Independent Predictors Of Failure Research Articles

Volume analysis of outcome following restorative proctocolectomy

This observational study aimed to determine national provision and outcome following pouch surgery (restorative proctocolectomy, RPC) and to examine the effect of institutional and surgeon caseload on outcome. All patients undergoing primary RPC between April 1996 and March 2008 in England were identified from the administrative database Hospital Episode Statistics. Institutions and surgeons were categorized according to the total RPC caseload performed over the study interval. Some 5771 primary elective pouch procedures were undertaken at 154 National Health Service hospital trusts. Median follow-up was 65 (interquartile range (i.q.r.) 28-106) months. The 30-day in-hospital mortality rate was 0·5 per cent and the 1-year overall mortality rate 1·5 per cent. Some 30·5 per cent of trusts performed fewer than two procedures per year, and 91·4 per cent of surgical teams (456 of 499) carried out 20 or fewer RPCs over 8 years. Median surgeon volume was 4 (i.q.r. 1-9) cases. Failure occurred in 6·4 per cent of cases. Low-volume surgeons operated on more patients at the extremes of age (P < 0·001) and a lower proportion with ulcerative colitis (P < 0·001). Older age, increasing co-morbidity, increasing social deprivation, and both lower provider and surgeon caseload were independent predictors of longer length of stay. Older patient age and low institutional volume status were independent predictors of failure. Many English institutions and surgeons carry out extremely low volumes of RPC surgery. Case selection differed significantly between high- and low-volume surgeons. Institutional volume and older age were positively associated with increased pouch failure.

Obstructive Sleep Apnea in Patients with Persistent Atrial Fibrillation Is Independent Predictor for Failure of Biatrial Ablation

Background: Recent investigations demonstrated that obstructive sleep apnea (OSA) is an important precipitating factor of atrial fibrillation (AF). This study attempts to determine whether OSA can affect success rate of biatrial ablation in patients with persistent AF. Method: Fifty-six patients with longstanding persistent atrial fibrillation (LPAF) (Mean age 57±9.9) had undergone radiofrequency catheter ablation (RFCA) including pulmonary vein isolation and 3-D complex fractionated atrial electrogram (CFAE) guided ablation at both atria. OSA was assessed by the Berlin Questionnaire (BQ). The primary endpoints during RF ablation were defined as complete elimination of the areas with CFAEs and conversion of AF to sinus rhythm. Result: Compared to patients with LPAF termination by biatrial ablation, patients who did not terminate AF (n=28, 50%) had a higher pulmonary pressure [33.1±6.4 mmHg vs. 29.0±3.5 mmHg, p=0.012] and greater number of the patients for high risk of OSA (n=17, 73.3%, vs. n=11, 41.5%, p=0.032]. Univariate analysis revealed that age (OR 0.94, p=0.038), pulmonary arterial pressure (OR 1.19, p=0.023) and high risk for OSA (OR 3.38, p=0.04) were related with failure of biatrial ablation. On multivariate analysis, age (OR 0.842, CI: 0.74–0.96, p=0.01) and high risk for OSA (OR 11.9, CI: 1.1–129.2, p=0.04) were independent predictors for RFCA failure. Conclusion: High risk for OSA predicts RFCA failure after extensive biatrial ablation in patients with LPAF.

Intermediate to Long-Term Results Following the Bernese Periacetabular Osteotomy and Predictors of Clinical Outcome

The Bernese periacetabular osteotomy is a commonly used non-arthroplasty option to treat developmental hip dysplasia in symptomatic younger patients. Predicting which hips will remain preserved and which hips will go on to require arthroplasty following periacetabular osteotomy is a major challenge. In the present study, we assessed the intermediate to long-term results following periacetabular osteotomy to demonstrate the clinical outcomes for patients with varying amounts of dysplasia and arthritis. From these results, a probability-of-failure analysis was conducted to predict the likelihood of hip preservation and to improve surgical decision-making. Of the 189 hips (in 157 patients) that were treated with periacetabular osteotomy by a single surgeon from May 1991 to September 1998, thirty-one had diagnoses other than developmental hip dysplasia and twenty-three were lost to follow-up. The remaining 135 hips (in 109 patients) were retrospectively reviewed at an average of nine years. Hips were evaluated with use of the pain subscale of the Western Ontario and McMaster Universities Osteoarthritis Index postoperatively as well as with radiographs that were made preoperatively and at one and more than five years postoperatively. Osteotomy failure was defined as a pain score of ≥10 or the need for total hip arthroplasty. One hundred and two hips (76%) remained preserved at an average of nine years, with an average Western Ontario and McMaster Universities pain score of 2.4 of 20. Thirty-three hips (24%) met the failure criteria: seventeen underwent arthroplasty at an average of 6.1 years after the osteotomy, and sixteen had a postoperative pain score of ≥10. Kaplan-Meier analysis with arthroplasty as the end point revealed a survival rate of 96% (95% confidence interval, 93% to 99%) at five years and 84% (95% confidence interval, 77% to 90%) at ten years. Complications occurred in twenty hips. Fifteen hips (11%) were treated with a subsequent arthroscopy because of chondral and/or labral lesions at an average of 6.8 years after the osteotomy. Two independent predictors of failure (defined as arthroplasty or a high pain score) were identified: (1) an age of more than thirty-five years and (2) poor or fair preoperative joint congruency. The probability of failure requiring arthroplasty was 14% for hips with no predictors of failure, 36% for those with one predictor (either an age of more than thirty-five years or poor or fair joint congruency), and 95% for those with both predictors. The Bernese periacetabular osteotomy can be effective for the treatment of painful hip dysplasia, but complications may be expected in as many as 15% of cases. The ideal candidate is the patient who is less than thirty-five years of age and who has good or excellent hip joint congruency.

