Significant Univariate Factors Research Articles

Reirradiation of Recurrent High Grade Gliomas: Outcomes and Prognostic Factors

Identify prognostic factors for progression-free survival (PFS) and overall survival (OS) after reirradiation (re-RT) for recurrent high grade glioma. An institutional database was queried for patients with high grade glioma (HGG) who received re-RT for progressive disease from 2010 to present. PFS and OS after re-RT were estimated using the Kaplan-Meier method, and prognostic variables were examined using univariate and multivariate Cox models. Receiver operative curve (ROC) analysis was used to determine best predictive thresholds for continuous variables. Fifty-eight eligible patients had received surgery and adjuvant radiation ± temozolomide for initial diagnosis of HGG (51 grade IV, 7 grade III). The median time to first progression after initial radiation was 11 months. Prior salvage therapy before re-RT included chemotherapy (60%) and surgery (45%). The median number of separate progression events before re-RT was 1 (range 0 – 5). The median time from first progression to re-RT was 2.7 months, and from initial radiation to re-RT was 18 months. 36% received single fraction stereotactic re-RT (SRS) (median 18 Gy, range 14 – 19 Gy) and 64% received fractionated re-RT (median 35 Gy in 10 fractions, range 10 – 60 Gy in 2 – 30 fractions). The median biologically effective dose (BED10) of re-RT was 47 Gy (range 15 – 72). The median planning target volume (PTV) was 16.8 mL (range 0.4 – 783.6). 50% received concurrent chemotherapy and 36% received bevacizumab concurrent and/or adjuvant to re-RT. Acute (≤ 3 months) toxicity ≥ grade 3 was 7%. The median PFS after re-RT was 4.7 months (1 year PFS 18%), and the median OS was 11 months (2 year OS 21%). By univariate analysis, lower PFS was significantly (p<0.05) associated with shorter time to first progression after initial radiation, lower KPS, and lower re-RT dose (BED10). Lower OS was associated with shorter time to first progression after initial radiation, lower KPS, and larger PTV. Time from initial RT to re-RT, time from first progression to re-RT, use of SRS, and chemotherapy or bevacizumab at re-RT were not significantly associated with PFS or OS. ROC analysis of time to first progression and re-RT dose showed best predictive thresholds at time > 12 months and BED10 > 42 Gy. All significant univariate factors retained significance on multivariate analysis except re-RT dose (p = 0.07). Reirradiation was well tolerated with infrequent high grade acute toxicity. PFS and OS after re-RT for high grade glioma were both predicted by time to progression after initial radiation. Published prognostic scores have used total time from first to second radiation courses; however in our series the period from initial progression to re-RT did not add prognostic information. There was evidence for a dose threshold of BED10 > 42 Gy (> 16 Gy in 1 fraction, 27.5 Gy in 5 fractions, or 32 Gy in 10 fractions) irrespective of radiotherapy technique. Use of chemotherapy and bevacizumab with re-RT were not associated with improved PFS or OS.

Here and Gone: Rapid Transfer From the General Care Floor to the PICU.

Children admitted to the general care floor sometimes require acute escalation of care and rapid transfer (RT) to the PICU shortly after admission. In this study, we aim to investigate the characteristics of RTs and the impact RTs have on patient outcomes, including PICU length of stay (LOS), mortality, and emergency transfer defined as critical care interventions occurring within 1 hour on either side of transfer to the PICU. We conducted a 2-year, single-center, retrospective analysis including all patients admitted to the general care floor of a tertiary children's hospital that were subsequently transferred to the PICU, with attention to those transferred within 4 hours of admission, meeting criteria as RTs. Patient-level data and outcomes were tracked. Statistical summaries were stratified by RT or non-RT strata and between-strata comparisons were performed. Significant univariate factors were entered into a multivariate logistic regression model and reduced with statistical significance required for final model inclusion. Of 450 patients with an unplanned PICU transfer, 105 (23.3%) experienced RTs. Significant factors in the reduced multivariate logistic regression model associated with decreased risk for RT were increased baseline Pediatric Overall Performance Category (P = .046) and PICU origin of admission (P = .012). RT patients had shorter PICU LOSs (2.8 vs 5.5 days, P < .001) compared with non-RT patients despite a higher rate of emergency transfer (15.2% vs 7.5%, P = .018) and no difference in mortality (P = .741). In this study, we demonstrate RTs have an increase in emergency transfer rate but no apparent risk of increased PICU LOS or mortality.

