Cardiovascular risk factors predictive for survival and morbidity-free survival in the oldest-old Framingham Heart Study participants

OBJECTIVES: To examine whether midlife cardiovascular risk factors predict survival and survival free of major comorbidities to the age of 85. DESIGN: Prospective community-based cohort study. SETTING: Framingham Heart Study, Massachusetts. PARTICIPANTS: Two thousand five hundred thirty-one individuals (1,422 women) who attended at least two examinations between the ages of 40 and 50. MEASUREMENTS: Risk factors were classified at routine examinations performed between the ages of 40 and 50. Stepwise sex-adjusted logistic regression models predicting the outcomes of survival and survival free of morbidity to age 85 were selected from the following risk factors: systolic and diastolic blood pressure, total serum cholesterol, glucose intolerance, cigarette smoking, education, body mass index, physical activity index, pulse pressure, antihypertensive medication, and electrocardiographic left ventricular hypertrophy. RESULTS: More than one-third of the study sample survived to age 85, and 22% of the original study sample survived free of morbidity. Lower midlife blood pressure and total cholesterol levels, absence of glucose intolerance, nonsmoking status, higher educational attainment, and female sex predicted overall and morbidity-free survival. The predicted probability of survival to age 85 fell in the presence of accumulating risk factors: 37% for men with no risk factors to 2% with all five risk factors and 65% for women with no risk factors to 14% with all five risk factors. CONCLUSION: Lower levels of key cardiovascular risk factors in middle age predicted overall survival and major morbidity-free survival to age 85. Recognizing and modifying these factors may delay, if not prevent, age-related morbidity and mortality.     

Determinants of morbidity and survival after elective non-curative resection of stage IV colon and rectal cancer

Purpose  The benefit of elective primary tumor resection for non-curable stage IV colorectal cancer (CRC) remains largely undefined. We wanted to identify risk factors for postoperative complications and short survival. Methods  Using a prospective database, we analyzed potential risk factors in 233 patients, who were electively operated for non-curable stage IV CRC between 1996 and 2002. Patients with recurrent tumors, resectable metastases, emergency operations, and non-resective surgery were excluded. Risk factors for increased postoperative morbidity and limited postoperative survival were identified by multivariate analyses. Results  Patients with colon cancer (CC = 156) and rectal cancer (RC = 77) were comparable with regard to age, sex, comorbidity, American Society of Anesthesiologists score, carcinoembryonic antigen levels, hepatic spread, tumor grade, resection margins, 30-day mortality (CC 5.1%, RC 3.9%) and postoperative chemotherapy. pT4 tumors, carcinomatosis, and non-anatomical resections were more common in colon cancer patients, whereas enterostomies (CC 1.3%, RC 67.5%, p < 0.0001), anastomotic leaks (CC 7.7%, RC 24.2%, p = 0.002), and total surgical complications (CC 19.9%, RC 40.3%, p = 0.001) were more frequent after rectal surgery. Independent determinants of an increased postoperative morbidity were primary rectal cancer, hepatic tumor load >50%, and comorbidity >1 organ. Prognostic factors for limited postoperative survival were hepatic tumor load >50%, pT4 tumors, lymphatic spread, R1–2 resection, and lack of chemotherapy. Conclusions  Palliative resection is associated with a particularly unfavorable outcome in rectal cancer patients presenting with a locally advanced tumor (pT4, expected R2 resection) or an extensive comorbidity, and in all CRC patients who show a hepatic tumor load >50%. For such patients, surgery might be contraindicated unless the tumor is immediately life-threatening. Financial support  Neither one of the authors nor the institutions from which the work originated have asked for, accepted, or received any direct or indirect financial support from a third party regarding the matter and materials discussed in this paper.     

