Risk Of Treatment-related Complications Research Articles

Direct Transfer to the Neuroangiography Suite for Patients With Stroke.

The therapeutic focus in acute ischemic stroke over the last 2.5 decades has been to balance the benefits of rapid reperfusion therapy with the risks of treatment-related complications. Both intravenous thrombolytics and endovascular thrombectomy are proven to substantially improve outcomes in a time-dependent manner. Each minute saved in achieving successful reperfusion grants an additional week of healthy life and may salvage up to 27 million neurons. The current approach to patient triage is inherited from the preendovascular thrombectomy era of stroke care. Current workflow concentrates on stabilization, diagnosis, and decision-making in the emergency department, followed by thrombolysis if eligible and subsequent transfer to the angiography suite as needed for further treatment. Multiple efforts have been directed toward minimizing the time from first medical contact to reperfusion therapy including prehospital triage and intrahospital workflow. Novel approaches for stroke patient triage such as the direct to angio approach, (also referred to as One Stop Management) are currently in development. The concept was initially introduced as several single-center experiences. In this narrative review article, we will consider various definitions of direct to angio and its variants, discuss its rationale, review its safety and efficacy, assess its feasibility, and delineate its limitations. Further, we will address methods to overcome these limitations and the potential impact of emerging data and new technologies on the direct-to-angio approach.

Obesity Is Not Associated With an Increased Risk of Serious Infections in Biologic-Treated Patients With Inflammatory Bowel Diseases.

INTRODUCTION:Obesity has been associated with adverse disease-related outcomes and inferior treatment response to biologic agents in patients with inflammatory bowel diseases (IBDs), but its impact on the risk of treatment-related complications is unknown. We performed a cohort study examining the association between obesity and risk of serious infections in biologic-treated patients with IBD.METHODS:Using an administrative claims database, in a cohort of biologic-treated patients with IBD between 2014 and 2018 with follow-up 1 year before and after treatment initiation, we compared the risk of serious infections (infections requiring hospitalization) between obese vs nonobese patients (based on validated administrative claims) using Cox proportional hazard analysis.RESULTS:We included 5,987 biologic-treated patients with IBD (4,881 on tumor necrosis factor-α antagonists and 1,106 on vedolizumab), of whom 524 (8.8%) were classified as obese. Of the 7,115 person-year follow-up, 520 patients developed serious infection. Risk of serious infection was comparable in obese vs nonobese patients (8.8% vs 8.5%; unadjusted hazard ratio, 1.15; 95% confidence interval, 0.86–1.54). After adjusting for age, comorbidities, disease characteristics, health care utilization, use of corticosteroids, immunomodulators, and opiates, obesity was not associated with an increased risk of serious infection (adjusted hazard ratio, 0.74 [95% confidence interval, 0.55–1.01]). Similar results were seen on stratified analysis by disease phenotype (Crohn's disease and ulcerative colitis) and index biologic therapy (tumor necrosis factor-α antagonists and vedolizumab).DISCUSSION:After adjusting for comorbid conditions and disease characteristics, obesity is not independently associated with an increased risk of serious infections in biologic-treated patients with IBD.

Thoracic Manifestations of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is one of the most common chronic systemic inflammatory diseases and the most common chronic inflammatory arthritis. Classically a progressive symmetric polyarthritis, RA is characterized by inflammation, erosions, bone loss, and joint destruction. Up to half of patients with RA exhibit extra-articular manifestations (EAMs), which may precede articular disease and are more common in patients with seropositive RA (patients with detectable serum levels of rheumatoid factor and/or anticitrullinated peptide antibodies). Cardiovascular and pulmonary EAMs are the largest contributors to morbidity and mortality in RA and may be especially devastating. Imaging has a significant role in diagnosing these EAMs and assessing response to treatment. Although treatment with disease-modifying antirheumatic drugs has redefined the natural history of RA and helped many patients achieve low disease activity, patients are at risk for treatment-related complications, as well as infections. The clinical features of drug-induced lung disease and infection can overlap considerably with those of EAMs, presenting a diagnostic challenge. Radiologists, by recognizing the imaging characteristics and evolution of these various processes, are essential in diagnosing and distinguishing among EAMs, treatment-related complications, and unrelated processes and formulating an appropriate differential diagnosis. Moreover, recognizing these disease processes at imaging and contextualizing imaging findings with clinical information and laboratory and pathologic findings can facilitate definitive diagnosis and proper treatment. The authors review the articular and extra-articular thoracic imaging manifestations of RA, including cardiovascular, respiratory, and pleural diseases, as well as treatment-related complications and common infections. ©RSNA, 2021.

