Presence Of Major Comorbidities Research Articles

Liver steatosis and fibrosis as independent prognostic factors affecting survival in colorectal cancer with liver metastases.

165 Background: Colorectal cancer is one of the leading causes of cancer-related death, and the liver represents the most common site of metastases. Greater depth of tissue invasion and lymph node metastases (more advanced T and N stage) are associated with increased risk of liver metastases, but how co-pathologies of the liver associate with disease progression and survival are not known. Further, prognostic factors associated with overall survival in patients with colorectal liver metastases (CRLM) remain poorly understood. Clinical factors affecting liver morphology and biomechanical properties, such as preexisting fibrosis or steatosis, may impact the pathogenesis of CRLM and thus the clinical prognosis. Current literature is mixed about whether prior steatosis and fibrosis contribute significantly to CRLM pathogenesis and prognosis. The purpose of this study is to evaluate whether liver steatosis and fibrosis impact outcomes in patients with CRLM. Methods: All CLRM cases (n = 197) that underwent resection between 2003 and 2007 from The Cancer Imaging Archive were included in our study cohort. For each clinical covariate, we generated a univariate model for overall survival and those meeting a modest predictive threshold (p < 0.15) were included in a multivariable model. These included: presence of major comorbidity, chemotherapy preceding resection of liver metastases, clinical risk score, presence of extrahepatic disease at time of diagnosis, presence of steatosis on CT imaging, percentage of residual tumor after treatment, and presence of fibrosis on CT. All statistics were performed in R (v.2022.12.0). Results: A multivariable Cox proportional hazards model identified four statistically significant clinical factors predictive of overall survival: clinical risk score (HR = 1.60, p = 0.026), presence of extrahepatic disease (HR = 2.33, p = 0.027), presence of steatosis (HR = 0.51, p = 0.0057), and fibrotic proportion of liver tissue less than 40% (HR = 2.63, p = 0.033). There were also four statistically significant clinical factors predictive of disease-free survival in the liver: chemotherapy preceding resection of liver metastases (HR = 2.28, p = 0.0011), presence of extrahepatic disease (HR = 2.18, p = 0.024), presence of steatosis (HR = 0.49, p = 0.0030), and fibrotic proportion of liver tissue less than 40% (HR = 2.74, p = 0.016). Conclusions: Our findings suggest that increased steatosis and fibrosis, as assessed by CT scans, are paradoxically protective in CRLM, showing longer disease-free survival and overall survival rates. We hypothesize that liver fibrosis and steatosis impact the microenvironment of the neoplastic cells in the liver, impairing tumor progression in this milieu. Further research is needed to assess how non-neoplastic co-pathologies resulting in biophysical changes affect tumor growth and overall survival.

Comorbidity in lipoprotein apheresis: Their role in the era of new lipid-lowering therapies.

Despite advance in pharmacotherapy of lipid disorders, lipoprotein apheresis (LA) plays a leading role in the management of severe hypercholesterolemia and in atherosclerosis prevention. Aim of this study was to retrospectively evaluate Charlson Comorbidity Index (CCI), presence of major comorbidity, and/or concomitant polypharmacy (definite as 5+ drugs daily) in patients with inherited dyslipidemias on chronic LA. Since 1994, we performed more than 500 LA treatment/year and followed a total of 83 patients (age 56 [47-65] years, male 75%). In subjects with more than 5 years of LA treatment (38 patients, age 54 [45-62] years, male 66%), at the end of the observation time (9 [7-16] years), patients had higher CCI, polypharmacy, anemia, heart failure, peptic ulcer disease, and benign prostatic hyperplasia. Even in the era of new lipid-lowering therapies, the LA treatment established itself as a safe and lifesaving intervention. Patients on chronic LA require a multidisciplinary approach to address their comorbidity and the apheresis unit's medical staff (doctors and nurses) play a pivotal role creating a bridge toward the general practitioner and other specialists for overcoming clinical issues.

