Outcomes After Liver Transplant in Patients Aged 70 Years or Older Compared With Those Younger Than 60 Years

OBJECTIVE: To compare mortality, graft loss, and postoperative complications after liver transplant in older patients (≥70 years) with those in younger patients (<60 years).PATIENTS AND METHODS: Outcomes for 42 patients aged 70 years or older who underwent liver transplant were compared with those of 42 matched controls younger than 60 years. All patients underwent transplants between March 19, 1998, and May 7, 2004. Information was collected on patient characteristics, comorbid conditions, laboratory results, donor and operative variables, medical and surgical complications, and mortality and graft loss.RESULTS: Preoperative characteristics were similar across age groups, except for creatinine (P=.01) and serum albumin (P=.03) values, which were higher in older patients, and an earlier year of transplant in younger patients (P<.001). Intraoperatively, older patients required more erythrocyte transfusions (P=.04) and more intraoperative fluids (P=.001) than did younger patients. Postoperatively, bilirubin level (P=.007) and international normalized ratios (P=.01) were lower in older patients, whereas albumin level was higher (P<.001). The median follow-up was 5.1 years (range, 0.1-8.5 years). Compared with younger patients, older patients were not at an increased risk of death (relative risk, 1.00; 95% confidence interval, 0.43-2.31; P>.99) or graft loss (relative risk, 1.17; 95% confidence interval, 0.54-2.52; P=.70). The frequency of other complications did not differ significantly between age groups, although older patients had more cardiovascular complications.CONCLUSION: Five-year mortality and graft loss in older recipients were comparable with those in younger recipients, suggesting that age alone should not exclude older patients from liver transplant.CI = confidence interval; LT = liver transplant; MELD = model for end-stage liver disease; RR = relative riskImproved patient and allograft survival after liver transplant (LT) reflects advances in surgical techniques, anesthesia, critical care, and infection control, as well as the development of targeted, potent immunosuppressants.¹ This success has expanded the pool of transplant recipients to include persons previously considered ineligible because of advanced age and comorbid conditions. In addition, the relative percentage of people in older age groups is increasing more rapidly than that of the other groups in the population; by the year 2030, the percentage of the population aged 75 years and older is estimated to increase from 6% to 9% and will continue to increase to 12% by 2050. More people will reach older age in better health than in previous generations.² Consequently, more elderly patients with liver failure might be considered candidates for LT. These developments will compound the relative shortage of donated organs and raise concern about the benefits of LT for older recipients. As decisions about organ allocation are made, they should be informed by outcomes data after LT.Outcomes of LT in elderly patients vary.^3-15 Most single-center case series for LT in recipients older than 60 years have reported overall success.^3-8 Three centers reported no difference in morbidity or mortality among LT recipients older than 70 years.^9-11 However, some studies have identified prolonged hospital stays and increased mortality after transplant in patients older than 60 years.^12-16 One study that showed no difference in short-term outcome found lower 5-year survival rates in patients older than 60 years.¹⁷Thus, the debate about the proper use of organs for LT based on age is ongoing.^18-22 To address this issue in our transplant center, we compared graft loss and mortality after LT in patients aged 70 years or older with those in patients younger than 60 years. We also compared other postoperative complications, length of overall hospital stay, length of intensive care unit stay, and readmissions in these 2 groups of patients.     

Analysis of Chemotherapy Dosage and Dosage Intensity and Survival Outcomes of High-Grade Osteosarcoma Patients Younger Than 40 Years

Background

Chemotherapy is essential for long-term survival of osteosarcoma patients. However, the impact of dosage and dosage intensity (DI) of chemotherapeutic agents on patients with high-grade osteosarcoma is largely unknown.

Objective

The object of this study was to evaluate the influence of these dosage-related variables on treatment outcomes in terms of event-free survival (EFS).

