Better Long-term Outcomes In Patients Research Articles

Use of direct oral anticoagulants is associated with better long-term outcomes in patients with atrial fibrillation and heart failure as compared with vitamin K antagonists

Abstract Background Direct oral anticoagulants (DOACs) have been shown to be safe and effective in patients with atrial fibrillation (AF) as compared with warfarin, a vitamin K antagonist. However, the safety and efficacy of DOACs in patients with AF and heart failure (HF) have been unclear. Purpose The purpose of this study was to determine whether DOACs can improve long-term outcomes in patients with AF and HF as compared with warfarin. Methods We analyzed the JROADHF registry, which was a multicenter registry of patients hospitalized for the worsening HF in Japan. Baseline data were collected during the episode of index hospitalization from April 2013 to March 2014. Follow-up data were collected up to 4.5 years after the index hospitalization. Patients with AF and creatinine clearance ≥15 ml/min/1.73m2 were included. Valvular heart disease, congenital heart disease, and constrictive pericarditis were excluded. Eligible patients were divided into two groups according to the use of warfarin or DOACs. The primary outcome was defined as all-cause death. The secondary outcomes were defined as cardiovascular death, composite of all-cause death or cardiovascular hospitalization, and composite of stroke death or stroke related hospitalization. A one to one propensity case-matched analysis was used. Complete case analysis and multiple imputation analysis were also conducted as sensitivity analyses. Results Out of the 14,847 patients in this registry, 2,175 had AF, creatinine clearance ≥15 ml/min/1.73m2 and discharged alive. Propensity score matching yielded 475 pairs. In matching cohort, mean age was 76.5 years and 513 (54.0%) was male. Mean left ventricular ejection fraction was 48.6±16.4%. During a mean follow-up of 3.2 years, patients with DOACs had a lower incidence rate of all-cause death than those with warfarin (75.2 vs. 99.9 death per 1000 patient-years; rate ratio (RR) 0.75; 95% confidence interval [CI] 0.59–0.96; P=0.022). The incidence of cardiovascular death tended to be lower in DOAC group (30.9 vs. 43.1; incidence rate ratio 0.72; 95% CI 0.49–1.04; P=0.081). There were no significant differences in the incidence of composite of all cause death or cardiovascular hospitalization (252.3 vs. 269.4; RR 0.94; 95% CI 0.79–1.11; P=0.45) or composite of stroke death or stroke related hospitalization (13.1 vs. 16.7; RR 0.79; 95% CI 0.39–1.59; P=0.50). Cox regression model showed that DOAC was associated with lower mortality than warfarin (hazard ratio (HR) 0.75; 95% CI 0.59–0.96; P=0.023). Complete case analysis (HR 0.78; 95% CI 0.63–0.98; P=0.035) and multiple imputation analysis (HR 0.78; 95% CI 0.68–0.84; P<0.001) also showed the same results. A restricted cubic spline analysis demonstrated that the effectiveness of DOACs over warfarin waned with age, and DOACs were effective in patients younger than 80 years old. Conclusion Use of DOACs was associated with better long-term outcome in patients with HF as compared with warfarin. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development

Surgical management of pancreatic neuroendocrine liver metastases.

Pancreatic neuroendocrine tumors (PNET) are a heterogeneous group of neoplasms that vary in their clinical presentation, behavior and prognosis. The most common site of metastasis is the liver. Surgical resection of neuroendocrine liver metastases (NELM) is thought to afford the best long-term outcomes when feasible. Initial preoperative workup should include surveillance for carcinoid syndrome, screening for evidence of liver insufficiency, and performance of imaging specific to neuroendocrine tumors such as a somatostatin receptor positron emission tomography scan. Standard surgical principles apply to hepatic surgery for NELM, namely prioritizing low central venous pressure anesthesia, minimizing blood loss, knowledge of liver anatomy, generous use of intraoperative ultrasound, as well as safe parenchymal transection techniques and practices to avoid bile leakage. Knowledge of established prognostic factors may assist with patient selection, which is important for optimizing short- and long-term outcomes of hepatic resection. Adjunct therapies such as concomitant liver ablation are used frequently and are generally safe when used appropriately. For patients with synchronous resectable NELM, resection of the primary either in a staged or combined fashion is recommended. Primary tumor resection in the setting of unresectable metastatic disease is more controversial, however generally recommended if morbidity is acceptable. For patients who are not surgical candidates, due to either patient performance status or burden of liver disease, several liver-directed therapies such as transarterial embolization, chemoembolization, and radioembolization are available to assist with locoregional control, extend progression-free survival (PFS), and improve symptoms of carcinoid syndrome. Multiple systemic therapy options exist for patients with metastatic PNET which are often prioritized for those patients with advanced or progressive disease. A systematic approach in a multi-disciplinary setting is likely to result in the best long-term outcomes for patients with pancreatic NELM. Ongoing research is needed to determine the optimal patient selection for hepatic surgery as well as the ideal treatment sequencing for those patients with NELM.

