Young Patients Undergoing Resection of Pancreatic Cancer Fare Better than their Older Counterparts

Background

The median age of pancreatic ductal adenocarcinoma (PDAC) patients is 71 years. PDAC rarely affects individuals under the age of 45. We investigated features of PDAC occurring in young patients (≤45 years) who underwent surgical resection in order to determine if any difference exists in comparison to elderly patients (≥70 years).

Methods

A retrospective analysis of patients with PDAC who were?≤?45 years on the date of surgery between 1975 and 2009 was performed. This cohort was compared with PDAC patients whose ages were over 70 years on the date of surgery over the same time interval. Information reviewed included demographics, Charlson Age–Comorbidity Index (CACI), pathological staging, surgical management, and death or last follow-up.

Results

Seventy five patients with PDAC of age?≤?45 years at surgery were identified. The reference group consisted of 870 patients with a median age of 75. The most common symptoms of young patients were jaundice (45 %), abdominal pain (32 %), or weight loss (33 %). This did not differ significantly from older patients. Among the younger patients, 7 (9 %) underwent total pancreatectomy, 60 (80 %) underwent pancreaticoduodenectomy, and 8 (11 %) had distal pancreatectomy. The distribution of type of surgery was similar between two groups. Fifty-two of the young patients (69 %) had an R0 resection and this did not differ from the older age group (n?=?616; 71 %). The rate of lymph node positivity was 68 % for younger patients and 74 % for older patients (p?=?0.27). Of the younger patients, 11, 13, 49, and 2 were classified as stage I, IIA, IIB, and III, respectively, and did not differ from the older age group. The median overall survival for the young patients cohort was 19 months (95 % CI 15–22 months) which is longer than 16 months (95 % CI 14–17 months) of the older group (p?=?0.007). The actual 5- and 10- year survival in young age group (24 and 17 %) was longer than that in old age group (11 and 3 %) (p?<?0.05). The median CACI of the younger patients was 0.5 and was lower than 4.1 of the older patients (p?<?0.0001).

Conclusions

The demographic, pathologic, and treatment characteristics of PDAC patients younger than 45 years were similar to those older than 70 years. Younger patients had fewer complications after curative resections. The better survival among younger patients is likely related to fewer comorbidities in this group. These findings will be useful in counseling young patients with resectable pancreatic cancer.     

Coronary endarterectomy on beating heart: Our experience

Introduction Coronary artery bypass grafting (CABG) associated with Endarterectomy is a high risk procedure. After the first report of coronary endarterectomy by Bailey et al in 1951, the preference for this surgical procedure was decreased due to increased morbidity and mortality In patients with total or subtotal large coronary artery obstructions in which there is no possibility to receive a conduit as graft for myocardial revascularisation, endarterectomy remains the procedure of choice. This study was designed to study early and midterm results of off pump coronary artery endarterectomy. Methods Of 172 Consecutive Off Pump CABG done at our institution from Jan 2003 to July 2005, 22 patients underwent supplementary coronary endarterectomy. 16 patients had chronic stable angina 4 had unstable angina two required emergency CABG with endarterectomy following perioperative infarction. The mean ejection fraction was 29.2±4.3 and all of the patients were in New York Heart Association (NYHA) III or IV. All patients were planned for complete total arterial revascularisation using Left Internal Mammary Artery (LIMA). Right Internal Mammary Artery (RIMA), Radial composite “Y” graft, Two patients operated for periop infarct received vein graft. In 16 patients closed endarterectomy was done in five patients double endarterectomy in single vessel was done to chase the plaque distally, in one patient open left anterior descending (LAD) endarterectomy with vein patch reconstruction was performed. Results There were no deaths. None of the procedures were converted to on pump operation. All endarterectomies and bypasses were performed on Beating Heart, all patients were completely revascularised. Peri operative cardiac enzymes studied showed no significant rise in the Creatinine Phoshpokinase (CPK)-Creatinine Phosphokinase myocardial Band (CPK-MB). The mean postoperative Ejection Fraction (EF) was 36.7%±7.2% which was significantly higher than the Preoperative one (p<.05). At the end of four months to one and half year 22 patients were in NYHA class I to II and all were angina free in canadian cardiovascular society class.f Conclusions Coronary End Arterectomy without cardiopulmonary bypass can be performed in patients who are expected to benefit from complete revascularisation. It can be performed with closed as well as open method. However to achieve complete endarterectomy by closed technique in some patients it is essential to chase the plaque. Early and mid term results are encouraging.     

Hepatitis B vaccination in human immunodeficiency virus-infected adults receiving hemodialysis

BACKGROUND: The Centers for Disease Control and Prevention (CDC) recommends hepatitis B virus (HBV) immunization for all hemodialysis (HD) patients because they are at high risk of infection. Several studies have shown that the development of protective antibody titers after HBV vaccination is much lower in HD patients. We hypothesized that human immunodeficiency virus (HIV) infection in patients with end-stage renal disease (ESRD) would further impair the immune response to hepatitis B vaccination. METHODS: We performed a retrospective cohort study of patients undergoing long-term hemodialysis from 1990 to 2002 at the United States-based dialysis facilities of Gambro Corporation, North America. The response rate defined as an increase in anti-HBs levels >/=10 mIU/L after a month of the third dose of HBV vaccination was determined in HIV-infected and a randomly selected group of ESRD patients. The demographic information, laboratory data, and hepatitis B surface antibody (anti-HBs) titers were recorded from the Gambro Corporation database on these patients. RESULTS: Of the 347 adult HIV ESRD patients, 116 received three doses of recombinant hepatitis B vaccination. Seventy percent were male, and the majority (86%) were black. Of the 116 patients who received three doses of HBV vaccination, 62 (53.4%) developed protective antibody titers. This was comparable to the response rate of 50.4% in the randomly selected 220 non-HIV hemodialysis patients. Among HIV ESRD patients, the mean hemoglobin (Hgb) was higher in patients who developed protective antibody titers (Hgb 11.61 +/- 2 vs. 10.55 +/- 1.86, P value <0.01). On multivariate logistic regression analysis, higher Hgb was associated with protective antibody titers (odds ratio: 1.34, 95% CI 0.99-1.72). Seventy percent of the HIV-infected responders maintained protective antibody titers 6 months after vaccination. CONCLUSION: Hepatitis B vaccination should be offered to all HIV-infected ESRD patients because over half of the patients with HIV and ESRD can develop protective antibodies.     