Methods

PubMed was searched for relevant English-language articles. Two reviewers extracted data independently. Sufficient data were presented to calculate the planned total dosage and DI for doxorubicin, cisplatin, ifosfamide, and methotrexate. Univariate analysis and partial regression analysis were performed to determine the association of 5-year EFS and the planned total dosage and DI of each drug.

Results

Seventeen studies comprising 23 trial arms met the inclusion criteria. The analysis recruited a total of 2257 patients. The study period ranged from 1976 to 2006. Using univariate analysis, the planned dosage and DI of methotrexate and ifosfamide correlated with better 5-year EFS (P = 0.001 for methotrexate dosage; P = 0.030 for ifosfamide dosage; P < 0.001 for methotrexate DI; and P = 0.033 for ifosfamide DI). There was a trend toward worse 5-year EFS with increase of doxorubicin DI (P = 0.055). Based on the partial regression analysis, the association of doxorubicin DI and ifosfamide dosage and DI with EFS became no longer statistically significant, and the planned total dosage and DI of methotrexate remained significantly correlated with better 5-year EFS (P = 0.001 and P = 0.004, respectively).

Conclusions

We observed a correlation of higher planned methotrexate total dosage and DI with better treatment outcomes in osteosarcoma patients. The present study showed that methotrexate dosage and DI were important predictors of the clinical outcomes and provided the rationale of high-dosage methotrexate in the context of multi-agent chemotherapy.     

60岁以上晚期非小细胞肺癌患者生存预后的危险因素分析

目的:分析60岁以上未手术晚期非小细胞肺癌(non-small cell lung cancer,NSCLC)患者的生存数据,探讨影响其预后的危险因素.方法:回顾分析上海交通大学附属胸科医院2003年1月-2005年12月收治的60岁以上未手术的晚期NSCLC患者296例,按年龄分4组,分别为60～64岁组(n=66)、65～69岁组(n=93),70～74岁组(n=89)及75岁以上组n=48,分析4组患者的临床特征及治疗情况对预后的影响.结果:296例患者中,73.0％为男性患者,50.3％病理类型为腺癌.中位生存期为13.2个月,患者1年、2年、3年的生存率分别为53.0％、22.0％、4.0％,4组患者的生存率及中位生存期总体上差异无统计学意义(P=0.32).单因素分析结果显示,患者性别、吸烟史、病理类型、临床分期及PS评分等因素在4组中的分布差异无统计学意义,而合并慢性疾病及是否化疗在4组中的分布差异有统计学意义(P＜0.01).偏相关控制分析表明,是否合并慢性疾病与年龄之间(r1=0.1916,P＜0.01)、是否化疗与年龄之间(,=-0.2550,P＜0.01)、是否接受化疗与是否合并慢性疾病之间存在显著的相关性(r3=-0.2003,P＜0.01).Cox多因素分析显示,患者的性别、病理类型、临床分期、化疗前PS评分是影响患者生存预后的危险因素,男性、病理分期为Ⅳ期、PS评分≥2分者的预后较差,而腺癌患者预后较好.结论:性别、临床分期、PS评分及组织学类型是影响60岁以上未手术晚期NSCLC患者生存预后的独立危险因素.     

Abnormal Atrioventricular Node Conduction and Atrioventricular Nodal Reentrant Tachycardia in Patients Older Versus Younger Than 65 Years of Age