10-Year Experience With I-125 Prostate Brachytherapy at the Princess Margaret Hospital: Results for 1,100 Patients

To report outcomes for 1,111 men treated with iodine-125 brachytherapy (BT) at a single institution. A total of 1,111 men (median age, 63) were treated with iodine-125 prostate BT for low- or intermediate-risk prostate cancer between March 1999 and November 2008. Median prostate-specific antigen (PSA) level was 5.4 ng/ml (range, 0.9-26.1). T stage was T1c in 66% and T2 in 34% of patients. Gleason score was 6 in 90.1% and 7 or 8 in 9.9% of patients. Neoadjuvant hormonal therapy (2-6 months course) was used in 10.1% of patients and combined external radiotherapy (45 Gy) with BT (110 Gy) in 4.1% (n = 46) of patients. Univariate and multivariate Cox proportional hazards were used to determine predictors of failure. Median follow-up was 42 months (range, 6-114), but for biochemical freedom from relapse, a minimum PSA test follow-up of 30 months was required (median 54; n = 776). There were 27 failures, yielding an actuarial 7-year disease-free survival rate of 95.2% (96 at risk beyond 84 months). All failures underwent repeat 12-core transrectal ultrasound -guided biopsies, confirming 8 local failures. On multivariate analysis, Gleason score was the only independent predictor of failure (p = 0.001; hazard ratio, 4.8 (1.9-12.4). Median International Prostate Symptom score from 12 to 108 months ranged between 3 and 9. Of the men reporting baseline potency, 82.8% retained satisfactory erectile function beyond 5 years. Iodine-125 prostate BT is a highly effective treatment option for favorable- and intermediate-risk prostate cancer and is associated with maintenance of good urinary and erectile functions.

HUMORAL IMMUNITY AGAINST HEPATITIS B, TETANUS, AND DIPHTHERIA FOLLOWING CHEMOTHERAPY FOR HEMATOLOGIC MALIGNANCIES: A Report and Review of Literature

Malignancy and its treatment are major causes of secondary immunodeficiency in childhood. The authors investigated the effects of chemotherapy on humoral immunity against hepatitis B, tetanus, and diphtheria in children with hematologic malignancies. The authors recruited 54 patients with hematologic malignancies after the completion of chemotherapy (group A), 25 patients with newly diagnosed hematologic malignancies before initiation of chemotherapy (group B), and 74 healthy controls (group C). All participants had been vaccinated against hepatitis B, tetanus, and diphtheria according to the Iranian national vaccination scheme. Patients in group A achieved protective levels of diphtheria and hepatitis B antibodies significantly less frequently than the other 2 groups and protective levels of tetanus antibody significantly less frequently than group C (P <.05). After controlling for age, the association observed for tetanus lost its significance, but chemotherapy was a significant and independent predictor of failure to achieve protective levels of antibodies against diphtheria (odds ratio [OR] = 7.7, P < .001) and hepatitis B (OR = 3.13, P = .008). These results indicate that chemotherapy has independent adverse effects on vaccine-induced antibody protection against diphtheria and hepatitis B.

Midline fascial plication under continuous digital transrectal control: which factors determine anatomic outcome?

