Does diabetes mellitus influence the perioperative outcome or long term prognosis after resection of hepatocellular carcinoma?

OBJECTIVE: This study aims to evaluate whether diabetes mellitus has a significant influence on the perioperative outcome or long term prognosis after resection of hepatocellular carcinoma (HCC). METHODS: The clinicopathological data and postoperative morbidity and mortality of 62 diabetic and 463 nondiabetic patients who underwent resection of HCC between 1989 and 2000 were compared. The long term overall and disease-free survival results were also compared, and the prognostic impact of diabetes mellitus was assessed by multivariate analysis. RESULTS: The diabetic and nondiabetic groups were comparable in terms of the frequency of cirrhosis, liver function, type of resection, and tumor factors such as size and pTNM stage. Overall complication rate (38.7% vs 37.1%, p = 0.820), 30-day mortality (3.2% vs 3.0%, p = 0.583), and hospital mortality (6.4% vs 6.0%, p = 0.782) were similar in diabetic and nondiabetic patients. There was no significant difference in the overall survival (median = 43.5 vs 43.2 months, p = 0.438) or disease-free survival (median = 18.2 vs 15.0 months, p = 0.418). On multivariate analysis, only tumor pTNM stage, operative blood loss, and preoperative indocyanine green retention at 15 min were significant predictors of overall survival. Tumor pTNM stage, size, and operative blood loss were significant predictors of disease-free survival. CONCLUSIONS: This study indicates that diabetes mellitus does not increase the perioperative morbidity or mortality after resection of HCC, nor does it significantly influence the long term prognosis. Based on the current study data, diabetes mellitus should not be considered an unfavorable factor in the selection of patients for resection of HCC.     

Hepatic resection for elderly patients with hepatocellular carcinoma: a systematic review of more than 17,000 patients

ABSTRACT

Background: With the aging population and increasing incidence of hepatic malignancies in elderly patients, establishing the safety and efficacy of hepatic resection for elderly patients with hepatocellular carcinoma (HCC) is crucial. The present systematic review investigates postoperative morbidity, hospital mortality, median survival time, overall and disease-free survival in elderly patients with undergoing hepatic resection.

Methods: Some databases were systematically searched for prospective or retrospective studies to reveal the safety and efficacy of hepatic resection for elderly patients with primary HCC.

Results: Fifty studies involving 4,169 elderly patients and 13,158 young patients with HCC were included into analyses. Elderly group patients had similar rate of median postoperative morbidity (28.2% vs. 29.6%) but higher mortality (3.0% vs. 1.2%) with young group patients. Moreover, elderly group patients had slightly lower median survival time (55 vs. 58 months), 5-years overall survival (51% vs. 56%) and 5-years disease-free survival (27% vs. 28%) than young group patients. There was an upward trend in 5-years overall and disease-free survival in either elderly or young group.

Conclusion: Though old age may increase the risk of hospital mortality for patients with HCC after hepatic resection, elderly patients can obtain acceptable long-term prognoses from hepatic resection.     

Surgery for advanced colorectal cancer in elderly patients with special emphasis for radio-chemotherapy role

BACKGROUND/AIMS: To compare the short- and long-term outcome of older and younger patients with advanced colorectal cancer who underwent elective surgery. METHODOLOGY: Six hundred and ninety-two patients were analyzed. Four hundred and seventy-nine patients were < 70 years (group 1), and 213 were > or = 70 years (group 2). RESULTS: The overall peroperative mortality rate in younger patients was 0.8% (n = 7), and 1.4% (n = 3) in the elderly (p = NS); morbidity was 35% and 42%, respectively (p = NS). On univariate analysis, elderly patients had a worse overall survival (OS) compared to younger, when only patients undergoing postoperative chemo-radiotherapy were considered (54% OS vs. 67% OS at 5 years; p = 0.03). Using logistic regression analysis, tumor stage (p < 0.0001) and radicality of surgery (p < 0.0001), were strongly associated with OS rates in the elderly. CONCLUSIONS: Colorectal surgery for malignancy can be performed safely in the elderly. Clinical trials are necessary to understand the real advantage of adjuvant or palliative treatments in these patients.     

Is age a risk factor for major pancreatic surgery? An analysis of 300 resections.