Study Objective: We examined the possible role of atrioventricular node (AVN) conduction abnormalities as a cause of AVN reentrant tachycardia (RT) in patients >65 years of age.
Study Population: Slow pathway radiofrequency catheter ablation (RFCA) was performed in 104 patients. Patients in group 1 (n = 14) were >65 years of age and had AV conduction abnormalities associated with structural heart disease. Patients in group 2 (n = 90) were <65 years of age and had lone AVNRT.
Results: Patients in group 1 versus group 2 (66% vs. 46% men) had a first episode of tachycardia at an older age than in group 2 (68 ± 16.8 vs 32.5 ± 18.8 years, P = 0.007). The history of arrhythmia was shorter in group 1 (5.4 ± 3.8 vs 17.5 ± 14, P = 0.05) and was associated with a higher proportion of patients with underlying heart disease than in group 2 (79% vs 3%, P < 0.001). The electrophysiological measurements were significantly shorter in group 2: atrial-His interval (74 ± 17 vs 144 ± 44 ms, P = 0.005), His-ventricular (HV) interval (41 ± 5 vs 57 ± 7 ms, P = 0.001), Wenckebach cycle length (329 ± 38 vs 436 ± 90 ms, P = 0.001), slow pathway effective refractory period (268 ± 7 vs 344 ± 94 ms, P = 0.005), and tachycardia cycle length (332 ± 53 vs 426 ± 56 ms, P = 0.001). The ventriculoatrial block cycle length was similar in both groups. The immediate procedural success rate was 100% in both groups, and no complication was observed in either group. One patient in group 2 had recurrence of AVNRT. One patient with a 98-ms HV interval underwent permanent VVI pacemaker implantation before RFCA procedure.
Conclusion: In patients undergoing RFCA for AVNRT at >65 years of age had a shorter history of tachycardia-related symptoms than patients with lone AVNRT. The longer AVN conduction intervals and refractory period might explain the late development of AVNRT in group 1.     

The Association Between Benzodiazepines and Survival in Patients With Cancer: A Systematic Review

Context

Patients with cancer often experience distressing symptoms such as anxiety or dyspnea, which can be managed with benzodiazepines; however, concerns regarding the impact of these drugs on survival may dissuade prescribing and compliance.

3023 Mayo Clinic Patients With Myeloproliferative Neoplasms: Risk-Stratified Comparison of Survival and Outcomes Data Among Disease Subgroups

Objective

To document the Mayo Clinic decades-long experience with myeloproliferative neoplasms (MPNs) and provide mature risk-stratified survival data and disease complication estimates.

Routine Invasive Versus Selective Invasive Strategy in Elderly Patients Older Than 75 Years With Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

Objective

To evaluate outcomes of routine invasive strategy (RIS) compared with selective invasive strategy (SIS) in elderly patients older than 75 years with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

Survival in 1,431 Pacemaker Patients: Prognostic Factors and Comparison With the General Population

A total of 1,431 patients (mean age 63.4 +/- 14.1) with pacemakers (96.2% VVI) primoimplanted between 1967 and 1985 were followed for a mean duration of 78.2 +/- 40 pacing months, with 0.6% loss to follow-up. Cumulative survival for 1, 3, and 10 years was 0.9427, 0.9136, and 0.7536, respectively. There was no significant difference in survival between atrioventricular block (AVB) and sick sinus syndrome (SSS) patients. In addition to age and gender, factors existent prior to implantation that independently affected prognosis included manifest coronary heart disease (CHD), congenital/acquired heart lesions, heart failure, noncardiac internal disease, syncope, and generalized fatigue. After implantation, the most important factor was generalized fatigue, then age, stroke, myocardial infarct (MI), gender (male), heart failure, and syncope. Patients with no underlying disease showed an extremely high cumulative survival (0.9173 at 10 years). Compared to the general population of Yugoslavia, the pacemaker patients showed a similar yearly mortality rate until 1981. After that, elderly males (70+) had a significantly lower yearly mortality than the matched population. Thus, in this large series of pacemaker patients followed into the most recent period with an extremely low loss to follow-up, short- and long-term survival was very high. Pacemaker patients of any age who are otherwise in good health have an excellent prognosis.     

Sex Differences in All-Cause and Cardiovascular Mortality,Hospitalization for Individuals With and Without Diabetes,and Patients With Diabetes Diagnosed Early and Late

OBJECTIVE

To compare risk of all-cause mortality, cardiovascular disease (CVD) mortality, acute myocardial infarction (AMI) mortality, stroke mortality, and hospitalizations for males and females with and without diabetes and those with diabetes diagnosed early and late.