Introduction and hypothesisThe aim of the study was to report anatomic and functional outcome of midline fascial plication under continuous digital transrectal control and to identify predictors of anatomic failure.MethodsProspective observational cohort. Anatomic success defined as POP-Q stage ≤ I of the posterior compartment. Validated questionnaires to measure bother and impact on quality of life. Logistic regression to identify risk factors for anatomic failure.ResultsTwo hundred thirty-three patients with posterior pelvic organ prolapse (POP) stage ≥ II underwent midline fascial plication under continuous digital transrectal control. Median follow-up was 14 months (12–35 months), and anatomic success was 80.3% (95% CI 75–86). Independent predictors of failure were posterior compartment POP stage ≥ III [OR 8.7 (95% CI 2.7–28.1)] and prior colposuspension [OR 5.6 (95% CI 1.1–27.8)]. Sixty-three percent of patients bothered by obstructed defaecation experienced relief after surgery.ConclusionsAnatomic and functional outcomes were good. Risk factors for anatomic failure were initial size of posterior POP (stage ≥ III) and prior colposuspension.

Intermediate to Long-Term Results Following the Bernese Periacetabular Osteotomy and Predictors of Clinical Outcome

The Bernese periacetabular osteotomy is a commonly used non-arthroplasty option to treat developmental hip dysplasia in symptomatic younger patients. Predicting which hips will remain preserved and which hips will go on to require arthroplasty following periacetabular osteotomy is a major challenge. In the present study, we assessed the intermediate to long-term results following periacetabular osteotomy to demonstrate the clinical outcomes for patients with varying amounts of dysplasia and arthritis. From these results, a probability-of-failure analysis was conducted to predict the likelihood of hip preservation and to improve surgical decision-making. Of the 189 hips (in 157 patients) that were treated with periacetabular osteotomy by a single surgeon from May 1991 to September 1998, thirty-one had diagnoses other than developmental hip dysplasia and twenty-three were lost to follow-up. The remaining 135 hips (in 109 patients) were retrospectively reviewed at an average of nine years. Hips were evaluated with use of the pain subscale of the Western Ontario and McMaster Universities Osteoarthritis Index postoperatively as well as with radiographs that were made preoperatively and at one and more than five years postoperatively. Osteotomy failure was defined as a pain score of >or=10 or the need for total hip arthroplasty. One hundred and two hips (76%) remained preserved at an average of nine years, with an average Western Ontario and McMaster Universities pain score of 2.4 of 20. Thirty-three hips (24%) met the failure criteria: seventeen underwent arthroplasty at an average of 6.1 years after the osteotomy, and sixteen had a postoperative pain score of >or=10. Kaplan-Meier analysis with arthroplasty as the end point revealed a survival rate of 96% (95% confidence interval, 93% to 99%) at five years and 84% (95% confidence interval, 77% to 90%) at ten years. Complications occurred in twenty hips. Fifteen hips (11%) were treated with a subsequent arthroscopy because of chondral and/or labral lesions at an average of 6.8 years after the osteotomy. Two independent predictors of failure (defined as arthroplasty or a high pain score) were identified: (1) an age of more than thirty-five years and (2) poor or fair preoperative joint congruency. The probability of failure requiring arthroplasty was 14% for hips with no predictors of failure, 36% for those with one predictor (either an age of more than thirty-five years or poor or fair joint congruency), and 95% for those with both predictors. The Bernese periacetabular osteotomy can be effective for the treatment of painful hip dysplasia, but complications may be expected in as many as 15% of cases. The ideal candidate is the patient who is less than thirty-five years of age and who has good or excellent hip joint congruency.

Clinical success using patient-oriented outcome measures after lower extremity bypass and endovascular intervention for ischemic tissue loss

Successful outcome after lower extremity revascularization is usually measured by physician-oriented terms such as graft patency and amputation-free survival. It has been increasingly appreciated that these criteria do not necessarily translate into success from the prospective of the patient. The purpose of this study, therefore, is to retrospectively examine success after lower extremity revascularization for tissue loss using patient-oriented measures and to include patients who underwent both open surgical bypass and endovascular therapy. Between 1998 and 2005, 677 patients (316 endovascular and 361 open surgery) underwent revascularization for ischemic tissue loss. The method of revascularization (endovascular or open surgery) was left to the discretion of the surgeon. Revascularization was considered to be clinically successful if each of the following occurred: reconstruction patency until wound healing, limb salvage for 1 year, maintenance of ambulation for 1 year, and survival for 6 months. The influence of 20 intrinsic patient factors, including type of revascularization (open vs endo) was examined using the chi(2) test. Significant factors in bivariate analysis were included in a logistic regression model to determine independent predictors and probability of failure. Overall clinical success was achieved in 277 (40.9%) patients. Success for open surgical and endovascular cohorts was 44.3% and 37.0%, respectively (P = .06). Type of intervention was not a significant factor in either bivariate or logistic regression analysis. Independent predictors of failure (odds ratio [OR]; 95% confidence interval [CI]) regardless of treatment type included impaired ambulatory status at the time of presentation (OR 3.24; CI 2.14, 4.90), diabetes (OR 1.62; CI 1.14, 2.32), endstage renal disease (ESRD) (OR 1.55; CI 1.07, 2.23), presence of gangrene (OR 2.0; CI 1.42, 2.82), and prior vascular intervention (OR 1.46; CI 1.02, 2.10). Paradoxically, hyperlipidemia (OR 0.70; CI 0.50, 0.98) was a predictor for success. Probability of failure was 35.4% (OR 1.0) if no independent predictors were present and increased with the addition of each adverse predictor. For instance, diabetic patients with impaired ambulatory status and gangrene had an 85.2% (OR 10.5) probability of failure. In the worst case scenario, a diabetic patient with ESRD, impaired ambulatory status, gangrene, and a prior vascular intervention was considered, probability of failure was a dismal 92.8% (OR 23.7). Clinical success after lower extremity revascularization for ischemic tissue loss is determined by intrinsic patient factors and not by method of revascularization. These data reiterate that future investigation efforts should be focused less on the method of revascularization and more on identification of patient cohorts at risk for failure regardless of treatment.

