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1.
Background
Cancer staging systems are designed to predict survival and stratify patients. The 7th edition of the American Joint Commission on Cancer (AJCC7) staging system for esophageal cancer was modeled using survival data on patients who underwent esophagectomy without induction or adjuvant therapy. In the United States, the standard of care for patients with locally advanced tumors often includes neoadjuvant therapy. The prognostic value of the pathologic stage for these patients is unknown.Methods
Data from the Surveillance Epidemiology and End Results (SEER) were used to identify 1,243 patients with adenocarcinoma of the esophagus who underwent surgery after neoadjuvant therapy from 1988-2009. Included in the analysis were pathologically-staged, non-metastatic patients who had radiation as part of their neoadjuvant therapy. The AJCC7 staging system and an alternate system were modeled using Kaplan-Meier survival methods. The two systems were compared using log-rank chi-squared statistics, with large chi-squared values indicating accuracy in survival prediction.Results
The AJCC staging system was able to predict survival for patients who had neoadjuvant therapy (P<0.001, chi-squared =81.8); however, there was little distinction between stage subgroups. Patients with neoadjuvant radiotherapy had improved survival for pathologic stage II and III disease. An alternative, simpler staging system was better able to stratify patients with neoadjuvant therapy (P<0.001, chi-squared =100.5).Conclusions
The current AJCC staging system is able to predict survival in esophageal adenocarcinoma patients undergoing neoadjuvant therapy, however, there is less distinction among stage subgroups. An alternative, simpler stage grouping may better stratify patients receiving neoadjuvant therapy. 相似文献2.
Hari Nathan Gilles Mentha Hugo P Marques Lorenzo Capussotti Pietro Majno Luca Aldrighetti Carlo Pulitano Laura Rubbia-Brandt Nadia Russolillo Benjamin Philosophe Eduardo Barroso Alessandro Ferrero Richard D Schulick Michael A Choti Timothy M Pawlik 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2009,11(5):382-390
Background:
Several staging systems for patients with hepatocellular carcinoma (HCC) have been proposed, but studies of their prognostic accuracy have yielded conflicting conclusions. Stratifying patients with early HCC is of particular interest because these patients may derive the greatest benefit from intervention, yet no studies have evaluated the comparative performances of staging systems in patients with early HCC.Methods:
A retrospective cohort study was performed using data on 379 patients who underwent liver resection or liver transplantation for HCC at six major hepatobiliary centres in the USA and Europe. The staging systems evaluated were: the Okuda staging system, the International Hepato-Pancreato-Biliary Association (IHPBA) staging system, the Cancer of the Liver Italian Programme (CLIP) score, the Barcelona Clinic Liver Cancer (BCLC) staging system, the Japanese Integrated Staging (JIS) score and the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) staging system, 6th edition. A recently proposed early HCC prognostic score was also evaluated. The discriminative abilities of the staging systems were evaluated using Cox proportional hazards models and the bootstrap-corrected concordance index (c).Results:
Overall survival of the cohort was 74% at 3 years and 52% at 5 years, with a median survival of 62 months. Most systems demonstrated poor discriminatory ability (P > 0.05 on Cox proportional hazards analysis, c≈ 0.5). However, the AJCC/UICC system clearly stratified patients (P < 0.001, c= 0.59), albeit only into two groups. The early HCC prognostic score also clearly stratified patients (P < 0.001, c= 0.60) and identified three distinct prognostic groups.Discussion:
The early HCC prognostic score is superior to the AJCC/UICC staging system (6th edition) for predicting the survival of patients with early HCC after liver resection or liver transplantation. Other major HCC staging systems perform poorly in patients with early HCC. 相似文献3.