RESEARCH DESIGN AND METHODS

We conducted a population-based retrospective cohort study including 73,783 individuals aged 25 years or older in Newfoundland and Labrador, Canada (15,152 with diabetes; 9,517 with late diagnoses).

RESULTS

Males and females with diabetes had an increased risk of all-cause mortality, CVD mortality, AMI mortality, and CVD hospitalizations compared with individuals without diabetes, and the risk was stronger in females than in males. For females, risks of all-cause mortality (hazard ratio [HR] 1.85 [95% CI 1.74–1.96]) and CVD hospitalizations (2.57 [2.24–2.94]) were significantly higher compared with their male counterparts (1.59 [1.51–1.69] and 1.92 [1.72–2.14]). Females with diabetes diagnosed late had an increased risk of CVD mortality (6.54 [4.80–8.91]) and CVD hospitalizations (5.22 [4.31–6.33]) compared with females without diabetes, and both were significantly higher compared with their male counterparts (3.44 [2.47–4.79]) and (3.33 [2.80–3.95]).

CONCLUSIONS

Females with diabetes have a greater risk of mortality than males with diabetes. CVD has a greater impact on females with diabetes than males, especially when diagnosed at a later stage. Different management strategies should be considered for males and females and those with early and late diagnoses of diabetes.Diabetes has become a health problem of increasing significance in the past two decades. The number of individuals with diabetes will reach 366 million in 2011 and will increase to 552 million by 2030 (1). In Canada, the age-standardized incidence and prevalence of diabetes have been increasing in recent years (2).A challenge with type 2 diabetes is the late diagnosis of the disease because many individuals who meet the criteria are often asymptomatic. Approximately 183 million people, or half of those who have diabetes, are unaware they have the disease (1). Furthermore, type 2 diabetes can be present for 9 to 12 years before being diagnosed and, as a result, complications are often present at the time of diagnosis (3). Insulin resistance and β-cell dysfunction are largely responsible for the development of diabetes and its related complications, and both are present very early in the natural history of diabetes (4). However, the potential does exist to prevent or at least delay the onset of type 2 diabetes because several randomized control trials have shown that both lifestyle and pharmacologic interventions in adults are effective (5–8). In addition to preventing diabetes, it is also possible to reduce diabetes-related complications through intensive blood glucose control. Results from the UK Prospective Diabetes Study (UKPDS) have shown that intensive blood glucose control reduces diabetes-related complications (6–9). Early detection of type 2 diabetes is critical because effective and active management is essential for those with newly diagnosed diabetes who have not developed complications.Cardiovascular disease (CVD) is the most common comorbidity associated with diabetes, and with 50% of those with diabetes dying of CVD it is the most common cause of death (1). Acute myocardial infarction (AMI) and stroke are other common comorbidities associated with diabetes. Individuals with diabetes have an increased risk of all-cause mortality and morbidity related to CVD, AMI, and stroke compared with individuals without diabetes (9–12). Although studies consistently have found that individuals with diabetes have a higher risk of mortality and hospitalizations compared with those without diabetes, results have been inconsistent when comparing males and females. Most studies have found that females with diabetes have a greater risk of mortality and hospitalizations than males with diabetes (9,10,12–17). Two previous meta-analyses found that diabetes is a stronger risk factor for CVD mortality in females than in males; however, studies that did not adjust for major CVD risk factors were included in these meta-analyses (18,19). A meta-analysis conducted by Kanaya et al. (20), which included studies that controlled for CVD risk factors, found that the risks associated with diabetes for coronary heart disease mortality, nonfatal myocardial infarction, and CVD were higher among females than males. However, the differences were not statistically significant.Newfoundland and Labrador has the highest age-standardized prevalence of diabetes in Canada (2), and the age-standardized mortality and hospitalization rates for CVD, AMI, and stroke are some of the highest in the country (21,22). A better understanding of mortality and hospitalizations associated with diabetes for males and females is important to support diabetes prevention and management. Therefore, the objectives of this study were to compare the risk of all-cause, CVD, AMI, and stroke mortality and hospitalizations for males and females with and without diabetes and those with early and late diagnoses of diabetes.     