Good Long-Term Outcomes in Patients With Primary Sclerosing Cholangitis Undergoing Living Donor Liver Transplantation

Primary sclerosing cholangitis (PSC) is a progressive cholestatic disorder with liver transplantation (LT) being the only definitive treatment in end-stage disease. Recurrence of PSC after LT is a significant concern which can lead to graft loss. The aim of this study is to find out the disease recurrence and long-term outcome after living donor liver transplantation (LDLT) in PSC. We conducted a retrospective review of all patients undergoing LDLT for PSC at our centre. Of 2268 adult LTs from August 2004 to July 2018, 32 (1.4%) patients underwent LDLT for PSC including 6 with PSC and autoimmune hepatitisoverlap. The data were reviewed to look for PSC recurrence, complications, and overall survival. All patients received tacrolimus-based immunosuppression. Data are shown as number, percentage, median, and interquartile range (IQR). The mean age of 32 LDLT recipients was 44±12 years (males 22, females 10). At the time of transplantation, the mean child's score was 9±1.6 and model for end-stage liver diseasescore was 18.9±6.4. Ulcerative colitiswas seen in 7 patients and none had cholangiocarcinoma. Majority of patients (n= 29) received right lobe graft and all but 3 underwent hepaticojejunostomy for biliary reconstruction. PSC recurrence was seen in 6 (20%) patients during a median follow-up of 59 (29-101) months, after exclusion of 2 patients with early mortality. A total of five patients died during follow-up, and one of these deaths was due to PSC recurrence. There were 2 perioperative deaths due to sepsis and 3 deaths on follow-up (sepsis in 2 and PSC recurrence in 1). LDLT can be performed in PSC with good overall long-term outcomes.

Hybrid esophagectomy for oesophageal cancer: long-term results. A single-centre experience.

IntroductionThe authors report long-term outcomes in patients who received neoadjuvant chemoradiotherapy and consequently underwent hybrid oesophagectomy for oesophageal cancer (OC).AimTo evaluate long-term outcomes in patients suffering from OC, who underwent hybrid oesophagectomy.Material and methodsOur cohort consisted of patients suffering from OC, who received neoadjuvant chemoradiotherapy. Hybrid esophagectomy was performed 8–10 weeks after oncological treatment.ResultsNinety-four patients underwent surgery for OC from 2011 to 2015. Histology revealed adenocarcinoma in 60.6%, squamous cell carcinoma (SCC) in 36.2%, and other type of cancer in 3.2%. Seventy-three (77.7%) patients with advanced stage (T3-4, N0-2, M0) were indicated to receive neoadjuvant chemoradiotherapy (nCRT). Trans-hiatal hybrid oesophagectomy was performed in 83 (88.3%) patients. Transthoracic hybrid oesophagectomy was performed in 11 (11.7%) patients. Histology of the resected specimens of 18 (24.7%) patients did not reveal OC, i.e. pathological complete response (pCR). In our cohort, we proved an association between occurrence of pCR and age as well as disease-free survival (DFS). The patients who presented with pCR were significantly younger – below 60 years of age (p = 0.017). They also showed significantly higher mean DFS (p = 0.004).ConclusionsCombined oesophagectomy with neoadjuvant chemoradiotherapy results in a better long-term outcome in patients suffering from oesophageal cancer. In our set of patients who underwent hybrid esophagectomy, satisfactory short-term and especially long-term results of surgical treatment for oesophageal cancer were observed.

Prognostic value of lymphadenectomy for long-term outcomes in node-negative intrahepatic cholangiocarcinoma: A multicenter study

BackgroundLymphadenectomy ensures accurate staging for patients with intrahepatic cholangiocarcinoma, especially for those without preoperatively suspected positive lymph nodes (clinically node-negative); however, its prognostic value has been poorly documented. The aim of this study was to evaluate the prognostic value of lymphadenectomy on long-term outcomes in patients undergoing surgery for clinically node-negative intrahepatic cholangiocarcinoma. MethodsData from all patients who underwent liver resection with or without lymphadenectomy for preoperatively diagnosed intrahepatic cholangiocarcinoma between 2000 and 2016 at 3 tertiary hepatobiliary centers were analyzed retrospectively. Propensity score matching in a 1:1 ratio was conducted based on clinically relevant covariates between patients with clinically node-negative intrahepatic cholangiocarcinoma who underwent liver resection with (LND group) and without (NLND group) lymphadenectomy. Overall survival and disease-free survival were compared in the matched cohort. ResultsAmong 350 patients who underwent surgery during the study period, 192 (55%) with clinically node-negative intrahepatic cholangiocarcinoma met the inclusion criteria. After propensity score matching, 2 well-balanced groups of 56 patients each were analyzed. There was no significant difference regarding postoperative variables among these 112 matched patients. Patients who underwent a liver resection with lymphadenectomy achieved better 3- and 5-year overall survival (78% and 65% vs 52% and 46%, P = .017) and disease-free survival (46% and 34% vs 31% and 31%; P = .042) compared with patients who underwent liver resection without lymphadenectomy. ConclusionLymphadenectomy can be associated with better long-term outcomes in patients with node-negative intrahepatic cholangiocarcinoma. Our data may support routine lymphadenectomy for node-negative intrahepatic cholangiocarcinoma with the objective of achieving better long-term outcomes.

