Internal thoracic artery grafting in the elderly patient undergoing coronary artery bypass grafting: room for process improvement?

OBJECTIVE: The acute and long-term benefits of internal thoracic artery grafting are clear in younger patients undergoing coronary artery bypass grafting. The elderly, however, face higher surgical risks and have shorter life expectancy, and thus the use of internal thoracic artery grafting in this age group has been debated. This study examined the use, complication risks, and operative (30-day) mortality associated with internal thoracic artery grafting in patients 75 years of age and older. METHODS: Between 1996 and 1999, 522,656 patients in the Society of Thoracic Surgeons National Cardiac Database underwent primary, nonemergency-salvage coronary artery bypass grafting; of these, 99,942 were 75 years of age or older. The influence of internal thoracic artery use on operative mortality and 5 major complications in this elderly group was examined by means of (1) risk adjustment (adjusting for 28 baseline risk factors and site) and (2) a treatment propensity score analysis that compares patients with similar baseline likelihood for receiving an internal thoracic artery graft. RESULTS: In the National Cardiac Database 77.4% of patients aged 75 to 84 years received an internal thoracic artery graft compared with 93.5% for those aged 55 years or less. In this elderly group use of the internal thoracic artery was strongly associated with decreased operative mortality (unadjusted mortality, 6.20% vs. 4.05%; P <.0001) that persisted after controlling for baseline risk and provider effects (adjusted odds ratio, 0.85; 95% confidence intervals, 0.79-0.91). This mortality benefit was seen among those with low-to-high baseline propensity for receiving an internal thoracic artery graft. CONCLUSIONS: Use of the internal thoracic artery in elderly patients undergoing coronary artery bypass grafting provides an acute survival benefit. This benefit is similar to that seen in younger patients and persists after adjusting for both patient and provider selection factors. The internal thoracic artery appears to be underused in elderly patients undergoing bypass grafting and is a potential area for quality improvement.     

Influence of age on outcomes in patients undergoing mitral valve replacement

BACKGROUND: Although increasing age has been associated with greater risk of mortality for patients undergoing mitral valve replacement, it is less clear whether this elevated risk is related to age-related differences in comorbidity or other clinical characteristics. METHODS: A population of 31,688 patients from The Society of Thoracic Surgeons National Cardiac Database undergoing mitral valve replacement either alone or in combination with coronary artery bypass grafting or tricuspid surgical procedures from 1997 to 2000 was examined to assess age-related variation in clinical features, morbidity, and mortality. Multivariable logistic regression was used to determine the effect of age after adjusting for other known risk factors. A classification tree was used to identify low-risk elderly (> or = 75 years) patients. RESULTS: Operative mortality increased four-fold from 4.1% in patients aged less than 50 years up to 17.0% in patients aged 80 years or more. Similarly, major operative complications (stroke, prolonged ventilation, reoperation for bleeding, renal failure, and sternal infection) also increased with age, rising from 13.5% (age < 50 years) to 35.5% (age > or = 80 years). Multivariable adjustment attenuated the odds of operative mortality, but age remained a significant risk factor. After adjusting for other patient risk factors, age accounted for 13% and 10% of the explainable risk for mortality and morbidity, respectively. Among the elderly, four variables (hemodynamic instability, New York Heart Association class IV, renal failure, and concomitant coronary artery bypass grafting) were identified to distinguish levels of risk, from operative mortality rates exceeding 31% to those with 7.7% mortality. CONCLUSIONS: Operative mortality and morbidity rise with increasing age of patients undergoing mitral valve replacement. Although this excess risk is partially a result of increased comorbid burden and other operative factors, age remains an independent powerful risk factor for operative risk for mitral valve replacement. Understanding the relationship of age with other risk factors for mitral valve replacement can help stratify risk, enabling physicians to identify lower risk patients.     

PLENARY LECTURES-PL3 Vascular dysfunctions and platelet activations by arsenic: two major contributing factors to cardiovascular disease

Arsenic in drinking water is a worldwide health problem that is associated with cardiovascular disease, but the cause is currently unknown. In order to examine whether arsenic affects vasomotor tone in blood vessels, we investigated the effect of arsenic on agonist-induced vasorelaxation and vasoconstriction using the isolated rat aortic rings in in vitro organ bath system.     

Diagnosis and management of cystic duct leakage after laparoscopic cholecystectomy, report of 3 cases

BACKGROUND： Operative complications after laparoscopic cholecystectomy （LC） vary. Abdominal pain and other symptoms caused by fluid accumulation in the operative area are not uncommon. Cystic duct （CD） leakage is one of the main sources of the fluid. This study was to evaluate the procedures used in the diagnosis and management of CD leakage after LC. METHOD： The clinical materials of 3 patients with CD leakage after LC were studied retrospectively.     