Presenting features and outcome of chronic lymphocytic leukemia patients diagnosed at age 80 years or more. An ICLLSG study

Although the incidence of chronic lymphocytic leukemia (CLL) increases exponentially with age, data on patients 80 years or older at diagnosis are sparse. The records of patients diagnosed with CLL at age ≥80 years at seven medical centers in Israel during 1979–2009 were reviewed. Patients included 118 men and 96 women with a mean age of 84 years (range 80–94). Diagnosis was established in 56.5% due to routine blood count; 56% had Rai stage 0 disease and 25% of the patients received treatment. By June 2010, 72% had died. Mean survival was 67.7 months (median 56 ± 5.4 months) and 5-year survival rate 47.2 ± 3.6%. On univariate analysis, factors associated with better survival were age <84 years (p = 0.002), early Rai and Binet stages (p = 0.023, 0.003), low white blood cell count at time of diagnosis (p = 0.015), low β2 microglobulin level (p = 0.006), diagnosis by routine blood test (p < 0.001), and low CD38 level (p = 0.036). Multivariate analysis using Cox regression revealed that younger age, low white cell count, and diagnosis by routine blood test were independent predictors of good prognosis (hazards ratios 1.8, 1.6, and 1.9, respectively). Patients diagnosed with CLL at age ≥80 years may expect to live a long life. This study identifies several factors predicting good prognosis which are easy to obtain.     

Impact of leukocytosis on thrombotic risk and survival in 532 patients with essential thrombocythemia: a retrospective study

Established risk factors for thrombosis in essential thrombocythemia (ET) include age (≥60 years) and previous vascular events. Recently, also leukocytosis has been proposed in risk stratification of ET patients. We report a retrospective study on 532 ET patients followed for a median of 7.6 years. Sixty-four patients (12%) developed 95 thrombotic events during follow-up. Together with the high-risk condition, a white blood cell (WBC) value above 11 × 10⁹/L, corresponding to the fourth percentile value, significantly correlated with a higher thrombotic risk (p = 0.033) by Cox proportional hazards. Moreover, the cumulative risk of thrombosis was significantly higher in high-risk patients with WBC >11 × 10⁹/L. JAK2 V617F mutation did not correlate with thrombosis. Overall, 123 (23%) patients died. Three independent parameters were noted as prognostic factors for survival in multivariate analysis: age >60 years, leukocytosis >11 × 10⁹/L, and hemoglobin level below normal values. Based on these parameters, three groups of risk were defined, with significantly different survivals. Baseline leukocytosis correlated with a higher thrombotic risk in high-risk patients and identified a cohort of patients with worse survival.     

Thrombosis-free survival and life expectancy in 187 consecutive patients with essential thrombocythemia

 A total of 187 consecutive patients with essential thrombocythemia (ET) were diagnosed and followed by our Hematology Department in the period October 1980–November 1994. The overall follow-up was 773 patient-years. Thrombosis-free survival and overall survival were calculated for the whole cohort; the same parameters were then calculated after arbitrary division of the cohort into two groups, according to the median age at diagnosis (55 years). Fifty percent of the patients had at least one thrombotic episode within 9 years after diagnosis. The thrombosis-free survival curves calculated for patients younger or older than 55 years at diagnosis were comparable. About 85% of the patients were alive 10 years after diagnosis. The survival curves for patients younger and older than 55 years at diagnosis were not significantly different in the observation period, and the observed mortality (seven patients) among patients younger than 55 years at diagnosis was significantly higher than expected (1.68 cases). The relative risk of death was four times greater (SMR=4.17, 95% C.I. 1.6–8.6, p<0.01) than for healthy, age-matched people living in the same area. Age at diagnosis, smoking, sex, hypercholesterolemia, peak number of platelets, hypertension, and diabetes were not significant prognostic cardiovascular risk factors in our cohort. In conclusion, our data show that ET has to be considered a serious disease that significantly decreases both quality of life (expected life without thrombosis) and life expectancy for younger patients. Received: January 7, 1999 / Accepted: June 1, 1999     

Improved survival rate in patients with diabetes and end-stage renal disease in Denmark