Long-term Clinical Outcomes of Ahmed and Baerveldt Drainage Device Surgery for Pediatric Glaucoma Following Cataract Surgery.

In this retrospective case series, both Baerveldt and Ahmed glaucoma drainage devices resulted in good long-term outcomes in eyes with pediatric glaucoma following cataract surgery (GFCS). The aim of this study was to describe the long-term safety and efficacy of primary glaucoma drainage device surgery in patients with pediatric GFCS. We retrospectively identified 28 eyes of 28 patients with GFCS that underwent tube shunt surgery with the Ahmed Glaucoma Valve or Baerveldt Glaucoma Implant. The primary outcome measure was a surgical failure, defined as intraocular pressure (IOP) >21 mm Hg or not reduced by 20% below baseline on 2 consecutive follow-up visits after 3 months, IOP <5 mm Hg on 2 consecutive follow-up visits after 3 months, and reoperation for glaucoma. The mean duration between cataract removal and the diagnosis of glaucoma was 3.6±1.5 years. Kaplan-Meier survival curves indicated a mean time to failure of 41.9±2.1 months after drainage device surgery. The cumulative probability of failure at 1, 2, 3, and 4 years was 3.6%, 19%, 28%, and 28%. IOP was significantly decreased from 29.3±4.1 mm Hg preoperatively to 17.6±1.6 mm Hg at the final follow-up visit (P<0.001). The number of glaucoma medications at baseline was 3.1±0.6, which decreased to 2.1±0.7 at the final visit (P=0.001). Glaucoma drainage device surgery results in good long-term outcomes in patients with GFCS.

Improvement of Superomedial Breast Reduction and Mastopexy with a New "Hammock" Flap.

Background:Oncoplastic breast reduction shares similar aims and principles with esthetic surgery. Superomedial breast reduction provides harmony, symmetry, and satisfactory lower pole projection, but long-term outcomes are not consistently good. We describe our experience with a new hammock-shaped flap, which was combined with superomedial pedicle breast reduction to improve long-term outcomes by enhancing pedicle support and preventing ptosis recurrence.Methods:From January 2017 to June 2018, 10 patients underwent unilateral breast reduction (n = 7) or bilateral esthetic reduction (n = 3) by a novel approach combining a superomedial pedicle and a perforator-based inferior advancement flap. The flap is based on the inframammary fold (IMF) and fixed to the pectoralis major fascia and the pedicle like a hammock. Preoperative and postoperative (1, 3, 6, 12, and 18 months) measurements included sternal notch-to-superior areola border length, nipple-to-IMF length, and lower pole convexity. Patients rated their satisfaction with breast shape, size, nipple-areola complex position, and lower pole projection at 12 months using a condensed form of the BREAST-Q questionnaire.Results:Esthetic outcomes at 12 and 18 months were good in all patients. There were no complications. Postoperative measurements were stable throughout follow-up. The BREAST-Q scores indicated that most patients were satisfied or very satisfied with their breast(s).Conclusions:This preliminary series demonstrates that the hammock flap, which is performed with autologous tissue, allows changing IMF position, it is safe, effective, and provides improved pedicle fixation and positioning. This technical refinement seems to afford good long-term outcomes in patients undergoing superomedial pedicle breast reduction and mastopexy.

Electrocardiographic Left Ventricular Hypertrophy Is Independently Associated With Better Long-Term Outcomes in Dilated Cardiomyopathy Patients.

Background: Electrocardiogram (ECG) findings of left ventricular hypertrophy (LVH; ECG-LVH) are observed in patients with dilated cardiomyopathy (DCM), but the prognostic importance is unclear. The present study assessed the impact of QRS voltage on long-term outcomes, including mortality and rehospitalization, in patients with DCM using a database of patients hospitalized for worsening heart failure (HF).Methods and Results: We analyzed a total of 261 patients with DCM in the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD), a prospective cohort studying the characteristics and treatments in a broad sample of HF patients. ECG-LVH were diagnosed according to the Sokolow-Lyon voltage criteria. A total of 81 patients (31.0%) had ECG-LVH. During a mean follow-up period of 1.8 years, patients with ECG-LVH had a lower rate of all-cause death (9.0% vs. 20.3%, P=0.029) and composite of all-cause death and rehospitalization due to worsening HF (26.9% vs. 45.9%, P=0.007) than those without it. After multivariable adjustment, ECG-LVH was an independent negative predictor for the risk of composite all-cause death and rehospitalization (hazard ratio, 0.358; 95% CI: 0.157–0.857, P=0.049).Conclusions: ECG-LVH were independently associated with better long-term outcome in patients with DCM.

