Rate Of Young Patients Research Articles

Exploring the high re-injury rate in younger patients undergoing anterior cruciate ligament reconstruction

Exploring the high re-injury rate in younger patients undergoing anterior cruciate ligament reconstruction

Allograft Anterior Cruciate Ligament Reconstruction Utilizing Internal Brace Augmentation

Anterior cruciate ligament (ACL) tears are among the most common sports-related injuries. Although studies have reported reliable outcomes with allograft tissue, several studies have shown a higher failure rate in younger patients. Although ACL graft augmentation has been met with varying levels of success, internal bracing of an allograft represents a promising area in ACL reconstruction. The purpose of this article is to detail allograft preparation involving a collagen-coated, ultrahigh-molecular-weight polyethylene/polyester suture tape as an internal brace augmentation for ACL reconstruction using the all-inside ACL GraftLink Technique (Arthrex, Naples, FL).

Patient-Reported Outcomes, Quality of Life, and Satisfaction Rates in Young Patients Aged 50 Years or Younger After Total Knee Arthroplasty

BackgroundRecent studies have shown a discrepancy between traditional functional outcomes and patient satisfaction, with some reporting less than 85% satisfaction in older patients undergoing total knee arthroplasty (TKA). As native knee biomechanics are not completely replicated, the resulting functional limitations may cause dissatisfaction in higher-demand individuals. Few studies have recorded patient-reported outcomes, health-related quality of life scores, and patient satisfaction in a young population undergoing TKA. MethodsOne hundred thirty-six primary TKAs were performed in 114 patients aged 50 years or younger (mean age, 47.0 years; range, 30-50 years) at a single institution. The main diagnoses were osteoarthritis (85%) and rheumatoid arthritis (10%). ResultsThe range of motion, Knee Society Score, Oxford Knee Score, and Physical and Mental Component Scores of Short Form-36 increased significantly (P < .001). At 2 years, 85.3% of patients had good/excellent knee scores, 71.3% had good/excellent function scores, 94.9% met the minimal clinically important difference for the Oxford Knee Score, and 84.6% met the minimal clinically important difference for the Physical Component Score. We found that 88.8% of patients were satisfied with their surgeries, whereas 86.8% had their expectations fulfilled. Survivorship using revision as an end point was 97.8% at a mean of 7 years (range, 3-16 years). ConclusionPatients aged 50 years or younger undergoing TKA can experience significant improvements in their quality of life, have their expectations met, and be satisfied with their surgeries, at rates similar to those of non–age-restricted populations. Surgeons should inform them of these benefits and the potential risk of revision surgery in the future, albeit increasingly shown to be low.

Exploring the High Reinjury Rate in Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction

Background: Younger age is being increasingly recognized as a risk factor for anterior cruciate ligament (ACL) graft rupture and contralateral ACL injury after ACL reconstruction. Recent reports estimate second ACL injury rates to be in the range of 20% to 40%, which is a significant concern and requires further exploration. Purpose: The primary purpose was to determine the rates of graft rupture and injury to the contralateral native ACL in younger athletes. We also sought to explore the influence of sex and age groupings (<18 years vs 18-19 years at the time of surgery) on the risk of subsequent ACL injury. Study Design: Cohort study; Level of evidence, 3. Methods: The study cohort consisted of 354 consecutive patients who were younger than 20 years when they underwent their first primary hamstring tendon autograft ACL reconstruction. The number of subsequent ACL injuries (graft rupture or a contralateral injury to the native ACL) was determined at a mean follow-up of 5 years (range, 3-10 years). Subgroup analysis included sex and age (<18 years vs 18-19 years at the time of surgery) comparisons. Descriptive statistics were calculated for the timing of ACL graft rupture and contralateral ACL injury. Results: The overall follow-up rate was 89% (316/354). Graft ruptures occurred in 57 patients (18%) at an average time of 1.8 years after surgery. Almost half (47%) occurred within the first postoperative year, and 74% occurred within the first 2 years. The highest graft rupture rate of 28.3% was in the youngest males (<18 years), and this was significantly higher than in females of the same age (12.9%), as well as in male patients older than 18 years (13.8%). Contralateral ACL injuries occurred in 56 patients (17.7%) at an average time of 3.7 years after surgery. There were no significant age- or sex-based differences for contralateral ACL injuries. The total number of patients who had at least 1 further ACL injury subsequent to the primary surgery was 110 (35%). Conclusion: The high rate of subsequent ACL injury in younger patients was confirmed. Early graft ruptures were more prevalent in patients who underwent surgery when they were younger than 18 years versus those in the 18- to 19-year age group. Males had higher rates of graft rupture than did females, with the youngest males (<18 years) at the highest risk in the investigated cohort.