196. Clinical characteristics of 98 patients presenting with hematogenous spinal osteomyelitis: An observational study

<h3>BACKGROUND CONTEXT</h3> Most spinal infection occurs in the wake of invasive procedures, wherein flora have been directly inoculated into the spine and its surrounding soft tissues. Hematogenous infections, on the other hand, result from bacterial spread from a distant site. Staphylococcus aureus is the most common cause of hematogenous spinal infections, and most cases resolve with a 6-week course of antibiotics. However, some patients, especially those that present with concurrent epidural abscess and neurological embarrassment, require debridement of the site and potential structural stabilization. Since very few studies report the clinical characteristics of patients requiring surgery or succumbing to this disease state, this study aims to detail our series of patients with hematogenous spinal osteomyelitis. <h3>PURPOSE</h3> To report clinical characteristics of patients with hematogenous spinal osteomyelitis <h3>STUDY DESIGN/SETTING</h3> Retrospective study. <h3>PATIENT SAMPLE</h3> A total of 98 patients with hematogenous vertebral osteomyelitis. <h3>OUTCOME MEASURES</h3> Preoperative (preop) and postoperative (postop) courses of antibiotics, surgery, reoperation, length of hospital stay, postop sequelae and death. <h3>METHODS</h3> The medical records of patients presenting to two tertiary care centers from January 2014 to January 2021 with hematogenous spinal osteomyelitis were abstracted using ICD-10 codes M46.20 to M46.59. We collected age, sex, body mass index (BMI), comorbidities, affected spinal region, microbiological details, type and duration of pre- and postop antibiotics, length of hospital stay (LOS), reoperation and mortality. Long-term antibiotics were those in use > 6 months. <h3>RESULTS</h3> A total of 98 consecutive patients presenting with hematogenous vertebral osteomyelitis were included. Demographically, the mean age was 62±10 years; 61.2% (n-=60) were male; mean BMI was 29.2±10.4. Most of the infections occurred in the lumbar region (44.2%), followed by the thoracic spine (37.9%), more than two spinal regions (9.5%) and cervical spine (8.4%). Biopsy was performed in 94.1% and returned positive cultures in 93.4%. Of the cultures taken, gram positive bacteria accounted for 69.2%, gram negative in 16.7%, and fungus in 2.6%. 11.5% of cultures returned no growth. 76 (77.6%) patients underwent surgery while 22 (22.4%) were treated with antibiotics only. Of the 76 undergoing surgery, 34.2% underwent secondary surgeries due to a heavy wound burden of necrotic tissue and pus or the failure of multimodal care including antibiotics and debridement. 51.6% of the patients had been prescribed antibiotics preoperatively, with a mean course of 37.2±25.7 days. Postoperative antibiotics were prescribed to all patients, with a mean length of 70.2 days. Mean LOS was 17.9±15.3 days. Additionally, 51.6% of the patients were prescribed long-term antibiotic therapy. The overall death rate was 3.1% (n=3). All 3 patients underwent surgery. Demographic and clinical characteristics of the deceased patients include a mean age of 64 years, majority male (66.7%), who had major comorbidities such as diabetes, anemia, obstructive lung disease and hypertension. Major cause of death was septic shock. Major post-infection sequelae occurred in 24.5% (n=24) of patients. Patients suffering sequelae had a mean age of 69.3 years, were mostly male (83%) and carried major comorbidities including diabetes, anemia, hypertension and renal disease. The most common sequelae were major motor weakness, wound dehiscence and meningitis. <h3>CONCLUSIONS</h3> This study describes the clinical characteristics of patients presenting with hematogenous spinal osteomyelitis, their treatment course and outcomes. As in other sites of infection, the presence of major comorbidities (diabetes, hypertension and renal failure) appear to increase the risk of developing post infection sequalae and death. Our population included patients hospitalized in a tertiary care center with spinal osteomyelitis. They were therefore more likely to carry concomitant diagnoses such as epidural abscess, resulting in a high rate of surgical intervention. A future study with a larger sample size utilizing logistic regression would be able to identify significant risk factors both for hematogenous infection itself and for failure of non-operative and initial operative care. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Volvulus of the Sigmoid Colon without Necrosis: Therapeutic Aspects in Hospital Fousseyni Daou Hospital in Kayes, Mali

The volvulus of the sigmoid is known since ancient Egypt. In the 5th century BC, hippocrates laid the foundations for its management. The first observation of this condition was not reported until 1836 by Von Rokitansky, and then in 1859, Melchior described its physiopathological consequences. It was the Norwegian Brusgaard who reported, for the first time, in 1947, the effectiveness of a non-operative treatment. Purpose: Describe morbidity, mortality and the impact of co-morbidity factors on the choice of operative techniques. Patients and Methods: This is a retrospective cross-sectional study performed at the Fousseyni Daou Hospital in Kayes from January 2014 to December 2021. We included all patients operated for sigmoid volvulus without necrosis. The parameters studied were the comorbidity factor, surgical modalities, morbidity and mortality. Results: We collected 31 patients, of whom 29 were men and 2 were women, for a sex ratio of 14.5. The mean age was 55 years with extremes (29 - 78 years). Sigmoidectomy with colorectal anastomosis was performed in 19 cases (61.3%), the average age of these patients was 46.16 years, the comorbidity factor was 1 case (3.2%), the postoperative course was simple in 12 cases (63.1%), the morbidity was 6 cases (26.3%) and mortality 1 case (3.2%). Untwisting with colopexy was performed in 11 cases (35.5%), the average age was 65.91 years, comorbidities were present in 9 cases (82%), the postoperative course was simple in 9 cases (82%), morbidity was 1 case (9%) and mortality 1 case (9%). Hartman colostomy was performed in 1 case (3.2%), the age was 60 years, the morbidity was nil. Overall, the postoperative course was simple in 22 cases (71%), the overall morbidity was 7 cases (22.6%) and mortality 2 cases (6.4%). Conclusion: At the end of our study, we can note that the choice of the operative technique for the volvulus of the sigmoid without necrosis can be influenced by the presence of major comorbidity and the morbi-mortality depends on it.

