Non-elderly Cohort Research Articles

Does Advanced Age Affect the Outcomes of Stereotactic Radiosurgery for Cerebral Arteriovenous Malformation?

Stereotactic radiosurgery (SRS) is generally considered a minimally invasive treatment modality. However, definitive evidence of the efficacy of SRS in the elderly population is still not available. The outcomes of 561 elderly and nonelderly patients who underwent SRS for AVM at our institution between 1990 and 2013 were reviewed, analyzed, and compared. Elderly patients were defined as those age ≥60 years at the time of SRS. The elderly cohort comprised 55 patients; the nonelderly cohort, 506. In the elderly cohort, the median age was 65 years, and the duration of follow-up was 91 months. The actuarial obliteration rates were 47% at 3 years, 70% at 4 years, and 76% at 5 years in the elderly cohort, and 57% at 3 years, 76% at 4 years, and 83% at 5 years in the nonelderly cohort. In the elderly cohort, the hemorrhage rates during the post-SRS latent phase were 5.2%/year in patients with hemorrhagic onset and 0%/year in those with nonhemorrhagic onset, and event-free survival (EFS) was 93% at 6 years and 89% at 12 years. The obliteration rate, mortality, and EFS rate were not significantly different between the 2 cohorts, whereas the rate of perifocal edema was significantly lower (P= 0.021) in the elderly cohort. The pre-SRS and post-SRS hemorrhage rates were slightly higher in the elderly cohort, albeit without statistical significance. Therapeutic effects and outcomes of SRS are similar in elderly and nonelderly patients. Treatment-related neurologic deficits are rare, and longer EFS can be expected.

Characterization of the urinary microbiota of elderly women and the effects of type 2 diabetes and urinary tract infections on the microbiota.

Evidence shows that urine has complex bacterial profiles with considerable variation between individuals. Aging and age-related conditions can lead to the changes to the composition of urine, which means that the available nutrition for bacteria in the bladder changes with age. We explored the characteristics of the urinary microbiota of elderly women and whether these are associated with age-related conditions such as diabetes and urinary tract infections. An elderly and a non-elderly cohort of women were included. Magnetic beads were used to isolate bacterial genomic DNA, which was analyzed based on the V3-V4 hypervariable region of the 16S rRNA gene. There were significant differences between the elderly and non-elderly regarding thirteen genera of bacteria. For example, the relative abundance of Lactobacillus was dramatically reduced in the elderly compared with the non-elderly; it also decreased with age in the elderly cohort and it was not correlated with urine pH. The relative abundance of Peptococcus increased with age in the elderly while the abundance of Bifidobacteria decreased with age. The abundance of Escherichia coli was the same in the two cohorts, and it increased with water intake and was not associated with urinary tract infection events. Higher levels of Lactobacillus (including Lactobacillus iners) in the elderly were associated with diabetes, and lower levels of Peptoniphilus and Dialister were correlated with asymptomatic bacteriuria. The urinary microbiota of women is affected by ageing, type 2 diabetes mellitus and asymtomatic bacteriuria.

Impact of clinic follow-up visits on body weight control in people with prediabetes or diabetes mellitus: Japanese nonelderly cohort study.

Body weight control is considered essential for the management of diabetes mellitus. Clinicians have an important role in educating and guiding patients with diabetes to control their body weight. The aim of the present study was to clarify if clinic visits influenced body weight control of people with prediabetes or diabetes mellitus. To examine whether individuals with diabetes mellitus who visit clinics show better weight control. We used a large Japanese database (Japan Medical Data Center, Tokyo, Japan) of screening for lifestyle disease linked with administrative claim data to retrospectively identify people with prediabetes or diabetes mellitus based on their fasting plasma glucose and glycated haemoglobin (HbA1c) concentration. We collected data on their baseline characteristics (including age, sex, body mass index and disease history) and their lifestyles. We used propensity-score inverse probability of treatment weighted generalized estimating equations to examine the association between clinic visits and change in body mass index. Between 2013 and 2014, we identified 11004 individuals with prediabetes or diabetes. The proportions visiting clinics after the first diagnosis made at screening was 27.8%. Clinic visit was significantly associated with lower body mass index after adjustment for baseline patient characteristics a year after first screening (-0.17 kg/m2; 95% confidence interval, -0.22 to -0.12). In Japanese people found to have prediabetes or diabetes during an annual health screen, those who visited clinics after their first diagnosis were likely to have better body weight control.