Long-Term Survival and Complications in Patients With Malignant Ventricular Tachyarrhythmias: Treatment With a Nonthoracotomy Implantable Cardioverter Defibrillator With or Without a Subcutaneous Patch

The Endotak lead system and ICD has been used to treat patients with malignant ventricular arrhythmias. We analyzed The clinical characteristics of 1,053 patients who underwent implantation of The Endotak lead system with or without a subcutaneous patch. Group A consisted of 567 patients receiving The Endotak lead with a subcutaneous patch: group B consisted of 486 patients receiving The Endotak lead alone. The 2-year survivals from sudden death, cardiac death, and total death in groups A and B were 97.6%/98.2% (P = 0.38), 88.6%/92.7% (P = 0.09), and 84.7%/86.8% (P = 0.06). respectively. Minimum tested effective defibrillation energy at implantation was 17.2 ± 5.2 J for group A and 15.8 ±5.1 J for group B (P < 0.01). The operative mortality was 1.8% in group A and 0.6% in group B (P = 0.09). The incidence of lead dislodgment, malfunction, and infection was 6,7% for group A and 3.5% for group B (P < 0,01), Sudden death survival was excellent in both groups with less lead complications in group B. The Endotak lead alone may be The preferred choice of lead configuration in those patients who have adequate defibrillation thresholds at implant. (PACE 1997: 20[Pt. I]:1305-1311)     

The Association Between Autonomic Dysfunction and Survival in Male Patients with Advanced Cancer: A Preliminary Report

ContextAutonomic nervous system dysfunction (AD) is a common syndrome in patients with advanced cancer. It is associated with decreased survival in several patient populations, including diabetes mellitus, heart failure, and neurological diseases. Based on this evidence, we hypothesized that autonomic dysfunction is associated with decreased survival in patients with advanced cancer.ObjectivesThe objective of this preliminary study was to test the association between AD, as measured by the standardized Ewing test and heart rate variability (HRV) measures, and survival in this patient population.MethodsWe examined the relationship between survival and parameters of AD in subjects who participated in a prospective study of autonomic dysfunction and hypogonadism in male patients with advanced cancer. Eligibility criteria were defined based on the prospective study protocol. We collected demographic information, date of death (obtained from the online Social Security Death Index database), date of study entry, and Ewing and HRV scores. We defined survival as the interval between study entry and date of death. A survival analysis was used to test the association between survival (in days) and Ewing test (0–5) and measures of HRV, including time domain (standard deviation of normal to normal beat interval [SDNN]) and frequency domain (ultra low, very low, low, and high). Four patients were still alive at the time of this study and included in the survival analysis as being censored.ResultsForty-seven male patients were included in this study. Median age was 59 years (range: 20–79), and 30 out of 47 (63%) were Caucasians. AD, defined as Ewing score greater than 2, was present in 38 out of 47 (80%) of the patients. Median Ewing score was 3 (1–5), indicating moderate to severe AD. Spearman correlation for Ewing score and SDNN was 0.44 (P = 0.002). There was a significant association between abnormal Ewing score and survival (P < 0.0001) and abnormal SDNN HRV and survival (P = 0.056).ConclusionAD is associated with shorter survival in male patients with advanced cancer. Further longitudinal research in a large cohort is justified based on.     

