Evaluation of estimation of physiologic ability and surgical stress (E-PASS) to predict the postoperative risk for hip fracture in elder patients

Introduction  The Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system is comprised of a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS) determined by both the PRS and SSS. E-PASS predicts the postoperative risk by quantifying the patient’s reserve and surgical stress in general surgery. This study aims to evaluate the usefulness of this scoring system for the hospitalization outcomes in hip fracture. Patients and methods  A consecutive series of 419 elderly patients who underwent surgery with osteosynthesis or arthroplasty for hip fracture were prospectively assessed for the E-PASS scoring system, which was compared with their postoperative course. Results  The postoperative morbidity and mortality rates in hospital increased linearly as the PRS and CRS increased, with significant correlation (ρ = 0.2, P < 0.01) in both operations. The cost of hospital stay also related significantly to the SSS (r = 0.6, P < 0.0001) and CRS (r = 0.4, P < 0.0001). Conclusion  These results suggest that E-PASS may be useful for predicting postoperative risk and estimating medical expense for surgical cases with hip fracture.     

Comparison of surgical outcome using the prediction scoring system of E-PASS for thoracic surgery

Objective

The purpose of this study was to determine if our predictive scoring system, E-PASS, can estimate the surgical outcome.

Methods

We conducted a multicenter cohort study for 3 years in four national hospitals. A consecutive series of 731 patients who underwent elective thoracic operations were analyzed. The preoperative risk score (PRS) and the comprehensive risk score (CRS) of the E-PASS were determined preoperatively and immediately after the operation, respectively. The cost of the surgical admission and the severity of the postoperative complications were recorded at the time of discharge.

Results

The CRS significantly correlated with the severity of the postoperative complications (r_s = 0.728, P < 0.0001) and the charge (r_s = 0.530, P < 0.0001). When the estimated/real morbidity ratio (MR) among the hospitals was compared, it varied from 0.16 to 0.59. A significant increase in the cost was observed according to the CRS.

Conclusion

The E-PASS scoring system may be useful for standardizing the patient population and surgical severity to compare the surgical outcome.     

Feasibility of E-PASS score to predict postoperative complications in laparoscopic nephrectomy

Purpose

To evaluate the usefulness of E-PASS score to predict postoperative complications after laparoscopic nephrectomy.

Methods

Between 2008 and 2020, 424 patients (179 patients: simple nephrectomy, 158 patients: radical nephrectomy, 87 patients: donor nephrectomy) who underwent laparoscopic nephrectomy in our clinic, were included in the study. Patient groups separated according to the presence of postoperative complications were compared retrospectively regarding demographic, clinical, intraoperative, and postoperative data, comorbidities, and E-PASS scores (PRS, SSS, and CRS). The relationship between postoperative complications and E-PASS scores was examined.

Results

Postoperative complications occurred in 43 (10.1%) of the patients. Age, previous abdominal/retroperitoneal surgery, radical nephrectomy rate of surgeries, operation time, amount of bleeding, need for blood transfusion, rate of conversion from laparoscopic surgery to open surgery, hospitalization time, E-PASS PRS, SSS, and CRS were statistically significantly higher in the group with postoperative complications. The cutoff value of the E-PASS CRS was ? 0.2996 to predict the development of postoperative complications (AUC?=?0.706; 95% CI 0.629–0.783; p?<?0.001). According to multivariate analysis, presence of previous abdominal/retroperitoneal surgery (OR?2.977; 95% CI?1.502–5.899; p?=?0.002), laparoscopic radical nephrectomy (OR?2.518; 95% CI?1.224–5.179; p?=?0.012), conversion from laparoscopic surgery to open surgery (OR?4.869; 95% CI?1.046–22.669; p?=?0.044) and E-PASS CRS?>?? 0.2996 (OR?2.816; 95% CI?1.321–6.004; p?=?0.007) were found to be independent risk factors predicting postoperative complications.