BACKGROUND/AIMS: The aim of this study was to analyze if age alone is a risk factor in major pancreatic surgery. METHODOLOGY: From September 1, 1985 to December 31, 1997, 806 patients underwent surgery for malignant and benign diseases of the pancreas in a prospective case control study performed at the Department of Surgery, Johannes Gutenberg University Hospital Mainz. In 228 patients (men: n = 139; women: n = 89; mean age: 61 years; range: 23-83 years) we performed partial (n = 178) or total (n = 50) pancreaticoduodenectomy, which was combined with portal vein resection in 16 cases. Left pancreatic resection was carried out in 72 patients (men: n = 40; women: n = 32; mean age: 65 years; range: 28-86 years). RESULTS: Surgical complications after pancreaticoduodenectomy occurred in 22.1% of patients < or = 70 years and in 30.2% of patients > 70 years, however, less than half of them had severe complications ranging below 50%. General complications developed in 16.1% of patients < or = 70 years and in 27.9% of patients > 70 years (p < 0.001). The mortality rates 30 and 90 days after surgery were 3.2% (< or = 70 years) and 2.3% (> 70 years), and 6.0% (< 70 years) and 6.9% (> 70 years), respectively. Regression analysis showed the following factors to exert an independent influence on mortality: Pre-operative serum bilirubin, the diameter of the pancreatic duct, intra-operative blood loss and the occurrence of surgical and nonsurgical complications. Age did not exert an independent influence on the prognosis of either morbidity or mortality. However, general complications developed significantly more often in elderly patients. After left pancreatic resection surgical complications developed in 29.3% (< or = 70 years) and 21.4% (> 70 years) of patients, however the rate of severe complications was below 10%. General complications occurred in 10.3% (< or = 70 years) and 28.6% (> 70 years) (p < 0.001). Mortality rates 30 and 90 days after operation were 1.7% (< or = 70 years) and 14.2% (> 70 years), and 3.4% (< or = 70 years) and 14.2% (> 70 years) (p = n.s.), respectively. Regression analysis showed the intra-operative blood loss to exert an independent influence on post-operative morbidity and mortality. Age had no independent influence on either morbidity or mortality. CONCLUSIONS: Results obtained by this study show that, although general complications develop significantly more often in elderly patients, age is not an independent risk factor for post-operative mortality after major pancreatic resection. Factors of importance in improving the outcome of this operation include the experience of the surgeon in selecting patients eligible to undergo the procedure, his operative skills in performing major pancreatic resections, as well as better anticipation and management of post-operative complications.     

Liver resection in hepatitis B related-hepatocellular carcinoma: Clinical outcomes and safety in elderly patients

AIM:To compare the morbidity and mortality in young and elderly hepatocellular carcinoma(HCC)patients undergoing liver resection.METHODS:We retrospectively enrolled 1543 consecutive hepatitis B(HBV)-related HCC patients undergoing elective hepatic resection in our cohort,including 207elderly patients(≥65 years)and 1336 younger patients(<65 years).Patient characteristics and clinical outcomes after liver resection were compared between the two groups.RESULTS:Elderly patients had more preoperative comorbidities and lower alanine aminotransferase and aspartate aminotransferase levels.Positive rates for hepatitis B surface antigen(P<0.001),hepatitis B e antigen(P<0.001)and HBV DNA(P=0.017)were more common in younger patients.Overall complications and their severity classified using the Clavien system were similarin the two groups(33.3%vs 29.6%,P=0.271).Elderly patients had a higher rate of postoperative cardiovascular complications(3.9%vs 0.6%,P=0.001),neurological complications(2.9%vs 0.4%,P<0.001)and mortality(3.4%vs 1.2%,P=0.035),and had more hospital stay requirement(13 d vs 12 d,P<0.001)and more intensive care unit stay(36.7%vs 27.8%,P=0.008)compared with younger patients.However,postoperative hepatic insufficiency was more common in the younger group(7.7%vs 3.4%,P=0.024).CONCLUSION:Hepatectomy can be safely performed in elderly patients.Age should not be regarded as a contraindication to liver resection with expected higher complication and mortality rates.     

Surgical resection of hepatocellular carcinoma in elderly cirrhotic patients.