Comparative evaluation of epidemiology and outcomes of methicillin-resistant Staphylococcus aureus (MRSA) USA300 infections causing community- and healthcare-associated infections

Methicillin-resistant Staphylococcus aureus (MRSA) USA300 clone is commonly found in the community and is being increasingly reported in the healthcare setting. A retrospective analysis was conducted to compare the epidemiology and outcomes between community-associated (CA) and healthcare-associated (HA) USA300 MRSA infections. The study enrolled 160 subjects with USA300 MRSA infections (47.5% CA-MRSA and 52.5% HA-MRSA). Failure in the HA group was higher (38.1%) compared with the CA group (23.7%) ( P = 0.05). Predictors of failure included male gender, age, presence of any co-morbidity, coronary artery disease, chronic kidney disease, history of MRSA, previous admission, fluoroquinolone exposure, HA infection and osteomyelitis ( P ≤ 0.05). Independent predictors of failure were osteomyelitis, history of MRSA, male gender and pneumonia. Recurrent disease was found in 32.6% of cases. Overall, USA300 MRSA most commonly causes infection of the skin and skin structure, however, 20% of subjects can experience more invasive disease with infection of the bloodstream, lung or bone. Failure rates are higher in subjects with healthcare risk factors or if the infection was acquired in the hospital, with these subjects experiencing more invasive infections such as bacteraemia, pneumonia or osteomyelitis.

Predictability of Outcome in Laparoscopic Gastric Banding

Background: The success rate of laparoscopic adjustable gastric banding (LAGB)in the treatment of morbid obesity isvery variable. A reasonable preoperative selection of eligible patients seems to be important for a successful outcome of LAGB. In the present study, criteria were investigated to predict the outcome of LAGB. Methods: 85 morbidly obese patients were operated with LAGB between 1999 and 2005. 71of these patients were analysed according to several possible predictive parameters of success or failure of LAGB. Success was defined as excess bodyweight loss (EBWL) > 50% without band removal, failure was defined as EBWL < 20% and/or band removal. Median follow-up was 27 months (range 8–90 months). Results: After LAGB a median EBWL of 43%(–41 to171.5%) was observed in all patients with a decrease in BMI of 8.0 kg/m² (– 9 to 35 kg/m²). The success rate after LAGB was 37%, the failure rate 19.7%. Female sex (p = 0.023), baseline weight (p = 0.024), and eating behaviour after LAGB (p = 0.008) were significant predictors of success following LAGB, whereas complications such as port dislocation and reoperation after LAGB did not have a significant impact on a successful course following LAGB. Significant predictors of failure were male sex (p = 0.038) and missing physical activity after LAGB (p = 0.045), where as the eating behaviour did not have a significant effect concerning failure following LAGB. Baseline excess body weight (EBW) was identified as an independent predictor of failure in a multivariate analysis. Conclusion: According to the results of this study, female patients with a lower EBW who improve their postoperative eating behaviour have the best chanceof success following LAGB.