Conclusion

The E-PASS scoring system is an effective and convenient system for predicting postoperative complications after laparoscopic nephrectomy.

     

Comparison of surgical outcome using the prediction scoring system of E-PASS for thoracic surgery.

OBJECTIVE: The purpose of this study was to determine if our predictive scoring system, E-PASS, can estimate the surgical outcome. METHODS: We conducted a multicenter cohort study for 3 years in four national hospitals. A consecutive series of 731 patients who underwent elective thoracic operations were analyzed. The preoperative risk score (PRS) and the comprehensive risk score (CRS) of the E-PASS were determined preoperatively and immediately after the operation, respectively. The cost of the surgical admission and the severity of the postoperative complications were recorded at the time of discharge. RESULTS: The CRS significantly correlated with the severity of the postoperative complications (rs = 0.728, P < 0.0001) and the charge (rs = 0.530, P< 0.0001). When the estimated/real morbidity ratio (MR) among the hospitals was compared, it varied from 0.16 to 0.59. A significant increase in the cost was observed according to the CRS. CONCLUSION: The E-PASS scoring system may be useful for standardizing the patient population and surgical severity to compare the surgical outcome.     

Less-invasive surgery for gastric cancer prolongs survival in patients over 80 years of age

This study was undertaken to determine the most appropriate form of surgery for elderly patients with gastric cancer in relation to postoperative complications and long-term survival. A total of 72 consecutive patients over 80 years of age who underwent partial or total gastrectomy were evaluated using an E-PASS scoring system. This system is comprised of a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS) determined by both the PRS and SSS. Patients with a CRS≥0.5 had significantly higher rates of morbidity and mortality at 45.0% and 20.0%, respectively, than those with CRS≤0.5, at 17.0% and 2.1%, respectively. A Cox regression analysis of long-term survival, including death from other causes, identified five significant prognostic factors, namely: stage, curability, SSS, CRS, and allogeneic blood transfusion. Among the patients without any apparent residual cancer, a significantly better survival was seen in those who underwent less invasive surgery (SSS<0.25), those with a CRS≤0.5, and those who had not been given a blood transfusion. These results suggest that less invasive surgery not requiring a blood transfusion is advisable for patients over 80 years of age with gastric cancer. Furthermore, gastrectomy with a CRS≥0.5 may have a poor therapeutic effect on both early and long-term outcome.     

High Hepatitis B Viral Load Predicts Recurrence of Small Hepatocellular Carcinoma after Curative Resection

A retrospective cohort study was conducted to identify risk factors for recurrence of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) after curative resection. A total of 317 patients who had received curative resection of pathologically proven small HCC (≤3 cm in diameter) were analyzed to ascertain the factors affecting recurrence. The median follow-up period was 33.7 months. Cumulative recurrence rates at 1, 3, and 5 years after resection were 23.5%, 49.5%, and 65.5%, respectively. Male sex, alpha-fetoprotein (AFP) ≥400 ng/mL, HBV DNA level ≥4 log₁₀ copies/mL, prolonged prothrombin time, tumor size ≥2 cm, microvascular invasion, absence of capsular formation, moderate/poor tumor differentiation, and absence of postoperative interferon-alpha (IFN-α) treatment were associated with increased cumulative risk of HCC recurrence. By multivariate analysis, HBV DNA level ≥4 log₁₀ copies/mL (P < 0.001, hazard ratio (HR) 2.110), AFP ≥400 ng/mL (P = 0.011, HR 1.574), microvascular invasion (P < 0.001, HR 1.767), and postoperative IFN-α treatment (P = 0.022, HR 0.562) remained to be independently associated with HCC recurrence. Those contributing to late recurrence (>2 years) were older age and HBV DNA level ≥4 log₁₀ copies/mL. Patients with persistent HBV DNA level ≥4 log₁₀ copies/mL at resection and follow-up had the highest recurrence risk (P < 0.001, HR 4.129). HBV DNA level ≥4 log₁₀ copies/mL at the time of resection was the most important risk factor for recurrence. Postoperative IFN-α treatment significantly decreased the recurrence risk after resection.     