BACKGROUND/AIMS: Both cirrhosis and old age have been reported to be risk factors for hepatic resection. This study evaluated the clinical results of hepatic resection in elderly hepatocellular carcinoma (HCC) patients with cirrhosis. METHODOLOGY: During a 5-year period, 248 patients with HCC underwent curative hepatic resection. Among them, 24 elderly patients (age: > or = 70 years) with cirrhosis (Group I), 24 patients (age: > or = 70 years) without cirrhosis (Group II), and 98 patients (age: < 70 years) with cirrhosis (Group III) were selected for the study. The clinical and pathologic parameters, including pre-operative demographic features, surgical factors, pathological factors, DNA flow-cytometric analysis of the resected specimen, and post-resection prognosis were compared among the three groups. RESULTS: Group I patients had a significantly higher incidence of small-size tumors, hepatitis C infection, concomitant esophageal varices, and minor resection with a shorter surgical margin in the resected specimen. The surgical morbidity and mortality of Group I was similar to that of Group II and III patients. However, the disease-free survival rate was significantly lower in the Group I patients than in Group II (p = 0.02) and Group III patients (p = 0.04). CONCLUSIONS: Our findings indicate that although hepatic resection can be done safely in elderly cirrhotic HCC patients, the prognosis for these patients was less favorable even when curative resection was performed.     

Clinicopathologic characteristics of esophagectomy for esophageal carcinoma in elderly patients

AIM: To evaluate the risk of esophagectomy for carcinoma of the esophagus in the elderly (70 years or more) compared with younger patients (< 70 years) and to determine whether the short-term outcomes of esophagectomy in the elderly have improved in recent years. METHODS: Preoperative risks, postoperative morbidity and mortality in 60 elderly patients (> or = 70 years) with esophagectomy for carcinoma of the esophagus were compared with the findings in 1782 younger patients (< 70 years) with esophagectomy between January 1990 and December 2004. Changes in perioperative outcome and short-time survival in elderly patients between 1990 to 1997 and 1998 to 2004 were separately analyzed. RESULTS: Preoperatively, there were significantly more patients with hypertension, pulmonary dysfunction, cardiac disease, and diabetes mellitus in the elderly patients as compared with the younger patients. No significant difference was found regarding the operation time, blood loss, organs in reconstruction and anastomotic site between the two groups, but elderly patients were more often to receive blood transfusion than younger patients. Significantly more transhiatal and fewer transthoracic esophagectomies were performed in the elderly patients as compared with the younger patients. Resection was considered curative in 71.66% (43/60) elderly and 64.92% (1157/1782) younger patients, which was not statistically significant (P>0.05). There were no significant differences in the prevalence of surgical complications between the two groups. Postoperative cardiopulmonary medical complications were encountered more frequently in elderly patients. The hospital mortality rate was 3.3% (2/60) for elderly patients and 1.1% (19/1 782) for younger patients without a significant difference. When the study period was divided into a former (1990 to 1997) and a recent (1997 to 2004) period, operation time, blood loss, and percentage of patients receiving blood transfusion of the elderly patients significantly improved from the former period to the recent period. The hospital mortality rate of the elderly patients dropped from the former period (5.9%) to the recent period (2.3%), but it was not statistically significant. CONCLUSION: Preoperative medical risk factors and postoperative cardiopulmonary complications after esophagectomy are more common in the elderly, but operative mortality is comparable to that of younger patients. These encouraging results and improvements in postoperative mortality and morbidity of the elderly patients in recent period are attributed to better surgical techniques and more intensive perioperative care in the elderly.     

Clostridium difficile-associated diarrhea in the elderly

OBJECTIVE: It is widely believed that Clostridium difficile (C. difficile)-associated diarrhea is a more severe disease in the elderly than in the young, associated with increased morbidity and mortality. These beliefs are largely anecdotal, and there are few data supporting them. METHODS: We conducted an evaluation in an urban, tertiary care hospital of 89 inpatients in whom C. difficile-associated diarrhea was identified. These patients were evaluated prospectively, and the group was divided by age into those < 60 yr of age (younger) and those > or = 60 yr (elderly). RESULTS: There was no difference in mortality or morbidity in elderly individuals with C. difficile-associated diarrhea when compared with younger persons similarly infected. The response to standard treatment was similar in both groups. Older patients were more likely to have an elevated white blood cell count in association with C. difficile-associated diarrhea (60% vs 26%, p < 0.05), and were more likely to have acquired their infection in the hospital (89% vs 50%, p < 0.0001). CONCLUSIONS: In the elderly, C. difficile-associated diarrhea is almost always acquired in institutions, and may not be obvious among patients' other problems. The elderly do not seem to have an increase in C. difficile diarrhea-associated morbidity or mortality. There is no evidence that C. difficile-associated diarrhea is more severe in the elderly than it is in the young.     