Aims/hypothesis We investigated the survival rate of Danish diabetic patients with end-stage renal disease (ESRD) between 1990 and 2005 and evaluated possible predictors of survival rate. Materials and methods Data were obtained from the Danish National Register on Dialysis and Transplantation and from the Scandiatransplant database. Survival rates in different patient groups and association with age, sex, calendar time, waiting-list status and renal transplantation were evaluated using a multivariate Cox regression model. Results During the study period 8,421 patients (13% type 1 diabetic, 9% type 2 diabetic and 78% non-diabetic) started renal replacement therapy. The overall survival rate improved by 15% per five calendar years (hazard ratio [HR]=0.85, 95% CI: 0.81–0.88). The percentage of patients within each group who received renal transplantation was: type 1 diabetic: 26%, type 2 diabetic: 5%, non-diabetic: 24%. The survival rate of transplanted patients with diabetes mellitus (types 1 and 2) compared with non-diabetic patients at 1 year was: 95 vs 93%, at 5 years: 80 vs 85% and at 10 years: 52 vs 71%. Among diabetic patients survival rate was better in transplanted than in waiting-list patients (HR = 0.21, 95% CI 0.13–0.34), whereas the survival rate in waiting-list patients seemed to be superior to the survival rate among non-transplantation candidates (HR = 0.75, 95% CI 0.53–0.1.02, p = 0.07). Conclusions/interpretation The survival rate of diabetic patients with ESRD has improved during the last 15 years. Although some selection bias may exist, significantly improved survival rate was observed among transplanted patients compared with dialysis patients on the waiting-list for transplantation. Renal transplantation should therefore be offered to diabetic patients with ESRD whenever possible.     

Subclinical atherosclerosis and endothelial dysfunction in young South-Asian patients with systemic lupus erythematosus

Patients with systemic lupus erythematosus (SLE), especially Asian Indians, are at increased risk of developing premature atherosclerosis. To find out the prevalence and predictors of carotid intima-medial thickness (IMT) and brachial artery flow-mediated dilatation (FMD). Endothelial dysfunction was assessed by FMD in brachial artery and IMT was measured in common carotid artery in SLE patients and healthy controls. Sixty SLE patients (mean age 31 ± 9 years) and 38 healthy controls (mean age 34 ± 6 years) were included. The IMT was higher in SLE patients as compared to controls (0.49 ± 0.08 mm vs. 0.39 ± 0.05 mm, p < 0.0001). SLE and damage were independent predictors of abnormal IMT. FMD was impaired in SLE patients compared to controls (9.97% vs. 18.97%, p < 0.00001). None of the classical cardiovascular risk factors were predictors of FMD or abnormal IMT. Indian patients with SLE have higher prevalence of subclinical atherosclerosis and endothelial dysfunction. Presence of damage was associated with abnormal IMT in SLE patients.     

Influence of Caregiving on Lifestyle and Psychosocial Risk Factors Among Family Members of Patients Hospitalized with Cardiovascular Disease

Background  Few data have evaluated the relationship between caregiving and cardiovascular disease (CVD) risk. Objective  The purpose of this study was to determine the prevalence and predictors of caregiver strain and to evaluate the association between caregiving and CVD lifestyle and psychosocial risk factors among family members of recently hospitalized CVD patients. Design and Participants  Participants in the NHLBI Family Intervention Trial for Heart Health (FIT Heart) who completed a 6-month follow-up were included in this analysis (n = 263; mean age 50 ± 14 years, 67% female, 29% non-white). Measurements  At 6 months, standardized information was collected regarding depression, social support, and caregiver strain (high caregiver strain = ≥7). Information on lifestyle risk factors, including obesity, physical activity, and diet, were also collected using standardized questionnaires. Logistic regression models on the association between caregiving and CVD risk factors were adjusted for significant confounders. Results  The prevalence of serving as a CVD patient’s primary caregiver or caring for the patient most of the time was 50% at 6 months. Caregivers (primary/most) were more likely to be women (81% vs 19%, p < .01), married/living with someone (p < .01), >50 years old (p < .01), have ≤ high school education (p < .01), be unemployed (p < .01), get less physical activity (p < .01), and have a higher waist circumference (p < .01) than non-caregivers (some/occasional/none). Mean caregiver strain scores were significantly higher among those with depressive symptoms (p < .01) and low social support (p < .01) in a multivariable adjusted model. Conclusions  Caregivers of cardiac patients may be at increased risk themselves for CVD morbidity and mortality compared to non-caregivers due to suboptimal lifestyle and psychosocial risk factors.     

