Significant Difference In Long-term Survival Research Articles

Quality of life after pancreaticoduodenectomy for ductal adenocarcinoma of the pancreatic head

This study examined quality of life (QoL) after classical partial pancreaticoduodenectomy (PPD) and pylorus-preserving pancreaticoduodenectomy (PPPD) in patients with adenocarcinoma of the pancreatic head, and also evaluated the influence of extended lymphadenectomy (ELA). Between January 1993 and March 2004, QoL was analysed in a prospective single-centre study that included 91 patients. Thirty-four patients underwent PPD and 57 had a PPPD. Seventy patients had an ELA and 21 underwent regional lymphadenectomy (RLA). QoL was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire and a pancreatic cancer-specific module. Data were collected before operation and for 24 months after surgery. The overall 5-year survival rate was 18 percent for all patients and 21 percent in those who had an R0 resection. QoL was impaired for 3-6 months after surgery and then recovered to preoperative levels. There was no significant difference in long-term survival after PPD versus PPPD and ELA versus RLA. Patients who had ELA reported clinically significant higher levels of diarrhoea and pain. PPPD showed a disadvantage in terms of pain. The surgical techniques of resection and reconstruction did not affect QoL, but extended lymphadenectomy was associated with an impairment in QoL.

Prognostic factors determining long-term survival in well-differentiated thyroid cancer: an analysis of four hundred eighty-four patients undergoing therapy and aftercare at the same institution.

Identification of the prognostic factors relevant for long-term survival in differentiated thyroid cancer in a homogenously treated patient cohort in order to allow a better initial risk stratification. Four hundred eighty-four (358 females/126 males) patients with differentiated thyroid cancer (330 papillary [68.2%]; 154 follicular [31.8%]) were included. Inclusion criteria consisted of treatment with a uniform therapy scheme and continuous aftercare in the same institution. Initial diagnosis was between 1975-1995 (age at diagnosis, 14-84 years, median, 49.7). Tumor stage: pT1, n = 92; pT2, 211; pT3, 58; pT4, 123. Low-risk: <or=pT3 NX M0, 331; high-risk pT4 and/or M1, 153. After thyroidectomy all patients had at least two (131)I therapies (4-month interval; first, 2-4 GBq; second, 3.7-8 GBq). The median follow-up was 7.6 years (range, 0.2-23.9). The role of eight variables as prognostic factors was tested by regression analysis. The corrected cause-specific 5-, 10-, and 20-year survival rates in the whole cohort were 0.95, 0.90, 0.83, respectively; for the low risk-category of papillary cancer, 0.99, 0.97, 0.89; for follicular cancer, 0.98, 0.89, 0.89 (difference papillary/follicular p = 0.0004). The cause-specific survival rates in the high-risk category of papillary cancer were 0.89, 0.85, and 0.85; for follicular cancer, 0.88, 0.73 and 0.52 (p = 0.0016). Variables with significant negative influence on survival were distant metastases, persisting elevated human thyroglobulin levels after one (131)I therapy, age greater than 45 and gender in follicular cancer. Locoregional external radiotherapy did not improve survival but was associated with comorbidity. The aggressiveness of the initial operative resection was also not a prognostic factor for survival. pT4 NX M0 patients of our patient cohort did not exert significant differences in long-term survival compared to pT13 NX M0. This was also true for patients older than 45 years, where the 5- and 10-year survival rates for pT4 NX M0 were 0.93 and 0.90. Our therapy and aftercare strategy results in a high long-term survival rate especially for high-risk patients. In our patient sample radical initial lymph node resection did not extend long-term survival.