Polysomnography parameters as predictors of respiratory adverse events following adenotonsillectomy in children

The first-line treatment of obstructive sleep apnea syndrome in children is adenotonsillectomy, but this may result in perioperative respiratory adverse events (PRAEs). The primary aim of this study is to examine whether the McGill oximetry score (MOS) and other polysomnography parameters can predict major PRAEs following adenotonsillectomy. We secondarily evaluated the MOS interrater reliability and correlation with other polysomnography parameters. This retrospective study included all children aged 0-18 years who underwent preoperative polysomnography between June 2010 and January 2016 prior to adenotonsillectomy at a tertiary pediatric institution. Oximetries from polysomnograms were assigned an MOS. Univariable and multivariable models for prediction of major PRAEs were constructed. MOS was correlated with polysomnography parameters and interrater reliability was evaluated. This study included 106 children; 15 had a major PRAE. A multivariable prediction model that combined MOS and age showed evidence for the ability to predict major PRAEs with an area under the receiver operating characteristic curve of 0.68 (95% confidence interval: 0.52, 0.84), whereby increased MOS and younger age were associated with PRAEs, but apnea-hypopnea index was not. MOS had excellent interrater reliability (κ = 0.95) and was highly correlated with oxygen saturation nadir and cumulative time percentage with oxygen saturation less than 90%. A prediction model including MOS and age may predict PRAEs following adenotonsillectomy. This suggests that nocturnal oximetry provides the most essential information of polysomnography measures to direct postoperative monitoring following adenotonsillectomy. Xiao L, Barrowman N, Momoli F, etal. Polysomnography parameters as predictors of respiratory adverse events following adenotonsillectomy in children. J Clin Sleep Med. 2021;17(11):2215-2223.

1097 Are There Demographic Variations Between Obese and Non-Obese (Lean) Patients With Non-alcoholic Steatohepatitis?

INTRODUCTION: Non-alcoholic steatohepatitis (NASH) in the absence of overweight and/or obesity is designated as non-obese (lean) NASH. Several studies suggested that lean NASH is a variant phenotype of NASH, where its features metabolically resemble obese NASH individuals with insulin resistance, and metabolic syndrome plays the pathogenetic role in both phenotypes. Limited data suggested that Asians have propensity to develop NASH at a comparatively lower BMI, mostly due to body composition and fat distribution. We aimed at assessing baseline demographic variations between obese and non-obese (lean) patients with NASH. METHODS: Based on fibroscan reports with CAP and fibrosis scores, 124 patients with NAFLD had been identified between 09/2018 and 05/2019 at the Liver Associates of Texas Hepatology Clinics in Houston. Standardized fibroscan report (steatosis, and fibrosis stage) was determined by expert clinicians. Demographic information, chronic infection with hepatitis B virus (HBV) and hepatitis C virus (HCV), baseline body mass index (BMI), presence of major comorbidities and metabolic syndrome were recorded for all patients. For continuous variables, we used the Student’s t test to compare differences in the mean values. The chi-squared test was used to compare the proportions of risk factors between groups. RESULTS: According to the baseline body mass index, patients were classified into obese (BMI ≥30) and non-obese (BMI &lt; 30). With the consideration of presence and absence of NASH and obesity, participants were further classified into four groups as seen in Table 1. Our data indicated that Asians (47.1%) especially men (57.1%), P = .06 are more likely to be classified as non-obese/NASH. No significant variation between all groups, however, with respect to age at diagnosis or gender distribution. CONCLUSION: No significant difference between obese and lean patients with NASH regarding age, gender or ethnicity. NASH should be considered in the differential diagnosis of unexplained liver disease even in presence of normal BMI. Management strategy, and surveillance protocol for NASH should be evaluated and validated in non-obese (lean) NASH subjects.

The relative contributions of the Genomic Prostate Score and comorbidity profile in predicting outcomes in surgically treated men with clinically low and intermediate-risk prostate cancer.