Improved survival in an Asian cohort of young colorectal cancer patients: an analysis of 523 patients from a single institution

Background  Colorectal cancer (CRC) in the young is rare. Outcomes remain varied compared to older populations. The study reviews characteristics and overall survival (OS) of CRC in patients ≤50 years old. Materials and methods  Five hundred and twenty-three (14%) of 3,796 sporadic CRCs were identified. Patients were compared for demographics, tumour characteristics, treatment, and 5-year overall specific survival. Independent prognostic factors were evaluated. Results  The majority were males (54%) with a median age of 45 years (range 19–50 years). Sixty-three percent of the patients presented with advanced stage disease (stage III and IV), and tumours were predominantly left-sided (83%). A higher frequency of mucinous or signet ring cell histological subtypes (16% vs 9%, p = 0.028) as well as poorly differentiated tumours (30% vs 12%, p = 0.0001) were present in younger patients ≤40 years. With a median follow-up of 41 months, the 5-year OS is 58% (95% confidence interval 53–64%). Younger patients ≤40 years had significantly superior 5-year OS of 62% vs 58% in the age group 41–50 years old (p = 0.004). Multivariate analysis identified five independent prognostic features: age group of 41–50 years, poorly differentiated tumour grade, presence of perineural infiltration, high tumour stage, and carcinoembryonic antigen values ≥5 ng/ml. Conclusion  This study has revealed significantly improved 5-year survival in young CRC compared to those reported in the literature.     

Colorectal Surgery in Cirrhotic Patients: Assessment of Operative Morbidity and Mortality

Purpose  The morbidity from colorectal surgery can be high and increases for patients with cirrhosis of the liver. This study was designed to assess morbidity, mortality, and prognostic factors for patients with cirrhosis undergoing colorectal surgery. Methods  From 1993 to 2006, 41 cirrhotic patients underwent 43 colorectal procedures and were included. Both univariate and multivariate analyses were performed to identify variables influencing morbidity and mortality. Results  Postoperative morbidity was 77 percent (33/43). Postoperative mortality was 26 percent (11/43) among whom six patients (54 percent) underwent emergency surgery. Four factors influenced mortality on univariate analysis: presence of peritonitis (P < 0.05), postoperative complications (P < 0.04), postoperative infections (P < 0.01), and total colectomy procedures (P < 0.02). On multivariate analysis, the only factor influencing mortality was postoperative infection (P < 0.04). The only factor influencing morbidity was the existence of preoperative ascites (P < 0.04). Conclusions  Colorectal surgery for cirrhotic patients has a high risk of morbidity and mortality. This risk is associated with the presence of infection, ascitic decompensation, and the urgent or extensive nature of the procedure. The optimization of patients through selection and preparation reduces operative risk.     