Patterns of care of cervical cancer in the elderly: A qualitative literature review.

Cancer of the uterine cervix is the fourth most common cancer worldwide among women. However, there is limited data about elderly patients with cervical cancer and gross underrepresentation of elderly patients in clinical trials. Hence, the optimal therapy of such patients is not well formulated. We conducted this systematic review of evidence to assess patterns of care in elderly patients with cervical cancer. A total of 17,338 publications are reported in PubMed until July, 2016 pertaining to cervical cancer. Out of these, only 24 publications (full length papers or meeting proceedings) reported about clinical outcomes of elderly patients with cervical carcinoma. These publications report data from as early as 1949 to the present. In these publications, out of 14,479 patients aged ≥60years of age, 11,279 (77.89%) received external beam radiation. Concurrent chemotherapy has been used in 11 publications. Brachytherapy usage has been reported in 19 publications. In a few studies, brachytherapy was not used because of fear of toxicity. Overall, low dose rate (LDR) was the most common modality, followed by high dose rate (HDR). The authors have showed technical reasons (48.7%), comorbidities (69.4%) and patient refusal (38.3%) as causes for not delivering brachytherapy. Five-year overall survival (OS) has been found to be inferior to the non-elderly cohort and ranges from 27%-69% for elderly patients compared to 58%-75% in the non-elderly population. An 11% 5year OS has been reported for patients treated with suboptimal radiation dose compared to 74% in those treated with chemo radiotherapy followed by brachytherapy. Gross underrepresentation of patients above 65years in clinical trials has resulted in treatment dilemmas in the elderly. Newer advances like immunotherapy, hypoxic modifiers, image guided radiation, image guided brachytherapy are promising approaches to reduce treatment complications and optimize outcome in elderly patients in cervical cancer.

Outcomes of Vestibular Schwannoma Surgery among the Elderly.

Objective To compare comorbidities and in-hospital complications between elderly and nonelderly patients undergoing vestibular schwannoma (VS) surgery. To examine average length of stay (LOS) and hospital charges among elderly patients. Study Design Population-based inpatient registry analysis. Setting Academic medical center. Subjects and Methods Retrospective analysis of the National Inpatient Sample for patients undergoing VS surgery from 2002 to 2010: 4137 patients met inclusion criteria, with 519 (12.5%) in the elderly cohort (≥65 years). Outcomes of elderly and nonelderly (<65 years) patient cohorts were compared. Results Compared with the nonelderly cohort, the elderly cohort had more comorbidities, including diabetes mellitus, hypertension, and pulmonary disease (all P < .001). Elderly patients had longer LOS (6.5 vs 5.4 days; P = .001) but did not incur significantly greater hospital charges. Rates of cerebrospinal fluid leak, meningitis, and facial nerve injury did not vary significantly between groups. The elderly cohort experienced higher rates of in-hospital complications, including acute cardiac events, iatrogenic cerebrovascular infarction/hemorrhage, postoperative bleeding (hemorrhage/hematoma), and in-hospital mortality (all P < .05). In binary logistic regression, correcting for patient demographics and presence of comorbidities, elderly status was associated with 1.848 (95% confidence interval, 1.167-2.927; P = .009) greater odds of medical complications and 13.188 (95% confidence interval, 1.829-95.113; P = .011) greater odds of in-hospital mortality. Conclusion Elderly patients undergoing VS surgery have more comorbidities, in-hospital complications, and longer LOS than nonelderly patients. The elderly cohort had a greater rate of in-hospital mortality, though rare. Interestingly, elderly patients did not have a higher rate of many known complications associated with VS surgery and did not incur more hospital charges.

Factors associated with hospitalization for seasonal influenza in a Japanese nonelderly cohort.