Contemporary Locoregional Recurrence Rates in Young Patients With Early-Stage Breast Cancer.

The aim of this study was to evaluate contemporary rates of local recurrence (LR) and regional recurrence (RR) in young patients with breast cancer in relation to tumor biology as expressed by biomarker subtypes. Women < 35 years of age who underwent surgery for primary unilateral invasive breast cancer between 2003 and 2008 were selected from the Netherlands Cancer Registry. Patients were categorized according to biomarker subtypes on the basis of hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) status. The 5-year risks of developing LR and regional lymph node recurrence were estimated by using Kaplan-Meier statistics. A total of 1,000 patients were identified, of whom 59% had a known subtype: 39% HR-positive/HER2-negative; 17% HR-positive/HER2-positive; 10% HR-negative/HER2-positive; and 34% HR-negative/HER2-negative (triple negative). Overall 5-year LR and RR rates were 3.5% and 3.7%, respectively. A decreasing trend for both rates was observed over time and was accompanied by a significant decrease in the risk of distant metastases (DM). LR occurred in 4.2%, RR in 6.1%, and DM in 17.8% of patients in 2003, and in 3.2%, 4.4%, and 10.0%, respectively, in 2008. LR and RR rates varied with biomarker subtype. These differences were borderline significant when analyzed for the entire study period (P = .056 and P = .014, respectively) and leveled off after the introduction of trastuzumab after 2005 (P = .24 and P = .42, respectively). Patients with lymph node metastases at the time of diagnosis had an increased risk of RR. The type of surgery performed-breast-conserving or mastectomy-did not influence rates of LR and RR. Overall, the rates of LR and RR in young patients with early-stage breast cancer were relatively low and varied by biomarker subtype.

TCTAP A-027 A Study on Coronary Risk Factors and Clinical Characteristics in Patients with Juvenile Ischemic Heart Disease in Our Hospital: A Retrospective Study

Recently, the rate of young patients under 50 years old has increased of ischemic heart disease in our hospital. Although smoking, dyslipidemia, hypertension, diabetes, and family history are risk factors, it has been reported that there is a tendency for young patients to have more than one of

Genomic landscape of pancreatic adenocarcinoma: Does age matter?

250 Background: State-of the art genomic analyses of pancreatic adenocarcinoma (PDAC) has yielded insights into signaling pathways underlying carcinogenesis. PDAC is characterized by substantial genomic heterogeneity. We aimed to determine if early-onset PDAC ( ≤ 55 yrs) displays a distinctive molecular landscape from average-age onset PDAC ( ≥ 70 yrs). Methods: Three distinct datasets of PDAC in age groups ≤ 55 and ≥ 70 years old were analyzed. In the first, patients undergoing treatment at MSKCC were consented for MSK-IMPACT (Integrated Mutation Profiling of Actionable Cancer Targets) next generation sequencing. The second cohort analyzed was The Cancer Genome Atlas (TCGA) dataset for differences in somatic mutations, gene expression and protein expression. The third dataset was the Australian cohort of PDAC (Waddell et al, Nature, 2015). Clinical data were correlated with genomic analyses. Results: One hundred and eighty-three samples were analyzed, yielding N = 56 patients (pts) aged ≤ 55 years and N = 127 pts aged ≥ 70 years. Several genes known to be associated with carcinogenesis differed in mutation frequency across age groups: SMAD4, MYC and PIK3CA displayed higher mutation rates in younger patients (p &lt; 0.05, table below). Comprehensive analysis by cellular pathways indicated that the PI3Kpathway is further altered in the younger population. Protein expression had different patterns in younger versus older patients. Smoking was more prevalent in the early-onset group in all three cohorts (59% vs. 47%). Survival outcomes revealed no differences between the age groups. Conclusions: This exploratory analysis suggests that there may be somatic gene alterations within the population of early onset PDAC patients that involve unique cellular pathways compared with average onset PDAC. Former studies imply these cellular pathways may play a role in smoking-related PDAC carcinogenesis. Larger genomic datasets are warranted for future analysis to support this observation. [Table: see text]

Long-term outcomes after stenting as a "bridge to surgery" for the management of acute obstruction secondary to colorectal cancer.