Implantable cardioverter defibrillators confer survival benefit in patients with renal insufficiency but not in dialysis-dependent patients

Randomized clinical trials have demonstrated that the implantable cardioverter defibrillator (ICD) reduces mortality in heart failure patients with reduced systolic function but have excluded patients with advanced chronic kidney disease (CKD). We investigated the impact of ICDs on survival in patients with moderate-to-severe CKD, including those requiring dialysis therapy (DT). Patients followed at our institution between 1998 and 2008 with left ventricular ejection fraction (LVEF) ≤35% and CKD, defined as glomerular filtration rate (GFR) <60 mL/min, or who were on DT were identified from the medical record. The primary endpoint of all-cause death was analyzed by ICD status. A total of 78 patients (age = 66±12  years {\hbox{age}} = 66\pm 12\;{\hbox{years}} , 73% men, EF = 0.24±0.07 {\hbox{EF}} = 0.24\pm 0.07 , GFR 39 ± 12 mL/min in those not on DT) of whom 32 had an ICD were followed for 2.7 ± 2.3 years. In the DT (n = 45) cohort, the presence of an ICD did not impact survival. In the CKD with no DT cohort (n = 33), survival was significantly better in patients with an ICD (2-year survival 80% vs. 54%, p = 0.027), and this benefit persisted after adjusting for gender, race, GFR, digoxin use, and presence of coronary disease, heart failure, or hypertension in a multivariate Cox regression model (odd ratio = 0.23, adjusted p = 0.028). Defibrillators improve survival in CKD patients with LVEF ≤ 35%, whereas patients requiring DT do not appear to extract such benefit. Further studies with larger number of patients are required to confirm these findings.     

Ageing of the postural vertical

A postural vertical (PV) tilted backward has been put forward as a reason explaining the backward disequilibrium often observed in elderly fallers. This raises the question of a possible ageing process of the PV involving a backward tilt of verticality perception increasing with age. We have explored this hypothesis by measuring PV in pitch using the wheel paradigm in 87 healthy subjects aged from 20 to 97 years. The possibility that this physiological ageing accelerated in the second part of life was also analysed. Two indices were calculated: the mean orientation (PV-orient) and the dispersion (PV-uncert). The correlation between age and PV-orient was r = −0.2 (p < 0.05). Added to the fact that PV was twice as shifted backward in the 38 seniors over 50 years (−1.15° ± 1.40°) as in the 49 young adults under 50 years (−0.45° ± 0.97°; t = 2.75, p < 0.01), this indicates the existence of a physiological ageing process on the direction perceived as vertical by the whole body, with a slight backward shift of PV throughout the life span. The correlation between age and PV-uncert was r = 0.35 (p < 0.001) in all subjects and r = 0.59 (p < 0.001) in seniors. This indicates that subjects get less and less accurate in their perception of the postural vertical with age, especially very old subjects who show great uncertainty in determining with their body the direction of the vertical. Taken together, these findings indicate that the internal model of verticality is less robust in elderly people. This may play a part in their postural decline.     

Predicting factors of postoperative relapse in T2-4N0M0 colorectal cancer patients via harvesting a minimum of 12 lymph nodes

Background and aim  The aim of this retrospective study was to determine which clinicopathological factors influenced the incidence of postoperative relapse and overall survival rates after radical resection of T_2-4N₀M₀ colorectal cancer (CRC) patients via harvesting a minimum of 12 lymph nodes. Materials and methods  Between January 2001 and June 2006, a total of 342 T_2-4N₀M₀ CRC patients who underwent radical resection were retrospectively analyzed in Kaohsiung Medical University Hospital. Of these 342 patients, 155 were observed by harvesting a minimum of 12 lymph nodes. These 155 patients were followed up intensively, and their outcomes were investigated retrospectively. Results  Of 155 patients, 83 were men (53.5%) and 72 (46.5%) were women. The mean age was 65.5 ± 11.1 years (range, 24–89 years). The median follow-up period was 49 months (range, 19–80 months). The present data showed invasive depth (P = 0.012), vascular invasion (P < 0.001), and perineural invasion (P = 0.009) as significantly prognostic factors for postoperative 5-year relapse rate by Kaplan–Meier analysis. Likewise, invasive depth (P = 0.013), vascular invasion (P < 0.001), and perineural invasion (P = 0.008) were significant factors for postoperative 5-year survival rate. Meanwhile, using a Cox proportional hazards analysis, depth of tumor invasion (P = 0.026) and vascular invasion (P = 0.001) were the independent predictors for postoperative relapse. Furthermore, the presence of vascular invasion was considerably correlated to the higher postoperative relapse rate and the poorer overall survival rates by survival analyses (P < 0.0001). Conclusions  Besides the conventional depth of tumor invasion, this study highlights the potential for using vascular invasion as a means of identifying a subgroup of T_2-4N₀M₀ CRC patients with adequate lymph node harvest at higher risk who would potential benefit from adjuvant therapy after surgery.     