Management of toxicities associated with targeted therapies for acute myeloid leukemia: when to push through and when to stop.

The recent advent of myriad targeted therapies for acute myeloid leukemia (AML) has led to new hope for our patients but has also introduced new challenges in managing the disease. For clinicians, the ability to treat AML in the outpatient setting with novel agents of equal or greater efficacy than 7+3 has been transformative. Despite the enthusiasm, however, the reality is that many patients are still frail and remain at risk for treatment-related complications. Translating the results of clinical trials into improved outcomes for these individuals requires an understanding of how best to manage the adverse effects of these agents. Which patients benefit most and what to watch for? When to stop therapy? Using illustrative case presentations, this review details the unique toxicities associated with each of the approved mutation-specific and nonspecific targeted drugs for AML. The goal of this review is to help clinicians determine the risk:benefit ratio in decision making for individual patients with AML.

Approach to radiation therapy in the Jehovah's Witness patient: An overview.

Jehovah's Witnesses are well-known in the medical community for their inability to accept blood products. Novel methods of treatment are often needed to avoid anemia and hematologic toxicity as inability to receive blood products may increase the risk of treatment related complications. We provide an overview of radiation treatment for Jehovah's Witness patients with an emphasis on bone marrow sparing strategies with intensity modulated radiation therapy (IMRT) to minimize hematologic toxicity.

Association between nutritional risk index and outcomes for head and neck cancer patients receiving concurrent chemo-radiotherapy.

Patients receiving chemoradiotherapy for head and neck cancer (HNC) are often malnourished. We assessed the utility of nutritional risk index (NRI) in HNC patients undergoing chemoradiotherapy. A population-based retrospective review of HNC patients treated with curative chemoradiation was performed. Demographics, anthropometrics, overall survival (OS), and the composite treatment complication rate (G-tube dependence, radiation incompletion, 90-day mortality, and unplanned hospitalization) were collected. Two hundred ninety-two patients were identified. Average pretreatment and posttreatment NRI were 110 (SD 3) and 99 (SD 12), respectively (P < .01). Pretreatment NRI risk category, age, ECOG status, and tumor subsites were associated with OS on multivariate analysis. Pretreatment NRI risk category was associated with risk of treatment related complications. There was a significant decrease between pretreatment and posttreatment NRI in HNC patients receiving chemoradiation. Pretreatment NRI risk category may predict OS and composite treatment complications. Investigation of NRI as a prognostic factor is warranted.

Intensity modulated proton therapy compared to volumetric modulated arc therapy in the irradiation of young female patients with hodgkin\u2019s lymphoma. Assessment of risk of toxicity and secondary cancer induction