Obstructive symptoms are present in 8% of cases at the time of initial diagnosis in cases of colorectal cancer. Emergency surgery has been classically considered the treatment of choice in these patients. However, in the majority of studies, emergency colorectal surgery is burdened with higher morbidity and mortality rates than elective surgery, and many patients require temporal colostomy which deteriorates their quality of life and becomes permanent in 10%-40% of cases. The aim of stenting by-pass to surgery is to transform emergency surgery into elective surgery in order to improve surgical results, obtain an accurate tumoral staging and detection of synchronous lesions, stabilization of comorbidities and performance of laparoscopic surgery. Immediate results were more favourable in patients who were stented concerning primary anastomosis, permanent stoma, wound infection and overall morbidity, having the higher surgical risk patients the greater benefit. However, some findings laid out the possible implication of stenting in long-term results of oncologic treatment. Perforation after stenting is related to tumoral recurrence. In studies with perforation rates above 8%, higher recurrences rates in young patients and lower disease free survival have been shown. On the other hand, after stenting the number of removed lymph nodes in the surgical specimen is larger, patients can receive adjuvant chemotherapy earlier and in a greater percentage and the number of patients who can be surgically treated with laparoscopic surgery is larger. Finally, there are no consistent studies able to demonstrate that one strategy is superior to the other in terms of oncologic benefits. At present, it would seem wise to assume a higher initial complication rate in young patients without relevant comorbidities and to accept the risk of local recurrence in old patients (> 70 years) or with high surgical risk (ASA III/IV).

The influence of AMH on IVF success.

Anti-Müllerian hormone has a regulative function in the activation of folliculogenesis and an influence on atresia rate. It is considered a marker for the ovarian reserve. We know that a relationship exists between AMH levels and oocyte retrieval numbers, antral follicle count, pregnancy rates and birth rates. The role of AMH as an efficient prognostic factor in determining the probability of pregnancy has been largely discussed in the literature. The aim of this study is to determine the role age and AMH levels play in success rates of IVF/ICSI therapies. To date, the sample group we examined was one of the biggest ever included in a single study of the subject. All patients who underwent an IVF/ICSI treatment with FSH stimulation in the Wiesbaden Kinderwunschzentrum between 2003 and 2010, were no older than 44 years old, and had an evaluation of serum AMH levels before treatment were included in this study. In total, 1287 patients were analysed retrospectively. Statistical analysis was performed with SPSS. Females' mean age was 34.89, ranging from 21 to 44 years. The patients underwent between 1 and 11 IVF cycles. Younger women had significantly higher AMH levels (p = 0.001). Patients with higher AMH levels had significantly lower break-off rates (p < 0.0005) and a significantly higher number of oocytes retrieved (p < 0.0005). Higher levels of AMH corresponded to higher pregnancy rates (p = 0.017). AMH levels do not influence pregnancy rates in younger patients (<36 years). AMH is a useful parameter that should be measured before performing an IVF/ICSI treatment. In younger patients, AMH levels do not predict pregnancy outcomes. In patients older than 36 years, AMH can be used as a prognostic factor. Even when a woman's AMH levels are too low to be detected, she still an acceptable chance of becoming pregnant.

Obinutuzumab treatment in the elderly patient with chronic lymphocytic leukemia.