Non-immune acute graft injury after lung transplantation and the risk of subsequent bronchiolitis obliterans syndrome (BOS)

Background Primary graft dysfunction remains a major cause of early morbidity and mortality after lung transplantation. Evidence from animal models shows acute non-immune lung injury increases organ immunogenicity by enhancing MHC Class II expression. We hypothesized that acute non-immune injury in the lung allograft may impact, not only on early survival, but also on longer term survival by increasing the incidence of bronchiolitis obliterans syndrome (BOS). Methods A single-center, retrospective, observational study in a population of over 320 lung transplant recipients was undertaken. The histologic diagnosis of diffuse alveolar damage (DAD) in an early graft biopsy was used to define those recipients at risk. Serial measurements of forced expiratory volume in 1 second (FEV 1) in long-term follow-up defined the incidence of BOS. Results Early graft biopsy was available in 291 of the recipients following transplantation. DAD was confirmed in 55 (19%); their 30-day survival (62.5%) was significantly worse than in recipients without DAD (87.5%; p < 0.0001, chi-square test). When 30-day deaths were excluded, however, there was no difference in survival between recipients with and without DAD (hazards ratio 0.69 [0.37 to 1.3]; p = 0.25, Wilcoxon’s survival analysis). The incidence of subsequent BOS over the follow-up period was not significantly different in those with and without DAD on early biopsy at 46% and 59%, respectively (hazards ratio 0.88 [0.48 to 1.62]; p = 0.22, chi-square test). BOS did not occur any earlier in the DAD group (median 953 days, range 152 to 1,393) days compared with the non-DAD group (median 665 days, range 52 to 4,299) ( p = 0.48, Fisher’s exact test). Conclusions The development of severe non-immune acute graft injury after lung transplantation has a poor early prognosis. However, recipients with non-immune acute graft injury who survive >30 days show no significant difference in long-term survival or BOS-free time compared with recipients without early injury.

Completion pneumonectomy for non-small cell lung cancer: experience with 59 cases.

The objective of this study was to assess the results of completion pneumonectomy performed for non-small cell lung cancer, classified as second primary or recurrence/metastasis. From 1982 to 2000, 59 patients underwent completion pneumonectomy for lung cancer, classified second primary or recurrence/metastasis according to a modified form of Martini's criteria, after a mean interval from first resection of 60 months for second primary lung cancers and 19 months for recurrences/metastases. Operative mortality was 3.4% and complications occurred in 30% of patients. Five-year survival rate for completely resected patients was 25% (median 20 months). No significant difference in long-term survival was detected between second primary and recurrent tumors; survival was not adversely affected by a resection interval of less than 2 years or less than 12 months. Completion pneumonectomy for non-small cell lung cancer is a safe surgical procedure in experienced hands; long-term survival is acceptable and the best results are obtained for stage I lung cancer. Distinction between second primary lung cancer and recurrence failed to demonstrate a prognostic value.

Sleeve lobectomy for non-small cell lung cancer and carcinoids: results in 160 cases.

To assess operative mortality (OM), morbidity and long-term results of sleeve lobectomies performed for non-small cell lung cancer (NSCLC) and carcinoids during a 35-year period. A retrospective review of patients who underwent a sleeve lobectomy for NSCLC and carcinoids was undertaken, univariate and multivariate analyses of factors influencing early mortality in NSCLC were performed and for this purpose the series was split into an early and a contemporary phase, the Kaplan-Meier method was used to calculate the cumulative survival rate, and statistical significance was calculated with the log-rank test. Causes of death were evaluated in relation to the stage of the disease. OM for NSCLC was 14.6% in the early phase and 6% in the contemporary one; late stenosis occurred in 7.7% of NSCLC patients in the early phase and in 2% in the contemporary one. No OM or late stenosis occurred in carcinoid patients. Three, 5 and 10-year survival rates excluding carcinoids were 77, 62 and 31% for stage I(A-B), 45, 34 and 27% for stage II(A-B), 33, 22 and 0% for stage III(A-B). The 10-year survival rate for carcinoids was 100%. There was no significant difference in long-term survival between stages II and III, while the difference between stage I and stages II and III was significant (P<0.001). When survival was analyzed in relation to nodal status, 3, 5 and 10-year survival rates were 71, 57 and 33% for N0 disease, 42, 33 and 22% for N1 disease, and 34 and 19% with the last observation at 82 months of 19% for N2 disease; there was no significant difference in survival between N1 and N2 disease. A second primary lung cancer occurred in six patients (3.7%) who underwent resection. Late mortality was not related to cancer in most stage I patients while in stages II and III patients it was related to local and distant recurrences. Sleeve lobectomy is a valid alternative to pneumonectomy: careful patient selection and surgical technique make it possible to achieve a mortality rate comparable to or lower than that for pneumonectomy along with a better quality of life. In addition, it allows further lung resection, if necessary.