Expression and immunogenicity of oncofetal antigen-immature laminin receptor in human renal cell carcinoma

PURPOSE: The 32 to 44 kDa. oncofetal antigen-immature laminin receptor (OFA-iLR) is a multifunctional protein expressed by various tumors, including breast, lung, ovary and prostate carcinoma as well as lymphoma. OFA-iLR has been implicated in tumor invasiveness, metastasis and growth. Interferon-gamma producing effector T cells and interleukin (IL)-10 producing suppressor T cells specific for OFA-iLR have been described. MATERIALS AND METHODS: The 43515 IgG2a anti-OFA-iLR monoclonal antibody was used to detect OFA-iLR expression in human renal cell carcinoma tissue by flow cytometry and immunoblotting. Spontaneous or therapy induced immune responses against OFA-iLR were determined in patients with metastatic renal cell carcinoma. Proliferative and cytokine (interferon-gamma and IL-10) responses of peripheral blood mononuclear cells from patients with renal cell carcinoma against recombinant OFA-iLR were assessed. RESULTS: Using flow cytometry OFA-iLR was detected in all 13 tumors tested. Immunoblotting revealed differences in OFA-iLR expression in renal cell carcinoma and normal kidney tissue. OFA-iLR specific proliferative and cytokine responses of mononuclear cells were detected in all 6 patients tested. Importantly evidence was also obtained that treating metastatic renal cell carcinoma with tumor lysate pulsed dendritic cells would enhance OFA-iLR specific immunity. CONCLUSIONS: This study demonstrates that OFA-iLR is an immunogenic tumor associated antigen in human renal cell carcinoma. OFA-iLR specific effector T cells producing interferon-gamma may have a role in the control of tumor growth, whereas suppressor T cells producing IL-10 may promote tumor tolerance and, thus, tumor progression.     

The usefulness of growth hormone treatment for psychological status in young adult survivors of childhood leukaemia: an open-label study

Background  

To reduce the risk of brain damage children with acute lymphoblastic leukaemia (ALL) are nowadays mainly treated with intrathecal chemotherapy (ITC) instead of central nervous system (CNS) radiation therapy (CRT) to prevent CNS relapse. However, chemotherapy may also lead to cognitive deficits. As growth hormone deficiency (GHD) or impaired growth hormone secretion are frequently found in ALL patients treated with cranial radiation therapy and/or chemotherapy, we hypothesized that GH therapy may reduce cognitive deficits in these patients.     

Empowering employees with chronic diseases; development of an intervention aimed at job retention and design of a randomised controlled trial

Background  

Persons with a chronic disease are less often employed than healthy persons. If employed, many of them experience problems at work. Therefore, we developed a training programme aimed at job retention. The objective of this paper is to describe this intervention and to present the design of a study to evaluate its effectiveness.     

Factors predictive of response and survival in patients with metastatic colorectal cancer in Taiwan

5-Fluorouracil in combination with leucovorin has been shown to be active in therapeutic trials of metastatic colorectal carcinoma. In this study, we administered these drugs to 72 patients with metastatic colorectal carcinoma. Thirty-six of them without previous exposure to 5-fluorouracil were treated with weekly bolus injections of 5-fluorouracil (425 mg/m2) and leucovorin (25 mg/m2) supplemented with oral levamisole. Another 36 patients with or without prior 5-fluorouracil treatment received 5-fluorouracil 3,000 mg/m2 and leucovorin 300 mg/m2 in a 48-hour continuous infusion every two weeks. Clinical efficacy and toxicity were assessed by WHO criteria. Variables were tested for relations to response and survival by univariate and multivariate analysis. The response rate was 19.4% in weekly bolus arm and 13.9% in biweekly high-dose infusion arm (P = 0.527). Median survivals in the two arms were 18.4 months (weekly) and 21 months (biweekly) respectively (P = 0.708). Gastrointestinal side effects including nausea, vomiting, diarrhea and mucositia were the major toxicities of these regimens. By multivariate analysis, the only factor to influence response rate was the site of metastases (P = 0.009). The only factor to affect survival was performance status of the patient (P = 0.0001). We concluded that the two 5-fluorouracil based regimens are well-tolerated and shown to have a response rate comparable with previous reports of similar regimens in patients with metastatic colorectal cancer. Only liver metastases seemed to have a better response to therapy. Performance status is the most important prognostic factor in patients with metastatic colorectal cancer.      

Langerhans' cell histiocytosis with thyroid involvement masquerading as thyroid carcinoma

A 28-year-old woman was admitted to our Hospital with a chief complaint of progressive gingival swelling and loosening of teeth over about a year. According to past history, she had received total thyroidectomy 2 years previously due to thyromegaly. The thyroidectomy specimen was at first interpreted as 'poorly differentiated carcinoma of the thyroid'. One year ago, she began to be aware of gingival swelling and loosening of teeth. A gum biopsy was taken and the pathologic features were similar to her 'thyroid carcinoma'. Subsequent investigations, including immunohistochemical stain, showed the gum was heavily infiltrated with histiocyte-like Langerhans' cells which were positive for S-100 protein. Ultrastructural examination of the cells under electron microscope revealed many typical intra-cytoplasmic Birbeck granules. Langerhans' cell histiocytosis was diagnosed. Langerhans' cell histiocytosis with thyroid involvement is extremely rare and may run a relatively indolent course. Even on a retrospective examination, it may easily be confused with poorly differentiated carcinoma of the thyroid. We suspect that this error may have been made on other occasions and that the occurrence of this condition may be underreported.