Chronic lymphocytic leukemia (CLL) is the most common leukemia in adults in Western countries. Fludarabine-based regimens demonstrate higher response rates in younger patients but have a significant risk of infection and are thus poorly tolerated by older, frail patients. Anti-CD20 monoclonal antibodies have added to the efficacy of chemotherapy in CLL. Obinutuzumab is a potent Type II anti-CD20 monoclonal antibody with enhanced antibody-dependent cellular toxicity and direct cell death compared with rituximab. In Phase I studies, infusion reactions and neutropenia were the predominant toxicities. Phase II studies demonstrated efficacy both as a single agent and in combination with chemotherapy in patients with CLL. The CLL11 trial was a Phase III randomized trial of chlorambucil alone or with either obinutuzumab or rituximab in elderly, unfit patients. Progression-free survival (the primary end point) was 26.7 months for patients receiving obinutuzumab plus chlorambucil versus 16.3 months for those receiving rituximab plus chlorambucil and 11.1 months for those receiving chlorambucil alone (P<0.001). Overall survival was improved for patients receiving obinutuzumab plus chlorambucil versus chlorambucil alone (P=0.002). This trial led to the US Food and Drug Administration (FDA) approval of obinutuzumab in this patient population.

The effect of age in breast conserving therapy: A retrospective analysis on pathology and clinical outcome data

Background and proposeAge is an important prognostic marker of patient outcome after breast conserving therapy; however, it is not clear how age affects the outcome. This study aimed to explore the relationship between age with the cell quantity and the radiosensitivity of microscopic disease (MSD) in relation to treatment outcome. Materials and methodsWe employed a treatment simulation framework which contains mathematic models for describing the load and spread of MSD based on a retrospective cohort of breast pathology specimens, a surgery simulation model for estimating the remaining MSD quantity and a tumor control probability model for predicting the risk of local recurrence following radiotherapy. ResultsThe average MSD cell quantities around the primary tumor in younger (age⩽50years) and older patients were estimated at 1.9∗108cells and 8.4∗107cells, respectively (P<0.01). Following surgical simulation, these numbers decreased to 2.0∗107cells and 1.3∗107cells (P<0.01). Younger patients had smaller average surgical resection volume (118.9cm3) than older patients (162.9cm3, P<0.01) but larger estimated radiosensitivity of MSD cells (0.111Gy−1 versus 0.071Gy−1, P<0.01). ConclusionThe higher local recurrence rate in younger patients could be explained by larger clonogenic microscopic disease cell quantity, even though the microscopic disease cells were found to be more radiosensitive.

Survival trends in advanced gastrointestinal stromal tumor patients: A population-based study.

136 Background: In February 2002, imatinib was approved by US FDA for treatment of patients with advanced gastrointestinal stromal tumor (GIST). This study was performed to evaluate survival trends in patients with advanced GIST in pre- (1992-2001) and post- (2002-2008) imatinib era in the United States. Methods: We selected adult patients (≥18 years) with advanced GIST (regional and distant metastasis based on SEER’s LRD staging) from the Surveillance, Epidemiology, and End Results 18 database diagnosed during 1992-2008. We excluded patients diagnosed at autopsy or from death certificate only, or those without survival date. We analyzed 1- and 3- year relative survival (RS) rates of the patients by age (all ages,18-64yrs,64+yrs), race [White, Black and Others (American Indian/AK Native, Asian/Pacific Islander)], and gender in pre-imatinib (1992-2001) and post-imatinib (2002-2008) eras. We used Z-test in SEER*Stat to compare RS rates. Results: There were total of 1,734 cases of advanced GIST (regional and distant metastasis) during the study duration. Of the total population, 744 were females and 990 were males. The 1- and 3- year RS rates were significantly higher for patients diagnosed in post-imatinib era compared to those in pre-imatinib era (83.8±1.1% vs 72.5±2.3%; Z 4.47 at one year and 68.8±1.4% vs 51.0± 2.6%; Z 6.25). The survival rates in younger patients (18-64 years) improved significantly in post-imatinib era compared to pre-imatinib era (88.60±1.2% vs 74.20±2.9%; Z 5.19 at 1 year and 75±1.6% vs 56.1±3.4%; Z 5.81 at 3 years). Among older patients, there was improvement in 3- year survival rate (76.90±2% vs 70.40±3.5%; Z 1.22 at 1 year and 59.80±2.5% vs 44.9±4%; Z 2.82 at 3 years). Survival rates improved for both sexes and for Whites and Blacks (1 year RS: 83.80±1.3% vs 73.40±vs2.6%; Z 3.45 for Whites and 85±2.4% vs 68.80±6%; Z 2.53 for Blacks; 3 year RS: 68.60±1.7% vs 51.20±3.1%; Z 5.02 for Whites and 69.10±3.3% vs 42.6±6.6%; Z 3.76 for Blacks). There was no improvement in survival rates for Others. Conclusions: Overall, survival rates of advanced GIST patients have improved significantly in post-imatinib era compared to pre-imatinib era. There was no improvement in survival rates of Others.