Effectiveness of and adverse events after percutaneous coronary intervention in patients with mild versus severe renal failure

Patients with renal failure undergoing percutaneous coronary intervention (PCI) experience reduced procedural success rates and increased in-hospital and long-term follow-up major adverse cardiac events. This study was designed to determine whether the severity of preprocedural renal failure influences the outcomes of patients with renal failure undergoing PCI. We compared the immediate and long-term outcomes of 192 patients with mild renal failure (creatinine 1.6 to 2.0 mg/dl, mean 1.76) with those of 131 patients with severe renal failure (creatinine >2.0 mg/dl, mean 2.90), selected from 3,334 consecutive patients undergoing PCI between 1994 and 1997. Although the overall population with renal failure represents a high-risk group, the severe renal failure cohort had a higher incidence of hypertension, multivessel disease, prior coronary bypass surgery, vascular disease, and congestive heart failure (all p values <0.05), yet had similar angiographic characteristics. Procedural success was higher in the group with severe renal failure (93.7% vs 87.7%, p = 0.04). There were no statistically significant differences in in-hospital mortality (11.5% vs 9.9%, p = 0.7), Q-wave myocardial infarction (0.5% vs 0%, p = 0.4), emergent bypass surgery (0% vs 0%, p = 1.0), and in-hospital major adverse cardiac events (11.5% vs 9.9%, p = 0.7) between the mild and severe renal groups, respectively. Kaplan-Meier analyses showed no statistically significant difference in long-term survival (log rank test, p = 0.1) or event-free survival (log rank test, p = 0.3) between the 2 groups. Finally, creatinine was not identified as an independent predictor of in-hospital or long-term follow-up major adverse cardiac events. In our high-risk population, patients with mild renal insufficiency undergoing PCI experience major adverse outcomes in the hospital and at long-term follow-up similar to those of patients with severe renal failure.

Non-immune acute graft injury after lung transplantation and the risk of subsequent bronchiolitis obliterans syndrome (BOS)

Abstract Background Primary graft dysfunction remains a major cause of early morbidity and mortality after lung transplantation. Evidence from animal models shows acute non-immune lung injury increases organ immunogenicity by enhancing MHC Class II expression. We hypothesized that acute non-immune injury in the lung allograft may impact, not only on early survival, but also on longer term survival by increasing the incidence of bronchiolitis obliterans syndrome (BOS). Methods A single-center, retrospective, observational study in a population of over 320 lung transplant recipients was undertaken. The histologic diagnosis of diffuse alveolar damage (DAD) in an early graft biopsy was used to define those recipients at risk. Serial measurements of forced expiratory volume in 1 second (FEV 1 ) in long-term follow-up defined the incidence of BOS. Results Early graft biopsy was available in 291 of the recipients following transplantation. DAD was confirmed in 55 (19%); their 30-day survival (62.5%) was significantly worse than in recipients without DAD (87.5%; p p = 0.25, Wilcoxon's survival analysis). The incidence of subsequent BOS over the follow-up period was not significantly different in those with and without DAD on early biopsy at 46% and 59%, respectively (hazards ratio 0.88 [0.48 to 1.62]; p = 0.22, chi-square test). BOS did not occur any earlier in the DAD group (median 953 days, range 152 to 1,393) days compared with the non-DAD group (median 665 days, range 52 to 4,299) ( p = 0.48, Fisher's exact test). Conclusions The development of severe non-immune acute graft injury after lung transplantation has a poor early prognosis. However, recipients with non-immune acute graft injury who survive >30 days show no significant difference in long-term survival or BOS-free time compared with recipients without early injury.

Appraisal of surgical resection of gallbladder carcinoma with special reference to hepatic resection.

