specific survival and disease recurrence were analyzed using Kaplan Meier method, and variables were compared with log rank test. Cox regression model was used in multivariate analysis. The cancer was situated in the colon and the rectum in 933 and 647 patients, respectively. Anastomotic leakage occurred in 60 patients (clinical leakage: n = 48; radiological leak: n = 12). The leakage rate was significantly higher in patients with surgery for rectal cancer (6.3 vs 2.0%, p < 0.001). The 5-year cancer-specific survivals were 56.9% in those with leakage and 75.9% in those without leakage (p = 0.012). The 5-year systemic recurrence rates were 48.4 and 22.6% in patients with and without anastomotic leak, respectively (p = 0.001), whereas the 5-year local recurrence rates were 12.9 and 5.7%, respectively (p = 0.009). Anastomotic leakage remained an independent factor associated with a worse cancer-specific survival (p = 0.043, hazard ratio: 1.63, 95% CI: 1.02–2.60) and a higher systemic recurrence rate (hazard ratio: 1.94, 95% CI: 1.23–3.06, p = 0.004) on multivariate analysis. In rectal cancer, anastomotic leakage was an independent factor for a higher local recurrence rate (hazard ratio: 2.55, 95% CI: 1.07–6.06, p = 0.034). In conclusion, anastomotic leakage is associated with a poor survival and a higher tumor recurrence rate after curative resection of colorectal cancer. Efforts should be undertaken to avoid this complication to improve the long-term outcome. This work was presented in the plenary session of the 47th Annual Meeting of the Society for Surgery of the Alimentary Tract at the Digestive Disease Week in Los Angeles on 22 May 2006.     

Extracapsular Lymph Node Involvement Differs Between Squamous Cell and Adenocarcinoma of the Esophagus

There is increasing evidence regarding extracapsular lymph node involvement (LNI) as a prognostic factor for recurrence and poor prognosis in gastrointestinal malignancies. The aim of this study was to assess the prevalence and prognostic impact of LNI in patients with resected esophageal cancer, comparing adenocarcinoma (AC) and squamous cell carcinoma (SCC). Between 1997 and 2006, 243 consecutive patients with resected esophageal cancer without neoadjuvant therapy (103 SCC, 140 AC) were studied. A total of 738 lymph node metastases were reexamined. Survival was analyzed according to intra- and extracapsular LNI. Median survival in patients with extracapsular LNI was 13 months [range 11–14 months, 95% confidence interval (CI)] compared with 28 months (21–34 months, 95% CI) for those with intracapsular LNI alone (p = 0.017). Node-positive patients with AC showed a prevalence of 66% extracapsular LNI compared with 35% in patients with SCC (p < 0.001). The number of resected lymph nodes and the frequency of pN1 cases were comparable between AC and SCC. However the number of infiltrated LN was significantly (p = 0.005) higher in patients with pN1 AC (median = 5) compared with pN1 SCC (median = 3). We conclude that extracapsular LNI is an independent negative prognostic factor which occurs more frequently in esophageal AC than SCC.     

Target vessel revascularization following percutaneous coronary intervention. A 10-year report from the Danish Percutaneous Transluminal Coronary Angioplasty Registry

Objective To present the rate of target vessel revascularization (TVR) in a consecutive and unselected national population over 10 years.

Design From 1989 to 1998 all percutaneous coronary interventions (PCIs) performed in Denmark were recorded in the Danish PTCA Registry.

Results From 1989 to 1998 the annual rate of PCI rose from 46 to 753 per million inhabitants. From 1995 to 1998 TVR with PCI or coronary artery bypass grafting (CABG) within 9 months from the index PCI decreased significantly (p<0.001) from 21.2% in 1995 (CABG 8.6% vs PCI 12.6%) to 11.7% in 1998 (CABG 4.3% vs PCI 7.4%). Independent predictors for TVR were: coronary stenting (OR 0.60; 95% CI 0.52–0.69, p<0.001), primary success rate (OR 0.69; 95% CI 0.53–0.89, p<0.005), pre-PCI stenosis severity (OR 1.01; 95% CI 1.00–1.01, p=0.03), left anterior descending coronary artery (OR 2.35; 95% CI 1.73–3.19, p<0.001), right coronary artery (OR 1.61; 95% CI 1.17–2.20, p=0.003), sapheneous vein graft (OR 2.03; 95% CI 1.13–3.63, p=0.017) and age (OR 0.99; 95% CI 0.98–1.00, p=0.002).

Conclusion Coronary stenting, primary success rate, pre-PCI stenosis severity, age and treated vessel were independent predictors for TVR.     

Pregnancy Following Gastric Bypass Surgery for Morbid Obesity: Maternal and Neonatal Outcomes

Background The purpose of this study was to compare obstetric and neonatal outcomes after Roux-en-Y gastric bypass (RYGB) to those in women without such surgery. Methods Women with RYGB (cases) were matched for maternal age and prior cesarean to the next two consecutive women delivering without prior bariatric surgery (controls). Pregnancy and newborn outcomes were compared by univariate analysis. Outcomes approaching or reaching statistical significance were evaluated by conditional logistic regression controlling for maternal body mass index (BMI). Results Despite gastric bypass, the 38 cases were heavier (BMI 33.4 ± 7.3 vs. 28.1 ± 6.7 kg/m², p < 0.001) and more often obese (BMI ≥ 30 kg/m², 26/38 (68.4%) vs. 20/76 (26.3%), p < 0.001) than controls. Variables evaluated by logistic regression adjusted for BMI did not differ in cases versus controls, including hypertension (odds ratio [OR] 2.62, 95% confidence interval [CI] 0.66–10.50), preterm premature rupture of membranes (OR 0.24, 95% CI 0.02–3.38), oligohydramnios (OR 2.39, 95% CI 0.66–8.61), and delivery ≥41 weeks (OR 0.57, 95% CI 0.11–2.97). Discussion Obstetric and neonatal outcomes after RYGB are similar to those of our general obstetric population. Reprints unavailable.