Ribero D Nuzzo G Amisano M Tomatis M Guglielmi A Giulini SM Aldrighetti L Calise F Gerunda GE Pinna AD Capussotti L;Italian Chapter of IHPBA 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2011,13(3):198-205
Background
The seventh TNM edition introduced a new, specific staging structure for intrahepatic cholangiocarcinoma (IHC).Objective
To compare the accuracy of the sixth and the new seventh edition to predict survival after hepatectomy for IHC.Methods
In all, 434 consecutive patients who underwent hepatectomy at 16 tertiary-care centres (1990–2008) were identified. End points were overall (OS) and recurrence-free survival (RFS) for both T cohorts and stage strata.Results
After a median follow-up of 32.4 months, 3- and 5-year OS and RFS estimates were 47.1% and 32.9%, and 26.5% and 19.1%, respectively. Overall, both the editions were statistically significant discriminators of OS and RFS (P < 0.05). However, the survival curves of the new T2a and T2b cohorts appear superimposed. Conversely, the old T2 and T3 cohorts accurately stratify patients into distinct prognostic groups (P < 0.01). The seventh edition does not show monotonicity of gradients (the T4 category demonstrates significantly better OS and RFS compared with T2 patients). The seventh edition stage I and II are significantly different whereas the old stage I and II were not.Conclusions
The new seventh edition of the AJCC/UICC Staging System proved to be adequate although further studies are need to confirm its superiority compared with the previous edition. 相似文献4.
Christina Brzezniak Sacha Satram-Hoang Hans-Peter Goertz Carolina Reyes Ashok Gunuganti Christopher Gallagher Corey A. Carter 《Journal of general internal medicine》2015,30(10):1406-1412
BACKGROUND
Lung cancer is the leading cause of cancer-related death in the United States (US) Military and worldwide, with non-small cell lung cancer (NSCLC) accounting for 87 % of cases.OBJECTIVES
Using a US military cohort who receives equal and open access to healthcare, we sought to examine demographic, clinical features and outcomes with NSCLC.DESIGN AND PARTICIPANTS
We conducted a retrospective cohort analysis of 4,751 patients, aged ≥ 18 years and diagnosed with a first primary NSCLC between 1 January 2003 and 31 December 2013 in the US Department of Defense (DoD) cancer registry.MAIN MEASURES
Differences by patient and disease characteristics were compared using Chi-square and t-test. Kaplan Meier curves and Cox proportional hazards regression assessed overall survival.RESULTS
The mean age at diagnosis was 66 years, 64 % were male, 72 % were Caucasian, 41 % were diagnosed at early stage, 77 % received treatment and 82 % had a history of tobacco use. Mean age at diagnosis was highest among Caucasians (67 years) and lowest among African Americans (AA; 62 years). Asian/Pacific Islanders (PI) were more likely to be female (p < 0.0001), have adenocarcinoma histology (p = 0.0003) and less likely to have a history of tobacco use (p < 0.0001) compared to other racial/ethnic groups. In multivariable survival analysis, older age, male gender, increasing stage, not receiving treatment, and tobacco history were associated with higher mortality risk. Untreated patients exhibited a 39 % higher mortality risk compared to treated patients (HR = 1.39; 95%CI = 1.23–1.57). Compared to Caucasian patients, Asian/PIs demonstrated a 20 % lower risk of death (HR = 0.80; 95%CI = 0.66–0.96). There was no difference in mortality risk between AAs and Hispanics compared to Caucasians.CONCLUSION
The lack of significant outcome disparity between AAs and Caucasians and the earlier stage at diagnosis than usually seen in civilian populations suggest that equal access to healthcare may play a role in early detection and survival.KEY WORDS: military, lung cancer, survival outcomes 相似文献5.
David Petermann Nicolas Demartines Markus Sch?fer 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2013,15(11):872-881
Background
As the long-term survival of pancreatic head malignancies remains dismal, efforts have been made for a better patient selection and a tailored treatment. Tumour size could also be used for patient stratification.Methods
One hundred and fourteen patients underwent a pancreaticoduodenectomy for pancreatic adenocarcinoma, peri-ampullary and biliary cancer stratified according to: ≤20 mm, 21–34 mm, 35–45 mm and >45 mm tumour size.Results
Patients with tumour sizes of ≤20 mm had a N1 rate of 41% and a R1/2 rate of 7%. The median survival was 3.4 years. N1 and R1/2 rates increased to 84% and 31% for tumour sizes of 21–34 mm (P = 0.0002 for N, P = 0.02 for R). The median survival decreased to 1.6 years (P = 0.0003). A further increase in tumour size of 35–45 mm revealed a further increase of N1 and R1/2 rates of 93% (P < 0.0001) and 33%, respectively. The median survival was 1.2 years (P = 0.004). Tumour sizes >45 mm were related to a further decreased median survival of 1.1 years (P = 0.2), whereas N1 and R1/2 rates were 87% and 20%, respectively.Discussion
Tumour size is an important feature of pancreatic head malignancies. A tumour diameter of 20 mm seems to be the cut-off above which an increased rate of incomplete resections and metastatic lymph nodes must be encountered and the median survival is reduced. 相似文献6.