Alcohol Abstinence and the Risk of Atrial Fibrillation in Patients With Newly Diagnosed Type 2 Diabetes Mellitus: A Nationwide Population-Based Study

OBJECTIVETo investigate the effects of alcohol abstinence on prevention of new-onset atrial fibrillation (AF) in patients with type 2 diabetes mellitus (T2DM).RESEARCH DESIGN AND METHODSA total of 1,112,682 patients newly diagnosed with T2DM between 2011 and 2014 were identified from the Korean National Health Insurance Service database. After excluding those with a history of AF, 175,100 patients were included. The primary outcome was new-onset AF.RESULTSDuring a mean follow-up of 4.0 years, AF occurred in 4,174 patients. Those with heavy alcohol consumption (alcohol intake ≥40 g/day) before T2DM diagnosis had a higher risk of AF (adjusted hazard ratio [aHR] 1.22; 95% CI 1.06–1.41) compared with patients with no alcohol consumption. After T2DM diagnosis, those with moderate to heavy alcohol consumption (alcohol intake ≥20 g/day) who abstained from alcohol had a lower risk of AF (aHR 0.81; 95% CI 0.68–0.97) compared with constant drinkers. Alcohol abstinence showed consistent trends toward lower incident AF in all subgroups and was statistically significant in men (aHR 0.80; 95% CI 0.67–0.96), those aged >65 years (aHR 0.69; 95% CI 0.52–0.91), those with CHA₂DS₂-VASc score <3 points (aHR 0.71; 95% CI 0.59–0.86), noninsulin users (aHR 0.77; 95% CI 0.63–0.94), and those with BMI <25 kg/m² (aHR 0.68; 95% CI 0.53–0.88).CONCLUSIONSIn patients with newly diagnosed T2DM, alcohol abstinence was associated with a low risk of AF development. Lifestyle modifications, such as alcohol abstinence, in patients newly diagnosed with T2DM should be recommended to reduce the risk of AF.     

Association Between the Swallowing Reflex and the Incidence of Aspiration Pneumonia in Patients With Dysphagia Admitted to Long-term Care Wards: A Prospective Cohort Study of 60 Days

ObjectiveTo investigate the association between the Simple Swallowing Provocation Test (SSPT) and the incidence of aspiration pneumonia in patients with dysphagia in long-term care (LTC) wards.DesignThe study design was a prospective cohort study. Participants were followed for 60 days from admission.SettingLTC wards.ParticipantsStudy participants were patients with dysphagia aged ≥65 years who were admitted to LTC wards between August 2018 and August 2019. In total, 39 participants were included in the analysis (N=39; 20 male, 19 female; mean age, 83.8±8.5y). Participants were divided into 2 groups based on SSPT results: normal swallowing reflex (SSPT normal group) and abnormal swallowing reflex (SSPT abnormal group). The covariates were age and sex, primary disease, history of cerebrovascular disease, Glasgow Coma Scale, body mass index, Geriatric Nutritional Risk Index, the Mann Assessment of Swallowing Ability, Food Intake Level Scale, FIM, and Oral Health Assessment Tool.InterventionsNot applicable.Main Outcome MeasuresThe outcome was the incidence of aspiration pneumonia during the first 60 days of hospitalization, and the predictive factor was SSPT: 0.4 mL.ResultsThe incidence of aspiration pneumonia was 33.3% in the SSPT normal group and 76.2% in the SSPT abnormal group. The φ coefficient (a measure of association for 2 binary variables) was 0.43, the risk ratio (the ratio of the probability of an outcome in an exposed group to the probability of an outcome in an unexposed group) was 2.29, and the 95% confidence interval was 1.14-4.58 for the SSPT abnormal group.ConclusionsOur findings suggest that the SSPT provides a valid index for the development of aspiration pneumonia in older patients with dysphagia admitted to LTC wards.     

Diagnosed,Identified, Current and Complete Depression Among Patients Attending Primary Care in Southern Catalonia: Different Aspects of the Same Concept

The aims of this study were to explore the prevalence and the conceptualizations of depression detected by the healthcare system, identified by the patient or classified/identified in the validated Goldberg's questionnaire in a community. We conducted a cross-sectional evaluation of 317 patients. The different types of depression diagnosed, identified, current or total were stratified by age and gender groups. The difference in the conceptualization of depression from the medical or ordinary people point of view indicate that depression care requires the understanding of the lifestyle, beliefs, attitudes, family and social networks of the people the physicians and nurses care for.