Effect of Hospital Volume of Thyroidectomies on Outcomes Following Substernal Thyroidectomy

Background Substernal thyroidectomy (ST), as compared to conventional, cervical thyroidectomy, is a technically demanding procedure that is associated with increased morbidity and mortality. We tested the hypothesis that outcomes following ST are improved at centers that perform a high volume of thyroidectomies. Methods Patients who underwent ST from 1998 to 2004 were extracted from the New York State Statewide Planning and Research Cooperative System database. Hospital volume of thyroidectomies was divided into low (<33 per year), middle (33–99 per year), and high (≥100 per year) volumes. Outcome variables included hospital length of stay (LOS), recurrent laryngeal nerve (RLN) injury, hypoparathyroidism, postoperative bleeding, respiratory failure, blood transfusion, and mortality. Results A total of 1153 STs were analyzed; 372 (32.2%) were performed at low-volume centers, 388 (33.7%) at middle-volume centers, and 393 (34.0%) at high-volume centers. Linear associations were observed between increasing hospital volume of thyroidectomies and decreasing age (p = 0.003), increasing co-morbidity (p < 0.0001), increased likelihood of total versus subtotal thyroidectomy (p < 0.0001), and increased likelihood of thyroid malignancy (p < 0.0001). Despite this, increasing hospital volume of thyroidectomies predicted a decreased likelihood of overall complications (p = 0.005), postoperative bleeding (p = 0.01), blood transfusion (p = 0.04), respiratory failure (p = 0.04) and mortality (p = 0.004), as well as a trend toward a decreased LOS (p = 0.06). The overall complication rate and the mortality rate remained significantly associated with volume group by multivariate analysis. Conclusion Despite more extensive surgery on patients with greater co-morbidity, LOS, morbidity, and mortality were all decreased when ST occurred at hospitals that perform a high volume of thyroidectomies.     

High Hospital Volume Is Associated with Better Outcomes for Breast Cancer Surgery: Analysis of 233,247 Patients

Background: The relationship between hospital volume and outcomes needs to be further elucidated for low-risk procedures such as surgical therapy of localized breast cancer. The objective of this investigation was to assess the relationship between hospital volume and outcomes for breast cancer surgery. Methods: A total of 233,247 patients who underwent breast-conserving therapy (BCT) and breast-ablative therapy (BAT) for localized breast cancer were extracted from 13 years (1988–2000) of the Nationwide Inpatient Samples. Hospital volume was classified as low (<30 cases/year), intermediate (≥ 30 to <70cases/year), and high (≥ 70 cases/year). Multiple linear and logistic regression analyses were used to assess the risk-adjusted association between hospital volume and outcomes. Results: In risk-adjusted analyses, patients operated on at low-volume hospitals were 3.04 (p = 0.03) times more likely to die after BCT compared with patients operated on at high-volume hospitals. Similarly, low-volume hospitals had a significantly higher likelihood of postoperative complications (odds ratio [OR] = 1.73, p = 0.01 for BCT; OR = 1.44, p < 0.001 for BAT) compared with high-volume hospitals. Compared with low-volume hospitals, length of hospital stay was significantly shorter and nonroutine patient discharge significantly lower for high-volume providers for both BCT and BAT (all p < 0.001). Patients were also significantly less likely to undergo BCT if operated on in a low- or intermediate-volume hospital compared with a high-volume provider (p < 0.001). Conclusions: High-volume hospitals had significantly lower nonroutine patient discharge, postoperative morbidity and mortality, shorter length of hospital stay, and higher likelihood of performing BCT. Referral of patients with localized breast cancer to high-volume hospitals may be justified.     