e16607 Background: The 17-gene Oncotype Dx Genomic Prostate Score® (GPS™) assay has been validated as a predictor of aggressive prostate cancer (PCa) in men treated with radical prostatectomy (RP) for clinically low and intermediate risk PCa. This study examined the performance of the GPS assay as a predictor of adverse pathology (AP) and biochemical recurrence (BCR)-free survival (BRFS), after adjusting for the presence of major comorbidities commonly seen in older men. Methods: Additional analyses were performed using data from a prior clinical validation study of the GPS assay. GPS values (scaled 0-100), determined from diagnostic biopsy tissue, were categorized into 3 levels: lowest quartile (Q1), middle quartiles (combined Q2-Q3) versus the highest quartile (Q4). Major comorbidities included heart disease, stroke, COPD, and other cancers. The associations between GPS result and the presence of ≥1 major comorbidity and outcomes were examined. AP was defined as high-grade (Gleason Score ≥ 4+3) and/or pT3 tumor. BCR was defined as 2 successive PSA levels &gt; 0.2 ng/mL. Logistic regression analysis was used to examine AP; Cox proportional hazards analysis was used to model BRFS. Results: Among 389 eligible men, median age at diagnosis and follow-up time was 62 and 5.6 years, respectively. The prevalence of ≥1 major comorbidity differed significantly across GPS category, rising from 10.2% to 19.7% to 25.5% for GPS Quartiles 1, 2-3, and 4, respectively (p = 0.0024). However, presence of ≥1 major comorbidity was not a significant predictor of AP or BCR in multivariable models with GPS, age, race, and NCCN risk stratum. Men whose GPS result was in the highest quartile had 4-fold higher odds of AP (OR: 4.1; 95% CI = 2.1-7.99, p &lt; 0.0001) at RP and a 3.5 times higher risk of BCR (HR = 3.49; 95% CI = 1.59-7.64, p = 0.002) compared to men in the lowest GPS quartile (Table 1). Conclusions: A high GPS result remains the strongest predictor of BCR and AP in this cohort of low and intermediate risk PCa men, after adjusting for the presence of major comorbidities. Further work will explore the relationships between specific comorbidities and metabolic syndrome, with GPS testing and PCa outcomes.

Perioperative predictors of rehabilitation placement after pancreaticoduodenectomy

Objective: Patients undergoing pancreaticoduodenectomy (PD) frequently require post-hospital recovery at rehabilitation facilities. Early identification of patients at risk for rehab placement may help with pre-operative education, risk stratification, and discharge planning. We evaluated the predictive role of early perioperative factors on rehabilitation facility placement to identify patients who may require this service. Methods: The ACS-NSQIP pancreas-targeted database was queried to identify patients who underwent pancreaticoduodenectomy (PD) in 2014. Patients who originated from a facility, those with unknown or expired discharge disposition, and emergency cases were excluded. All perioperative variables were assessed via multivariate logistic regression analysis to identify predictors of discharge to a rehabilitation facility. Results: Of 3073 PD patients with complete data, 409 (13.3%) were discharged to rehab. Mean age was 64, 53.7% were male. Most PDs (80%, n=2458) were performed for malignant disease. Vascular resection was performed in 16.4% of cases, while 7.1% underwent an additional major concurrent procedure, the most common of which were ventral hernia repair, partial colectomy, component separation, hepatic resection, and partial/total nephrectomy. On multivariate analysis, age, ASA score, BMI, dyspnea, COPD, ascites, chronic dialysis, non-malignant indication, and major concurrent procedure were predictive of rehab disposition. Neoadjuvant therapy and vascular resection were not significant, even on subgroup analysis of exclusively malignant cases. Conclusion: Perioperative risk factors that predict need for post-operative rehabilitation after PD include advancing age, BMI, ASA score, presence of major comorbidities, and undergoing a major concurrent procedure. At-risk patients may benefit from additional preoperative education/risk stratification, and earlier engagement of advanced discharge planning services.Table 1Multivariate model for predictors of rehabilitation placement amongst patients undergoing pancreaticoduodenectomy.VariableOdds ratio95% Confidence intervalP valueAge1.0941.0771.110.000Female1.214.9471.557.126ASA ≥ 31.5081.0462.172.028BMI1.0361.0141.059.001Diabetes1.222.9771.409.073Dyspnea1.6221.0112.603.045Non-Caucasian0.854.5671.287.451Active smoker1.293.9991.500.051COPD2.0931.3143.331.002Ascites11.0722.34752.244.002CHF2.576.29522.495.392Hypertension1.185.9251.382.148Acute renal failure1.167.08715.686.908Dialysis36.6661.938693.878.016Open wound/infection present at time of surgery1.190.1449.810.872Chronic steroids1.352.7341.678.204Preop sepsis.897.2722.958.859Transfusion with 72 hrs1.440.2921.816.308Weight loss >10%1.137.8231.367.353Bleeding disorder1.351.5341.391.649Wound classification ≥31.251.9601.461.085Obstructive jaundice.825.6051.126.226Preoperative biliary stent0.933.6861.273.663Minimally-invasive approach0.548.2901.033.063Vascular resection0.984.7021.379.925Major concurrent procedure2.2451.4683.435.000Malignant indication0.504.350.728.000Pancreatitis histology0.546.301.990.046Age, ASA score, BMI, dyspnea, COPD, ascites, chronic dialysis, and undergoing major concurrent procedure were predictive of rehabilitation placement. Malignant (compared to benign) indication and pancreatitis present on histology were protective against rehab placement. Open table in a new tab Age, ASA score, BMI, dyspnea, COPD, ascites, chronic dialysis, and undergoing major concurrent procedure were predictive of rehabilitation placement. Malignant (compared to benign) indication and pancreatitis present on histology were protective against rehab placement.

Quality of life and hernia development 5 years after open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction.