Comparison of results of coronary angioplasty for acute myocardial infarction in patients > or =75 years of age versus patients <75 years of age

We reviewed 1,063 consecutive patients treated with direct coronary angioplasty for acute myocardial infarction (AMI): 261 were > or =75 and 802 were <75 years of age. Compared with the younger group, the older group had a higher percentage of women (48% vs 22%, p <0.0001), multivessel coronary disease (50% vs 39%, p <0.01), overall in-hospital mortality (8.4% vs 3.7%, p <0.01), cardiac mortality rate (6.1% vs 3.1%, p <0.05), and noncardiac mortality rate (2.3% vs 0.6%, p <0.05). Successful reperfusion was achieved in both groups at a similarly high rate (93% and 95%, p = NS). Hospital mortality was similar whether reperfusion was successful or failed. Successful compared with unsuccessful angioplasty decreased mortality rates in the older (6.6% vs 33%, p <0.0001) and younger (3.0% vs 18%, p <0.0001) groups. When reperfusion was successful, the cardiac mortality rate in older patients was not significantly higher than in younger patients: 4.1% vs 2.4%, p = NS.     

Univariate and multivariate analysis of prognostic factors in the surgical treatment of hepatocellular carcinoma in cirrhotic patients

BACKGROUND/AIMS: Evaluation of the short- and long-term outcome of liver resections for HCC in cirrhotic patients. METHODOLOGY: A retrospective analysis was performed on 106 consecutive cirrhotic patients with HCC resected between June 1974 and September 2002. Univariate and multivariate analyses were performed on several clinicopathological variables to analyze factors affecting the long-term outcome and intrahepatic recurrence. RESULTS: Overall mortality and morbidity were 10.7% and 26% respectively. These rates significantly decreased in the last years: from 1997 to 2002 no hospital mortality has been recorded. After a median follow-up of 19 months (interquartile range: 10-36), tumor recurrence appeared in 25 patients (23.5%). The 1-, 3-, and 5-year overall survival rates were 86.6%, 70.3%, and 60.6%, respectively. The 1-, 3-, and 5-year disease-free survival rates were 86.3%, 58.1%, and 40.7%. Univariate analysis showed that viral etiology of cirrhosis (p=0.03), presence of multiple nodules (p=0.02) and vascular invasion (p=0.05) are related to a worse long-term survival. Multivariate analysis showed that only the viral etiology of cirrhosis and the presence of multiple nodules were significant independent prognostic factors. CONCLUSIONS: Results after hepatic resection for HCC in cirrhotic patients can be improved by using a limited surgical approach. The viral etiology of cirrhosis, the presence of multiple nodules and vascular invasion negatively affected recurrence rate and long-term survival.     

Clinical outcome and survival after esophagectomy for carcinoma in elderly patients

Advances in perioperative management have allowed more and more elderly patients to undergo major surgery with postoperative morbidity and mortality rates comparable to those of younger individuals. The aim of this study was to evaluate the impact of age on the clinical outcome and long-term survival of patients with esophageal carcinoma undergoing esophagectomy. Nine-hundred patients with esophageal carcinoma were divided into two groups: A (n = 403) with age > or = 65 years, and B (n = 497) with age < 65 years. One-hundred and fifty three (38%) patients of group A underwent surgery compared to 272 (55%) of group B (P < 0.01). Postoperative mortality, and the prevalence of anastomotic leak and respiratory complications were similar in both groups; conversely, there was a higher prevalence of cardiovascular complications in group A (13% vs 3%, P < 0.01). Five-year survival was about 35% in both groups. In conclusion, advanced age should no longer be considered an absolute contraindication to esophagectomy for carcinoma in selected patients. In fact, the postoperative mortality and long-term survival rates of elderly patients undergoing resection are comparable to that of younger individuals.     