Usefulness of an Estimation of Physiologic Ability and Surgical Stress (E-PASS) Scoring System to Predict the Incidence of Postoperative Complications in Gastrointestinal Surgery

Surgical intervention induces various host responses to maintain homeostasis. When postoperative inflammation is intense and persists for a long time, postoperative complications may occur, sometimes developing into multiple organ failure. Therefore, it is very important to assess surgical stress and predict the risk of morbidity and mortality. Using a new scoring system, an estimation of physiologic ability and surgical stress (E-PASS) scoring system, surgical stress following gastrointestinal surgery was evaluated to assess the feasibility of this scoring system. This system comprises a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS) that is calculated from both the PRS and the SSS. The relationship of the E-PASS score to the incidence of morbidity and mortality was examined. The relationship between the E-PASS score and a sequential organ failure (SOFA) score was also evaluated. The CRS had a significant positive correlation between not only the incidence but also the grade of postoperative complications. Total maximum SOFA score in patients with a CRS of more than 1 was significantly higher than that in patients with a CRS of less than 1. In conclusion, the E-PASS scoring system will be useful for predicting and recognizing the risk of postoperative complications. This scoring system is brief, simple, and reproducible and can be useful in all types of hospitals.     

Estimation of physiologic ability and surgical stress (E-PASS) as a predictor of immediate outcome after elective abdominal aortic aneurysm surgery

BACKGROUND: The Estimation of Physiologic Ability and Surgical Stress (E-PASS) score was designed on the premise that the balance between the patient's physiologic reserve capacity and the surgical stress inflicted at operation was important in the occurrence of postoperative complications. The aim of this study was to assess its value in predicting mortality and morbidity after open elective abdominal aortic aneurysm (AAA) repair. METHODS: E-PASS data items were collected prospectively in a group of 204 patients undergoing elective open AAA repair over a 6-year period. The operative morbidity and mortality rates were compared with the preoperative risk score (PRS), surgical stress score (SSS) and comprehensive risk score (CRS) of E-PASS. The group comprised 180 (88%) males and the median age was 73 (range 44 to 86) years. RESULTS: There were 13 (6%) deaths and 121 (59%) experienced a postoperative complication. As the PRS, SSS and CRS increased, the incidence of postoperative morbidity and mortality significantly increased (P < .0001). Overall mean CRS was .52 (+/-.27). Mean CRS in the groups of patients who survived and died were .49 (+/-.24) and .98 (+/-26), respectively. PRS, SSS, and CRS all had extremely good predictive power for both mortality and morbidity as demonstrated by high areas under the receiver operator curve (range .799 to .953). CRS also showed a strong statistically significant association with the severity of postoperative complication (P < .0001) and length of hospital stay (P < .0001). CONCLUSIONS: The E-PASS model appears to be a promising method of predicting death and the development of postoperative complications in patients undergoing elective open AAA surgery. It requires further validation in arterial surgery at different geographical locations.     

生理能力与手术侵袭度评分系统评估结肠癌手术风险的临床价值

目的 探讨生理能力与手术侵袭度(E-PASS)评分系统预测结肠癌患者择期手术后并发症风险的临床应用价值.方法 回顾性分析2009年8月至10月四川大学华西医院收治的符合本研究纳入标准的158例结肠癌患者的临床资料.采用E-PASS评分系统评估其手术风险,并比较E-PASS评分系统中的术前风险分数(PRS)、手术侵袭度分数(SSS)和综合风险分数(CRS)评分与实际手术预后的关系.采用多元线性回归分析E-PASS评分系统各项指标与术后风险的关系.结果 纳入分析的158例患者中,经过E-PASS评分系统预评估的术后近期并发症总体发生率为19.4%±2.0%,术后实际并发症发生率为17.1%(27/158).并发症的发生与Dukes分期、体能状态指数分级、严重心脏疾病、严重肺部疾病、手术时间有关(r=0.193,0.410,0.183,0.174,0.198,P＜0.05);且PRS、CRS和SSS均具有良好的预测作用(r=0.299,0.349,0.183,P＜0.05).结论 E-PASS评分系统是一个相对方便有效,易操作的手术风险评估系统,能够准确预测结肠癌患者的术后早期并发症发生风险.     