Passive tobacco exposure may impair symptomatic improvement in patients with chronic angina undergoing enhanced external counterpulsation

BackgroundThe adverse effects of tobacco abuse on cardiovascular outcomes are well-known. However, the impact of passive smoke exposure on angina status and therapeutic response is less well-established. We examined the impact of second-hand smoke (SHS) exposure on symptomatic improvement in patients with chronic ischemic coronary disease undergoing enhanced external counterpulsation (EECP).MethodsThis observational study included 1,026 non-smokers (108 exposed and 918 not-exposed to SHS) from the Second International EECP Patient Registry. We also assessed angina response in 363 current smokers. Patient demographics, symptomatic improvement and quality of life assessment were determined by self-report prior and after EECP treatment.ResultsNon-smoking SHS subjects had a lower prevalence of prior revascularization (85% vs 90%), and had an increased prevalence of stroke (13% vs 7%) and prior smoking (72% vs 61%; all p < 0.05) compared to non-smokers without SHS exposure. Despite comparable degrees of coronary disease, baseline angina class, medical regimens and side effects during EECP, fewer SHS non-smokers completed a full 35-hour treatment course (77% vs 85%, p = 0.020) compared to non-smokers without SHS. Compared to non-smokers without SHS, non-smoking SHS subjects had less angina relief after EECP (angina class decreased ≥ 1 class: 68% vs 79%; p = 0.0082), both higher than that achieved in current smokers (66%). By multivariable logistic regression, SHS exposure was an independent predictor of failure to symptomatic improvement after EECP among non-smokers (OR 1.81, 95% confidence intervals 1.16–2.83).ConclusionNon-smokers with SHS exposure had an attenuated improvement in anginal symptoms compared to those without SHS following EECP.

Unicameral Bone Cyst: A Retrospective Study of Three Surgical Treatments

Between 1979 and 2004, 167 patients younger than 20 years were treated surgically for humeral or femoral unicameral bone cysts with either injection of corticosteroids (steroids), curettage plus bone grafting (curettage), or a combination injection of steroids, demineralized bone matrix, and bone marrow aspirate (SDB) at Children's Hospital of Boston and Massachusetts General Hospital (mean followup, 7.3 years; range, 1 month-27 years). Outcomes included treatment failure (defined clinically as subsequent pathologic fracture or need for retreatment to prevent pathologic fracture) and complications. Information was obtained from medical records and by telephone questionnaire. After one treatment, 84% of cysts treated with steroids experienced failed treatment versus 64% with curettage and 50% with SDB. For unicameral bone cysts requiring retreatment (regardless of first treatment), 76% retreated with steroids had failed treatment versus 63% with curettage and 71% with SDB. Curettage was associated with the lowest rate of posttreatment pathologic fractures and highest rate of pain and other complications. Multivariate logistic regression indicated treatment with steroids alone and younger age were independent predictors of failure. We believe SDB is a reasonable first treatment for unicameral bone cysts in the humerus and femur in patients younger than 20 years, being less invasive yet comparable to curettage in preventing recurrence.

Long‐Term Safety and Efficacy of Circumferential Ablation with Pulmonary Vein Isolation

Each of the two main approaches to catheter ablation of atrial fibrillation (AF, segmental and circumferential) is associated with moderate long-term efficacy. To report the long-term outcomes of a modified technique that combines circumferential ablation with pulmonary vein (PV) isolation, determined by a circular mapping catheter and to determine the relationship between complete PV isolation and long-term efficacy. The patient population was composed of 64 consecutive patients (47 men [73%]; age 59 +/- 11 years) with AF who underwent catheter ablation. AF was paroxysmal in 29 (45%) and nonparoxysmal in 35 (55%). Each patient was followed for a minimum of 12 months. After a mean follow-up of 13 +/- 1 months, the long-term single-procedure success rate was 45% (n = 29) with an additional 4% (n = 3) of patients demonstrating improvement. With repeat procedures in 19 patients, the overall long-term success rate was 62% (n = 40) with 9% (n = 6) demonstrating improvement. All the patients who underwent repeat ablations had recovered PV conduction. Incomplete PV isolation was the only independent predictor of failure. A major complication occurred in four (6%) patients, including three patients with vascular complications and one with cardiac tamponade. Our results suggest that the long-term single-procedure efficacy of circumferential ablation with PV isolation in a cohort of patients with predominantly nonparoxysmal AF approaches 50%. Repeat procedures involving re-isolation of the PVs result in a significant improvement in outcomes. Complete electrical isolation of the PVs has a significant impact on the long-term efficacy of the procedure.

A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding

The currently recommended treatment for acute variceal bleeding is the association of vasoactive drugs and endoscopic therapy. However, which emergency endoscopic treatment combines better with drugs has not been clarified. This study compares the efficacy and safety of variceal ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin. Patients admitted with acute gastrointestinal bleeding and with suspected cirrhosis received somatostatin infusion (for 5 days). Endoscopy was performed within 6h and those with esophageal variceal bleeding were randomized to receive either sclerotherapy (N=89) or ligation (N=90). Therapeutic failure occurred in 21 patients treated with sclerotherapy (24%) and in nine treated with ligation (10%) (RR=2.4, 95% CI=1.1-4.9). Failure to control bleeding occurred in 15% vs 4%, respectively (P=0.02). Treatment group, shock and HVPG >16 mmHg were independent predictors of failure. Side-effects occurred in 28% of patients receiving sclerotherapy vs 14% with ligation (RR=1.9, 95% CI=1.1-3.5), being serious in 13% vs 4% (P=0.04). Six-week survival probability without therapeutic failure was better with ligation (P=0.01). The use of variceal ligation instead of sclerotherapy as emergency endoscopic therapy added to somatostatin for the treatment of acute variceal bleeding significantly improves the efficacy and safety.