Liver resection for HCC: analysis of causes and risk factors linked to postoperative complications

BACKGROUND/AIMS: Hepatic resection is widely accepted as the best treatment for localized hepatocellular carcinoma (HCC), even in those patients affected by cirrhosis after a sharp selection. Notwithstanding technical advances and high experience of liver resection of specialized centers, the rate of complication after surgical resection could be high. Herein we analyzed causes and foreseeable risk factors on the grounds of data derived from a single center surgical population. METHODOLOGY: From September 1989 to March 2005, 134 consecutive patients had liver resection for HCC on cirrhosis at our department. We performed 54 major liver resections and 80 limited resections. RESULTS: In-hospital mortality rate was 7.4%, about 50% of these cases were Child-Pugh B patients. Morbidity rate was 47.7%, caused by the rising of ascites, hepatic insufficiency, biliary fistula, hepatic abscess, hemoperitoneum and pleural effusion. Intraoperative mortality resulted to be influenced by the amount of resected liver volume (p < 0.05), and the rising of complication (p = 0.006). Some technical aspects of surgical procedure are responsible of the rising of complication as: Pringle maneuver length (p = 0.02), the amount of resected liver volume (p = 0.03) and the request of blood transfusion (p = 0.03). CONCLUSIONS: Complications that arise during the postoperative period, although treatable, delay patient's recovery and resumption of liver function; the evaluation of causes and foreseeable risk factors linked to postoperative morbidity during the planning of surgical treatment should play the same role as other factors weighted in the selection of patients eligible for liver resection.     

The elderly: health status benefits and recovery of function one year after coronary artery bypass surgery

OBJECTIVES: The purpose of this study was to describe the health status (symptoms, function, and quality of life) changes of elderly patients undergoing coronary artery bypass grafting (CABG) and compare these to younger patients. BACKGROUND: Despite increasing use of CABG in the elderly, few data exist about elderly patients' health status benefits from CABG. METHODS: A total of 690 consecutive patients (n = 156, >75 years of age; n = 534, 相似文献   

In-hospital mortality of elderly patients with acute myocardial infarction: data from the MITRA (Maximal Individual Therapy in Acute Myocardial Infarction) registry

BACKGROUND: Advanced age remains one of the principal determinants of mortality in patients with acute myocardial infarction (AMI). HYPOTHESIS: The aim of this study was to determine the in-hospital outcome of elderly (> 75 years) patients with AMI who were admitted to hospitals participating in the national MITRA (Maximal Individual Therapy in Acute Myocardial Infarction) registry. METHODS: MITRA is a prospective, observational German multicenter registry investigating current treatment modalities for patients presenting with AMI. All patients with AMI admitted within 96 h of onset of symptoms were included in the MITRA registry. MITRA was started in June 1994 and ended in January 1997. This registry comprises 6,067 consecutive patients with a mean age of 65 +/- 12 years, of whom 1,430 (17%) were aged > 75 years. Patients were compared with respect to patient characteristics, prehospital delays, early treatment strategies, and clinical outcome. RESULTS: In the elderly patient population, the prehospital delay was 210 min, which was significantly longer than that for younger patients (155 min, p = 0.001). Although the incidence of potential contraindications for the initiation of thrombolysis was almost equally distributed between the two age groups (8.7 vs. 8.2%, p = NS), elderly patients (> 75 years) received reperfusion therapy less frequently (35.9 vs. 64.6%) than younger patients. Mortality increased with advanced age and was 26.4% for all patients aged > 75 years. If reperfusion therapy was initiated, in-hospital mortality was 21.8 versus 28.9% in patients aged > 75 years (p = 0.001) and 29.4 versus 38.5% in patients aged > 85 years (p = 0.001). CONCLUSION: In this registry, elderly patients with AMI had a much higher in-hospital mortality than that expected from randomized trials. In MITRA, the mortality reduction with reperfusion therapy was found to be highest in the very elderly patient population.     

Short-term postoperative outcomes after liver resection in the elderly patient: a nationwide population-based study

BackgroundLiver resection is high-risk surgery in particular in elderly patients. The aim of this study was to explore postoperative outcomes after liver resection in elderly patients.MethodsIn this nationwide study, all patients who underwent liver resection for primary and secondary liver tumours in the Netherlands between 2014 and 2019 were included. Age groups were composed as younger than 70 (70-), between 70 and 80 (septuagenarians), and 80 years or older (octogenarians). Proportion of liver resections per age group and 30-day major morbidity and 30-day mortality were assessed.ResultsIn total, 6587 patients were included of whom 4023 (58.9%) were younger than 70, 2135 (32.4%) were septuagenarians and 429 (6.5%) were octogenarians. The proportion of septuagenarians increased during the study period (aOR:1.06, CI:1.02–1.09, p < 0.001). Thirty-day major morbidity was higher in septuagenarians (11%) and octogenarians (12%) compared to younger patients (9%, p = 0.049). Thirty-day mortality was higher in septuagenarians (4%) and octogenarians (4%) compared to younger patients (2%, p < 0.001). Cardiopulmonary complications occurred more frequently with higher age, liver-specific complications did not. Higher age was associated with higher 30-day morbidity and 30-day mortality in multivariable logistic regression.ConclusionThirty-day major morbidity and 30-day mortality are higher after liver resection in elderly patients, attributed mainly to non-surgical cardiopulmonary complications.     