Matched pair analysis of survival after chest-wall recurrence compared to mammary recurrence: a long-term follow up

Background: Local recurrence remains a major concern after primary treatment of breast cancer and has a major impact on subsequent survival. While most studies report a poorer survival rate in patients with a local recurrence after mastectomy than after breast conservation, it remains controversial whether different risk profiles at the time of primary diagnosis may account for this difference. Method: Matched pair analysis of 134 patients with newly diagnosed locoregional recurrence of breast cancer without evidence of systemic disease. Matching criteria included the primary surgical treatment, tumor size, nodal status, and age. The significance of various prognostic parameters at the time of primary diagnosis and at the time of recurrence were evaluated, by univariate and multivariate analyses, with respect to survival after recurrence. The median follow-up was 8.4 years. Results: Risk factors at the time of presentation, such as tumor size and lymph node status, were comparable between both groups. Local recurrence occurred on an average 9 months earlier in patients after mastectomy (P=0.08). Univariate analysis showed that lymph node status (P=0.0001) and disease-free interval from primary treatment to local recurrence (P=0.0002) were the most significant single prognostic factors for subsequent survival after local recurrence. The primary surgical treatment modality was shown to be of marginal statistical influence (only P=0.05). Conclusion: Local recurrence after mastectomy seems to be associated with worse survival than after breast-conserving therapy. Early onset of chest-wall recurrence, moreover, represents the highest independent risk for cancer-associated death. Received: 22 November 2000 / Accepted: 3 January 2001     

Medium- and long-term survival after pacemaker implant: Improved survival with right ventricular outflow tract pacing

Introduction Long-term prognosis after pacemaker implant depends on numerous variables, particularly structural heart disease. There is evidence that apical stimulation could favor the development of heart failure and, therefore, influence mortality. Other right ventricular pacing sites have been studied, for example the outflow tract, but no reports regarding long-term clinical outcome are available. Objective Compare all-cause mortality between two different sites of stimulation in the right ventricle. Methods We retrospectively analyzed 150 consecutive patients who underwent pacemaker implantation because of complete AV block (spontaneous or after AV node ablation), symptomatic second-degree AV block, and symptomatic atrial fibrillation with slow ventricular response. All patients were implanted at the same institution with the standard technique. Apical stimulation was performed with a passive or active fixation lead and outflow tract pacing with an active fixation lead. Data collection period began in July 1999 and ended on December 2004. All patients included were greater than 70% ventricular paced during pacemaker follow-up. Patients older than 85 years were excluded from the analysis. Age, pacemaker mode, sex, ejection fraction, diabetes, and structural cardiac disease were analyzed. Mean age was 72 ± 7 years (median 74 years, range 27–85 years), 101 (67%) were male, 56 had implanted a VVI PM, and 94 patients a DDD PM. Patients were divided into two groups: outflow tract (55 patients) and apical pacing (95 patients). Mean follow-up was 1,231 ± 642 days (median 1,158 days, range 9 to 2,694 days), which ended on July 2007. Total mortality was examined with the Kaplan–Meier method to construct overall survival curves. Multivariate Cox proportional hazards regression models were performed. Results All patients or relatives were contacted personally or by phone. There were no major statistical differences in patient background between the two groups. During follow-up, 18 patients (32%) died in the outflow tract group and 49 (51%) in the apical group (log-rank p = 0.02). Cox regression multivariate analysis showed that outflow tract pacing and a low left ventricular ejection fraction (<40%) were the only independent variables with significant correlation with survival (p = 0.006 and 0.003, respectively). Conclusions Outflow tract pacing appears to improve medium- and long-term survival. Prospective randomized trials with a greater amount of patients are necessary to confirm the findings of this study.     