BackgroundTo investigate the role of intensity modulated proton therapy (IMPT) compared to volumetric modulated arc therapy (VMAT) for advanced supradiaphragmatic Hodgkin’s lymphoma (HL) in young female patients by assessing dosimetric features and modelling the risk of treatment related complications and radiation-induced secondary malignancies.MethodsA group of 20 cases (planned according to the involved-site approach) were retrospectively investigated in a comparative planning study. Intensity modulated proton plans (IMPT) were compared to VMAT RapidArc plans (RA). Estimates of toxicity were derived from normal tissue complication probability (NTCP) calculations with either the Lyman or the Poisson models for a number of endpoints. Estimates of the risk of secondary cancer induction were determined for lungs, breasts, esophagus and thyroid. A simple model-based selection strategy was considered as a feasibility proof for the individualized selection of patients suitable for proton therapy.ResultsIMPT and VMAT plans resulted equivalent in terms of target dose distributions, both were capable to ensure high coverage and homogeneity. In terms of conformality, IMPT resulted ~ 10% better than RA plans. Concerning organs at risk, IMPT data presented a systematic improvement (highly significant) over RA for all organs, particularly in the dose range up to 20Gy. This lead to a composite average reduction of NTCP of 2.90 ± 2.24 and a reduction of 0.26 ± 0.22 in the relative risk of cardiac failures. The excess absolute risk per 10,000 patients-years of secondary cancer induction was reduced, with IMPT, of 9.1 ± 3.2, 7.2 ± 3.7 for breast and lung compared to RA. The gain in EAR for thyroid and esophagus was lower than 1. Depending on the arbitrary thresholds applied, the selection rate for proton treatment would have ranged from 5 to 75%.ConclusionIn relation to young female patients with advanced supradiaphragmatic HL, IMPT can in general offer improved dose-volume sparing of organs at risk leading to an anticipated lower risk of early or late treatment related toxicities. This would reflect also in significantly lower risk of secondary malignancies induction compared to advanced photon based techniques. Depending on the selection thresholds and with all the limits of a non-validated and very basic model, it can be anticipated that a significant fraction of patients might be suitable for proton treatments if all the risk factors would be accounted for.

Fatal case of TAFRO syndrome associated with over-immunosuppression: a case report and review of the literature.

ABSTRACTTAFRO syndrome is a novel disease concept characterized by Thrombocytopenia, Anasarca, myeloFibrosis, Renal dysfunction, Organomegaly, multiple lymphadenopathy and a histopathological pattern of atypical Castleman’s disease. A 58-year-old man was diagnosed as TAFRO syndrome by clinical and histopathological findings. After receiving intensive immunosuppressive therapy, his thrombocytopenia and anasarca had not improved. He developed complications such as methicillin-resistant Staphylococcus aureus sepsis, gastrointestinal bleeding, peritonitis caused by Stenotrophomonas maltophilia, gastrointestinal perforation, and disseminated candidiasis resulting in death. Autopsy revealed disseminated candidiasis and hemophagocytic lymphohistiocytosis, with no evidence of TAFRO syndrome. During treatment, we regarded his lasting thrombocytopenia and anasarca as insufficient control of TAFRO syndrome. However, the autopsy revealed that thrombocytopenia was caused by secondary hemophagocytic lymphohistiocytosis caused by over-immunosuppression. We reviewed the published literature to identify indicators of adequate treatment, which suggested improvement of platelet count and anasarca several weeks after initial therapy. This indicated that we could not depend on the platelet count and anasarca in acute medical care after initial treatment. We should treat TAFRO syndrome based on patients’ clinical status and obviate the risk of treatment-related complications caused by over-immunosuppression.