To report incisional hernia (IH) incidence, abdominal wall (AW) discomfort and quality of life (QoL) 5 years after open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). Five-year follow-up of patients included in a prospective study 2006-2009. The protocol included physical examination, patient interview, chart review, questionnaires on abdominal wall and stoma complaints and the SF-36 questionnaire. Fifty-five (12 women, 43 men; median age 70 years) of 111 included patients were alive. Follow-up rate was 91 %. Cumulative IH incidence during the whole study was 62 %. One-third of the IHs was repaired. At 5-year follow-up 59 % of IHs were clinically detectable. AW symptoms were equivalent in patients with (15/23) and without (11/21) IH (p = 0.541). SF-36 scores were lower than population mean for component scores and all subscales except bodily pain. Patients with major co-morbidity had lower physical component score [31.6 (95 %, CI 25.6-37.4)] compared to those without [48.9 (95 %, CI 46.2-51.4)]. Major co-morbidity was not associated with IH (p = 0.56), AW symptoms (p = 0.54) or stoma (p = 0.10). Patients with IH or other AW symptoms had similar SF-36 results compared to those without, whereas patients with a stoma had >5 point lower mean scores for general health, social function and physical component score compared to those without. VAWCM treatment results in high incidence of IH. However, at five years, there was no detectable difference in abdominal wall complaints and QoL in patients with IH compared to those without. Lower QoL appeared mainly to be associated with the presence of major co-morbidity.

Prediction of Clinically Significant Bleeding Following Wide-Field Endoscopic Resection of Large Sessile and Laterally Spreading Colorectal Lesions: A Clinical Risk Score.

Clinically significant bleeding (CSPEB) is the most frequent adverse event following wide-field endoscopic mucosal resection (WF-EMR) of large sessile and laterally spreading colorectal lesions (LSL). There is limited knowledge regarding accurate prediction of CSPEB. We aimed to derive a score to predict the risk of CSPEB. Data on patient and lesion characteristics and outcomes from WF-EMRs of LSL ≥20 mm at 8 referral hospitals were analyzed. The cohort was divided at random into equal sized training and test groups. Independent predictors of CSPEB in the training cohort were identified by multiple logistic regression analysis and used to develop a risk score. The performance of this score was assessed in the independent test cohort. Over 80 months to June 2015, 2,128 patients with 2,424 LSL were referred for WF-EMR. Two thousand and twelve patients were eligible for analysis. There were 135 cases of CSPEB (6.7%). In the training cohort of 1,006 patients, the independent predictors of CSPEB were lesion size >30 mm (odds ratio (OR) 2.5), proximal colonic location (OR 2.3), presence of a major comorbidity (OR 1.5), and epinephrine in injection solution (OR 0.57). The derived risk score comprised lesion size >30 mm (2 points), proximal colon (2 points), presence of major comorbidity (1 point), and absence of epinephrine use (1 point). The probabilities of CSPEB for scores of 0, 1, 2, 3, 4, and ≥5 in the training cohort were 1.5, 2.0, 5.6, 7.8, 9.1, and 17.5% and were 0.9, 6.7, 4.9, 6.2, 9.0, and 15.7% in the test cohort. The probabilities of CSPEB in those with low (score 0-1), medium (score 2-4), and elevated (score 5-6) risk levels were 1.7, 7.1, and 17.5% in the training cohort and 3.4, 6.2, and 15.7% in the test cohort. Patients at elevated risk of CSPEB can be identified using four readily available variables. This knowledge may improve the management of those undergoing WF-EMR and assist in designing studies evaluating CSPEB.

Cardiometabolic Profile Related to Body Adiposity Identifies Patients Eligible for Bariatric Surgery More Accurately than BMI.

Eligibility criteria for bariatric surgery (BS) are based on BMI and the presence of major comorbidities. Our aim was to analyze the usefulness of body adiposity determination in establishing the indication for BS. In order to analyze the cardiometabolic risk according to eligibility criteria for BS, four groups were studied. Morbidly obese patients with BMI ≥ 40 kg/m(2) (n = 360), and obese subjects with BMI ≥ 35 kg/m(2) and at least one comorbidity (n = 431), represented two groups of patients meeting original NIH criteria for BS. A third group included two cohorts of patients with a high body fat (BF)% that do not meet the original NIH eligibility criteria for BS: patients with either a BMI <35 kg/m(2) or a BMI ≥ 35 kg/m(2) without comorbidities (n = 266, NEHF). Lean subjects by BMI were the reference group (n = 140). BMI, BF% and markers of insulin sensitivity, lipid profile, and cardiovascular risk were measured. Individuals from the NEHF group exhibited increased HbA1c (P < 0.05) and decreased insulin sensitivity evidenced by a significant reduction in QUICKI (P < 0.001). Triglyceride concentrations were similarly increased (P < 0.05) in the three groups of obese patients. Uric acid concentrations were significantly elevated (P < 0.01) to a similar extent in the obese groups. Levels of the inflammatory marker CRP and hepatic enzymes were significantly increased in the three obese groups. The present study provides evidence for the existence of an adverse cardiometabolic profile in subjects currently considered to be outside traditional NIH guidelines but exhibiting a highly increased adiposity. It is concluded that body composition analysis yields valuable information to be incorporated into indication criteria for BS and that adiposity may be an independent indicator for BS.