Clinical Pregnancy Rate after Single Euploid Embryo Transfer is Age Independent

BackgroundSingle embryo transfer (SET) is a proven option to achieve high pregnancy rates in young patients [1]. Introduction of PCR-based preimplantation genetic testing (PGT) can become a basis to expand SET to the older patient population. Precise evaluation of the genetic status of embryos should facilitate accurate embryo selection for the transfer [2].ObjectiveThe purpose of this study was to compare pregnancy rates after SET for patients under 38 y.o. and over 38 y.o. in PGT cycles.DesignA retrospective study of SNP PGT pregnancy outcome data from single embryo transfers was conducted to identify differences in clinical pregnancy for patients <38 y.o. and ≥38 y.o.Materials and Methods140 cycles of IVF treatment with PGT between January 2013 and June 2014 were included in the study. In all cases only one euploid embryo was selected for transfer. 63 IVF cycles (53 patients) were included in the young (<38 y.o.) patient group (average age - 33.45±3.31) and 77 IVF cycles (72 patients) in the older (≥38 y.o.) patient age group (average age - 40.22±1.85). The average number of embryos available for biopsy per case in the group of patient <38 y.o. was significantly higher than in the group of for patients ≥38 y.o.: 6.63±2.39 and 3.96±1.91 respectively, p<0.05.ResultsThe clinical pregnancy rate for patients <38 y.o. was 52.4% (33/63). The clinical pregnancy rate for patients ≥38 y.o. was 54.6%, (42/77). The difference in pregnancy rate between two groups was not statistically significant: p=0.968, χ2=0.065. 60 out of 63 SETs in the young patient group were elective SETs (two or more euploid embryos were available for transfer), while in the older patient group only 47 out of 77 SETs were elective SETs. Euploidy rate was statistically higher in young patient group than in older patient group: 55.14% and 38.35% respectively (p<0.05, χ2= 28.284).ConclusionsAnalysis of the data proved effectiveness of preimplantation genetic testing for infertile patients of advanced maternal age. Single embryo transfer in PGT cases can significantly decrease multiple gestation rate without compromising clinical pregnancy rate regardless of patient age.SupportNone.

Adenoma detection rate in patients younger than 50 years of age: relationship of the adenoma detection rate to interval cancer.

See Article on Page 46-51 The incidence of colorectal cancer in Korea has been increasing rapidly, and worldwide age-standardized rate of colorectal cancer per 100,000 population was the highest in the world in 2012 [1]. Thus, now is the time to make an effort to prevent colorectal cancer nationwide. Colonoscopy is the gold standard for primary or follow-up testing to detect colorectal cancer, and the early detection and removal of a precancerous adenoma by using colonoscopy is well known to reduce the risk of colorectal-cancer-related death [2, 3]. The authors of Distribution of the Colonoscopic Adenoma Detection Rate According to Age: Is Recommending Colonoscopy Screening for Koreans Over the Age of 50 Safe? cautiously suggest an earlier first-time colonoscopy based on the higher adenoma detection rate for males in their 40's [4]. An inverse relation between the adenoma detection rate (ADR) and the risk of interval cancer has been shown in large-scale studies [5, 6]. Corley et al. [6] compared interval cancer risks among ADRs. According to their report, for patients with an ADR higher than 33.5%, as compared with patients with an ADR lower than 19.05%, the risk of receiving a diagnosis of fatal interval colorectal cancer was reduced by 62%. In their report, each 1% increase in the ADR was associated with a 5% decrease in the risk of a fatal interval colorectal cancer. Therefore, an ADR rate higher than 30% needs to be the focus in terms of preventing fatal interval cancer. Adenoma detection by colonoscopy depends on various factors concerning the patient, the endoscopist, and the procedure. Bae et al. [4] showed an overall detection rate of 35.4%, which is similar to or a little bit higher than the values published in other reports in Korea [7, 8]. The reason for the higher ADR is not clear. The higher ADR might be due to an actual increase in adenoma occurrence because colonoscopy is now being performed more and physicians have become more experienced. In that report, the ADR of males in their 40's is noteworthy. It is similar to the overall ADR for patients in their 50's. Therefore, the authors' suggestion appears reasonable, especially in circumstances where the rate of young-age colorectal cancer (age lower than 50 years) is increasing [9]. However, before any discussion of early first-time colonoscopy, whether or not this high ADR rate in younger patients is an institution-specific finding needs to be considered. The ADR by age needs to be determined based on a large-scale database review or a prospective evaluation, with patient- and physician-specific factors considered.