Risk Factors for Massive Blood Transfusion in Cytoreductive Surgery: A Multivariate Analysis of 243 Procedures

Background  Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has demonstrated improved survival in selected patients with peritoneal carcinomatosis (PC). This treatment modality is associated with high blood loss and often requires massive allogenic red blood cell transfusion (MABT). Our study is the first of its kind to evaluate the risk factors for intraoperative MABT in peritonectomy procedures. Methods  Two hundred and forty-three consecutive CRS and PIC procedures were evaluated. The associations between 17 preoperative and intraoperative risk factors and intraoperative MABT (≥6 units) were assessed by univariate and multivariate analysis. Results  One hundred and eighty-six (77%) procedures required intraoperative transfusion of packed red blood cells. Ninety-one procedures required MABT (37%). Multivariate analysis showed six significant risk factors for intraoperative MABT: operative length > 9 h (p < 0.001), preoperative hemoglobin < 125 g/l (p < 0.001), operation date prior to 2004 (p = 0.002), peritoneal cancer index ≥ 16 (p = 0.006), preoperative international normalized ratio (INR) ≥ 1.2 (p = 0.008), and number of peritonectomy procedures ≥ 4 (p = 0.021). Statistical analysis also revealed that MABT was associated with increased intensive care unit (ICU) (p < 0.001), high-dependency unit (HDU) (p = 0.020), and total hospital stay (p < 0.001) and with severe morbidity (p < 0.001). Conclusions  Patients with preoperative anemia, impaired coagulation profile or extensive tumor burden are at high risk of MABT. Appropriate blood conservation strategies should be adopted in these patients on the basis of their risk factors.     

The Effect of 17β-Estradiol at Doses of 0.5, 1 and 2 mg Compared with Placebo on Early Postmenopausal Bone Loss in Hysterectomized Women

In a randomized double-masked placebo-controlled parallel-group trial 166 hysterectomized (± oophorectomy) perimenopausal and postmenopausal women aged 45–55 years with a follicle stimulating hormone level above 20 IU/l were treated with one daily dose of either 0.5 mg 17β-estradiol (E₂), 1 mg E₂, 2 mg E₂ or placebo for 2 years. Bone mineral density (BMD) and biochemical bone markers were determined. All three doses of E₂ were significantly better than placebo with respect to change in BMD at the lumbar spine (L1–L4) (p<0.0001 for all pairwise comparisons) and hip (femoral neck, trochanter, Ward’s triangle). The mean percentage change from baseline at the lumbar spine was −0.2%, 0.8% and 1.8% in the 0.5, 1 and 2 mg E₂ groups respectively compared with −3.5% in the placebo group. Both 1 and 2 mg E₂ were significantly better than placebo in increasing the BMD at the femoral neck (p<0.001), trochanter (p<0.01) and Ward’s triangle (p<0.0001), while 0.5 mg E₂ was significantly better than placebo at the femoral neck (p<0.001) and Ward’s triangle (p<0.0001). The overall difference in mean percentage change in BMD at the femoral neck versus placebo (−0.2%) was 3.8% for 0.5 mg, 4.0% for 1 mg and 3.9% for 2 mg E₂; the corresponding numbers for trochanter were −0.3%, 1.3%, 3.3% and 3.2%, respectively, and −2.2%, 2.9%, 2.9% and 4.0%, respectively, for Ward’s triangle. More than half the women who received placebo presented with a decrease in BMD at the hip. The percentage of women in the 0.5 mg E₂ group who maintained or increased BMD at the femoral neck, trochanter and Ward’s triangle was 69%, 56% and 44%, respectively. For 1 mg E₂ the numbers were 69%, 78% and 61% respectively, and for 2 mg E₂ were 59%, 68% and 59% respectively. Osteocalcin, serum pyridinium crosslinks, urinary pyridinium crosslinks and urinary hydroxyproline/creatinine decreased significantly (p<0.0001, p<0.05) in the 0.5, 1 and 2 mg E₂ groups compared with the placebo group after 6 and 24 months of treatment. Received: 28 May 2001 / Accepted: 11 October 2001     