Left ventricular reverse remodelling predicts long-term outcomes in patients with functional mitral regurgitation undergoing MitraClip therapy: results from a multicentre registry.

To explore whether left ventricular reverse remodelling (LVRR) is a predictor of outcomes in patients with functional mitral regurgitation (FMR) undergoing MitraClip procedure. We analysed 184 consecutive patients with FMR who underwent successful MitraClip procedure. LVRR was defined as a reduction in left ventricular end-systolic volume ≥ 10% from baseline to 6 months. LVRR was observed in 79 (42.9%) patients. Compared with non-LVRR, LVRR patients were more likely to be females, less likely to have an ischaemic aetiology of mitral regurgitation or a prior (<6 months) heart failure (HF) hospitalization, and had smaller left ventricular dimensions. New York Heart Association class improved from baseline up to 1-year follow-up in both groups. Higher rates of overall survival (87.3% vs. 75.2%, P = 0.039), freedom from HF hospitalization (77.2% vs. 60%, P = 0.020), and freedom from the composite endpoint (cardiovascular mortality or HF hospitalization) (74.7% vs. 55.2%; P = 0.012) were observed in LVRR vs. non-LVRR patients at 2-year follow-up. LVRR was associated with a significant reduction of the adjusted relative risk of mortality, HF hospitalization and composite endpoint [hazard ratio (HR) 0.44; 95% confidence interval (CI) 0.20-0.96, P = 0.040; HR 0.55; 95% CI 0.32-0.97, P = 0.038; and HR 0.54; 95% CI 0.32-0.92, P = 0.023, respectively]. Female gender, absence of diabetes, freedom from prior HF hospitalization, non-ischaemic aetiology of mitral regurgitation, and left ventricular end-diastolic diameter < 75 mm were found to be independent predictors of LVRR. Left ventricular reverse remodelling is associated with better long-term outcomes in patients with FMR successfully treated with MitraClip. A careful patient selection may be useful as specific baseline features predict favourable left ventricular remodelling. [Correction added on 17 January 2019, after online publication: the preceding sentence has been changed.].

Higher Thioguanine Nucleotide Metabolite Levels are Associated With Better Long-term Outcomes in Patients With Inflammatory Bowel Diseases.

The aim of this study was to assess whether sustained 6-thioguaninenucleotide (6-TGN) levels were associated with improved long-term outcomes in patients with inflammatory bowel diseases (IBD). Cross-sectional data have shown that thiopurine metabolites are correlated with clinical efficacy in patient receiving thiopurines for IBD but the role for serial measurements through treatment course is unclear. We conducted a retrospective cohort study including patients with IBD on thiopurine monotherapy and had serial 6-TGN levels measured. Predictive variables included demographics, disease phenotype, 6-TGN levels (nadir, median, and peak levels). The primary outcome was the development of a disease relapse. The secondary outcome was the need for IBD surgery. Two hundred eighteen 6-TGN samples from 87 patients were analyzed. Nadir and median 6-TGN levels were significantly higher in patients who did not relapse [185 and 233 pmol per 8×10 red blood cells (RBCs)] as compared with levels in patients who did relapse (150 and 167 pmol per 8×10 RBCs, P=0.025) but there was no significant difference in peak 6-TGN level. When adjusted for confounding factors, a nadir 6-TGN level ≥161 and a median 6-TGN level ≥264 were associated with a significant decrease in the rate of disease exacerbation (hazard ratio: 0.5; 95% confidence interval, 0.26-0.87; P=0.016 and hazard ratio: 0.4; 95% confidence interval, 0.2-0.82; P=0.14). Serial thiopurine metabolite level assessments and dose adjustment aiming to maintain higher 6-TGN levels may be helpful to improve long-term outcomes in patients with IBD.

Impact of Different Types of Statins on Clinical Outcomes in Patients Hospitalized for Ischemic Heart Failure.