Evaluating high-grade prostatic intraepithelial neoplasia as a predictor of outcome following radical prostatectomy

4612 Background: The presence of high-grade prostatic intraepithelial neoplasia (HGPIN) has been associated with future development of prostate cancer. High-grade intraepithelial neoplasia in other malignancies is associated with adverse outcome. This study examines the relationship between the presence of HGPIN in prostatectomy specimens, biochemical disease free survival (bDFS) and other cancer specific outcomes following radical retropubic prostatectomy (RRP). Methods: The Columbia University Urologic Oncology Database was reviewed and 2,522 were identified who had undergone radical prostatectomy from 1988 to 2005; 2,133 patients with or without HGPIN were included. Two-sample proportion analysis of means with 95% confidence intervals and ANOVA techniques were used to evaluate the relationship between HGPIN and pathologic stage, Gleason sum, perineural invasion, multifocality, extracapsular extension (ECE), margin status, and nodal status. Kaplan-Meier analysis with log-rank test and a multivariate Cox proportional hazard model controlling for preoperative PSA, Gleason sum and pathologic stage were used to assess differences in bDFS. Results: 1,885 of 2,133 (88.4%) patients demonstrated HGPIN. There was no significant difference in the distribution of pathologic stage or Gleason sum between the patients with and without HGPIN. The HGPIN-positive group had higher rates of perineural invasion (69.9 vs. 57.5%; p = 0.003), multifocality (63.0 vs. 38.4%; p = 0.000) and ECE (56.4% vs. 48.4%; p = 0.059). There was no statistically significant difference observed in nodal status or margin status between the two groups. Patients without HGPIN had an increased bDFS demonstrated by a predicted disease free survival of 73.6% versus 67.0% at 9 years (p = 0.045) with a median follow-up of 50 months. In the multivariate Cox hazard model HGPIN, PSA, Gleason sum and pathologic stage were validated as independent predictors of failure (p &lt; 0.001). The risk of failure was 1.9 × greater in the HGPIN-positive group than the HGPIN-negative group (p=0.006). Conclusions: The presence of HGPIN in the radical prostatectomy specimen denotes a significantly higher rate of tumor multifocality, perineural invasion, ECE, and ultimately biochemical recurrence. No significant financial relationships to disclose.

Invited commentary

The article by Gaissert and colleagues [1Gaissert H.A. Lin N. Wain J.C. Fankhauser G. Wright C.D. Mathisen D.J. Transthoracic Heller myotomy for esophageal achalasia analysis of long-term results.Ann Thorac Surg. 2006; 81: 2044-2049Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar] represents a large series of patients treated by a very experienced group during 4 decades. The authors show that post-esophagomyotomy results are excellent in 91% of patients early after surgery, and that this outcome deteriorates to 61% of patients with long-term follow-up. Early postoperative dysphagia predicts late failure. The addition of fundoplication is not a significant predictor of outcome in their analysis. Finally, sigmoid esophagus is not an independent predictor of failure after esophagomyotomy. Therefore, esophagomyotomy, not esophagectomy with reconstruction, should be the first-line therapy for achalasia patients with sigmoid esophagus. It is essential to maintain a lifelong perspective in treating achalasia, as patients present at a young age, and treatment is considered palliative. An ideal treatment option is safe, durable, and does not preclude further treatment options. Clearly the excellent results presented by Gaissert and colleagues [1Gaissert H.A. Lin N. Wain J.C. Fankhauser G. Wright C.D. Mathisen D.J. Transthoracic Heller myotomy for esophageal achalasia analysis of long-term results.Ann Thorac Surg. 2006; 81: 2044-2049Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar] will serve as a benchmark to compare with other treatments, including minimally-invasive esophagomyotomy methods. Optimal management of the subset of achalasia patients with sigmoid esophagus remains an unresolved issue. Gaissert and colleagues [1Gaissert H.A. Lin N. Wain J.C. Fankhauser G. Wright C.D. Mathisen D.J. Transthoracic Heller myotomy for esophageal achalasia analysis of long-term results.Ann Thorac Surg. 2006; 81: 2044-2049Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar] argue that esophagomyotomy, not esophagectomy, should be the first line of surgical treatment, because transthoracic myotomy is safe and results are comparable with its use in patients without esophageal enlargement. The authors argue that replacing one aperistaltic conduit (i.e., the native esophagus) with another one (i.e., the stomach, colon, or jejunum) does not make sense and does not justify the risks involved. However, the authors’ conclusions are based on results with 12 patients over 40(+) years, in which long-term data was available for only 11 years. In addition, the authors define sigmoid esophagus solely on the basis of size (i.e., diameter > 6 cm). In fact, in most achalasia patients, as the esophagus dilates (> 6 cm), it also lengthens and begins to twist and fold. It is this acquired luminal tortuosity, not luminal diameter, that renders an esophagus as “end-stage.” A dilated, tortuous esophagus will not empty well even with esophagomyotomy, because of its shape. Esophageal replacement for end-stage achalasia can be performed safely and with good results. The report by Banbury and colleagues [2Banbury M.K. Rice T.W. Goldblum J.R. et al.Esophagectomy with gastric reconstruction for achalasia.J Thorac Cardiovasc Surg. 1999; 117: 1077-1085Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar] is an example of this. There were no deaths in their series of 32 patients, and 83% were able to swallow with no or mild dysphagia. Eighty-seven percent felt better after esophagectomy. Median follow-up time was only 43 months; however, as shown in the current study, early failures predict long-term outcome. Furthermore, there is no reason to expect deterioration in the long-term swallowing result after esophagectomy. Transthoracic Heller Myotomy for Esophageal Achalasia: Analysis of Long-Term ResultsThe Annals of Thoracic SurgeryVol. 81Issue 6PreviewSwallowing deteriorates over time in some patients after transthoracic esophagomyotomy for achalasia. The causes of decline are poorly understood. Full-Text PDF