Zeljka Jutric W. Cory Johnston Helena M. Hoen Pippa H. Newell Maria A. Cassera Chet W. Hammill Ronald F. Wolf Paul D. Hansen 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2016,18(1):79-87
Introduction
Routine lymphadenectomy in the surgical treatment of intrahepatic cholangiocarcinoma (ICC) is not routinely performed. We aim to define predictive indicators of survival in patients with positive lymph nodes.Methods
The National Cancer Data Base (NCDB) was queried for patients who underwent major hepatectomy for ICC between 1998 and 2011. Clinical and pathologic data were assessed using uni- and multi-variate analyses. A sub-analysis was performed on the 160 patients with positive lymph nodes.Results
Of 849 patients with lymph node data, 57% had at least one lymph node examined. Median survival for lymph node negative patients was 37 months versus 15 months for lymph node positive patients. In lymph node positive patients, poorer survival was associated with not receiving chemotherapy (HR 1.83, p = 0.003), tumor size > 5 cm (p = 0.029), and older age (p < 0.0001). Lymph node positive patients age less than 45 had a median survival of 27 months.Conclusions
Overall survival in patients with lymph node metastases from ICC is poor. Adjuvant therapy was associated with a longer survival in lymph node positive patients, although prospective data are needed. Routine lymphadenectomy should be strongly considered to provide prognostic information and guidance for adjuvant therapy. 相似文献7.
Caroline D M Witjes Henrike E Karim-Kos Otto Visser Esther de Vries Jan N M IJzermans Robert A de Man Jan Willem W Coebergh Cornelis Verhoef 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2012,14(11):777-781
Background
To explore trends in the incidence and survival of patients with intrahepatic cholangiocarcinoma (ICC) an unselected population in Western Europe was studied.Methods
Between 1989 and 2009, all patients newly diagnosed with ICC were selected from the Netherlands Cancer Registry (n = 809). Trends in incidence, treatment and relative survival were calculated according to gender and age. Follow-up for vital status was complete until 1st January 2010.Results
The incidence rates of ICC increased significantly between 1999 and 2009, especially in the age group 45–59 years [estimated annual percentage change +3.0%, 95% confidence interval (CI) 0.2–5.8]. In the other age groups ICC incidence remained stable. Patients diagnosed with Tumour Lymph Node Metastasis (TNM) stage I mainly underwent surgery (68%), and the majority of the patients with stage II, III and IV received best supportive care (73%). One-year relative survival for patients with ICC increased significantly from 24% in 1989–1994 to 28% in 2005–2009 (P = 0.03), and corresponding 3-year relative survival improved from 4% to 8% (P = 0.02). Three-month and 1-year relative survival for patients with ICC receiving surgery was 91% and 71%, respectively.Discussion
Between 1999 and 2009, the incidence of ICC rose, especially in the age group 45–59 years, suggesting aetiological influences. Survival rates have improved during the study period. 相似文献8.