Pulmonary resection for metastases from colorectal cancer: prognostic factors and survival

Backgrounds Pulmonary metastases occur in up to 10% of all patients who undergo curative resection. Surgical resection is an important part in the treatment of pulmonary metastasis from colorectal cancer. We analyzed the treatment outcome and prognostic factors affecting survival in this subset of patients. Materials and methods Between October 1994 and December 2004, 59 patients underwent curative resection for pulmonary metastases of colorectal cancer. Uncontrollable synchronous liver and lung metastasis or synchronous colorectal cancer with isolated lung metastasis were excluded from this study. A retrospective review of patient characteristics and factors influencing survival was performed. Survival was analyzed by the Kaplan–Meier method. Comparison between groups were performed by a log-rank analysis and the Cox proportional hazard model. Results The 5-year overall survival rate of all patients who received pulmonary resection was 50.3%. The number of pulmonary metastases was significantly related with survival in univariate analysis, but not in multivariate analysis (p = 0.032). Prethoracotomy carcinoembryonic antigen (CEA) level exceeding 5 ng/ml was related with poor survival (p = 0.001). A disease-free interval of greater than 2 years did not correlate with survival after thoracotomy (p = 0.3). Conclusion The prethoracotomy CEA level and the number of metastases were independent prognostic factors. Resection of pulmonary metastasis from colorectal cancer may result in improved survival or even healing in selected patients. Pulmonary resection of colorectal cancer is regarded as a safe and effective treatment with low morbidity and mortality rates.     

Risk Factors and Oncologic Impact of Anastomotic Leakage after Rectal Cancer Surgery

Purpose  The impact of anastomotic leakage on the long-term oncologic outcome is not clear. This retrospective study evaluated risk factors and oncologic impacts of anastomotic leakage after rectal cancer surgery. Methods  Data were analyzed from 1,391 patients who underwent sphincter preservation for rectal cancer between January 1997 and August 2003. Operations were classified as anterior resection (n = 164), low anterior resection (n = 898), or ultralow anterior resection (n = 329). Results  The anastomotic leakage rate was 2.5 percent. Multivariate analysis identified male (hazard ratio, 3.03), old age (hazard ratio, 2.42), and lower anastomosis level (hazard ratio, 2.68) as risk factors for leakage. The local recurrence rates were 9.6 and 2.2 percent for the leakage and nonleakage groups, respectively but were not significant (P = 0.14). The overall five-year survival rates were 55.1 and 74.1 percent in the leakage and nonleakage groups, respectively (P < 0.05), and the cancer-specific survival rates were 63 and 78.3 percent in the leakage and nonleakage groups, respectively (P = 0.05). However, in subgroup analysis, significant differences were identified only in Stage III patients. Conclusions  Age, sex, and ultralow anterior resection were found to be risk factors for anastomotic leakage after rectal cancer surgery. In addition, leakage was associated with poor survival. Poster presentation at the meeting of The American Society Colon and Rectal Surgeons, Seattle Washington, June 3 to 7, 2006.     