Arterial Versus Venous Bypass Grafts in Patients With In-Stent Restenosis

In patients who develop in-stent restenosis, successful revascularization can be difficult to achieve using percutaneous methods. This study was designed to verify the surgical results in this setting and to evaluate the potential beneficial role of arterial bypass conduits. Sixty consecutive coronary artery bypass patients with previous in-stent restenosis and 60 control cases were randomly assigned to receive an arterial conduit (either right internal thoracic or radial artery; study group) or a great saphenous vein graft (control group) on the first obtuse marginal artery to complete the surgical revascularization procedure. At a mean follow-up of 52+/-11 months, patients were reassessed clinically and by angiography. Freedom from clinical and instrumental evidence of ischemia recurrence was found in 19 of 60 subjects in the study group versus 45 of 60 in the control series (P=0.01). The results of the arterial grafts were excellent in both the study and control groups (right internal thoracic artery patency rate, 19 of 20 for both, and radial artery patency rate, 20 of 20 versus 19 of 20; P=0.99). Saphenous vein grafts showed lower patency rate than arterial grafts in both series and had extremely high failure rate in the study group (patency rate, 10 of 20 in the study group versus 18 of 20 in the control group; P=0.001). Use of venous graft was an independent predictor of failure in the study group, whereas hypercholesterolemia was associated with graft failure in both series. Venous grafts have an high incidence of failure among cases who previously developed in-stent restenosis, whereas the use of arterial conduits can improve the angiographic and clinical results. Arterial grafts should probably be the first surgical choice in this patient population.