Introduction:The effect of statins on risk of heart failure (HF) hospitalization and lethal outcome remains dubious. Aim:To investigate whether statin therapy improves clinical outcomes in patients hospitalized for ischemic heart failure (HF), to compare the efficacy of lipophilic and hydrophilic statins and to investigate which statin subtype provides better survival and other outcome benefits. Material and Methods:Total amount of 155 patients in the study were admitted to the Clinic for Cardiology, Rheumatology and Vascular diseases in Clinical Center University of Sarajevo in the period from January 2014- December 2017. Inclusion criteria was HF caused by ischemic coronary artery disease upon admission. For each patient the following data were obtained: gender, age, comorbidities and medications on discharge. New York Heart Association (NYHA) class for heart failure was determined by physician evaluation and left ventricle ejection fraction (LVEF) was determined by echocardiography. The patients were followed for a period of two years. Outcome points were: rehospitalization, in-hospital death, mortality after 6 months, 1 year and 2 years. All-cause mortality included cardiovascular events or worsening heart failure. Results:Overall, 58.9% of HF patients received statin therapy, with 33.9% patients receiving atorvastatin and 25.0% rosuvastatin therapy. The most frequent rehospitalization was in patients without statin therapy (66.7%), followed by patients on rosuvastatin (64.1%), and atorvastatin (13.2%), with statistically significant difference p = 0.001 between the groups. Mortality after 6 months, 1 year and 2 years was the most frequent in patients without statin therapy with a statistically significant difference (p = 0.001). Progression of HF accounted for 31.7% of mortality in patients without statin therapy, 12.8% in patients on rosuvastatin therapy and 3.8% in patients on atorvastatin therapy (p = 0.004). Conclusion:Lipophilic statin therapy is associated with substantially better long-term outcomes in patients with HF.

An Outcomes-Based Definition of Proteinuria Remission in Focal Segmental Glomerulosclerosis.

Proteinuria is used as an indicator of FSGS disease activity, but its use as a clinical trial end point is not universally accepted. The goal of this study was to refine proteinuria definitions associated with long-term kidney survival. Data on 466 patients with primary FSGS with proteinuria (urine protein-to-creatinine ratio >1 g/g) were analyzed from five independent cohorts. Proteinuria by months 1, 4, and 8 after study baseline was categorized by conventional definitions of complete (<0.3 g/g) and partial remission (<3.5 g/g and 50% reduction in proteinuria). Novel remission definitions were explored using receiver operating curves. Kaplan-Meier methods were used to estimate the associations of proteinuria with progression to ESRD or a 50% loss in kidney function. Propensity score-adjusted Cox proportional hazards models were used to adjust for baseline proteinuria, eGFR, and therapy. In the initial derivation cohort, conventional partial remission was not associated with kidney survival. A novel definition of partial remission (40% proteinuria reduction and proteinuria<1.5 g/g) on the basis of receiver operating curve analyses of 89 patients was identified (Sensitivity=0.70; Specificity=0.77). In the validation cohort analyses, complete remission was associated with better prognosis (6 out of 41 patients progressed to kidney failure; 6.6 per 100 patient-years) as was the novel partial remission (13 out of 71 progressed; 8.5 per 100 patient-years), compared with those with no response (51 out of 116 progressed; 20.1 per 100 patient-years). Conventional partial remission at month 8, but not month 4, was also associated with better response (19 out of 85 patients progressed; risk=10.4 per 100 patient-years). Propensity score-adjusted analyses showed the novel partial remission was associated with less progression at months 4 and 8 (month 4: hazard ratio, 0.50; P=0.01; month 8: hazard ratio, 0.30; P=0.002). Reaching either a complete or partial remission using a novel or conventional definition was associated with better long-term outcomes in patients with FSGS. This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_02_20_CJASNPodcast_18_3_T.mp3.

Abstract 12767: Trajectory of Exercise Capacity in Childhood and Its Impact on Their Adult Pathophysiology in Patients After the Fontan Operation

Background: Preserved exercise capacity in childhood may predict better long-term outcome in patients after the Fontan operation. Purpose: This study was to elucidate an impact of trajectory of exercise capacity in childhood on the long-term exercise capacity and non-cardiac multi-organ function. Method and Results: Since 1990, consecutive 197 Fontan patients had undergone two serial cardiopulmonary exercise testing (CPX) at the age of 8±2 and 14±2 years and we measured the change in %-predicted peak oxygen uptake (dPVO 2 : %). Of these, 94 patients had performed CPX in the adulthood (24±4 years). Our patients were subdivided into 2 groups; those with positive dPVO 2 (n=113, group I) and those with negative dPVO 2 (n=84, group D). Early era at operation, heterotaxy, protein losing enteropathy, high PVO 2 and plasma brain natriuretic peptide levels (BNP) at 1 st CPX had independent negative impact on dPVO 2 (p&lt;0.05-0.0001). Group I showed significantly higher PVO 2 and lower BNP in their adulthood, while 49 clinical events, including 9 deaths occurred after 2 nd CPX. When compared with group I, group D had high hazard ratio of 2.1 and 6.5 for morbidity and mortality, respectively (p&lt;0.05 for both); however, there were no differences in high prevalence of impaired glucose tolerance, liver MELD XI score, or 24-hour creatinine clearance between two groups in their adulthood. Conclusions: The trajectory of exercise capacity in childhood is improving in current Fontan children which is associated with better prognosis, higher PVO 2 and lower BNP in the adulthood. However, the non-cardiac multi-organ dysfunction may progress regardless of the trajectory.