Remission of Metabolic Syndrome: A Study of 140 Patients Six Months after Roux-en-Y Gastric Bypass

Background Metabolic Syndrome (MS) is a complex disorder characterized by a number of cardiovascular risk factors usually associated with central fat deposition and insulin resistance. Nowadays, there are many different medical treatments to MS, including bariatric surgery, which improves all risk factors. The present study aims to evaluate the influence of gastric bypass in the improvement of risk factors associated with MS, during the postoperative (6 months). Methods This was a retrospective study of 140 patients submitted to gastric bypass. The sample was comprised of a female majority (79.3 %). The mean body mass index (BMI) was 44.17 kg/m². We evaluated the weight of the subjects, the presence of diabetes mellitus and hypertension as comorbidities, as well as plasma levels of triglycerides (TG), total cholesterol and its fractions, and glycemia, in both preoperative and postoperative. Results The percentage of excess weight loss (%EWL) was similar in men and women, with an average of 67.82 ± 13.21%. Concerning impaired fasting glucose (≥100 mg/dl), 41 patients (95.3%) presented normal postoperative glycemia. There has been an improvement of every appraised parameter. The mean decrease in TG level was 66.33 mg/dl (p < 0.0001). Before the surgery, 47.1% were hypertensive; after it, only 15% continued in antihypertensive drug therapy (p < 0.0001). Otherwise, the only dissimilar variable between sexes was the high-density lipoprotein (HDL) level. Conclusion Gastric bypass is an effective method to improve the risk factors of metabolic syndrome in the morbidly obese.     

Risk Factors for Hypoxemia After Surgery for Acute Type A Aortic Dissection

Purpose Postoperative hypoxemia is a frequent complication of surgery for acute type A aortic dissection. We tried to determine the factors associated with postoperative hypoxemia. Methods Between 1997 and 2003, 114 patients underwent surgery for acute type A aortic dissection. Multivariate logistic regression analysis was done to identify the independent predictors of postoperative hypoxemia, defined by an arterial partial oxygen/inspired oxygen fraction (PaO₂/FiO₂) ratio of 200 or lower. Results The overall in-hospital mortality was 6.1% (7 of 114 patients), being 5.2% in the hypoxemia group and 6.9% in the non-hypoxemia group. The ventilation time and intensive care unit stay were significantly longer in the hypoxemia group than in the non-hypoxemia group (P = 0.0044, P = 0.038, respectively). Logistic regression identified the following variables as predictors for postoperative hypoxemia: body mass index ≥25 (odds ratio [OR], 5.6; 95% confidence interval [CI], 2.1–15.01; P < 0.001), preoperative PaO₂/FiO₂ ratio ≤300 (OR, 2.6; 95% CI, 1.09–6.13; P = 0.031), and the volume of transfused blood (OR, 1.08; 95% CI, 1.01–1.18; P = 0.037). Conclusions Initiating early treatment for hypoxemia and reducing the volume of blood transfused intraoperatively may improve the postoperative clinical course of obese patients with preoperative hypoxemia.     