Rates and risk of hospitalisation among patients with type 2 diabetes: retrospective cohort study using the UK General Practice Research Database linked to English Hospital Episode Statistics

AimsTo investigate the rates and risk of hospitalisations in patients with type 2 diabetes (T2D) mellitus in England.MethodsThis retrospective population-based cohort study used computerised records from the General Practice Research Database linked to Hospital Episode Statistics data in England. Patients with T2D from January 2006 to December 2010 were selected. Primary outcome measures were all-cause, non-diabetes-related, diabetes-related and hypoglycaemia-related hospitalisations. Factors associated with all-cause and diabetes-related hospitalisations were investigated with Cox's proportional hazards models.ResultsAmongst 97,689 patients with T2D, approximately 60% had at least one hospitalisation during the 4-year study period. Rates of hospitalisation were as follows: all-cause, 33.9 per 100 patient-years (pt-yrs); non-diabetes-related, 29.1 per 100 pt-yrs; diabetes-related, 18.8 per 100 pt-yrs and hypoglycaemia, 0.3 per 100 pt-yrs. The risk of all-cause hospitalisation increased with hospitalisation in the previous year, insulin use and the presence of major comorbidities. The risk of a diabetes-related hospitalisation increased with age, female gender, insulin use, chronic renal insufficiency, hypoglycaemia (as diagnosed by a general practitioner) and diabetes-related hospitalisation in the previous year.ConclusionsPatients with T2D are hospitalised at a considerably high rate for causes directly related with diabetes complications and stay longer in hospital. History of hospitalisation and complications of diabetes were found to be predictive of inpatient hospitalisations suggesting previous hospitalisation episodes could serve as points of intervention. This study highlights important areas for healthcare intervention and provides a reminder for vigilance when risk factors for hospitalisation in patients with T2D are present.

Comparison of Skeletal Complications and Treatment Patterns Associated With Early vs. Delayed Zoledronic Acid Therapy in Multiple Myeloma

This study retrospectively compared the risks of skeletal-related events (SREs) and zoledronic acid (ZOL) treatment discontinuation associated with early vs. delayed ZOL therapy for patients with symptomatic multiple myeloma (MM). Data were collected from a physician-administered medical chart review among US patients with a confirmed diagnosis of symptomatic MM treated after 01/01/2002. Early and delayed ZOL therapy were defined, respectively, as initiating ZOL ≤ 60 days (N = 126) vs. > 60 days (N = 186) after the first symptomatic MM diagnosis. Kaplan-Meier analysis with a log-rank test was performed to compare the risk of SREs between the cohorts. Cox proportional hazard modeling compared the risk of SREs associated with early vs. delayed ZOL treatment, controlling for demographic factors, stage of MM, bone health status, and presence of major comorbidities at diagnosis. Time to ZOL discontinuation was evaluated using the Kaplan-Meier method, following patients from the date of ZOL initiation. Time to the first SRE was significantly longer for patients who received early treatment with ZOL (P = .005). At 2 years after diagnosis, the SRE-free rate was 74.6% vs. 56.5% in the early vs. delayed treatment group, respectively. Early ZOL therapy was associated with a significantly lower risk of any SRE (hazard rate [HR] = .625 vs. delayed ZOL therapy; P = .029). At 2 years from ZOL therapy initiation, rates of ZOL discontinuation were 9.6% vs. 16.4% among patients with early vs. delayed therapy, respectively (P < .05). Early treatment with ZOL was associated with significantly reduced risks of SREs and with better treatment persistence compared with delayed treatment.

Comparison of Skeletal Complications and Treatment Patterns Associated with Early Versus Delayed Zoledronic Acid Therapy In Multiple Myeloma