BackgroundNonelderly patients may require hospitalization if their symptoms of influenza are severe. However, little evidence is available about the risk factors for hospitalization for influenza.MethodsWe used a multicenter outpatient and inpatient database to obtain patients’ characteristics and clinical procedures. We identified patients aged <65 years with a confirmed diagnosis of influenza between October 2013 and December 2014. We used a Cox regression model to identify the risk factors for hospitalization, using a comparison group of individuals with a confirmed diagnosis of influenza but who were not hospitalized.ResultsOf 88,054 patients diagnosed with influenza, 276 (0.3 %) patients were hospitalized. With reference to patients aged 18–64 years, the hazard ratio (95 % confidence interval) for hospitalization in patients aged <2, 2–4, and 5–17 years was 12.25 (8.37–17.93), 4.56 (3.10–6.72) and 1.45 (1.03–2.05), respectively. Anemia, chronic obstructive pulmonary disease, neurologic disease, and regular steroid use were significantly associated with hospitalization. Hazard ratios were adjusted for age, sex, comorbidities, respiratory co-infection, virus type, and influenza season.ConclusionsOur findings suggest that younger age and several comorbidities are associated with higher probability of hospitalization for influenza.

Elderly and octogenarian cohort: Comparable outcomes with nonelderly cohort after open or laparoscopic inguinal hernia repairs

To understand whether the elderly (>65 years of age) or octogenarian cohort is at greater risk for poor clinical outcomes after open or laparoscopic inguinal hernia repairs. Beginning in June 2009, all patients presenting to our institution for inguinal hernia repair were asked to participate in a prospective database. Demographics, presenting symptoms, preoperative findings on examination, intraoperative variables, postoperative outcomes, and readmission data were collected. Additionally, patient-centered outcomes were evaluated with the Short Form-36 and Carolina Comfort Score questionnaires at follow-up visits (3 weeks, 6 months, 1 year, and for the Short Form-36 preoperatively as well). A total of 471 patients were included in the study; 285 were nonelderly, 155 patients were aged 65-80 years, and 31 patients were older than 80 years of age. Of these patients, the percent who underwent laparoscopic repair was 86% for the nonelderly, 79% for the elderly, and 41.9% for the octogenarian cohorts (P < .001). After laparoscopic repairs, the older cohorts had greater rates of minor postoperative complications than the nonelderly cohort (38% and 58% vs 15%; P < .001) attributable to greater rates of seroma and urinary retention. Intraoperative complications and recurrence rates were not different among the cohorts; however, the octogenarian cohort was more likely to be readmitted compared with both the nonelderly and elderly cohorts (17% vs 2% and 2%, respectively, P < .001) and to have a greater duration of stay (P < .001). For laparoscopic repairs over all the cohorts, the Carolina Comfort Scale improved over time (P < .001). Laparoscopic repairs in the octogenarians (P = .07) but not in the elderly (P = .6) had better scores over time (8.1 and 1.0 and points less/better, respectively) than the nonelderly cohort. Laparoscopic inguinal hernia repair is safe and effective in elderly and octogenarian patients with no major morbidities or mortalities. Although these patients are at greater risk for postoperative seroma and urinary retention, and octogenarians are at greater risk for readmission, patient-centered outcomes may be better after laparoscopic repairs with the proper patient selection in the older population.

Laparoscopic gastrectomy for gastric cancer in the elderly patients.

This study aimed to investigate the short-term surgical outcomes of laparoscopic gastrectomy for gastric cancer in elderly patients in order to determine the safety, feasibility, and risk factors for postoperative complications associated with this procedure. We retrospectively investigated 208 patients who underwent laparoscopic gastrectomy for gastric cancer between January 2007 and September 2014. After excluding 15 patients with unusual medical histories or surgical treatments, 193 were selected for this cohort study. We divided the patients into two cohorts: elderly patients (≥75 years old) and non-elderly patients (<74 years old). We compared these cohorts with respect to clinicopathological characteristics and intraoperative and postoperative parameters. The overall complication rates were 11.4% (8 of 70 patients) in the elderly cohort and 8.1% (10 of 123 patients) in the non-elderly cohort (P = 0.449). In a univariate analysis, Charlson comorbidity index (CCI) of ≥3, American Society of Anesthesiologists (ASA) score of 3, operative time of ≥330 min, and intraoperative blood loss of ≥50 ml were found to correlate significantly with postoperative complications. In a multivariate analysis, CCI of ≥3 (P = 0.034), ASA score of 3 (P = 0.019), and intraoperative blood loss of ≥50 ml (P = 0.016) were found to be independent risk factors of postoperative complications. In contrast, age was not found to significantly affect the risk of postoperative complications. Laparoscopic gastrectomy for gastric cancer can be successfully performed in elderly patients with an acceptable complication rate. This study suggested that high CCI, ASA score, and intraoperative blood loss volume were identified as independent predictors of postoperative complications after laparoscopic gastrectomy for gastric cancer.