Challenges in Awake Craniotomy for Intrinsic Brain Tumors in Eloquent Cortex

Introduction: Surgical treatment of brain tumors in the eloquent areas has high risk of functional impairment like speech or motor. These tumors represent a unique challenge as most of the patients have a higher risk of treatment related complications. A wake craniotomy is a useful surgical approach to help to identify and preserve functional areas in the brain and maximizes tumor removal and minimizes complications. Methods: Selected patients admitted with intrinsic brain tumor between from July, 2011 to August, 2016 in the eloquent area of brain like speech or motor area were chosen for awake craniotomy. A retrospective analysis was done. A preoperative assessment was also done. These patients were presented with seizure and or progressive neurological deficit like speech or motor. A standard anesthesia monitoring was done during surgery. Long acting local anesthesia (Bupivacaine) was used for scalp block. The surgeries were performed in a state of asleep-awake-asleep pattern, keeping the patients fully awake during tumor removal. Propofol and Fentanyl was used as anesthetic agents which was completely withdrawn prior to tumor removal. The speech and motor functions were closely monitored clinically by verbal commands during tumor resection. No brain mapping was performed due to lack of resources. All patients underwent noncontrast computed tomogram head in the first post-operative day. Results: A total of 35 patients were included in the study. The oldest patient was 55 years and youngest being 24 years (mean 36 years). 20 (57.14 %) were females and 15(42.85 %) males. 20 (57.14%) patients presented with predominantly seizure disorders and rest with progressive neurological deficit like speech or motor. 30 (85.71%) patients were discharged on second post-operative day. Complications were encountered in 4 (11.42 %) patients who developed brain swelling intraoperatively and 5(14.28 %) deteriorated neurologically in the immediate post-operative period however managed successfully and discharged in a week’s time. 5(14.28%) patients require ICU/ HDU care for different reasons. There was no mortality during the hospital stay. Histopathology revealed 25 (71.42 %) patients as low grade glioma, 8 (22.85%) as high grade glioma and 2 (5.71%) of them were metastases. Conclusion: A wake Craniotomy is a safe surgical management for intrinsic brain tumors in the eloquent cortex although surgery and anesthesia is a challenge. It offers great advantage towards disease outcome. However long follow up and more studies are required.

Germline Genetic Predisposition to Hematologic Malignancy.

Development of hematologic malignancies is driven by mutations that may be somatic or germline. Availability of next-generation DNA sequencing technologies has facilitated the development of individualized diagnostic evaluations and tailored treatment strategies. Until now, such personalized medical approaches have largely centered on prognostic stratification and treatment strategies informed by acquired somatic mutations. The role of germline mutations in children and adults with hematologic malignancies was previously underappreciated. Diagnosis of an inherited predisposition to hematologic malignancy informs choice of therapy, risk of treatment-related complications, donor selection for hematopoietic stem cell transplantation, evaluation of comorbidities, and surveillance strategies to improve clinical outcomes. The recognition that patients with inherited hematologic malignancy syndromes may present without classic clinical stigmata or suspicious family history has led to increased reliance on genetic testing, which, in turn, has raised new diagnostic challenges. Genomic testing is a rapidly evolving field with an increasing number of choices for testing for the practicing clinician to navigate. This review will discuss general approaches to diagnosis and management of patients with germline predisposition to hematology malignancies and will consider applications and limitations of genomic testing in clinical practice.

A Pound of Cure Requires An Ounce (or More) of Prevention: Survivorship and Complications of Therapy for Hematologic Malignancies

Patients treated for a hematologic malignancy are at risk for treatment-related complications. As the goal of therapy is frequently curative, treatments are especially intensive and long-term toxicity is common. Chemotherapy and radiation are associated with increased risk for cardiac and pulmonary disease, endocrine disorders, infertility, sexual dysfunction, second cancers, and psychosocial distress. The risk for each complication is dictated by patient characteristics including age, co-morbidities, and genetic predispositions, as well as the specifics of therapy. Survivors of pediatric cancers and allogeneic hematopoietic stem cell transplantation have unique risks due to vulnerable age at time of toxic exposure and ongoing immune dysfunction, respectively.

Head and Neck Paragangliomas: A Case‐Oriented Approach to Evaluation and Management

Program Description: Despite increased knowledge about head and neck paragangliomas, educational gaps still exist regarding diagnosis, evaluation, and management options. This miniseminar will provide up-to-date clinically relevant information using a case-based format. Best available evidence-based medicine presentations on focused learning points and audience response will be incorporated. Basic concepts and controversial topics will include accurate disease diagnosis; tumor genetics and defining the at risk-population for familial disease; management decision making between surgery, radiation, and observation with expected tumor-control outcomes; identification of patients at particular risk for treatment-related complications; and rehabilitation options to maximize functional outcomes. Educational Objectives: (1) Describe the current “state-of-the-art” for evaluation and management of head and neck paragangliomas. (2) Discuss the considerations that affect how treatment decisions are made. (3) Use methods for minimizing complications while maximizing tumor-control and functional outcomes.