Reply

We thank Dai et al1Dai C. et al.Clinical Gastroenterol Hepatol. 2016; ([Epub ahead of print])Google Scholar for their interest in our meta-analysis analyzing long-term outcomes in patients with active ulcerative colitis (UC) who achieve endoscopic mucosal healing compared with those who do not.2Shah S.C. et al.Clin Gastroenterol Hepatol. 2016; ([Epub ahead of print])Google Scholar Based on our findings that achieving endoscopic healing is associated with long-term clinical remission, avoidance of colectomy, and corticosteroid-free clinical remission in UC, we believe that endoscopic healing is a reasonable target for clinical practice and should be a therapeutic goal in conjunction with control of symptoms. This may be adequately assessed by flexible sigmoidoscopy, given the findings of a recent study showing a high degree of correlation between flexible sigmoidoscopy and colonoscopy in patients with UC with respect to endoscopic activity and assessment of endoscopic healing.3Colombel J.F. et al.Gastroenterology. 2016; 150: 389-395Google Scholar Flexible sigmoidoscopy permits objective evaluation of treatment and is likely more acceptable to patients, providers, and payees than full colonoscopy for assessment of endoscopic healing. We agree with Dai et al1Dai C. et al.Clinical Gastroenterol Hepatol. 2016; ([Epub ahead of print])Google Scholar some unresolved issues remain, as outlined in our article, including the need for a consistent definition of mucosal healing and determination of the degree of healing needed to label the mucosa as healed. Distinction should be made between endoscopic healing (which was the topic of our meta-analysis) and mucosal healing, which may imply histologic healing.4Peyrin-Biroulet L. et al.Clin Gastroenterol Hepatol. 2014; 12: 929-934Google Scholar Furthermore, the degree of endoscopic healing needed to achieve long-term clinical benefit is unclear and whether it is indeed necessary to target complete endoscopic healing according to the stricter definition of endoscopic subscore of 0, or complete absence of ulcerations. Some observational data suggest better long-term outcomes in patients with UC achieving endoscopic subscore 0 versus 1.5Colombel J.F. et al.Gastroenterology. 2011; 141: 1194-1201Google Scholar, 6Manginot C. et al.Gut. 2015; 64: 1181-1182Google Scholar Unfortunately, there was only 1 study included within our meta-analysis that stratified outcomes according to endoscopic subscores 0 versus 1, thus precluding meta-analysis of this outcome.2Shah S.C. et al.Clin Gastroenterol Hepatol. 2016; ([Epub ahead of print])Google Scholar Although Dai et al7Dai C. et al.PLoS One. 2014; 9: e110797Google Scholar found that achieving mucosal (endoscopic) healing did not predict sustained remission in patients stopping infliximab after 1 year, there are data suggesting that patients who achieve deep remission (including clinical remission and biochemical improvement with normalized C-reactive protein in addition to endoscopic remission) are more likely to maintain clinical remission when anti–tumor necrosis factor is discontinued.8Louis E. et al.Gastroenterology. 2012; 142: 63-70Google Scholar Finally, we acknowledge that inflammation may persist despite achieving both clinical and endoscopic remission. We agree with Dai et al that the clinical benefit of achieving endoscopic and histologic healing is an unanswered question and welcome prospective clinical trials aiming to determine whether adjusting therapy to target endoscopic and/or histologic healing in UC (and Crohn’s disease) is associated with improved long-term clinical outcomes. There are emerging data showing that patient-reported symptoms, such as stool frequency and rectal bleeding, persist despite endoscopic healing and histologic inactivity, suggesting that perhaps noninflammatory changes and/or bowel damage may underlie symptom persistence in the absence of disease activity endoscopically and histologically.9Colombel JF, et al. Presented at Digestive Disease Week, May 21–24, 2016.Google Scholar We are hopeful that the recent Food and Drug Administration mandate that clinical trials of inflammatory bowel disease therapies now include endoscopic outcomes will help corroborate or refute our findings that achieving endoscopic healing is associated with improved long-term outcomes of patients with active UC.2Shah S.C. et al.Clin Gastroenterol Hepatol. 2016; ([Epub ahead of print])Google Scholar Mucosal Healing in the Treatment of Ulcerative Colitis: A Reliable Target?Clinical Gastroenterology and HepatologyVol. 14Issue 9PreviewWe read with interest the article by Shah et al1 comparing long-term outcomes of patients with ulcerative colitis (UC) with mucosal healing (MH) with those without MH. They found that MH is associated with long-term clinical remission, avoidance of colectomy, and corticosteroid-free clinical remission in UC. The results affirm the view of many gastroenterologists about the importance of MH as a positive predictive factor in the course of UC. This meta-analysis raises the question of whether MH should be the treatment goal in UC. Full-Text PDF

Limitations of the barcelona clinic liver cancer staging system with a focus on transarterial chemoembolization as a key modality for treatment of hepatocellular carcinoma.