Carcinoma of the gallbladder a gastrointestinal malignancy with an extraordinarily poor prognosis. However, aggressive surgery, with special reference to hepatic resection, may improve survival. To prove this, we performed a retrospective analysis over an 18-year period to investigate the experience of a center that began employing liver resection in patients with gallbladder cancer in 1978. The analysis was based on patients' documentation and regular follow-up to January 1996. The standard procedures were extended cholecystectomy (cholecystectomy with lymphadenectomy and wedge hepatic resection), anatomic segmentectomy of segments IVa and V, and extended hepatectomy. Significance was assessed by the log-rank test. Thirty-nine patients were resected, curatively in 41% (n = 22; group I) and palliatively in 31% (n = 17; group 2). In 28% (n = 15; group 3) a palliative or no operation was performed. Only curatively resected patients were analyzed and followed up to January 1996. No patients in group 1 died postoperatively. The actuarial 5-year survival rate of the patients with curative resection was 55%. Four patients had stage I, two had stage II, four had stage III, and two had stage IV disease according to TNM-classification. Six of the 16 patients without lymph node metastasis survived more than 5 years. A significant difference in long-term survival was recognised between stage II and stage IV patients and between stage (pT1a)- and (look table 1b) (pT1b)-patients (P < 0.01). Diagnostic efforts should focus on detecting early stages I and II gallbladder cancer. In advanced cases, aggressive surgery, particularly with hepatic resection, is the method of choice and is successful even in patients 70 years and older.

Early referral and its impact on emergent first dialyses, health care costs, and outcome

Early referral (ER) to nephrologists of patients with chronic renal failure was assessed for its impact on the incidence of emergent first dialyses and choice of dialysis modality (hemodialysis [HD] or peritoneal dialysis [PD]), and survival. We reviewed events preceding first dialyses of 238 patients with end-stage renal disease (ESRD) starting dialysis between January 1990 and April 1997, with follow-up extending through November 1997. Patients referred more than 1 month before needing dialysis (early referral [ER]) were compared with patients presenting within 30 days of needing dialysis (late referral [LR]). The need for emergent HD was significantly less among ER (29%) as compared with LR (90%) (P < 0.0001). Initial modality chosen was similar among ER patients (59% for HD v 41% for PD), a finding that contrasts with national percentages, which approximate 85% and 15%, respectively. Whereas most patients had not changed modality at 4 months, significantly more had changed from HD to PD (36 of 160 or 23%) than from PD to HD (7 of 78 or 9%) (P < 0.0001). Despite starting out on HD, ER and LR patients were amenable to ultimately changing to PD. ER and LR groups had similar numbers of Medicaid patients and patients living 1 hour or more distant to tertiary medical care. Furthermore, no difference was observed in the incidence of emergent HD when ER and LR living more than 1 hour away were compared. LR was not associated with lack of insurance or distance from referral site, although these patients more often required emergent HD, with its higher attendant medical care costs. Controlling for age and cause of ESRD, there was no statistically significant difference in long-term survival when ER patients were compared with LR patients or when patients who had received emergent HD were compared with those who had not. Despite the lack of difference in long-term survival, the financial costs of emergent HD alone merit greater promotion of ER and the psychosocial preparation and modality choice it allows. (Am J Kidney Dis 1998 Aug;32(2):278-83)

General oncologic effects of the laparoscopic surgical approach. 1997 Frankfurt international meeting of animal laparoscopic researchers.