Body mass index (BMI) influence on survival in adult patients with newly diagnosed acute myeloid leukemia (AML)/high-risk MDS: Retrospective study of 130 patients from a single institution.

e18011 Background: The incidence of obesity is increasing worldwide and is associated with numerous adverse health outcomes. In AML high body mass index (BMI) is associated with increased risk of treatment-related complications; the overall survival in patients with acute myeloid leukemia is inferior, with most studies conducted in the pediatric population. Aim: To evaluate the effect of increasing (BMI) in the overall survival (OS) of adult patients with AML/High risk MDS. Methods: After obtaining IRB approval, all adult patients with AML diagnosed and treated at our institution (2002–2010) were studied. Data collection included patient demographics, laboratory tests, bone marrow biopsies, BMI, and survival information. We classified the AML patients into two groups according to BMI (kg/m2) classification by WHO; normal Weight 18-25 kg/m2, overweight and obese &gt;25 kg/m2. Chi-Square and T-test were used for between group comparisons and Kaplan-Meier test was applied for survival estimates. Results: Adult patients with newly diagnosed AML (n = 130) had a median age of 55 years (range: 19-90), and 43 (56%) patients were older than 75 years. Seventy-two patients (55%) were male and 58 (45%) were female. 45 patients (35%) in total had complex cytogenetics, 20 patients (15%) had AML arise from MDS.Forty-four patients (34%) were considered normal weight; Eighty-six patients (66%) were classified as overweight or obese. Overall median survival was 28 weeks; patients with BMI 18-25 kg/m2 had a 36-week median survival, while patients with BMI &lt;25 kg/m2 had a 25-week median survival (p&lt;0.499). Conclusions: Overall survival was low in the study population; survival in obese and overweight patients (BMI&gt;25) was slightly lower than normal weight group (18-25 kg/m2), although this did not translate into a survival benefit. Future large scale studies may be needed to further define the role of BMI in survival benefit for these patients.

Long-term outcome of biopsy-proven minimal-change nephrotic syndrome in Chinese children

Previous studies have shown that up to 40% of childhood-onset minimal-change nephropathy (MCN) cases persist after puberty. However, data are scarce concerning the long-term renal prognosis and prevalence of treatment-related complications of this group of patients after they become adults. The clinical records of 55 consecutive pediatric patients with biopsy-proven MCN treated in our hospital from 1984 to 2004 were reviewed to evaluate the disease pattern, treatment regimen, and the development of treatment-related complications. Of the 55 patients treated, 35 were followed after age 18 years; 13 (37%) had relapses during adulthood. Treatment-related complications were observed in 20 patients (57%), including being overweight (23%), impaired fasting glucose (14%), infertility (14%), persistent low grade proteinuria (11%), fracture (9%), and hypertension (9%). All patients had normal renal function when last assessed. A substantial proportion of patients with childhood-onset MCN continued to have relapse after they became adults. Although almost all patients have normal renal function, prolonged use of steroid and immunosuppressive agents results in a considerable risk of treatment-related complications. Life-long follow-up seems advisable for this group of patients, not only for detecting relapses, but also to allow timely diagnosis of treatment-related complications. 之前的研究顯示，童年病發的微小變化型腎病變(MCN)有高達40%會持續至青春期之後；然而，對於這類病情延續至成年的患者，至今少有研究對其長期腎臟預後及治療相關併發症比率作出報告。 針對經活檢證實的MCN兒童患者，我們回顧了55位於1984至2004在本院接受治療的連續個案，從而對其病情發展、治療用藥、及治療相關併發症作出瞭解。 在所有55位兒童病人中，35人持續接受追蹤至成年期。在成年階段中，13人(37%)出現復發，20人(57%)發生治療相關併發症，後者包括過重(23%)、空腹血糖過高(14%)、不孕症(14%)、持續性輕度蛋白尿(11%)、骨折(9%)、及高血壓(9%)。在最後追蹤中，所有人均呈現正常的腎功能。 不少的童年病發MCN患者會在成年期復發，即使幾乎所有人的腎功能正常，持續使用的類固醇及免疫抑制劑所導致的治療相關併發症風險卻不容忽視。對於這些病人，似乎應予以終生的追蹤，以利於病情復發及治療相關併發症的及早發現。