Limitations of the barcelona clinic liver cancer staging system with a focus on transarterial chemoembolization as a key modality for treatment of hepatocellular carcinoma.

Transarterial radioembolization vs chemoembolization for hepatocarcinoma patients: A systematic review and meta-analysis.

To compare the efficacy and safety of yttrium-90 radioembolization (Y90RE) and transarterial chemoembolization (TACE) in hepatocellular carcinoma patients. Bibliographic research was conducted on main scientific databases. When there was no statistically significant heterogeneity, pooled effects were calculated using a fixed-effects model by means of Mantel-Haenszel test, otherwise, a random-effects model was used with DerSimonian and Laird test. Summary estimates were expressed in terms of odds ratios (ORs) and 95%CI. The probability of publication bias was assessed using funnel plots and with Begg and Mazumdar's test. Sensitivity analysis was finally conducted using the method of excluding extreme data. A total of 10 studies were analyzed, of which 2 randomized controlled trials. Survival rate (SR) assessed at 1 year showed an absolute similarity between the two treatment groups (OR = 1.01, 95%CI: 0.78-1.31, P = 0.93). As long as time elapsed since the treatment, ORs for survival rate tended to significantly increase, thus meaning better long-term outcomes in patients who underwent Y90RE (2-year SR: OR = 1.43, 1.08-1.89, P = 0.01; 3-year SR: OR = 1.48, 1.03-2.13, P = 0.04). Meta-analysis of plotted hazard ratios (HRs) determined a non-significant overall estimate in favor of Y90RE (HR = 0.91, 0.80-1.04, P = 0.16). Y90RE showed a statistically significant benefit as compared to TACE in terms of higher progression-free survival rate assessed at 1 year (OR = 1.67; 95%CI: 1.10-2.55; P = 0.02). Pooled analyses do not revealed a statistically significant increase in OR for tumor objective responses after Y90RE with respect to TACE (OR = 1.22, 95%CI: 0.69-2.16, P = 0.50). A non-significant trend in favor of Y90RE was observed according to adverse event rate (OR = 0.70, 0.38-1.30, P = 0.26). Our meta-analysis reveals that Y90RE and TACE show similar effects in terms of survival, response rate and safety profile, although tumor progression is delayed after radioembolization.

Palliative Stent Insertion for Acute Malignant Colorectal Obstruction: Long-term Patency and Survival.

To investigate the long-term outcome of palliative stent insertion for acute malignant colorectal obstruction. From May 2009 to February 2015, consecutive patients with acute malignant colorectal obstruction underwent palliative stent insertion in our center. Technical success, clinical success, and long-term outcomes were analyzed retrospectively. A total of 45 patients with acute malignant colorectal obstruction underwent palliative stent insertion. Technical success was achieved in 42 of 45 patients. Clinical success was achieved in 41 of 42 patients. During a follow-up of 5 days to 25 months (mean, 6.9±4.5 mo), the cumulative 6- and 12-month patency rates were 88.6% and 72.7%, respectively. The cumulative 6- and 12-month survival rates were 60.1% and 14.3%, respectively. The independent predictor of prolonging survival was subsequent chemotherapy after stenting (P=0.017). Palliative colorectal stent insertion can provide a good long-term outcome in patients with malignant colorectal obstruction.

Contemporary Outcomes for Open Infrainguinal Bypass in the Endovascular Era

The role of infrainguinal bypasses in this era of increasing endovascular interventions remains the subject of significant debate. In this study, we evaluate contemporary long-term outcomes of lower-extremity open revascularization for peripheral arterial disease (PAD). We evaluated all patients who underwent infrainguinal bypass with autogenous vein conduits for claudication or critical limb ischemia in our institution between January 1st, 2007 and July 31st, 2014. Kaplan-Meier and Cox regression analyses were used to evaluate graft failure and identify its predictors. Outcomes were defined per the Society for Vascular Surgery standards. There were 428 autogenous vein grafts (femoro-popliteal: 32%, femoro-tibial: 39%, popliteo-tibial: 27%, and tibio-tibial: 2%) placed in 368 patients (mean age of 67 ± 11.4 years). Most patients were male (59%), white (73%), and presented with critical limb ischemia (81%). Sixty-five cases (15%) were redo bypasses. Arm veins and spliced vein conduits were used in 15% and 14% of cases, respectively. Primary patency at 1, 3, and 5 years was 66%, 59%, and 55%, respectively. Primary-assisted patency was 78%, 69%, and 64% at 1, 3, and 5 years, respectively. Secondary patency was 88%, 84%, and 82% at 1, 3, and 5 years, respectively. Patency was higher for grafts harvested from the lower versus upper extremities and for proximal versus distal bypass (all P < 0.05). Limb salvage rate was 88% after a mean follow-up of 2 ± 1.8 years. Significant predictors of graft failure were younger age, diabetes mellitus, and hyperlipidemia (all P < 0.05). In this contemporary cohort of patients, we have demonstrated that infrainguinal bypass for lower-extremity revascularization has good long-term outcomes in patients with symptomatic PAD. Patency and limb salvage rates are optimized with careful selection of autogenous conduits, close monitoring of high-risk groups and management of comorbidities.