Gastrointestinal endoscopy in patients aged 75 years and older: risks, complications, and findings--a retrospective study.

Endoscopy of the gastrointestinal tract offers simultaneously diagnostic and therapeutic options and is increasingly performed in elderly patients due to a continuously growth of this population segment. Whereas safety data of diagnostic and interventional endoscopy in patients younger than 65 years are well characterized, only scarce data exist for elderly patients older than 75 years. We analyzed outcomes and complications of endoscopic procedures with focus on colonoscopy in patients aged 75 and older at a single tertiary referral center in Germany between 1996 and 2006. A total of 3770 endoscopies (2270 gastroscopies, 735 colonoscopies, 765 ERCP) were performed in 1841 patients with a mean age of 79 years (range 75 to 97 years). Seventy-four percent of all patients suffered from relevant comorbidities. Therapeutic interventions were carried out in 43 % of colonoscopies. Complications were observed in approximately 1 %. The observed complication rate in diagnostic and therapeutic endoscopic procedures is not increased in elderly patients compared to the reported complication rates in younger patients.

Self-reported fertility in long-term survivors of acute myeloid leukemia.

Acute myeloid leukemia (AML) survival rates in younger patients have improved considerably since the 1970s. In order to evaluate the impact of AML and its treatment on fertility and family situation in adult long-term survivors, we used the Swedish population-based registries to identify 161 adult patients diagnosed with AML within the Leukemia Group of Middle Sweden (LGMS) 1973-2003, who survived for more than 5years and were alive in 2010. Ninety-eight patients (61%) completed a questionnaire including items on reproductive concerns, family situation, and infertility-related distress. After excluding women >45years and/or postmenopausal women and men >55years, 22 women and 38 men were included in the final analysis. Nine of the women (41%) tried to conceive after treatment, but only three succeeded. Five (83%) of the unwillingly childless women reported "a moderate" or "a lot" of distress caused by this. Among men in the same age group, all six who wanted children after treatment succeeded. None of the men 46-55years old cryopreserved their sperm or tried to father a child. Among patients who wanted children after AML treatment, 46% of the women and 40% of the younger men reported that they were not, or not fully, informed about fertility-related issues. In contrast, among men 46-55 years, none reported they would have wanted more information. Infertility among young female AML survivors thus remains an important clinical issue, and there is a need for improved clinical counseling and education in this area.

Letter to the Editor

To the editor, We read with great interest the article by Whelan and colleagues [13] comparing two different immobilization methods for first time shoulder dislocations. We applaud the efforts of this research team, as well as others [3, 9] who have attempted to reproduce the results found by Itoi et al. [8, 10] with randomized clinical trials. However, the results of these three studies still leave questions regarding the ideal method for shoulder immobilization in this population. While several factors (smoking, sex hormones) [6] can affect soft tissue healing and should be evaluated as potential covariates in future studies, we believe that the length of immobilization may be one of the more important factors. The length of immobilization (3 to 4 weeks) were inadequate in these studies. Although considered a standard timeframe, studies suggest 3 to 4 weeks is too short of a time to allow for proper healing [7, 12]. The remodeling phase for soft tissue in the shoulder may not begin until 3 to 4 weeks after the proliferation phase peaks, which typically occurs within 1 to 3 weeks [1, 4]. The damaged tissue will likely not reach maximum tensile strength until a minimum of 12 weeks [11]. Is it possible that recurrence rates in younger patients would decrease with slightly longer immobilization timeframes due to increased stability of the soft tissue repair [2]? The answer may influence interpretation of other studies such as noninferiority trials comparing surgical to conservative management [5]. The risk of prolonged immobilization may be worth taking, especially in the younger patient [2], where reports of adhesive capsulitis younger than the age of 35 are practically nonexistent in the literature. In our experience, from a rehabilitation perspective, it has proven much easier to address stiffness in a young, active patient, after a longer period (6 weeks minimum) of immobilization than to address instability in a patient with normal ROM. If length of immobilization proves to be a significant factor associated with recurrence, then the secondary question related to proper position may have more relevance.