The results from the majority of the reviewed studies support the hypothesis that abdominal surgery, performed via either a large incision or CO2 pneumoperitoneum, systemically encourages tumor growth in the postoperative period. A full laparotomy incision appears to have a significantly greater effect than CO2 pneumoperitoneum on postoperative tumor growth. Whether the large tumor observed in the surgical groups are the result of increased tumor cell proliferation or diminished tumor cell death remains unclear. There is some evidence pointing to both mechanisms. The loss of the postoperative tumor growth differences between the open and pneumo animals in the athymic mouse experiment suggests that cell-mediated immune function plays a role in tumor containment. The proliferation study results, however, suggest that other stimulatory influence(s) are also at work. Clearly, much research needs to be done regarding the etiology of these tumor growth differences. Other tumor cell lines need to be studied, and investigations regarding tumor growth in an intra-abdominal location need be performed as well. This body of research suggests that the manner in which the surgeon gains access to the abdominal cavity may have an impact on the propensity of tumor cells to implant, survive, and grow in the period immediately after surgery. If true, this may be the most compelling justification for the use of minimally invasive techniques for the curative resection of malignancies. However, it remains to be proven that human tumors will demonstrate differences in tumor growth similar to those noted in some of these animals models. Furthermore, it is not all clear that slight differences in tumor growth postoperatively will translate into significant differences in long-term survival or recurrence rates. At first glance, the existence of port-site tumors would appear to contradict totally the conclusions of many studies discussed in this synopsis. If laparoscopic methods are associated with decreased rates of tumor growth and establishment, then why do port-site tumors form? This is a complex issue calling for discussion that goes far beyond the scope of this article. However, several brief comment on this topic follow. The etiology of port tumors is unknown, although traumatization of the tumor during mobilization, resection, or removal is likely to play a significant role in the liberation of tumor cells from the primary. A relatively small protective benefit, in terms of slower tumor growth rates in laparoscopic patients, will likely not be sufficient to prevent a large inoculum of viable tumor cells in an abdominal wound from establishing a metastasis. Furthermore, as suggested earlier, the systemic effects on tumor growth may be different from the local (i.e., intra-abdominal or abdominal wound) effects. Finally, the true incidence of port tumors remains unknown. It has not been definitively established that the laparoscopic wound tumor incidence is significantly higher than the open rate, although this is the assumption of most surgeons. Several relatively large recently published laparoscopic series have reported port tumor incidences of 0 to 1.2%, which is in the same "ballpark" as the 0.6 1.0% abdominal wound tumor incidences mentioned in several open colectomy series. Clearly, much more research in this area is needed to understand port tumors better and to reconcile the port tumor results with the systemic tumor growth benefits that may be associated with minimally invasive methods.

Possible effect of pneumoperitoneum on the spreading of colon cancer tumor cells.

By using a murine hepatic metastatic model, we tried to investigate the possible influence of gas insufflation in colon cancer cells spreading from the portal system to the liver. After transducing the human placental ALP gene into murine colon cancer cell line CT26, we successfully selected a clone of CT26/DAP that would yield a specific color following histochemical staining. Fifty mice were assigned into two groups, receiving either an intrasplenic injection of 10(6) CT26/DAP cells alone or the cells followed by intra-abdominal helium insufflation with the pressure of 15 cm H2O for ten minutes. Five mice in each group were used to observe their survival and the other mice were killed at four different time periods: 10 minutes, 24 hours, 48 hours, and 72 hours following cell injection. The livers and spleens were removed for histochemical staining. By counting the numbers of specific dark reddish spots of CT26/DAP cells, we could estimate the number of tumor cells on the hepatic surface. At the very beginning following tumor cell injection, we found a significantly greater number of tumor cells on the hepatic surface in mice with gas insufflation (6354 +/- 1072 vs. 2133 +/- 223, respectively; P = 0.012). But the difference of these two groups became smaller and smaller as time went by. The number of tumor cells on the hepatic surface would reach the lowest level at postoperative 48 hours, and the tumor foci then began to grow both in size and number. The above patterns of dynamic change in tumor cell distribution were similar in mice both with and without gas insufflation. Average survival was slightly shorter in mice with gas insufflation, but the difference was not statistically significant. Pneumoperitoneum caused by gas insufflation may increase tumor cell spread from the portal system to the liver at the very beginning stage; however, there was no significant difference in long-term survival between mice with and without gas insufflation in this murine animal model.

Accumulation of p53 in relation to long-term prognosis in colorectal carcinoma

To evaluate the prognostic value of p53 in colorectal cancer. A retrospective study to investigate the correlation between p53 in tumour tissue and the course of patients' disease. One hundred and two patients who underwent radical surgery for colorectal cancer and were followed up for a minimum of 5 years, or until death, were included in this study. The p53 expression in tumour tissue was studied by immunohistochemistry using CM1 polyclonal rabbit antibody and formalin-fixed, paraffin-embedded material. p53 accumulation was detected in 46% (47/102) of the tumours. There was no significant difference in long-term survival between the patients with p53 positive and negative tumours (P=0.86). Five-year survival rates were 55% for p53 positive tumours compared with 56% for patients with p53 negative tumours. However, patients with p53 overexpressing tumours showed a higher local recurrence rate than those having carcinomas with undetectable levels of p53, 23% versus 9% respectively; the 2-year actuarial rates of 26% and 9% were statistically different (P=0.015). The results suggest that in colorectal carcinoma accumulation of p53 is not associated with a difference in long-term prognosis. However, this phenomenon might be useful in the identification of patients with a high risk of local recurrence.