AbstractAbstract 1956 Introduction:Zoledronic acid (ZOL) is currently the standard of care to reduce/delay progressive skeletal-related events (SREs) in multiple myeloma (MM). However, limited evidence is available on the relationship between the timing of ZOL initiation and patient outcomes in this indication. This study retrospectively compared the risks of SREs and ZOL treatment discontinuation associated with early versus delayed ZOL therapy for patients with symptomatic MM. Methods:Data were collected from a physician-administered medical chart review among patients with a confirmed diagnosis of symptomatic MM treated after 01/01/2002. Participating hematologists and oncologists were asked to provide detailed information for patients meeting the inclusion criteria, including demographics, comorbidity profiles, disease severity and bone health at diagnosis, bisphosphonate treatment patterns, and timing of SREs. Analyses were conducted among patients who received early or delayed ZOL therapy, defined respectively as initiating ZOL ≤60 days versus >60 days after the first symptomatic MM diagnosis. Kaplan-Meier analysis with a log-rank test was performed to compare the risk of SREs between the study cohorts. Patients were followed from their diagnosis date until the first subsequent SRE, or until loss of follow-up. SREs included pathologic fractures (vertebral or non-vertebral), spinal cord compression, radiation to relieve bone pain, hypercalcemia, and prophylactic surgery to treat impending fractures. Cox proportional hazard modeling was used to compare the risk of SREs associated with early versus delayed ZOL treatment, controlling for demographic factors, stage of MM, bone health status, and presence of major comorbidities at diagnosis. To evaluate the implications of early treatment on persistence, risk of ZOL discontinuation was compared between the cohorts in a survival analysis framework. Time to discontinuation for any reason was evaluated using the Kaplan-Meier method, which followed patients from the date of ZOL initiation; as a sensitivity analysis, time to discontinuation for reasons other than stable or remitted MM was also assessed. Results:A total of 312 patients met the study inclusion criteria. Median time to ZOL initiation from symptomatic MM diagnosis was 25 days in the early treatment cohort (N=126) and 242 days in the delayed treatment cohort (N=186). Baseline characteristics assessed at the time of diagnosis were generally well-balanced between the study groups; however, patients with early ZOL therapy were older on average (62.3±10.0 vs. 60.1±10.6 years; p=.022), were more likely to have Durie-Salmon stage III MM (57.9% vs. 44.1%; p=.034), and had a higher average number of lytic lesions (7.1±7.8 vs. 4.8±7.0; p<.001) than those with delayed therapy. Following the diagnosis date, time to the first SRE was significantly longer for patients who received early treatment with ZOL (p=.005). At 2 years post-diagnosis, the SRE-free rate was 74.6% in the early treatment group compared to 56.5% in the delayed treatment group. Adjusting for baseline characteristics, Cox regression analysis confirmed that early ZOL therapy was associated with a significantly lower risk of any SRE (hazard ratio=.625 vs. delayed ZOL therapy; p=.029). The risk of ZOL treatment discontinuation over time was also significantly lower in the early treatment group. At 2 years from ZOL initiation, rates of discontinuation for any reason were 9.6% versus 16.4% among patients with early versus delayed therapy, respectively (p=.032). Rates of discontinuation for reasons other than stable or remitted MM showed a similar pattern in the early versus delayed treatment groups (6.5% vs. 12.0% at 2 years; p=.044). Conclusion:This retrospective chart review among patients with symptomatic MM found that early treatment with ZOL was significantly associated with reduced risks of SREs and with better persistence compared to delayed treatment. Results indicate that early initiation of ZOL therapy may have important clinical implications in MM. Disclosures:Yu:Novartis Pharmaceuticals Corporation: Consultancy. Bensimon:Novartis Pharmaceuticals Corporation: Consultancy. Marynchenko:Novartis Pharmaceuticals Corporation: Consultancy. Wu:Novartis Pharmaceuticals Corporation: Consultancy. Namjoshi:Novartis Pharmaceuticals Corporation: Employment, Equity Ownership. Guo:Novartis Pharmaceuticals Corporation: Employment, Equity Ownership. Ericson:Novartis Pharmaceuticals Corporation: Employment, Equity Ownership. Raje:Novartis Pharmaceuticals Corporation: Consultancy.

A prospective cohort study of microvascular decompression and Gamma Knife surgery in patients with trigeminal neuralgia

The aim of this study was to analyze 1 surgeon's 4-year experience with microvascular decompression ([MVD], 36 patients) and Gamma Knife surgery ([GKS], 44 patients) in 80 consecutive patients with trigeminal neuralgia (TN). The authors conducted a prospective cohort study from March 1999 to December 2003 with an independent clinical assessment of the results and serial patient satisfaction surveys. All patients completed a 2004 patient satisfaction survey (0.5-5 years postoperative), and 70% of surviving patients completed the same survey in 2007 (3.9-8.5 years postoperative). Follow-up was undertaken in 100% of the patients (mean 3.4 +/- 2.14 years, range 0.17-8.5 years). Respective initial and latest follow-up raw pain-free rates were 100 and 80.6% for MVD and 77.3 and 45.5% for GKS. The median time to the maximal benefit after GKS was 4 weeks (range 1 week-6 months). Respective initial, 2-, and 5-year actuarial pain-free rates were 100, 88, and 80% for MVD and 78, 50, and 33% for GKS (p = 0.0002). The relative risk of losing a pain-free status by 5 years posttreatment was 3.35 for patients in the GKS group compared with the MVD group. Initial and 5-year actuarial rates for >or= 50% pain relief after GKS were 100 and 80%, respectively. The respective rates of permanent mild and severe sensory loss were 5.6 and 0% for patients in the MVD group, as opposed to 6.8 and 2.3% for patients in the GKS group. Anesthesia dolorosa did not occur during the study. Both procedures enjoyed a high degree of early patient satisfaction (95-100%). Microvascular decompression maintained the same rate of patient satisfaction, but satisfaction with GKS decreased to 75% as pain control waned. Twenty-three patients (29%) died of causes unrelated to the TN or the surgical intervention during the follow-up, and their pain status was known at the time of death. Statistically significant intergroup differences for the MVD versus GKS cohorts were age (median 54 years, range 36-70 years vs median 74 years, range 48-92 years, respectively), preoperative symptom duration (median 2.58 years, range 0.33-15 years vs median 7.5, range 0.6-40 years, respectively), and the presence of major comorbidities (2.8 vs 58.3%, respectively). In this nonrandomized prospective cohort trial of selected patients with potentially relevant intergroup differences, MVD was significantly superior to GKS in achieving and maintaining a pain-free status in those with TN and provided similar early and superior longer-term patient satisfaction rates compared with those for GKS. The complications of wound cerebrospinal fluid leakage, hearing loss, and persistent diplopia (1 case each in the MVD group) were not seen after GKS.