W AlJaroudi C Halley P Houghtaling S Agarwal V Menon L Rodriguez R A Grimm J D Thomas W A Jaber 《Nutrition & diabetes》2012,2(8):e39
Background:
Obesity is a major public health epidemic and is associated with increased risk of heart failure and mortality. We evaluated the impact of body mass index (BMI) on the prevalence of diastolic dysfunction (DD).Methods:
We reviewed clinical records and echocardiogram of patients with baseline echocardiogram between 1996 and 2005 that showed normal left ventricular ejection fraction (LVEF). Diastolic function was labeled as normal, stage 1, stage 2 or stage 3/4 dysfunction. Patients were categorized as normal weight (BMI <25 kg m−2), overweight (25–29.9 kg m−2), obese (30–39.9 kg m−2) and morbidly obese (⩾40 kg m−2). Multivariable ordinal and ordinary logistic regression were performed to identify factors associated with DD, and evaluate the independent relationship of BMI with DD.Results:
The cohort included 21 666 patients (mean (s.d.) age, 57.1 (15.1); 55.5% female). There were 7352 (33.9%) overweight, 5995 (27.6%) obese and 1616 (7.4%) morbidly obese patients. Abnormal diastolic function was present in 13 414 (61.9%) patients, with stage 1 being the most common. As BMI increased, the prevalence of normal diastolic function decreased (P<0.0001). Furthermore, there were 1733 patients with age <35 years; 460 (26.5%) and 407 (23.5%) were overweight and obese, respectively, and had higher prevalence of DD (P<0.001). Using multivariable logistic regression, BMI remained significant in both ordinal (all stages of diastolic function) and binary (normal versus abnormal). Also, obesity was associated with increased odds of DD in all patients and those aged <35 years.Conclusions:
In patients with normal LVEF, higher BMI was independently associated with worsening DD. 相似文献9.
James E. Aikens Ranak Trivedi Alicia Heapy Paul N. Pfeiffer John D. Piette 《Journal of general internal medicine》2015,30(6):797-803
Background
Although telephone care management improves depression outcomes, its implementation as a standalone strategy is often not feasible in resource-constrained settings. Moreover, little research has examined the potential role of self-management support from patients’ trusted confidants.Objective
To investigate the potential benefits of integrating a patient-selected support person into automated mobile health (mHealth) for depression.Design
Patient preference trial.Participants
Depressed primary care patients who were at risk for antidepressant nonadherence (i.e., Morisky Medication Adherence Scale total score > 1).Intervention
Patients received weekly interactive voice response (IVR) telephone calls for depression that included self-management guidance. They could opt to designate a lay support person from outside their home to receive guidance on supporting their self-management. Patients’ clinicians were automatically notified of urgent patient issues.Main Measures
Each week over a period of 6 months, we used IVR calls to monitor depression with the Patient Health Questionnaire-9 (PHQ-9; with total < 5 classified as remission), adherence (single item reflecting perfect adherence over the past week), and functional impairment (any bed days due to mental health).Key Results
Of 221 at-risk patients, 61% participated with a support person. Analyses were adjusted for race, medical comorbidity, and baseline levels of symptom severity and adherence. Significant interaction effects indicated that during the initial phase of the program, only patients who participated with a support person improved significantly in their likelihood of either adhering to antidepressant medication (AOR = 1.31, 95% CI: 1.16–1.47, p < 0.001) or achieving remission of depression symptoms (AOR = 1.24, 95% CI: 1.14–1.34, p < 0.001). These benefits were maintained throughout the 6-month observation period.Conclusions
Incorporating the “human factor” of a patient-selected support person into automated mHealth for depression self-management may yield sustained improvements in antidepressant adherence and depression symptom remission. However, this needs to be confirmed in a subsequent randomized controlled trial.KEY WORDS: depression, mHealth, self-management, caregiving, social support 相似文献10.
Tony C Pang Calista Spiro Tim Ramacciotti Julian Choi Martin Drummond Edmund Sweeney Jaswinder S Samra Thomas J Hugh 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2015,17(2):185-193
Background
It has been suggested that adverse postoperative outcomes may have a negative impact on longterm survival in patients with colorectal liver metastases.Objectives
This study was conducted to evaluate the prognostic impact of postoperative complications in patients submitted to a potentially curative resection of colorectal liver metastases.Methods
A retrospective analysis of outcomes in 199 patients submitted to hepatic resection with curative intent for metastatic colorectal cancer during 1999–2008 was conducted.Results
The overall complication rate was 38% (n = 75). Of all complications, 79% were minor (Grades I or II). There were five deaths (3%). The median length of follow-up was 39 months. Rates of 5-year overall and disease-free survival were 44% and 27%, respectively. Univariate analysis demonstrated that an elevated preoperative level of carcinoembryonic antigen (CEA), intraoperative blood loss of >300 ml, multiple metastases, large (≥35 mm) metastases and resection margins of <1 mm were associated with poor overall and disease-free survival. In addition, male sex and synchronous metastases were associated with poor disease-free survival. Postoperative complications did not have an impact on either survival measure. The multivariate model did not include complications as a predictive factor.Conclusions
Postoperative complications were not found to influence overall or disease-free survival in the present series. The number and size of liver metastases were confirmed as significant prognostic factors. 相似文献11.