Abnormalities in metabolic pathways in celiac disease investigated by the metabolic profiling of small intestinal mucosa,blood plasma and urine by NMR spectroscopy

Celiac disease (CeD) is an autoimmune enteropathy caused by gluten intake in genetically predisposed individuals. We investigated the metabolism of CeD by metabolic profiling of intestinal mucosa, blood plasma and urine using NMR spectroscopy and multivariate analysis. The metabolic profile of the small intestinal mucosa was compared between patients with CeD (n = 64) and disease controls (DCs, n = 30). The blood plasma and urinary metabolomes of CeD patients were compared with healthy controls (HCs, n = 39). Twelve metabolites (proline (Pro), arginine (Arg), glycine (Gly), histidine (His), glutamate (Glu), aspartate, tryptophan (Trp), fumarate, formate, succinate (Succ), glycerophosphocholine (GPC) and allantoin (Alln)) of intestinal mucosa differentiated CeD from controls. The metabolome of blood plasma with 18 metabolites (Pro, Arg, Gly, alanine, Glu, glutamine, glucose (Glc), lactate (Lac), acetate (Ace), acetoacetate (AcAc), β‐hydroxybutyrate (β‐OHB), pyruvate (Pyr), Succ, citrate (Cit), choline (Cho), creatine (Cr), phosphocreatine (PCr) and creatinine) and 9 metabolites of urine (Pro, Trp, β‐OHB, Pyr, Succ, N‐methylnicotinamide (NMN), aminohippurate (AHA), indoxyl sulfate (IS) and Alln) distinguished CeD from HCs. Our data demonstrated changes in nine metabolic pathways. The altered metabolites were associated with increased oxidative stress (Alln), impaired healing and repair mechanisms (Pro, Arg), compromised anti‐inflammatory and cytoprotective processes (Gly, His, NMN), altered energy metabolism (Glc, Lac, β‐OHB, Ace, AcAc, Pyr, Succ, Cit, Cho, Cr and PCr), impaired membrane metabolism (GPC and Cho) and intestinal dysbiosis (AHA and IS). An orthogonal partial least square discriminant analysis model provided clear differentiation between patients with CeD and controls in all three specimens. A classification model built by combining the distinguishing metabolites of blood plasma and urine samples gave an AUC of 0.99 with 97.7% sensitivity, 93.3% specificity and a predictive accuracy of 95.1%, which was higher than for the models built separately using small intestinal mucosa, blood plasma and urine. In conclusion, a panel of metabolic biomarkers in intestinal biopsies, plasma and urine samples has potential to differentiate CeD from controls and may complement traditional tests to improve the diagnosis of CeD.     

Cost comparison of andexanet versus prothrombin complex concentrates for direct factor Xa inhibitor reversal after hemorrhage

Journal of Thrombosis and Thrombolysis - Andexanet-alpha is a specific reversal agent for direct factor Xa inhibitors (dFXaI). We aimed to project utilization rates and cost of andexanet for...     

Indian child with novel variant in OFD1 gene

Orofaciodigital syndrome (OFD) can have variable phenotype and presents with oral anomalies, facial dysmorphism, and digital malformations like syndactyly, and polydactyly. Other presentations also include renal and cardiac defects, and central nervous system anomalies like hydrocephalus and cerebellar abnormalities. OFD1 is a X‐linked dominant form of the syndrome presenting in females with mutations in CXorf5 or OFD1 gene. We describe a young child with sparse hairs, milia over face and absence of corpus callosum. Next generation sequencing showed frameshift pathogenic variant in the exon 13 of the OFD1 gene, consistent with diagnosis of OFD1.     

Kuttner tumour (chronic sclerosing sialadenitis) of the submandibular gland: sonographic appearances

Patients with Kuttner tumours present with clinical features simulating a submandibular tumour. This article aims to familiarise sonologists with the sonographic appearances of these tumours, to help in their differentiation from other salivary lesions. In 13 patients with histologically or cytologically proven Kuttner tumours, the features evaluated on sonography included: shape and border of the gland, internal architecture, duct dilatation, presence/absence of calculi and presence and distribution of vascularity. There was diffuse involvement of the submandibular glands in 11 patients and focal involvement in 2. The majority (9 of 11) of the patients with diffuse involvement showed sonographic appearances simulating a "cirrhotic" liver; 2 showed diffuse heterogeneous involvement with duct dilatation and calculus. Doppler showed prominent intraglandular vessels, with no evidence of displacement. Focal lesions (2 of 11) were seen as hypoechoic, heterogeneous "masses," with a radial branching vascular pattern within, on Doppler. In conclusion, sonographic features may help in identifying Kuttner tumours of the submandibular glands.