Treatment of Aplastic Anemia

There is general agreement that in children and adolescents with an HLA-identical or syngeneic sibling, bone-marrow transplantation (BMT) should be performed without delay. More controversial are young-to-middle-aged adults with an HLA-identical sibling. Because of comparable survival rates, some centers advocate BMT; others advocate immunosuppression as primary treatment. BMT cures severe aplastic anemia (SAA), but has a higher early mortality. Immunosuppression usually induces hemopoietic improvement and has hardly any early mortality. However, there are late problems. After immunosuppression, there may be relapse and clonal hematopoietic disease. After BMT, there may be late graft failure, severe or even fatal chronic graft-versus-host-disease (GVHD). Both procedures are followed by a slight increase in second malignancies. Retrospective studies show no significant differences in long-term survival between the two treatment modalities. In patients over the age of 40, immunosuppression is favored by most centers because in this age group there is a very high transplant-related mortality with BMT. Androgens and hematopoietic growth factors have hardly any role in therapy of SAA. Splenectomy helps some patients with severe thrombocytopenia and problems with supportive care, but does not improve the overall prognosis. BMT with unrelated donors has usually been performed in late stages of the disease with disappointing results.

American Heart Association 68th Scientific Sessions, Anaheim, California, November 13 to 15, 1995.

Dr Elliott Antman, of Harvard Medical School and Brigham and Women’s Hospital in Boston, Massachusetts, presented the results of the Thrombolysis in Myocardial Infarction (TIMI) 9B study at a Satellite Symposium sponsored by George Washington University immediately prior to the American Heart Association Meetings in Anaheim, California, in November 1995. The TIMI 9 trial was a randomized, double-blind study conducted in 150 clinical centers that was designed to compare the efficacy and safety of intravenous heparin versus the direct-acting thrombin inhibitor hirudin in patients with acute myocardial infarction (<12 hours from onset) treated with a thrombolytic agent (streptokinase or tissue-type plasminogen activator [TPA], at the discretion of the treating physician). The TIMI 9A study (n=757) was suspended in April 1994 because of excessive bleeding in both the heparin and hirudin groups. The TIMI 9B trial was restarted in May 1994 with lower doses of both heparin and hirudin; enrollment (n=3002) continued through August 1995. The primary end point of the study was the 30-day incidence of death, myocardial infarction, congestive heart failure, and shock. At 30 days, there was no significant difference in the primary end point between heparin (11.8%) and hirudin (12.8%) and no difference in the incidence of death and myocardial infarction (9.3% in the heparin group, 9.6% in the hirudin group). Similarly, there was no significant difference in major bleeding events (including intracranial hemorrhage) between treatment groups. The TIMI 9 Investigators concluded that hirudin was equally effective as but not superior to heparin with respect to either clinical outcome or bleeding risk in patients with acute myocardial infarction receiving thrombolytic therapy. Also at the George Washington University Satellite Symposium, Dr Eugene Braunwald, of Harvard Medical School and Brigham and Women’s Hospital in Boston, presented the results of the TIMI 10A phase I trial. TIMI 10A is an …

The influence of age on operative mortality and long-term relative survival following emergency abdominal aortic aneurysm operations

To study operative mortality and long-term survival following emergency operations for abdominal aortic aneurysm. Retrospective survey in a university hospital. Two hundred and twenty-seven patients with median age 72 years, (17% women). Founded on data from the Norwegian Registrar's Office, operative mortality and long-term survival was estimated using the life-table method. Expected survival for demographically matched subgroups was calculated from death rate tables issued by the Norwegian Central Bureau of Statistics. Operative mortality was 41% for the 175 patients with ruptured aneurysms and 17% for the 52 with imminent rupture. The 6-year survival rate was 61% for all the successfully operated patients, and not different from that of a demographically matched population. For the patients of 72 years or older the 6-year survival rate was 53%. This was equal to that of an age and sex matched population. The younger patients had an observed 6-year survival rate of 64%, which was significantly lower than the expected of 84%. The standard mortality rate for this group was 2.25. No statistically significant difference in long-term survival was detected between the two age groups. Age at the time of the operation for a symptomatic abdominal aortic aneurysm does not seem to influence long-term survival. Consequently, younger patients experience a higher relative mortality compared to the older.