Nadya Postriganova Airazat M Kazaryan B?rd I R?sok ?smund A Fretland Leonid Barkhatov Bj?rn Edwin 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2014,16(9):822-829
Objectives
Recent studies of margin-related recurrence have raised questions on the necessity of ensuring wide resection margins in the resection of colorectal liver metastases. The aim of the current study was to determine whether resection margins of 10 mm provide a survival benefit over narrower resection margins.Methods
A total of 425 laparoscopic liver resections were carried out in 351 procedures performed in 317 patients between August 1998 and April 2012. Primary laparoscopic liver resections for colorectal metastases were included in the study. Two-stage resections, procedures accompanied by concomitant liver ablations and one case of perioperative mortality were excluded. A total of 155 eligible patients were classified into four groups according to resection margin width: Group 1, margins of < 1 mm [n = 33, including 17 patients with positive margins (Group 1a)]; Group 2, margins of 1 mm to < 3 mm (n = 31); Group 3, margins of ≥ 3 mm to < 10 mm (n = 55), and Group 4, margins of ≥ 10 mm (n = 36). Perioperative and survival data were compared across the groups. Median follow-up was 31 months (range: 2–136 months).Results
Perioperative outcomes were similar in all groups. Unfavourable intraoperative incidents occurred in 9.7% of procedures (including 3.2% of conversions). Postoperative complications developed in 11.0% of patients. Recurrence in the resection bed developed in three (1.9%) patients, including two (6.1%) patients in Group 1. Rates of actuarial 5-year overall, disease-free and recurrence-free survival were 49%, 41% and 33%, respectively. Median survival was 65 months. Margin status had no significant impact on patient survival. The Basingstoke Predictive Index (BPI) generally underestimated survival. This underestimation was especially marked in Group 1 when postoperative BPI was applied.Conclusions
Patients with margins of < 1 mm achieved survival comparable with that in patients with margins of ≥ 10 mm. When modern surgical equipment that generates an additional coagulation zone is applied, the association between resection margin and survival may not be apparent. Further studies in this field are required. Postoperative BPI, which includes margin status among the core factors predicting postoperative survival, seems to be less precise than preoperative BPI. 相似文献12.
Bernardo Franssen Ghalib Jibara Parissa Tabrizian Myron E Schwartz Sasan Roayaie 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2014,16(9):830-835
Objectives
This study was conducted to compare 10-year survivors with patients who survived <10 years in a large Western series of patients submitted to hepatectomy for hepatocellular carcinoma (HCC).Methods
A retrospective review of a series of hepatic resections conducted in a referral centre for HCC between January 1987 and October 2002 was conducted.Results
A total of 176 patients were analysed. Twenty-eight patients survived ≥ 10 years (Group A) and were compared with the 148 patients who did not (Group B). Group A had smaller tumours (5.7 cm versus 8.2 cm; P = 0.001) and a lower incidence of microvascular invasion (18.5% versus 37.1%; P = 0.004). Recurrence did not differ significantly (Group A 18/28, 64.3% versus Group B 94/148, 63.5%). Median time to recurrence was longer in Group A (70 months versus 15 months; P < 0.0001), and more patients in Group A were able to undergo curative treatment for recurrence (88.8% versus 40.4%; P < 0.0001). Multivariate analysis showed that lack of vascular invasion (P = 0.020), absence of perioperative transfusion (P = 0.014), and recurrence at >2 years after primary resection (P = 0.045) were significantly associated with 10-year survival.Conclusions
Ten-year survival after liver resection for HCC can be expected in approximately 15% of patients. Recurrence does not preclude longterm survival. Recurrence at >2 years after resection, absence of vascular invasion, and absence of perioperative transfusion are independently associated with 10-year survival. 相似文献13.