Validation of hepatectomy for elderly patients with hepatocellular carcinoma.

380 Background: Hepatectomy for hepatocellular carcinoma (HCC) and its outcomes in the elderly population have yet to be defined. We aimed to validate our current strategy to determine surgical indication regardless of age. Methods: A single-center, retrospective cohort study was conducted for 104 patients who underwent hepatectomy for HCC from 2005 to 2010. The patients were divided into 2 groups according to age; i.e. &lt;75 years (non-elderly cohort; n=82) and ≥75 years (elderly cohort; n=22), and short-/long-term results were compared. Results: In the elderly cohort, the prevalence of ECOG performance status 1 preoperatively (p&lt;0.001) and HCV or non-HBV/non-HCV were higher than in the non-elderly cohort (p=0.04). Otherwise, patient/tumor characteristics were comparable between the 2 groups. The elderly cohort suffered postoperative complications more frequently (42% vs. non-elderly, 16%, p=0.01) but the length of hospital stay was equivalent. Ninety-day mortality occurred in 1 case each (elderly, respiratory failure; non-elderly, liver failure; p=0.38). During a median follow-up period of 47 months, unadjusted 5-year disease-free and overall survivals were comparable per log-rank comparison (elderly, 25% and 80% vs. non-elderly, 33% and 79%, p=0.96 and 1.00, respectively). Cox univariate analyses on recurrent HCC showed hypertension, Child-Pugh grade B, tumor size, recurrent/multiple tumors, preoperative alpha-fetoprotein level, moderate/poor differentiation, portal invasion, intrahepatic metastases, and positive margins to have p values &lt;0.20. After adjustment, the hazard ratio of recurrent HCC at 5 years in the elderly cohort was 0.87 (95% CI, 0.40-1.91; p=0.74). Tumor size, alpha-fetoprotein level, and intrahepatic metastases emerged as independent predictors of diminished 5-year disease-free survival in the entire cohort. Conclusions: Although postoperative complications develop more frequently, hepatectomy in the elderly patients affords comparable short- and long-term prognoses to the non-elderly patients. Surgical strategy for HCC should be based on tumor factors and hepatic reserve and not by age alone. Perioperative management needs to be individualized according to coexisting disorders.

Economic Burden of Renal Cell Carcinoma in the US

The economic burden of renal cell carcinoma (RCC) came into sharp focus when the UK's National Institute for Health and Clinical Excellence denied coverage (later reversed) of sunitinib for metastatic RCC. Following an updated review of RCC-related economic studies, we supplemented the costs of RCC reported in the literature with estimates from the latest US databases that capture the utilization of several newly approved targeted agents. We conducted analyses using the 1991-2007 SEER (Surveillance, Epidemiology and End Results)-Medicare and 1996-2007 MarketScan Commercial Claims and Encounter (CCAE) and Medicare Supplemental databases, and based our estimates on a prevalent cohort of patients with RCC or kidney cancer constructed from each database. All cost estimates were normalized to $US, year 2009 values. The incremental costing approach was applied to estimate the annual cost of RCC by treatment phases using a prevalent cohort of patients with RCC identified from the 2005 SEER-Medicare database. We used the method of extended estimation equations to estimate the impact of patients' use of targeted therapies on the annual costs of RCC, while controlling for confounding factors such as patients' age, sex, tumour characteristics, co-morbidity and geographic regions. The method was applied to two elderly cohorts of RCC patients identified from the SEER-Medicare and the MarketScan Medicare Supplemental databases and a non-elderly cohort of patients with RCC identified from the MarketScan CCAE database. Compared with the cost of treating an elderly, non-cancer patient in the matched sample, the average cost of treating an elderly patient with RCC was $US11,169 (95% CI 10,683, 11,655) more per year, based on our analyses of the latest SEER-Medicare data. The annual cost to treat patients with RCC who received targeted therapies was 3- to 4-fold greater than the cost to treat patients with RCC who received other therapies. Results from the multivariate analysis showed that, after controlling for potential confounders, the annual medical cost was $US31,000-65,000 higher for RCC patients treated with targeted therapies, with the largest increase observed among the non-elderly patients. The economic burden of RCC is likely to grow with an increasing use of targeted therapies. Future research is needed to understand the impact of various forces on the economic burden of RCC, such as increased disease incidence, use of minimally invasive surgical techniques and more prevalent adoption of emerging targeted therapies.