In response to Dr. Halperin

We appreciate the comments of Dr. Halperin about the differences in patients with localized prostate cancer treated with different modalities as reported in our study ( 1 Kupelian P.A. Potters L. Khuntia D. et al. Radical prostatectomy, external beam radiotherapy <72 Gy, external beam radiotherapy > or =72 Gy, permanent seed implantation, or combined seeds/external beam radiotherapy for stage T1–T2 prostate cancer. Int J Radiat Oncol Biol Phys. 2004; 58: 25-33 Abstract Full Text Full Text PDF PubMed Scopus (417) Google Scholar ). Specifically, the concern was that the difference in outcomes observed between patients receiving <72 Gy vs. ≥72 Gy is secondary to differences in follow-up period and/or a resultant of the ASTRO definition of biochemical failure. With respect to the failure definition, the differences observed in outcomes should be the same, because the same definition was applied to both groups. With respect to follow-up periods, there is no doubt that with the use of KM curves, some of the difference between the two dose levels is due to the difference in follow-up periods. Therefore, with analysis of subgroups that have closer follow-up periods, that difference will decrease. However, although the magnitude of the difference might vary, the dose effect is real, regardless of follow-up duration. This was demonstrated by the well-known randomized study reported by Pollack et al. ( 2 Pollack A. Zagars G.K. Starkschall G. et al. Prostate cancer radiation dose response: Results of the M. D. Anderson phase III randomized trial. Int J Radiat Oncol Biol Phys. 2002; 53: 1097-1105 Abstract Full Text Full Text PDF PubMed Scopus (1206) Google Scholar ), and more recently the randomized dose escalation protocol with protons reported by Zietman et al. ( 3 Zietman A. DeSilvio M. Slater J. et al. A randomized trial comparing conventional dose (70.2 GyE) and high-dose (79.2 GyE) conformal radiation in early stage adenocarcinoma of the prostate: Results of an interim analysis of PROG 95-09. Int J Radiat Oncol Biol Phys. 2004; 60: S131 Google Scholar ). In addition, in a separate multi-institutional data set that we looked at for patients treated only in 1994 and 1995, radiation therapy dose was again an independent predictor of failure ( 4 Kupelian P.A. Kuban D. Thames H. et al. Improved biochemical relapse-free survival with increased external radiation doses in patients with localized prostate cancer: The combined experience of nine institutions in patients treated in 1994 and 1995. Int J Radiat Oncol Biol Phys. 2003; 57: S271-272 Abstract Full Text Full Text PDF Google Scholar ). All these analyses were done with patient groups with identical follow-up periods. In regard to Kupelian et al.: Radical prostatectomy, external beam radiotherapy <72 Gy, external beam radiotherapy ≥72 Gy, permanent seed implantation, or combined seed/external beam radiotherapy for stage T1-T2 prostate cancer (Int J Radiat Oncol Biol Phys 2004;58:25–33)International Journal of Radiation Oncology, Biology, PhysicsVol. 61Issue 2PreviewKudos to Kupelian et al. for their excellent analysis describing biochemical failure rates for prostate cancer patients treated by radical prostatectomy, external beam radiotherapy, and brachytherapy (1). In this analysis, patients who received external beam radiotherapy with <72 Gy were reported to have a significantly higher biochemical failure rate than all other groups analyzed. A review of the data showed that the median follow-up duration for <72 Gy patients was 75 months, which is the longest of all of the evaluated groups by at least 9 months. Full-Text PDF

Safety of Percutaneous Internal Jugular Catheterization in Cancer Patients: Prospective Observational Study

To determine predictors for failure and early complications of percutaneous internal jugular catheterization (IJC) in cancer patients. Six hundred and thirty consecutive cancer patients who required central venous catheterization were included in a prospective observational study. The rates of failure (defined as the intervention of a second physician and/or failure at initial insertion site) and of early complications were prospectively ascertained. Logistic regression analysis estimated odds ratio (OR) and 95% confidence intervals (95% CI) for independent predictors for failure and early complications of percutaneous IJC. The failure rate was 6.7%, and the early complication rate was 6.7%. In multivariate analysis, left-side initial catheterization (p<0.01), prior catheterization at the same site (p=0.001) and physician inexperience (p<0.0001) were independently associated with failure. Placement requiring more than one needle pass (p<0.01 for two and p<0.0001 for three and more) and absence of fluoroscopy (p<0.0001) were independently associated with early complications. Percutaneous IJC is a valid option in the central venous catheterization of cancer patients due to its reliability and safety. Skilled physicians must manage difficult placements. If placement requires more than one needle pass or is made without fluoroscopy, patients must be carefully followed for potential complications.

Monotherapy for stage T1–T2 prostate cancer: radical prostatectomy, external beam radiotherapy, or permanent seed implantation

Background and Purpose To review the freedom from biochemical recurrence (FBR) rates after permanent prostate brachytherapy (PPB), external beam radiotherapy (RT) to a minimum 70 Gy, or radical prostatectomy (RP) for clinically localized stage T1–T2 adenocarcinoma of the prostate. Patients and Methods The study cohort consisted of 1819 consecutively treated clinical stage T1–T2 (AJCC 1997) localized prostate cancer patients between 1992 and 1998. All patients received monotherapy treatment without additional adjuvant therapy. The distribution by treatment modality was as follows: RT for 340, RP for 746, and PPB for 733 cases. The median follow-up time was 58 months for all cases (51 months for PPB cases, 56 months for RT cases, and 64 months for RP cases). Biochemical relapse was defined as to be detectable PSA levels in RP cases, and the ASTRO consensus panel definition for the RT and PPB cases. Results The 7-year FBR rates for PPB vs EBRT vs RP were 74, 77, and 79%, respectively. Multivariate analysis identified iPSA ( P<0.001) and bGS ( P<0.001), as independent predictors of relapse. Treatment modality, age, clinical T-stage, and race were not independent predictors of failure. Conclusions Pretreatment PSA levels, and biopsy Gleason score determined outcome in this study cohort. Biochemical failure rates in this study cohort are similar between PPB, RT, and RP as monotherapy for clinically localized prostate cancer.