Areej El-Jawahri Susan L. Mitchell Michael K. Paasche-Orlow Jennifer S. Temel Vicki A. Jackson Renee R. Rutledge Mihir Parikh Aretha D. Davis Muriel R. Gillick Michael J. Barry Lenny Lopez Elizabeth S. Walker-Corkery Yuchiao Chang Kathleen Finn Christopher Coley Angelo E. Volandes 《Journal of general internal medicine》2015,30(8):1071-1080
BACKGROUND
Decisions about cardiopulmonary resuscitation (CPR) and intubation are a core part of advance care planning, particularly for seriously ill hospitalized patients. However, these discussions are often avoided.OBJECTIVES
We aimed to examine the impact of a video decision tool for CPR and intubation on patients’ choices, knowledge, medical orders, and discussions with providers.DESIGN
This was a prospective randomized trial conducted between 9 March 2011 and 1 June 2013 on the internal medicine services at two hospitals in Boston.PARTICIPANTS
One hundred and fifty seriously ill hospitalized patients over the age of 60 with an advanced illness and a prognosis of 1 year or less were included. Mean age was 76 and 51 % were women.INTERVENTION
Three-minute video describing CPR and intubation plus verbal communication of participants’ preferences to their physicians (intervention) (N = 75) or control arm (usual care) (N = 75).MAIN MEASURES
The primary outcome was participants’ preferences for CPR and intubation (immediately after viewing the video in the intervention arm). Secondary outcomes included: orders to withhold CPR/intubation, documented discussions with providers during hospitalization, and participants’ knowledge of CPR/ intubation (five-item test, range 0–5, higher scores indicate greater knowledge).RESULTS
Intervention participants (vs. controls) were more likely not to want CPR (64 % vs. 32 %, p <0.0001) and intubation (72 % vs. 43 %, p < 0.0001). Intervention participants (vs. controls) were also more likely to have orders to withhold CPR (57 % vs. 19 %, p < 0.0001) and intubation (64 % vs.19 %, p < 0.0001) by hospital discharge, documented discussions about their preferences (81 % vs. 43 %, p < 0.0001), and higher mean knowledge scores (4.11 vs. 2.45; p < 0.0001).CONCLUSIONS
Seriously ill patients who viewed a video about CPR and intubation were more likely not to want these treatments, be better informed about their options, have orders to forgo CPR/ intubation, and discuss preferences with providers.Trial registration: Clinicaltrials.gov Registry Name: A prospective randomized trial using video images in advance care planning in seriously ill hospitalized patients. NCT01325519相似文献14.
Christos Skouras Alastair J Hayes Linda Williams O James Garden Rowan W Parks Damian J Mole 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2014,16(9):789-796
Background
The effect of early organ dysfunction on long-term survival in acute pancreatitis (AP) patients is unknown.Objective
The aim of this study was to ascertain whether early organ dysfunction impacts on long-term survival after an episode of AP.Methods
A retrospective analysis was performed using survival data sourced from a prospectively maintained database of patients with AP admitted to the Royal Infirmary of Edinburgh during a 5-year period commencing January 2000. A multiple organ dysfunction syndrome (MODS) score of ≥ 2 during the first week of admission was used to define early organ dysfunction. After accounting for in-hospital deaths, long-term survival probabilities were estimated using the Kaplan–Meier test. The prognostic significance of patient characteristics was assessed by univariate and multivariate analyses using Cox''s proportional hazards methods.Results
A total of 694 patients were studied (median follow-up: 8.8 years). Patients with early organ dysfunction (MODS group) were found to have died prematurely [mean survival: 10.0 years, 95% confidence interval (CI) 9.4–10.6 years] in comparison with the non-MODS group (mean survival: 11.6 years, 95% CI 11.2–11.9 years) (log-rank test, P = 0.001) after the exclusion of in-hospital deaths. Multivariate analysis confirmed MODS as an independent predictor of long-term survival [hazard ratio (HR): 1.528, 95% CI 1.72–2.176; P = 0.019] along with age (HR: 1.062; P < 0.001), alcohol-related aetiology (HR: 2.027; P = 0.001) and idiopathic aetiology (HR: 1.548; P = 0.048).Conclusions
Early organ dysfunction in AP is an independent predictor of long-term survival even when in-hospital deaths are accounted for. Negative predictors also include age, and idiopathic and alcohol-related aetiologies. 相似文献15.