EUS and ERCP Complication Rates Are Not Increased in Elderly Patients

Further studies evaluating the safety of advanced endoscopic procedures in elderly patients are needed. To evaluate the safety of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in the elderly. The study population, consisting of 1,000 patients who underwent ERCP or EUS, was divided into two cohorts. The elderly cohort consisted of patients ≥ 75 years old. The nonelderly cohort consisted of patients <75 years old. The data collected included demographic information, type of procedure completed, procedure medication used, and endoscopic intervention performed. Complications included any event which occurred during the procedure or up to 1 month post procedure. A total of 600 ERCPs and 400 EUS were included. The mean age of the elderly cohort was 80 years (range 75-95 years, n = 184) versus 54 years (range 13-74 years, n = 816) for the nonelderly cohort. The ERCP complication rate was 10.0% in the elderly versus 10.6% (P = 1.0) for the nonelderly. The EUS complication rate was 4.8% in the elderly versus 3.1% in the nonelderly (P = 0.49). The overall complication rates were identical at 7.6% (P = 1.0). Sedation doses were lower for the elderly cohort (P < 0.001). There was a higher rate of procedure bleeding in the elderly cohort (P = 0.016). Advanced age is not a contraindication for advanced endoscopic procedures. There is no significant increase in the rate of overall procedure-related complications seen with either ERCP or EUS in elderly patients; however, elderly patients have a higher risk of bleeding. Less procedure-related sedation medication is required for elderly patients.

ERCP and EUS Complication Rates Are Not Increased in Elderly Patients

Introduction: As the elderly population continues to grow, further studies evaluating the safety of advanced endoscopic procedures in this population are needed. The purpose of this study was to evaluate the safety of endoscopic retrograde cholangiopancreatography (ERCP) ± sphincterotomy and endoscopic ultrasound (EUS) ± FNA in the elderly population. Methods: This is a retrospective review of 650 consecutive patients in which ERCP and/or EUS ± FNA were performed over a 20 month period at our tertiary care institution. The study population was divided into two cohorts. The elderly cohort consisted of patients ≥75 years old. The non-elderly cohort consisted of patients <75 years old. Collected data included patient demographics, type of procedure completed, procedure medication used and endoscopic intervention preformed. Complications included any event which occurred up to one month post procedure. Complications were defined as hemodynamic or respiratory compromise, over sedation, pancreatitis, bleeding, perforation, infection, abdominal pain or any event leading to post procedure hospital admission. The data was analyzed between the cohorts using either a Fisher's test or Student's t-test. Results: There were 650 procedures included, 409 ERCPs (63%) and 241 EUS (37%). The study population was 55% male. The mean age of the elderly cohort was 80 yrs (75-95) and included 130 patients. The mean age of the non-elderly cohort was 53 yrs (13-74) and included 520 patients. The elderly cohort ERCP complication rate was 9 %, the non-elderly cohort ERCP complication rate was 9 % (P = 0.47). The elderly cohort EUS complication rate was 2 %, the non-elderly cohort EUS complication rate was 2% (P = 0.30). The overall complication rates for the elderly and non-elderly cohorts were 8% and 7 % respectively (P = 0.45). There was no significant difference in the rate of sphincterotomy related complications between cohorts (P = 0.40). All EUS complications were associated with FNA. The sedation doses of droperidol, fentanyl and midazolam were significantly higher for the non-elderly cohort (P < 0.01). There was a significantly higher rate of post procedure admission for observation for the elderly cohort (P = 0.016). Conclusions: Advanced age is not a contraindication for advanced endoscopic procedures. There is no significant increase in the rate of procedure related complications seen with either ERCP or EUS procedures in elderly patients. Less procedure related sedation medications are required for elderly patients. Gastroenterologists are more likely to admit elderly patients for observation overnight after advanced endoscopic procedures.