Completion pneumonectomy: experience with 47 cases.

From 1982 through March 1994, fourty-seven patients underwent completion pneumonectomy for a reappearing lung cancer, lung metastases, late complications, benign lung diseases, and early complication of bronchial or pulmonary artery sleeve resections. Intraoperative bleeding was higher than in standard pneumonectomy; there was one intraoperative mortality (2.3%). Operative mortality was 14.9% overall but was 3.6% in completion pneumonectomy for lung cancer, 20% for late complications and benign disease, and 57% for the treatment of early complications of sleeve resections. Three and five-year survival in patients with lung cancer who survived the operation was 43.8% and 28.7% according to the Kaplan-Meier method; no significant difference in long-term survival was present between patients with a second primary lung cancer or recurrence. Completion pneumonectomy is indicated in reappearing lung cancer and should be considered in benign disease when a less invasive procedure is not available. Completion pneumonectomy for the treatment of early complications of bronchial or pulmonary artery sleeve resections has a very high mortality but no alternative is available.

Prognosis of acute myocardial infarction complicated by complete heart block (the Worcester heart attack study)

As part of a community-based study of patients hospitalized with acute myocardial infarction (AMI) in the Worcester, Massachusetts, metropolitan area, changes over time in the incidence rates of complete heart block (CHB) complicating AMI, and the prognostic impact of CHB on the in-hospital and long-term survival of these patients were examined. In all, 4,762 patients with validated AMI hospitalized at 16 hospitals in the Worcester metropolitan area during 1975, 1978,1981, 1984, 1986 and 1988 constituted the study sample. The incidence rates of CHB complicating AMI remained relatively stable at 5.8% over the 13-year (1975 to 1988) period studied. The incidence rates of CHB were approximately twice as high in patients with inferior/posterior wall AMI (7.7%) as in those with anterior wall AMI (3.9%). Use of a multivariate regression analysis to control for factors affecting the incidence rates of CHB revealed that patients were at highest risk for developing CHB during the latter 2 study years (1986 and 1988). Patients with AMI developing CHB had higher in-hospital case fatality rates than did those without CHB overall, as well as during each of the 6 periods studied. The in-hospital survival associated with CHB did not improve over time. After use of a multivariate regression analysis to control for additional prognostic factors, the independent effect of CHB on in-hospital prognosis remained (adjusted risk of dying = 2.10; 95% confidence intervals = 1.37, 3.21). Patients with inferior wall AMI complicated by CHB were at significantly increased risk of dying during hospitalization compared with those without CHB (adjusted risk of dying = 2.71; 95% confidence intervals = 1.60, 4.59). Long-term survival rates for up to a 14-year follow-up period for discharged surviving patients were not significantly different for AMI patients with compared with those without CHB, with no significant differences in long-term survival observed concerning the location of the AMI. The results of this observational, population-based study suggest that the incidence rates of CHB resulting from AMI have not changed over time and that CHB is associated with an unfavorable short- but not long-term prognosis.

Survival of the older patient compared with the younger patient with hodgkin's disease. Influence of histologic type, staging, and treatment