Sentinel Node Biopsy Improves Prognostic Stratification in Patients with Thin (pT1) Melanomas and an Additional Risk Factor

Sentinel lymph node (SLN) biopsy (SLNB) for pT1 melanomas is not generally recognized as a clinical standard. We studied the value of SLNB for pT1 melanoma patients having at least one additional risk factor. Among 931 patients with SLNB, 210 had pT1 melanomas. All of the latter showed at least one of the following risk factors: ulceration (4 %) Clark level IV (44 %), nodular growth pattern (11 %), mitoses (59 %), regression (38 %) or age ≤ 40 years (27 %). In this selected pT1 population, we observed a surprisingly high SLN positivity rate of 18 %. The melanoma-specific overall survival significantly depended on SLN status. Compared with Clark IV, a lower invasion level (Clark II/III) was associated with a higher proportion of positive SLNs (25 vs. 10 %; p < 0.01). There was a trend towards a higher SLN positivity rate in younger patients (p = 0.06). Breslow, ulceration, mitoses, nodular growth pattern, and sex did not reach significance. Regression was significantly more frequently found in very thin melanomas (≤ 0.75 mm) and tended to be significant in this subgroup (p = 0.075). SLNB improves prognostic stratification in patients with thin melanomas having an additional risk factor. Clark level IV most likely does not belong to these risk factors. The impact of regression deserves further consideration. Our data suggest that SLNB should be offered to patients with thin melanomas, if ulceration, nodular growth pattern, mitoses, or regression are present, or if the patient is younger than 40 years of age.

Ecological study of gastric cancer in Brazil: geographic and time trend analysis.

To investigate the geographic distributions and time trends of gastric cancer (GC) incidence and mortality in Brazil. An ecological study of the DATASUS registry was conducted by identifying hospitalizations for GC between January 2005 and December 2010. The data included information on the gender, age, and town of residence at the time of hospital admission and death. The GC rates, adjusted according to available hospital beds, decreased from 13.8 per 100000 in 2005 to 12.7 per 100000 in 2010. The GC rates decreased more among the younger age groups, in which the male-to-female difference also decreased in comparison to the older age groups. Although the lethality rates tended to increase with age, young patients were proportionally more affected. The spatial GC distribution showed that the rates were higher in the south and southeast. However, while the rates decreased in the central-west and south, they increased in the northern regions. A geographic analysis showed higher rates of GC in more urbanized areas, with a coast-to-inland gradient. Geographically, GC lethality overlapped greatly with the hospital admission rates. The results of this study support the hypothesis of a critical role for environmental factors in GC pathogenesis. The declining rates in young patients, particularly males, suggest a relatively recent decrease in the exposure to risk factors associated with GC. The spatial distribution of GC indicates an ongoing dynamic change within the Brazilian environment.

Learning From Implantable Cardioverter-Defibrillator Leads in Children

If you want to break something, give it to your kid. That truism applies to many items from toys to technology. The paper describing the results of the PLEASE study (Pediatric Lead Extractability and Survival Evaluation Study) from Berul et al in this issue of Circulation provides sobering but important evidence that this also applies to implantable cardioverter-defibrillator (ICD) leads.1 Most ICD systems are implanted in adults, but many are implanted in children. These pediatric patients with ICD systems now participate in larger ICD registries,2 but an earlier specific pediatric registry is the target of this study. This study encompasses 874 patients and 965 ICD leads, spanning 24 centers. The initial ~1/5th of the patients were enrolled in a randomized study comparing two specific lead designs: the smaller Medtronic Fidelis lead, and a larger but ePTFE coated Boston Scientific alternative. This portion of the study was terminated when concerns about Fidelis lead performance surfaced, and these and all subsequent patients entered into a registry, with more patients and nearly inclusive entry for the latter portion of the enrollment. Although not pre-specified, I think this flexibility was laudatory, allowing the salvage of useful and generalizable information, and does not appear to be an obvious source of bias or scientific compromise. The study design however is essentially that of a registry rather than a randomized study.