Recommended reporting standards for endovenous ablation for the treatment of venous insufficiency: Joint Statement of the American Venous Forum and the Society of Interventional Radiology

Sanjoy Kundu, MD, FRCPC, FCIRSE, FASA, Fedor Lurie, MD, Steven F. Millward, MD, FRCPC, FSIR, Frank Padberg Jr, MD, Suresh Vedantham, MD, Steven Elias, MD, Neil M. Khilnani, MD, William Marston, MD, John F. Cardella, MD, FSIR, FACR, Mark H. Meissner, MD, Michael C. Dalsing, MD, Timothy W.I. Clark, MD, FSIR, and Robert J. Min, MD, MBA, FSIR, Toronto and Peterborough, Ontario, Canada; Honolulu, Hawaii; Newark and Englewood, NJ; Saint Louis, Mo; New York, NY; Chapel Hill, NC; Springfield, Mass; Seattle, Wash; and Indianapolis, Ind

L’hémoptysie massive : prise en charge et traitement Quelle est la place de la chirurgie ?

To define the role of interventional radiology and surgery respectively, in the treatment of massive haemoptysis. GENERAL CONSIDERATIONS: For the management of massive haemoptysis in non-terminal pathologies an intensive care facility and a multi-disciplinary team are necessary. It is of paramount importance to identify rapidly the pulmonary or bronchial source of the bleeding. CT scanning and bronchoscopy are essential to localise the bleeding and determine its cause. Initial management. An attempt to control the initial bleeding to allow localisation of its origin and determine the treatment. Bronchial or systemic embolisation and surgery are the only effective medium and long-term treatments. Embolisation achieves excellent results in bleeding from bronchial or parietal systemic arteries prior to surgery and may be the only technique possible in the presence of major co-morbidity. Surgery is necessary in the case of failure, in certain specific conditions, and in the case pulmonary artery haemorrhage from a proximal lesion. Various surgical techniques are available depending on the type of lesion encountered and the facilities for post-operative care. Emergency surgery carries a high risk and deferred surgery gives better results. The management of massive haemoptysis should be multi-disciplinary. Intensive care, respiratory and radiological diagnosis, Surgical management and interventional radiology should be combined to improve the prognosis of this grave condition. Pulmonary arterial haemorrhage from a necrotic tumour constitutes a surgical emergency and should be operated on without delay.

How Bad Are Bacteremia and Sepsis?

To evaluate the short-term and long-term outcomes of patients with suspected bacteremia, we performed a prospective cohort study. Clinical data were collected within 24 hours of initial culture from a random sample of 1516 episodes in which blood cultures were performed in an urban tertiary care hospital. One hundred forty-two patients with bacteremia were compared with two comparison groups: (1) 142 randomly selected patients with negative cultures, matched in age within 5 years, gender, severity of underlying disease, and presence of major comorbidity, and (2) all 155 patients with contaminant cultures. The main outcome measures were death, death secondary to bacteremia, and major complications. In the 439 patients, there were 142 deaths (32%), 114 at 1 year (26%) and 46 within 30 days (11%). Mortality at 30 days was most highly correlated with predicted fatality of underlying disease: 48% for the 65 patients with a rapidly fatal disease, 9% for the 156 patients with an eventually fatal disease, and 0.5% for the 217 patients with no fatal disease. In a Cox survival analysis, the risk ratio associated with bacteremia was 1.6 (95% confidence interval, 1.0 to 2.4) vs the comparison groups. When we performed time-dependent Cox analyses in which the hazard ratio was allowed to change at 30 days, we found that the risk ratios associated with bacteremia were 2.3 (95% confidence interval, 1.2 to 4.4) for the first 30 days, and 1.3 (95% confidence interval, 0.76 to 2.1) after 30 days. We conclude that this population has a high mortality, which is strongly correlated with severity of underlying disease. Short-term mortality was higher in patients with bacteremia even after controlling for severity of illness, but the increase in risk was present only during the first month and most deaths occurred in patients with a rapidly fatal disease.