Determining patient risk factors associated with accelerated growth of popliteal artery aneurysms

ObjectiveThe objective of this study was to determine the natural progression of popliteal artery aneurysms (PAAs) and clinical variables associated with their accelerated growth. MethodsRetrospective chart review of 224 patients with encounters between January 2008 and May 2016 and with at least one PAA was conducted. From this group, 65 asymptomatic patients had either unilateral (n = 43) or bilateral (n = 22) PAAs that were observed for at least 1 year of medical management before intervention. We divided these aneurysms into two groups based on whether their overall growth rate was above or below the eventual mean. Aneurysm diameter was taken from duplex ultrasound and computed tomography angiography. ResultsThere were 87 aneurysms evaluated among 65 patients. Mean age at diagnosis was 70.9 years (standard deviation [SD], 9.39 years), and 64 patients were male (98%); 50 (77%) were white and 7 (11%) were African American. The average body mass index was 27.69 (SD, 4.90). At or before initial diagnosis, 61 (94%) patients had a concomitant lower extremity or abdominal aortic aneurysm; 51 (78%) patients were current or former smokers; and 16 (25%) had atrial fibrillation. The average growth rate of all aneurysms was 1.22 mm/y (SD, 1.93 mm). The mean surveillance time from initial diagnosis to last follow-up or intervention was 3.12 years (SD, 1.66 years). Of 87 aneurysms, 25 (29%) were repaired; 18 (21%) were repaired because of size criteria, 2 (2%) because of symptom criteria (claudication or acute limb ischemia), and 5 (6%) because of both criteria. During our study window, 62 aneurysms (71%) remained asymptomatic or did not undergo an intervention. The mean initial diameter at diagnosis was 16.9 mm (SD, 5.32 mm). Within the study, 50 (57%) aneurysms presented with or developed mural thrombus. Univariate analysis identified larger initial diameter (19.2 vs 14.7 mm; P = .020), atrial fibrillation (35% vs 16%; P = .042), and mural thrombus (38% vs 20%; P < .001) as predictors of diameter expansion greater than the mean. Multivariable analysis of the significant univariate factors determined that only initial diameter (odds ratio, 5.53; P = .007) and the presence or development of mural thrombus (odds ratio, 4.00; P = .008) maintained significance. ConclusionsPatients presenting with a PAA at 20 mm or >20 mm in diameter, presence of luminal thrombus, or atrial fibrillation may need to be observed at more frequent scanning intervals than those without these risk factors. Further studies are required to validate these predictive growth factors.

Prediction of Long-Term Survival After Lung Cancer Surgery for Elderly Patients in The Society of Thoracic Surgeons General Thoracic Surgery Database