Changes in Erythrocyte Deformability after Liver Resection for Hepatocellular Carcinoma Associated with Chronic Liver Disease

p < 0.05). The incidence of postoperative complications was higher ( p = 0.001) in the patients (group A) with ETT increased during the first 3 postoperative days by ≥1 SD of the mean of the preoperative value than in patients (group B) with less change. Of the 12 patients whose ICGR ₁₅ value was ≥20%, all 9 patients in group A had postoperative complications. The increase in ETT (decrease in erythrocyte deformability) is associated with the development of postoperative complications. The measurement of erythrocyte deformability gives information useful for postoperative management, and special monitoring for postoperative complications is necessary in patients with the increase soon after liver resection.RID=" ID=" <E5>Correspondence to:</E5> K. Horii, M.D.     

Abbreviated mycophenolic acid AUC from C0, C1, C2, and C4 is preferable in children after renal transplantation on mycophenolate mofetil and tacrolimus therapy

In order to allow a similar algorithm to be used for both adults and children on tacrolimus-based and mycophenolate mofetil [MMF, a pro-drug for mycophenolic acid (MPA)]-based immunosuppression, a limited sampling technique from the trough level (C0) and the levels 30 min (C0.5) and 2 h (C2) after intake was to be developed from MPA area under the time–concentration curves (AUC). We retrospectively analyzed 49 full ten-point pharmacokinetic (PK) profiles from 29 pediatric patients on MMF and tacrolimus. We used stepwise multiple regression analysis to calculate limited sampling approaches. Agreement with the AUC was tested by means of Bland and Altman analysis. The correlation between AUC and pre-dose trough concentration was r²=0.5188 (P<0.0001) and between AUC and post-dose trough concentration r²=0.6924 (P<0.0001). The next best correlations were with 2 h (C2, r²=0.6711, P<0.0001), 4 h (C4, r²=0.6411, P<0.0001), 1.5 h (C1.5, r²=0.6344, P<0.0001), and 6 h (C6, r²=0.6219, P<0.0001). Three-point estimates at C0, C0.5, and C2 resulted in an acceptable correlation between predicted AUC and AUC from the full profile when we used the formula AUC = 10.01391+3.94791×C0+3.24253×C0.5+1.0108×C2, Pearsons r=0.8996, 95% confidence interval 0.8277–0.9424. However, even better results could be obtained when we used AUC = 8.217+3.163×C0+0.994×C1+1.334×C2+4.183×C4, Pearsons r=0.9456, 95% confidence interval 0.9051–0.9691. Bland and Altman analysis revealed good agreement between AUC predicted from C0, C0.5, and C2 and AUC from the full profile, but was inferior to the four-point approach. Also, the previously reported formula derived for adults was not usable in these patients. A special formula must be used for children. The AUC of MPA can be predicted by limited sampling including C0, C0.5, and C2, while an approach using C0, C1, C2, and C4 is preferable.     

Preoperative Spirometry Versus Expired Gas Analysis During Exercise Testing as Predictors of Cardiopulmonary Complications After Lung Resection

Purpose As cardiopulmonary load increases with the amount of lung resected, to perform surgery safely it is important to be able to predict cardiopulmonary insufficiency. However, lung function testing with spirometry and blood gas analysis does not accurately measure cardiopulmonary reserve. We conducted this study to evaluate expired gas analysis during exercise testing for predicting postoperative complications after lung resection.Methods Expired gas analysis during exercise and spirometry were done 1 week preoperatively in 211 patients who underwent pulmonary resection for lung cancer. Patients were divided postoperatively according to whether cardiopulmonary complications were absent (group A) or present (group B).Results In group B there were more men than women (P < 0.01), and the mean age was greater (P < 0.05). There was no difference in disease stage, but more patients underwent pneumonectomy in group B than in group A (P < 0.005). The results of expired gas analysis during exercise testing and of spirometry showed that maximum oxygen uptake/m² (P < 0.0005), anaerobic threshold/m² (P < 0.01), vital capacity (VC)/m² (P < 0.005), %VC (P < 0.0001), forced expiratory volume in 1s (FEV_1.0)/m² (P < 0.0001), and FEV_1.0% (P < 0.05) were lower in group B than in group A.Conclusions The combination of expired gas analysis during exercise and conventional pulmonary function tests identified patients at risk for postoperative cardiopulmonary complications following pulmonary resection.     