A Clinicopathological Analysis Of Primary Gastric Lymphoma

Introduction:Primary gastrointestinal lymphoma represents the most common location of extranodal lymphoma (1).The stomach represents 50-75% of the gastrointestinal tract localizations (2). Primary gastric lymphomas are divided into indolent (low grade) and aggressive (high grade) types. They are mainly the disease of middle age, with a male predominance reported by most of the studies (3). Controversy remains regarding the best treatment for early stages of the disease. Chemotherapy, Surgery and combination have been studied and shared almost comparable results with survival rate of 70-90%. However, chemotherapy possesses the advantage of preserving gastric anatomy (4). Recent years have seen a dramatic paradigm shift in the treatment approach to the most common gastrointestinal lymphomas, i.e. DLBCL and MALT lymphoma of the stomach. While surgery had been the main stay of treatment for decades, it has now virtually been abolished due to the absence of a beneficial effect as compared to conservative therapy (5). The discovery of an association between Helicobacter pylori (HP) and gastric MALT lymphoma and the subsequent reports of lymphoma regression following HP-eradication have revolutionized treatment options for such patients. HP-eradication is currently considered standard first-line therapy in patients with gastric MALT lymphoma and evidence of HP-infection, with complete responses being obtained in roughly 75% of selected patients [My paper] (6). Also combined modality treatment by chemo-radiation for localized gastric lymphoma is associated with a low risk of treatment related complications, with avoidance of long term sequelae after gastric resection (7). In DLBCL of the stomach, the association with HP-infection is less pronounced than in MALT lymphoma at roughly 50% of patients. While gastric DLBCL had also been subjected to surgery in order to prevent bleeding and perforation during subsequent chemotherapy and radiation, it has been demonstrated that such prophylactic surgery is not necessary with the consequent application of a high dose proton pump inhibitors for the whole duration of therapy. In addition, the relapse rate and survival are not beneficially influenced by additional surgery, while quality of life may be severely impaired. Most large studies have been performed combining anthracycline - based chemotherapy and radiation therapy (5). The response rate after Chemotherapy was 90%, while after radiotherapy it was 100%, only 10% of patients had relapse after ending treatment. Only one case died during the follow up Table 2.Grade I nausea and vomiting was the most frequent complication of chemotherapy among studied patients* Oncology Department of Ain Shams University.** Oncology Department of Ahmed Maher Teaching Hospitalfollowed by Grade I myelosuppression where only 25% of patients complained from it Fig 2Grade I anorexia was the most common complication of radiotherapy among studied patients followed by Grade I nausea and vomiting where 40% of patients complained from it Fig 3.The mean overall survival time was 21 months, from the survival curve; the survival rate was estimated at 24 months to be 94.7%. The mean disease free survival time was 19.97 months, from the survival curve; the disease free survival rate was estimated at 12 and 24 months to be 98.7% and 94.2% respectively. There was no significant difference between male and females, high and low grade type, different tumor stage, H.Pylori infection, increased LDH level, fungating or ulcerating mass as regarding the mean survival time and mean disease free survival time. Significant association between B2 microglobulin increase and relapse of patients, as 50% of relapsed patients had an increase in B2 microglobulin. Highly significant association between LDH increase during follow up and occurrence of relapse as 100% of relapsed patients showed increases LDH levels during follow up, on the other hand none of the non-relapsed patients had elevated LDH.