Prior risk models using the STS General Thoracic Surgery database (STS-GTSD) have been limited to 30-day outcomes. We have now linked STS data to Medicare data and sought to create a risk prediction model for long-term mortality after lung cancer resection in patients older than 65 years. The STS-GTSD was linked to Medicare data for lung cancer resections from 2002 to 2013 as previously reported. Successful linkage was performed in 29,899 lung cancer resection patients. Cox proportional hazards modeling was used to create a long-term survival model. Variable selection was performed using statistically significant univariate factors and known clinical predictors of outcome. Calibration was assessed by dividing the cohort into deciles of predicted survival and discrimination assessed with a C-statistic corrected for optimism via 1,000 bootstrap replications. Median age was 73 years (interquartile range, 68 to 78 years), and 48% of the patients were male. Of the 29,094 patients with nonmissing pathologic stage, 69% were stage I, 18% stage II, 11% stage III, and 2% stage IV. Procedure performed was lobectomy in 69%, bilobectomy in 3%, pneumonectomy in 3%, segmentectomy in 7%, sleeve lobectomy in 1%, and wedge resection in 17%. Thoracoscopic approach was performed in 47% of resections. The final Cox model reveals that stage and age are the strongest predictors of long-term survival. Even after controlling for stage, wedge resection, segmentectomy, bilobectomy, and pneumonectomy are all associated with increased hazard of death in comparison with lobectomy. Thoracoscopic approach is associated with improved long-term survival in comparison with thoracotomy. Other modifiable predictive factors include smoking and low body mass index. Calibration of the model demonstrates excellent performance across all survival deciles and a C-statistic of 0.694. The STS-GTSD-Medicare long-term risk model includes several novel factors associated with mortality. Although medical factors predict long-term survival, age and stage are the strong predictors. Despite this, procedure choice and thoracoscopic/open approach are potentially modifiable predictors of long-term survival after lung cancer resection.

Smoking Cessation Rates among Patients Undergoing Vascular Surgery in a Canadian Center

Smoking is the single most important modifiable risk factor for patients with vascular disease. The aim of this study was to determine the prevalence of smoking and cessation rates among patients undergoing vascular surgery in a Canadian center. As part of the Vascular Quality Initiative, a prospectively maintained database was used to identify the patients undergoing vascular surgery between 2010 and 2013. Smoking prevalence data were collated preprocedure, postprocedure, and at year follow-up after intervention at a median of 13months (mean=14.4±7.8months). Cessation rates at 13-month follow-up were assessed to determine any statistically significant univariate factors. These factors were then used to build a model through backwards logistic regression. Multicollinearity was tested by assessing both variance inflation factors and tolerance. Overall, 624 patients had complete follow-up data. Of these, 209 (33.5%) were smokers presurgically. At 1-year follow-up, of those 209 patients who were smokers preoperatively, 87 (41.6%) had stopped smoking while 122 (58.4%) had not. Patients who were male and aged >70 years were more likely to be smokers preoperatively (P=0.001 and P<0.001, respectively). Cessation rates were increased in those aged >70years (P=0.005) and in those with chronic obstructive pulmonary disease (P=0.016). Gender was also statistically associated, with cessation rates higher in females (P=0.011). More than one-third of patients who underwent surgery in a Canadian vascular center continue to smoke. Uniquely, we report a statistically significant association between gender and postoperative cessation rates.

Relation between tumor FDG uptake and hematologic prognostic indicators in stage I lung cancer patients following curative resection.

Hematologic parameters of systemic inflammation are receiving attention as promising prognostic indicators in cancer patients. Here, we investigated the relation and compared the prognostic values of circulating blood cell-based parameters and tumor 18F-fluoro-2-deoxyglucose (FDG) uptake in patients with stage I nonsmall cell lung cancers (NSCLC).Subjects were 1034 patients with newly diagnosed stage I NSCLC who underwent FDG positron emission tomography/computed tomography (PET/CT) followed by curative resection. Total white blood cell (WBC) count, absolute neutrophil, lymphocyte and platelet counts, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) were obtained. Tumor FDG uptake was measured as SUVmax.WBC, neutrophil and lymphocyte counts, and NLR demonstrated weak but significant correlation to tumor SUVmax. Using the upper quartile as cutoff, patients with high tumor SUVmax had significantly higher WBC, neutrophil and lymphocyte counts, and greater NLR. There were 144 recurrences (13.9%) over a median follow-up of 29.5 months. On Cox proportional hazards regression analysis, WBC count, tumor SUVmax, age, gender, smoking, cell type, and tumor stage were significant univariate prognostic factors. On multivariate analysis, high tumor SUVmax (HR = 2.22; 95% CI, 1.52–3.25; P < 0.001), tumor stage 1B (HR = 2.11; 95% CI, 1.47–3.01; P < 0.001), and old age (HR = 1.03; 95% CI, 1.01–1.05; P = 0.002) were significant independent predictors of poor survival. Finally, high tumor SUVmax remained a significant predictor of prognosis in both low and WBC count groups.Circulating blood counts showed significant correlation to tumor FDG uptake in early stage NSCLC. WBC count was a significant univariate variable, but tumor FDG uptake was a superior and independent predictor of outcome. Hence, tumor FDG uptake effectively stratified prognosis in patients with low as well as high WBC count.