Current management of esophageal perforation: 20 years experience

Esophageal perforations are surgical emergencies associated with high morbidity and mortality rates. No single strategy has been sufficient to deal with the majority of situations. We aim to postulate a therapeutic algorithm for this complication based on 20 years of experience and also on data from published literature. We performed a retrospective clinical review of 44 patients treated for esophageal perforation at our hospital between January 1989 and May 2008. We reviewed the characteristics of these patients, including age, gender, accompanying diseases, etiology of perforation, diagnosis, location, time interval between perforation and diagnosis, treatment of the perforation, morbidity, hospital mortality, and duration of hospitalization. Perforation occurred in the cervical esophagus in 14 patients (31.8%), thoracic esophagus in 18 patients (40.9%), and abdominal esophagus in 12 patients (27.3%). Management of the esophageal perforation included primary closure in 23 patients (52.3%), resection in 7 patients (15.9%), and nonsurgical therapy in 14 patients (31.8%). In the surgically treated group, the mortality rate was 3 of 30 patients (10%), and 2 of 14 patients (14.3%) in the conservatively managed group. Four of the 14 nonsurgical patients were inserted with covered self-expandable stents. The specific treatment of an esophageal perforation should be selected according to each individual patient. To date, the most effective treatment would appear to be operative management. With improvements in endoscopic procedures, the morbidity and mortality rates of esophageal perforations are significantly decreased. We suggest that minimally invasive techniques for the repair of esophageal perforations will be very important in the future treatment of this condition.     

Outcomes of bile duct drainage by means of ERCP in geriatric patients]

BACKGROUND AND OBJECTIVE: Endoscopic retrograde cholangiopancreatography (ERCP) is usually the procedure of choice for relieving bile duct obstruction. a large number of patients undergoing this intervention are geriatric population (aged 75 years of age and older). Our aim was to assess the efficacy of ERCP in this group of patients as compared to younger ones. PATIENTS AND METHODS: A retrospective study. All patients in whom a therapeutic biliary endoscopy had been performed over a four-year period of time (2002-2005) were included. RESULTS: 178 geriatric patients and 159 younger ones underwent ERCP. No differences were found in successful biliary drainage (97.7 vs. 98.7%), complication number (11.8 vs. 14.4%), or mortality rate (1.1 vs. 0.6%). On the other hand, more common bile duct stones were found in geriatric patients (57.3 vs. 39.6%, p = 0.004), and also more self-expanding metal stents were employed to drain malignant obstructive jaundice (47 vs. 8%, p = 0.0035). In the youngest group, more ERCPs were repeated in the same patients (4 vs. 10%, p = 0.001). CONCLUSIONS: The geriatric population showed similar success and morbidity and mortality rates when compared to younger patients in draining their bile duct by means of ERCP. Common bile duct stones were more frequently found in geriatric patients. No patients needing an ERCP should be excluded only because of their age.     

Process of care performance, patient characteristics, and outcomes in elderly patients hospitalized with community-acquired or nursing home-acquired pneumonia