A smoking cessation program as a resource for bladder cancer patients

Background: Continued tobacco use following a bladder cancer(CaB) diagnosis puts patients at risk for other tobacco-associateddiseases and has also been associated with heightened risks oftreatment-related complications, tumour recurrence, morbidity andmortality. Our aim was to determine if patients with CaB who continueto smoke warrant a smoking cessation program as a resourcefor improving their prognosis and long-term health.Methods: A cross-sectional quantitative questionnaire-based studywas performed between January and April 2009. We surveyedpatients with a pathologically confirmed diagnosis of CaB duringtheir cystoscopy appointments at a single cancer centre.Results: One hundred patients completed the survey with 72% ofthem admitting to smoking in their lifetime. A third of respondentssmoked at the time of their diagnosis; 76% of patients who hadbeen active smokers at the time of their diagnosis (n = 33) reportedsmoking at some point thereafter and 58% continued to smoke. Among continued smokers, they were classified in the following categories: 26% were in “precontemplation,” 5% in “contemplation,”16% in “preparation,” and 53% in “action;” 37% of patientswho continued to smoke were interested in a hospital-based smokingcessation program. Overall, 70% reported smoking as a risk factor for a poor CaB prognosis. The two most common barriersto quitting were “trouble managing stress and mood” and “fear ofgaining weight.”Conclusion: Based on the data from our centre, patients with CaBwho continue to smoke after their diagnosis warrant a smoking cessationprogram as a resource for improving prognosis and long-term health. Further research should focus on establishing an efficacious and cost-effective program that provides these patients with theresources they need to quit smoking.

Detoxification as a treatment goal in hepatic failure

Acute liver failure (ALF) is a dramatic clinical syndrome with high mortality because of cerebral oedema (type A hepatic encephalopathy) and multi-organ failure. With intensive care medicine and emergent liver transplantation being the mainstay of treatment, alternatives to transplantation are increasingly needed. Ammonia has been recognised as a major toxin in patients with ALF. It can be effectively removed by haemodialysis, haemofiltration and artificial liver support (a combination of extracorporeal toxin absorption and haemodialysis). Previous studies of extracorporeal detoxification, however, have either not specifically targeted ammonia or were hampered by poor biocompatibility and obsolete pathophysiological assumptions, ultimately failing to improve the prognosis. Moreover, most patients were treated only late after the emergence of advanced HE and multi-organ failure, while detoxification should prevent these complications. Acute-on-chronic liver failure (AOCLF) occurs in the setting of chronic liver disease and has an equally poor prognosis. Here, the goals of extracorporeal blood detoxification are renal support and haemodynamic stabilisation in order to support recompensation. Patients with AOCLF, unfortunately, are at a risk for treatment-related complications including bleeding, thrombocytopenia, hypotension and acute renal failure, making biocompatibility a critical issue. Peritoneal dialysis could possibly emerge as a more biocompatible way of treating refractory hepatorenal syndrome. This article will critically analyse the pathophysiological concepts and goals of extracorporeal detoxification in acute and chronic liver diseases.

Incidental major artery aneurysms in patients with non-hemorrhagic moyamoya disease

Major artery aneurysms may be found incidentally while evaluating moyamoya disease (MMD). The purpose of this study was to delineate the prevalence and characteristics of these uncommon aneurysms with a brief mention of their management and outcomes. We conducted a retrospective review of 249 adult patients who were diagnosed with non-hemorrhagic MMD. Cerebral angiograms obtained at the time of initial diagnosis were carefully reviewed to identify incidental aneurysms located on a major intracranial artery or near its tributaries. Aneurysms originating from distal peripheral arteries or moyamoya vessels were ineligible for this study. Nine patients (3.6%) were found to have 13 major artery aneurysms, 7 (54%) of which were located in the posterior circulation, especially in older patients with bilateral MMD. The sizes of all aneurysms were less than 10mm. Surgical clipping was performed on two aneurysms, and endovascular coiling on six (five posterior circulation aneurysms). Ischemic complications occurred in two patients after clipping of an anterior communicating artery aneurysm and in one patient after the second coiling of a recanalized basilar tip aneurysm. Incidental major artery aneurysms can be found in 3.6% of adult patients with non-hemorrhagic MMD, an observed frequency that increases with age. About half of these aneurysms are located in the posterior circulation, particularly in older patients with bilateral MMD. Considering the risks of treatment-related complications, more information about the natural course of these aneurysms is needed to design proper management strategies both for the aneurysms and MMD.