Prabhu P. Gounder Tiffany G. Harris Holly Anger Lisa Trieu Jeanne Sullivan Meissner Betsy L. Cadwell Elena Shashkina Shama D. Ahuja 《Journal of general internal medicine》2015,30(6):742-748
Background
Patients with prior positive tuberculin skin test (TST) results may benefit from prophylaxis after repeat exposure to infectious tuberculosis (TB).Objective
To evaluate factors associated with active TB disease among persons with prior positive TST results named as contacts of persons with infectious TB.Design
Population-based retrospective cohort study.Participants
A total of 2,933 contacts with prior positive TST results recently exposed to infectious TB identified in New York City’s TB registry during the period from January 1, 1997 through December 31, 2003.Main Measurements
Contacts developing active TB disease ≤ 4 years after exposure were identified and compared with those who did not, using Poisson regression analysis. Genotyping was performed on selected Mycobacterium tuberculosis-positive isolates.Key Results
Among contacts with prior positive TST results, 39 (1.3 %) developed active TB disease ≤ 4 years after exposure (≤2 years: 34). Risk factors for contacts that were independently associated with TB were age < 5 years (adjusted prevalence ratio [aPR] = 19.48; 95 % confidence interval [CI] = 7.15–53.09), household exposure (aPR = 2.60;CI = 1.30–5.21), exposure to infectious patients (i.e., cavities on chest radiograph, acid-fast bacilli on sputum smear; aPR = 1.9 3;CI = 1.01–3.71), and exposure to a U.S.-born index patient (aPR = 4.04; CI = 1.95–8.38). Receipt of more than1 month of treatment for latent TB infection following the current contact investigation was found to be protective (aPR = 0.27; CI = 0.08–0.93). Genotype results were concordant with the index patients among 14 of 15 contacts who developed active TB disease and had genotyping results available.Conclusions
Concordant genotype results and a high proportion of contacts developing active TB disease within 2 years of exposure indicate that those with prior positive TST results likely developed active TB disease from recent rather than remote infection. Healthcare providers should consider prophylaxis for contacts with prior TB infection, especially young children and close contacts of TB patients (e.g., those with household exposure).KEY WORDS: contact tracing, tuberculosis infection, prevention and control, epidemiology 相似文献16.
Jean Marc Regimbeau David Fuks Patrick Pessaux Philippe Bachellier Denis Chatelain Momar Diouf Artigas Raventos Georges Mantion Jean-Francois Gigot Laurence Chiche Gerard Pascal Daniel Azoulay Alexis Laurent Christian Letoublon Emmanuel Boleslawski Michel Rivoire Jean-Yves Mabrut Mustapha Adham Yves-Patrice Le Treut Jean-Robert Delpero Francis Navarro Ahmet Ayav Karim Boudjema Gennaro Nuzzo Michel Scotte Olivier Farges 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2015,17(1):79-86
Introduction
As mortality and morbidity after a curative resection remains high, it is essential to identify pre-operative factors associated with an early death after a major resection.Methods
Between 1998 and 2008, we selected a population of 331 patients having undergone a major hepatectomy including segment I with a lymphadenectomy and a common bile duct resection for a proven hilar cholangiocarcinoma in 21 tertiary centres. The study''s objective was to identify pre-operative predictors of early death (<12 months) after a resection.Results
The study cohort consisted of 221 men and 110 women, with a median age of 61 years (range: 24–85). The post-operative mortality and morbidity rates were 8.2% and 61%, respectively. The 1-, 3- and 5-year overall survival rates were 85%, 64% and 53%, respectively. The median tumour size was 23 mm on pathology, ranging from 8 to 40. A tumour size >30 mm [odds ratio (OR) 2.471 (95% confidence interval (CI) 1.136–7.339), P = 0.001] and major post-operative complication [OR 3.369 (95% CI 1.038–10.938), P = 0.004] were independently associated with death <12 months in a multivariate analysis.Conclusion
The present analysis of a series of 331 patients with hilar cholangiocarcinoma showed that tumour size >30 mm was independently associated with death <12 months. 相似文献17.