Severe systemic lupus erythematosus in emergency department: a retrospective single-center study from China

This study describes the characteristics of severe systemic lupus erythematosus (SLE) patients who visited the emergency department of the Shanghai Renji Hospital, and the aim is to identify the causes, the outcome, and the prognostic factors. SLE patients who visited the emergency department between January 2007 and August 2010, and who were subsequently hospitalized or who died in emergency department, were included in this retrospective study. Of the total 131 SLE emergency events, overall mortality was 16.8%. Older age (≥45 years), longer duration of disease, presence of pulmonary hypertension, renal insufficiency, and invasive infections are risk factors. Higher organ damage index (SLICC, 3.86 ± 2.14 vs. 0.93 ± 1.14, p < 0.001) but relatively lower disease activity (SLEDAI, 11.5 ± 7.7 vs. 16.5 ± 9.0, p = 0.015) were the characteristics of the deceased when compared with the survivors. Recent-onset (duration of disease ≤3 months) SLE accounts for 32.1% of the patients in emergency, and this group showed a distinctive pattern of younger age with higher frequencies of neuropsychiatric and hematologic manifestations. A good short-term outcome with a 95.2% survival rate can be observed in such patients. Older age, longer disease duration and cumulative damage of vital organs determine the short-term outcome of severe SLE in the emergency department. Recognizing disease patterns and objective prognostic parameters may help physicians to provide better care, based on a risk-fitted approach, for the SLE patients in emergencies.     

Major liver resections in the elderly—is an aggressive approach justified?

Background and aims  As the mean life expectancy rises, the incidence of patients 75 years of age and older who present with colorectal liver metastases continues to increase. The purpose of our study was to evaluate the outcome of major hepatic resections in the elderly population. Patient and methods  From April 1998 to December 2006, 572 consecutive patients with colorectal liver metastases were treated at our Institution. Of these, 59 were 75 years or older. There was an intent to proceed with major liver resections in all cases. Data were analyzed according to diagnosis, comorbidities, extent of liver resection, postoperative complications, overall survival, and disease-free survival. Results  Surgical treatment included right hepatectomies (n = 8), left hepatectomies (n = 4), and sectionectomies (more than three segments; n = 33). Fourteen (n = 14) patients received an explorative laparotomy alone. Morbidity and hospital mortality were 10% and 3%, respectively. Overall survival of 1, 3, and 5 years was 90%, 64%, and 33%, respectively. The corresponding disease-free survival was 74%, 42%, and 32%. Resection margin (R class) was the only predictor of survival by both uni- and multivariate analyses. Conclusion  Hepatic resections can be performed safely in selected patients 75 years of age or older.     

Autologous hematopoietic stem cell transplantation—what determines the outcome: an experience from North India

Limited information is available from developing countries about complications, pattern of infections, and long-term outcome of patients following high-dose chemotherapy (HDCT) and autologous blood stem cell transplantation (ASCT). Between April, 1990 and December 2009, 228 patients underwent ASCT. Patients’ median age was 48 years, ranging from 11 to 68 years. There were 158 males and 70 females. Indications for transplant included multiple myeloma, n = 143; lymphoma, n = 44 (Hodgkin’s, n = 25 and non-Hodgkin’s, n = 19); leukemia, n = 22; and solid tumors, n = 18. Patients received HDCT as per standard protocols. Following ASCT, 175 (76.7%) patients responded; complete, 98 (43%); very good partial response, 37 (16.2%); and partial response, 40 (17.5%). Response rate was higher for patients with good Eastern Cooperative Oncology Group (ECOG) performance status (0–2 vs. 3–4, p < 0.001), pretransplant chemo-sensitive disease (p < 0.001) and those with diagnosis of hematological malignancies (p < 0.003). Mucositis, gastrointestinal, renal, and liver dysfunctions were major nonhematologic toxicities, 3.1% of patients died of regimen-related toxicities. Infections accounted for 5.3% of deaths seen before day 30. At a median follow-up of 66 months (range, 9–234 months), median overall (OS) and event-free survival (EFS) were 72 months (95% CI 52.4–91.6) and 24 months (95% CI 17.15–30.9), respectively. For myeloma, OS and EFS were 79 months (95% CI 52.3–105.7) and 30 months (95% CI 22.6–37.4), respectively. Pretransplant good performance status and achievement of significant response following transplant were major predictors of survival. Our analysis demonstrates that such procedure can be successfully performed in a developing country with results comparable to developed countries.