Health status of the oldest adult survivors of cancer during childhood

Young adult survivors of childhood cancer have an increased risk for treatment-related morbidity and mortality. In this study, the authors assessed how treatment for childhood cancer affects older-adult health and health practices. One hundred seven adults treated for childhood cancer between 1947 and 1968, known to have survived past age 50 years, were identified from a single-institution cohort established in 1975. Updated vital status on eligible cases was obtained from public records. Survivors and a control group of their age-matched siblings and cousins completed a mailed survey to assess physical and social function, healthcare practices, and the prevalence of common adult illnesses. Of the 107 survivors known to be alive at age 50 years, 16 were deceased at follow-up; 7 deaths could be associated with prior treatment (second malignancy in radiation field [3], small bowel obstruction after abdominal radiation [2], and cardiac disease after chest irradiation [2]). The 55 survivors (median age, 56 years; range, 51-71 years), and 32 family controls (median age, 58 years; range, 48-70 years), reported similar health practices, health-related quality of life, and social function. However, survivors reported more frequent visits to healthcare providers (P < .05), more physical impairments (P < .05), fatigue (P = .02), hypertension (P = .001), and coronary artery disease (P = .01). An increased risk of hypertension was associated with nephrectomy during childhood (odds ratio, 18.9; 95% confidence interval, 3.0-118.8). The oldest adult survivors of childhood cancer continue to be at risk for treatment-related complications that potentially decrease their life expectancy and compromise their quality of life.

Can preoperative assessment of cancer in the elderly (PACE) predict 30-days postoperative outcomes?

8537 Background: Surgery is the treatment of choice for solid cancers. Frequent functional impairment/comorbidities in the elderly enhances the risk of treatment related complications. Inability to forecast short term outcomes after cancer surgery in elderly affects clinical practice, denying optimal treatment. No validated instrument is available to help make informed decision; a compilation of validated questionnaires (PACE) is established to preoperatively inform on the health condition of elderly cancer pts. This international multicentre study investigates how components of PACE preoperatively assessed are associated with postoperative outcomes. Methods: A prospective series of consenting elderly cancer pts (≥70 yrs) receiving elective surgery (moderate-major+) were recruited from 8 hospitals (UK, Netherlands, Italy, Japan, Belgium) (07/2003–12/2005) and assessed using PACE (Comorbidities, IADL, ADL, GDS, BFI, PS, MMS, ASA). 30day morbidity, hospital stay and mortality were recorded. Results: 448 pts [breast (48%), GI (30%), GU (16%), miscellaneous (6%)] were recruited and followed postoperatively. Observed morbidity was 36% (161 pts), mortality 4% (16 pts) and median hospital stay was 5 days (range 2 -10). All components of PACE but ASA were associated with morbidity (p&lt;0.05) and hospital stay (p&lt;0.05) on univariate analysis. Operative deaths were too few to look for associations. Forward stepwise logistic regression models (multivariate analysis) identified 3 components of PACE as best describing the occurrence of post-surgical morbidity: BFI (OR (upper quartile)= 2.4; 95% CI=1.2–4.9); PS (OR=1.9; 95% CI=1.1–3.4); IADL (OR=1.7; 95% CI=1.0–3.0). The same components were also selected into the model as best describing hospital stay beyond average: BFI (OR (upper quartile)=18.1; 95% CI=7.2–45.3), PS (OR=2.2; 95%=1.2–4.4) and IADL (OR=2.7; 95% CI=1.4–5.1). Of those pts exposed to all 3 factors entered into the regression models 61% experienced complications and &gt;80% had a longer hospital stay. Conclusions: BFI, PS and IADL appear to be the most relevant prognosticators of short term surgical outcomes. A holistic appraisal of elderly pts undergoing surgery is warmly recommended when consenting the patient and during the decision making process. No significant financial relationships to disclose.