STUDY OBJECTIVES: To compare process of care performance, patient characteristics, and outcomes in a contemporary cohort of elderly (> or = 65 years) patients hospitalized with community-acquired pneumonia (CAP) or with nursing home-acquired pneumonia (NHAP). DESIGN: State-wide retrospective cohort study. SETTING: Thirty-four acute-care hospitals in Connecticut. PATIENTS: Elderly Medicare patients hospitalized in 1995-1996 with CAP (1,131) or with NHAP (528). MEASUREMENTS: Antibiotic administration within 8 h of hospital arrival, blood culture collection within 24 h of hospital arrival, oxygenation assessment within 24 h of hospital arrival, demographic and clinical characteristics, in-hospital complications, mortality, and length of stay. RESULTS: Process of care performance rates for patients with CAP and NHAP were equivalent for antibiotic administration within 8 h of hospital arrival (76.8% vs 76.3%, respectively; p = 0.82), blood culture collection within 24 h of hospital arrival (78.1% vs 81.1%, respectively; p = 0.31), and oxygenation assessment within 24 h of hospital arrival (94.7% vs 95. 3%, respectively; p = 0.70). Patients with CAP were younger than those with NHAP (median age, 80 vs 84 years, respectively; p < 0. 001), had less cerebrovascular disease (16.8% vs 34.7%, respectively; p < or = 0.001), and lower mortality risk scores at hospital presentation (median, 100 vs 137, respectively; p < or = 0. 001) than patients with NHAP. The median length of stay was equivalent (7 days), but the in-hospital mortality rate was lower in patients with CAP than in patients with NHAP (8.0% vs 18.6%, respectively; p < or = 0.001). CONCLUSION: Initial hospital processes of care are performed at the same rate in patients hospitalized with CAP or NHAP. However, patients with CAP are younger, are less acutely and chronically ill, and have lower in-hospital mortality rates than patients with NHAP.     

Acute type A aortic dissection in the elderly: clinical characteristics,management, and outcomes in the current era

OBJECTIVES: We sought to evaluate the clinical characteristics, management, and outcomes of elderly patients with acute type A aortic dissection. BACKGROUND: Few data exist on the clinical manifestations and outcomes of acute type A aortic dissection in an elderly patient cohort. METHODS: We categorized 550 patients with type A aortic dissection enrolled in the International Registry of Acute Aortic Dissection into two age strata (<70 and >or=70 years) and compared their clinical features, management, and in-hospital events. RESULTS: Thirty-two percent of patients with type A dissection were aged >or=70 years. Marfan syndrome was exclusively associated with dissection in the young, whereas hypertension, atherosclerosis and iatrogenic dissection predominated in older patients. Typical symptoms (abrupt onset of chest or back pain) and signs (aortic regurgitation murmur or pulse deficits) of dissection were less common among the elderly. Fewer elderly patients were managed surgically than younger patients (64% vs. 86%, p < 0.0001). Hypotension occurred more frequently (46% vs. 32%, p = 0.002) and focal neurologic deficits less frequently (18% vs. 26%, p = 0.04) among the elderly. In-hospital mortality was higher among older patients (43% vs. 28%, p = 0.0006). Logistic regression analysis identified age >or=70 years as an independent predictor of hospital death for acute type A aortic dissection (odds ratio 1.7, 95% confidence interval 1.1-2.8; p = 0.03). CONCLUSIONS: Our study shows significant differences between older (age >or=70 years) and younger (age <70 years) patients with acute type A aortic dissection in their clinical characteristics, management, and hospital outcomes. Future research should evaluate strategies to improve outcomes in this high-risk elderly cohort.     

Hepatocellular carcinoma confined to Couinaud segment VIII: experience with extensive or limited resection

BACKGROUND/AIMS: Surgical treatment of hepatocellular carcinoma (HCC) confined to Couinaud segment VIII has been regarded as difficult. This study evaluates surgical and oncological results after extensive or limited resection of the tumor(s). METHODOLOGY: Of the 399 HCC patients that underwent hepatic resection, 36 patients had the tumor(s) confined to segment VIII. These 36 patients were divided into group 1 (extensive resection) (n=15) (three right hepatectomies, 12 anterior segmentectomies) and group 2 (limited resection) (n=21) (11 subsegmentectomies, 10 wedge resections). Data were collected prospectively and analyzed retrospectively. RESULTS: Hospital mortality and morbidity were 0% and 20% in group 1, 9.5%, and 38% in group 2 (P>0.05). Group 1 patients had larger tumor (4.0cm vs. 2.8cm; P=0.01), heavier resected specimen (380g vs. 118g; P<0.01), and a higher incidence of wide surgical margin (> or =1cm) (67% vs. 29%; P=0.041) than those in group 2. The percentage of patients in whom the a-fetoprotein levels returned to the normal range after resection was higher in group 1 (75.0%, 6 of 8 patients) than in group 2 (26.7%, 4 of 15 patients) (P=0.037). The 1-, 3-, and 5-year disease-free survival in group 1 (93%, 79% and 52%) were significantly better than those of group 2 (67%, 38% and 22%) (P=0.021). CONCLUSIONS: In selected patients, extensive resection of HCC located in segment VIII correlates with better survival.