Kendra D Conzen Neeta Vachharajani Kelly M Collins Christopher D Anderson Yiing Lin Jason R Wellen Surendra Shenoy Jeffrey A Lowell M B Majella Doyle William C Chapman 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2015,17(3):251-257
Objective
The effects of obesity in liver transplantation remain controversial. Earlier institutional data demonstrated no significant difference in postoperative complications or 1-year mortality. This study was conducted to test the hypothesis that obesity alone has minimal effect on longterm graft and overall survival.Methods
A retrospective, single-institution analysis of outcomes in patients submitted to primary adult orthotopic liver transplantation was conducted using data for the period from 1 January 2002 to 31 December 2012. Recipients were divided into six groups by pre-transplant body mass index (BMI), comprising those with BMIs of <18.0 kg/m2, 18.0–24.9 kg/m2, 25.0–29.9 kg/m2, 30.0–35.0 kg/m2, 35.1–40.0 kg/m2 and >40 kg/m2, respectively. Pre- and post-transplant parameters were compared. A P-value of <0.05 was considered to indicate statistical significance. Independent predictors of patient and graft survival were determined using multivariate analysis.Results
A total of 785 patients met the study inclusion criteria. A BMI of >35 kg/m2 was associated with non-alcoholic steatohepatitis (NASH) cirrhosis (P < 0.0001), higher Model for End-stage Liver Disease (MELD) score, and longer wait times for transplant (P = 0.002). There were no differences in operative time, intensive care unit or hospital length of stay, or perioperative complications. Graft and patient survival at intervals up to 3 years were similar between groups. Compared with non-obese recipients, recipients with a BMI of >40 kg/m2 showed significantly reduced 5-year graft (49.0% versus 75.8%; P < 0.02) and patient (51.3% versus 78.8%; P < 0.01) survival.Conclusions
Obesity increasingly impacts outcomes in liver transplantation. Although the present data are limited by the fact that they were sourced from a single institution, they suggest that morbid obesity adversely affects longterm outcomes despite providing similar short-term results. Further analysis is indicated to identify risk factors for poor outcomes in morbidly obese patients. 相似文献18.
Laura Panattoni Ashley Stone Sukyung Chung Ming Tai-Seale 《Journal of general internal medicine》2015,30(3):327-333
BACKGROUND
The growing number of primary care physicians (PCPs) reducing their clinical work hours has raised concerns about meeting the future demand for services and fulfilling the continuity and access mandates for patient-centered care. However, the patient’s experience of care with part-time physicians is relatively unknown, and may be mediated by continuity and access to care outcomes.OBJECTIVE
We aimed to examine the relationships between a physicians’ clinical full-time equivalent (FTE), continuity of care, access to care, and patient satisfaction with the physician.DESIGN
We used a multi-level structural equation estimation, with continuity and access modeled as mediators, for a cross-section in 2010.PARTICIPANTS
The study included family medicine (n = 104) and internal medicine (n = 101) physicians in a multi-specialty group practice, along with their patient satisfaction survey responses (n = 12,688).MAIN MEASURES
Physician level FTE, continuity of care received by patients, continuity of care provided by physician, and a Press Ganey patient satisfaction with the physician score, on a 0–100 % scale, were measured. Access to care was measured as days to the third next-available appointment.KEY RESULTS
Physician FTE was directly associated with better continuity of care received (0.172 % per FTE, p < 0.001), better continuity of care provided (0.108 % per FTE, p < 0.001), and better access to care (−0.033 days per FTE, p < 0.01), but worse patient satisfaction scores (−0.080 % per FTE, p = 0.03). The continuity of care provided was a significant mediator (0.016 % per FTE, p < 0.01) of the relationship between FTE and patient satisfaction; but overall, reduced clinical work hours were associated with better patient satisfaction (−0.053 % per FTE, p = 0.03).CONCLUSIONS
These results suggest that PCPs who choose to work fewer clinical hours may have worse continuity and access, but they may provide a better patient experience. Physician workforce planning should consider these care attributes when considering the role of part-time PCPs in practice redesign efforts and initiatives to meet the demand for primary care services.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-014-3104-6) contains supplementary material, which is available to authorized users.KEY WORDS: part-time work, continuity of care, access to care, patient satisfaction 相似文献19.
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