Comparison of Five-Year Outcome of Percutaneous Coronary Intervention With Coronary Artery Bypass Grafting in Triple-Vessel Coronary Artery Disease (from the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2)

Studies evaluating long-term (≥5 years) outcomes of percutaneous coronary intervention (PCI) using drug-eluting stents compared with coronary artery bypass grafting (CABG) in patients with triple-vessel coronary artery disease (TVD) are still limited. We identified 2,978 patients with TVD (PCI: n = 1,824, CABG: n = 1,154) of 15,939 patients with first coronary revascularization enrolled in the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2. The primary outcome measure in the present analysis was a composite of death, myocardial infarction (MI), and stroke. Median follow-up duration for the surviving patients was 1,973 days (interquartile range 1,700 to 2,244). The cumulative 5-year incidence of death/MI/stroke was significantly higher in the PCI group than in the CABG group (28.2% vs 24.0%, log-rank p = 0.006). After adjusting for confounders, the excess risk of PCI relative to CABG for death/MI/stroke remained significant (hazard ratio [HR] 1.38, 95% confidence interval [CI] 1.13 to 1.68, p = 0.002). The excess risks of PCI relative to CABG for all-cause death, MI, and any coronary revascularization were also significant (HR 1.38, 95% CI 1.10 to 1.74, p = 0.006; HR 2.81, 95% CI 1.69 to 4.66, p <0.001; and HR 4.10, 95% CI 3.32 to 5.06, p <0.001, respectively). The risk for stroke was not significantly different between the PCI and CABG groups (HR 0.88, 95% CI 0.61 to 1.26, p = 0.48). There were no interactions for the primary outcome measure between the mode of revascularization (PCI or CABG) and the subgroup factors such as age, diabetes, and Synergy Between PCI With Taxus and Cardiac Surgery score. In conclusion, CABG compared with PCI was associated with better long-term outcome in patients with TVD.

Long-term outcome of nasopharyngeal carcinoma treated with reduced-volume intensity-modulated radiotherapy and chemotherapy

Objective To analyze the long-term outcome of nasopharyngeal carcinoma (NPC)patients treated with intensity-modulated radiotherapy (IMRT) with reduced clinical target volume (CTV)and to provide a basis for the application of reduced-volume IMRT in the treatment of NPC.Methods Between November 2003 and April 2007,413 patients with NPC were treated with IMRT according our institutional protocol.The median age was 45 years;the patients included 311 males and 102 females.Of all patients,3(0.7％) had stage Ⅰ NPC,66(16％) had stage Ⅱ NPC,235(56.9％) had stage Ⅲ NPC,78(18.9％) had stage Ⅳa NPC,and 31 (7.5％) had stage Ⅳb NPC,according to the 6th edition of AJCC staging system.IMRT was delivered as follows:GTV 66.00-69.75 Gy/30-33 f; CTV-1 60.00-66.65Gy/30-33 f; CTV-2/CTV-N 54.0-55.8 Gy/30-33 f.A total of 336 patients received cisplatin-based chemotherapy in addition to IMRT.Results The follow-up rate was 100％.With a median follow-up of 72months,the 5-year overall survival (OS),local control,loco-regional recurrence-free survival,distant metastasis-free survival (DMFS),and disease-free survival rates were 80％,93％,96％,81％,and 75％,respectively.The multivariate analysis revealed that T stage,N stage,and age were independent prognostic factors for OS (P =0.001,0.001,0.002) ; T stage and N stage were independent prognostic factors for DMFS (P =0.000,0.001).Among patients with stage Ⅲ and Ⅳ NPC,the 5-year OS rate was nonsignificantly higher in those treated with induction chemotherapy than in those not treated with induction chemotherapy (78％ vs.68％,P =0.053),but the 5-year DMFS rate was significantly lower in those treated with adjuvant chemotherapy than in those not treated with adjuvant chemotherapy (65％ vs.83％,P =0.003).Conclusions IMRT with reduced CTV is safe and reliable and can lead to a good long-term outcome in patients with NPC. Key words: Nasopharyngeal neoplasms/intensity-modulated radiotherapy; Nasopharyngeal neoplasms/chemotherapy ; Prognosis