Functional outcome of patients with unstable pelvic ring fracture

The purpose of this study was to evaluate factors that correlated with unsatisfactory short- and long-term outcome in patients who sustained unstable pelvic ring fracture. The study subjects of this study were those of type B and C pelvic ring fractures (82 patients; mean age 54 years). Age, gender, associated injuries, fracture type, Injury Severity Score rating and treatment methods were assessed, and Majeed score for functional outcome and radiographic studies at 1 year after injury (short-term) and at final follow-up (long-term), with mean follow-up of 98 months were analyzed. Significant univariate factors ( p < 0.05) were entered in a multivariate logistic regression model to determine the independent predictors of unsatisfactory functional outcome. Univariate analysis showed that fractures of the lower extremity, nerve damage, conservative treatment, and radiological outcome correlated with unsatisfactory short-term functional outcome, while female gender, brain injury, nerve damage, conservative treatment, fracture location at the posterior portion of pelvic ring, radiological outcome, and pure sacroiliac dislocation only for type C fracture correlated with unsatisfactory long-term outcome. Multiple logistic regression analysis identified fractures of the lower extremity (odds ratio (OR): 5.364), conservative treatment (OR: 13.690), and nerve damage (OR: 21.392) as determinants of unsatisfactory short-term functional outcome and nerve damage (OR: 66.926) and poor radiological results (OR: 33.944) as determinant of long-term functional outcome. In patients with unstable pelvic ring injury, fractures of the lower extremity, conservative therapy, and nerve damage influenced short-term functional outcome, while that nerve damage and the pelvic ring displacement over 20 mm negatively affected long-term outcome.

Neutrophilia in locally advanced cervical cancer: A novel biomarker for image-guided adaptive brachytherapy?

ObjectiveTo study the prognostic value of leucocyte disorders in a prospective cohort of cervical cancer patients receiving definitive chemoradiation plus image—guided adaptive brachytherapy (IGABT).Results113 patients were identified. All patients received a pelvic irradiation concomitant with chemotherapy, extended to the para-aortic area in 13 patients with IVB disease. Neutrophilia and leukocytosis were significant univariate prognostic factors for poorer local failure-free survival (p = 0.000 and p = 0.002, respectively), associated with tumor size, high-risk clinical target volume (HR-CTV) and anemia. No effect was shown for distant metastases but leukocytosis and neutrophila were both poor prognostic factors for in-field relapses (p = 0.003 and p < 0.001). In multivariate analysis, HR-CTV volume (p = 0.026) and neutrophils count > 7,500/μl (p = 0.018) were independent factors for poorer survival without local failure, with hazard ratio (HR) of 3.1.Materials and methodsWe examined patients treated in our Institution between April 2009 and July 2015 by concurrent chemoradiation (45 Gy in 25 fractions +/− lymph node boosts) followed by a magnetic resonance imaging (MRI)-guided adaptive pulse-dose rate brachytherapy (15 Gy to the intermediate-risk clinical target volume). The prognostic value of pretreatment leucocyte disorders was examined. Leukocytosis and neutrophilia were defined as a leukocyte count or a neutrophils count exceeding 10,000 and 7,500/μl, respectively.ConclusionsNeutrophilia is a significant prognostic factor for local relapse in locally advanced cervical cancer treated with MRI-based IGABT. This biomarker could help identifying patients with higher risk of local relapse and requiring dose escalation.