Age as an independent risk factor for survival of Hodgkin's disease (HD) was investigated using data for the 6345 patients in the American College of Surgeons, Patterns of Care Study. Patients were divided into those 15 to 34 years of age, and those older than 50 years. Older patients had higher rates of advanced stage and B symptoms (e.g., Stage IVB, 19.7% compared with 7.7%) and significantly higher rates of poor prognosis histologic types, odds ratio (OR) = 3.7. The older population with clinical stage (CS) I and II disease was also less likely to have received any of the selected staging procedures, bone marrow biopsy, lymphogram, or laparotomy (OR = 4.48). The two populations were equivalently understaged when CS was compared with pathologic stage (PS). In each category the older patients were more likely to have received no therapy; for PS I and II disease the OR for older patients compared with the younger patient was 2.14. When stratified by PS, B symptom status, histologic type, and treatment the older patients continued to show poorer 5-year survival by the life-table method. The authors' hypothesis--that older patients equivalently staged and treated would have no significant difference in long-term survival--was not substantiated by the data. However, in the analyses in which corrections for the known risk factors were made, the difference in survival was not as great as that in the crude, unstratified data. This study, as well as other recent studies utilizing smaller numbers of patients, finds age an independent predictor of poorer survival in HD patients.

Operative treatment of aortic dissections: Experience with 125 patients over a sixteen-year period

An unselected, consecutive cohort of 125 patients underwent operative repair of acute and chronic aortic dissections with tubular graft interposition over a 16 year span. The absence of remote geographical referral biases and the unselected nature of this series provided a patient population that was representative of the disease process (as assessed heretofore only from autopsy series). Furthermore, this enabled high-risk subsets to be defined by retrospective analysis. Patients were classified according to whether the ascending aorta was involved (type A with involvement, type B without), irrespective of the site of intimal tear, and according to age of the dissection: Fifty-three patients had acute type A (Ac-A), 29 had chronic type A (Ch-A), 20 had acute type B (Ac-B), and 23 had chronic type B (Ch-B) dissections. Fourteen percent (17/125) of the dissections had ruptured. Concomitant aortic valve replacement (AVR) was performed in 11% (6/53) for Ac-A cases and 38% (11/29) of the Ch-A cases. A total of 391 patient-years of follow-up was analyzed; follow-up averaged 4.5 years and extended to 13.7 years. Over-all operative mortality rate was 34% (18/53) for Ac-A, 14% (4/29) for Ch-A, 45% (9/20) for Ac-B, and 22% (5/23) for Ch-B; during the most recent 5 year interval these figures were lower: 27%, 8%, 20%, and 20%, respectively, N = 50. Multiple preoperative variables were found to correlate significantly with both operative death and long-term survival. Operative survivors generally experienced satisfactory functional benefit. Late attrition averaged 8% per year; 61% of all late deaths were related to cardiac or cerebral causes. Over-all actuarial survival (+/- SEM) for the entire cohort was 54% +/- 5% at 5 years and 26% +/- 7% at 10 years; for the 89 patients surviving operation, these figures were 76% +/- 5% and 37% +/- 10%, respectively. No significant differences in long-term survival were evident between the different subgroups. Whether the primary intimal tear had been resected or concomitant AVR had been performed had no statistically significant bearing on operative mortality, functional result, necessity for late reoperation, or late attrition. The long-term "natural" history of surgically treated patients with aortic dissections, as defined in this study, should facilitate comparison with other treatment modalities. Results of the present analysis support immediate operative intervention for patients with Ac-A dissections and probably for those with Ac-B dissections. Additionally, surgical treatment of patients with symptomatic or enlarging Ch-A and Ch-B dissections provides satisfactory rehabilitation and long-term survival. Finally, we re-emphasize our recommendation for simplified classification of aortic dissections, based solely upon the presence or absence of ascending aortic involvement. Pathophysiology and expected biologic behavior pivot on this feature, and appropriate clinical strategy can thereby be defined.

Acute Myocardial Infarction

A community-wide study was conducted in metropolitan Baltimore in which the prognosis of 330 patients hospitalized with an acute myocardial infarction (MI) complicated by ventricular fibrillation or cardiac arrest (VFib/CA) was compared with that of 1,071 patients hospitalized with acute MI not complicated by VFib/CA. As expected, the in-hospital case-fatality rate among patients with MI complicated by VFib/CA was significantly higher than that in patients without VFib/CA. However, for patients discharged alive from the hospital, no significant differences in long-term survival were found between patients with MI with or without VFib/CA. These results suggest that attempts at preventing subsequent mortality should be diligently pursued in patients with MI who are discharged alive from the hospital regardless of the occurrence of VFib/CA in the acute phase. (<i>JAMA</i>241:2024-2027, 1979)