Evaluation of p21WAF1/CIP1 and cyclin D1 expression in the progression of superficial bladder cancer

Immunoreactivity of p21^WAF1/CIP1 and cyclin D₁ proteins was assessed in a cohort of 207 patients with superficial (pTa-pT₁) bladder cancer followed up for a mean of 4.9 years. The results of the immunostainings were compared with T category, WHO grade, tumor cell proliferation rate (MIB-1 score), the expressions of p53 and bcl-2 as well as survival. Sixty-eight percent and 75% of the tumors were p21^WAF1/CIP1 positive (≥5% of cells positive) and cyclin D₁ positive (≥10% of cells positive), respectively. The p21^WAF1/CIP1 expression was related to cyclin D₁ immunolabelling (P < 0.001) but not to the other variables studied. The expression of cyclin D₁ was inversely associated with T category (P=0.001), WHO grade (P=0.006), MIB-1 score (P=0.014), p53 expression (P=0.001), and bcl-2 (P=0.011) immunoreactivity. In univariate analysis, T category (P=0.0001), WHO grade (P < 0.0001), MIB-1 score (P < 0.0001), bcl-2 (P=0.0092), p53 (P=0.0016) and p21^WAF1/CIP1 (P=0.009) expressions were significant prognostic factors with regard to tumor progression, whereas cyclin D₁ was without any prognostic significance (P=0.1). Out of 123 p21 positive tumors 21 progressed, whereas only 2 out of 58 p21 negative tumors progressed. In multivariate analysis, the MIB-1 score was the only independent predictor of cancer-specific survival (P=0.03), whereas tumor grade (P=0.002) and cyclin D₁ expression (P=0.04) were independent predictors of tumor recurrence. Only the WHO grade (P=0.04) retained its prognostic value indicating the risk of progression. We suggest that in superficial bladder cancer p21^WAF1/CIP1 and cyclin D₁ immunohistochemistry provide no additional prognostic information compared with already established prognostic factors for predicting the risk of progressive disease. Received: 13 September 1999 / 22 March 2000     

Correlation between epicardial fat and cigarette smoking: CT imaging in patients with metabolic syndrome

Background. The aim of our study was to assess the relationship between cigarette smoking and epicardial fat in a cohort of patients with metabolic syndrome (MetS) at risk for coronary artery disease. Methods. We studied, in primary prevention, 54 subjects diagnosed with MetS. According to their smoking habits, the subjects were divided into two groups: smokers and non-smokers. Besides anthropometric characterization and screening laboratory tests, the subjects had a multidetector computerized tomography scan, which allowed epicardial fat quantification and calcium score (CS) evaluation. Results. Compared with non-smokers, smokers showed older age (61.6 ± 1.8 vs 56.8 ± 1.2 yrs; p < 0.05). Also, the smokers displayed increased epicardial fat volume (138 [123; 150] vs 101[79; 130] ml; p < 0.01) as well as higher CS (94 [3; 301.5] vs 0 [0;10.2]; p < 0.001), in comparison with non-smokers. Notably, CS was positively correlated with smoking habit (r_s 0.469; p < 0.01), epicardial fat (r_s 0.377; p < 0.01), age (r_s 0.502; p < 0.001) and uric acid (r_s 0.498; p < 0.01). Accordingly, the associations between both CS or epicardial fat and cigarette smoking were still maintained after adjustment for age (r 0.317; p < 0.05; r 0.427; p < 0.01). Finally, multiple regression analysis showed that smoke was the variable that best predicted CS (R² 0.131; β 0.362; p < 0.05) and epicardial fat (R² 0.177; β 0.453; p = 0.01). Conclusions. Our findings suggest that, in subjects with MetS, cigarette smoking is an independent predictor of increased epicardial fat volume and higher CS.