Pulmonary Vascular Dysfunction and Cor Pulmonale During Acute Respiratory Distress Syndrome in Sicklers.

Acute chest syndrome (ACS) is the most common cause of death among sickle cell disease (SCD) adult patients. Pulmonary vascular dysfunction (PVD) and acute cor pulmonale (ACP) are common during acute respiratory distress syndrome (ARDS) and their prevalence may be even more important during ARDS related to ACS (ACS-ARDS). The objective of this study was to evaluate the prevalence and prognosis of PVD and ACP during ACS-ARDS. This was a retrospective analysis over a 10-year period of patients with moderate-to-severe ARDS. PVD and ACP were assessed by echocardiography. ARDS episodes were assigned to ACS-ARDS or nonACS-ARDS group according to whether the clinical insult was ACS or not, respectively. To evaluate independent factors associated with ACP, significant univariable risk factors were examined using logistic regression and propensity score analyses. A total of 362 patients were analyzed, including 24 ACS-ARDS. PVD and ACP were identified, respectively, in 24 (100%) and 20 (83%) ACS-ARDS patients, as compared with 204 (60%) and 68 (20%) nonACS-ARDS patients (P < 0.0001). The mortality did not differ between ACS-ARDS and nonACS-ARDS patients. Both the crude (odds ratio [OR], 19.9; 95% confidence interval [CI], 6.6-60; P < 0.0001), multivariable adjustment (OR, 27.4; 95% CI, 8.2-91.5; P < 0.001), and propensity-matched (OR, 11.7; 95% CI, 1.2-110.8; P = 0.03) analyses found a significant association between ACS-ARDS and ACP. All SCD patients presenting with moderate-to-severe ARDS as a consequence of ACS experienced PVD and more than 80% of them exhibited ACP. These results suggest a predominant role for PVD in the pathogenesis of severe forms of ACS.

Characterization of Perioperative Contralateral Stroke After Carotid Endarterectomy

Contralateral stroke is an infrequent cause of perioperative stroke after carotid endarterectomy (CEA). Whereas the risks of ipsilateral stroke complicating CEA have been discriminated, factors that lead to contralateral stroke are poorly defined. The goal of this study was to identify the risk of perioperative (30-day) contralateral stroke after CEA as well as predisposing preoperative and operative factors. The Vascular Study Group of New England was queried from April 1, 2003, to February 29, 2016, for all CEAs. Duplicated patients and those without complete data were excluded. Those patients sustaining contralateral stroke in the postoperative period were identified. Demographic, preoperative, and operative factors were analyzed to identify discriminators between those with and without contralateral stroke. Logistic regression modeling was performed to identify factors independently associated with contralateral stroke. There were 10,837 CEAs performed during the study. Average age was 70.4 ± 9.3 years, and 6605 patients (61%) were male; 40% (n = 4324) were performed for symptoms. Most were current or former smokers (n = 8619 [80%]); 8% (n = 831) had serum creatinine concentration ≥1.8 mg/dL, and dialysis dependence was present in 162 (2%). Coronary artery disease and congestive heart failure were identified in 31% and 8.6%, respectively; 59 patients (0.5%) were identified having contralateral perioperative stroke. Preoperative, operative, and postoperative significant univariate factors along with notable factors not affecting perioperative contralateral stroke are presented in Table. After logistic regression analysis of significant factors, with and without contralateral occlusion represented, length of procedure (odds ratio [OR], 1.01/minute; 95% confidence interval [CI], 1.008-1.009; P = .02), urgency of operation (OR, 2.5; 95% CI, 1.3-4.6; P = .006), and concomitant proximal endovascular procedure (OR, 8.7; 95% CI, 4.5-31.2; P = .001) remain predictors of contralateral stroke after CEA. Contralateral stroke after CEA is rare, affecting 0.5% of patients. Traditional risk reduction medical therapy does not affect occurrence. Degree of contralateral stenosis, including contralateral occlusion, does not predict perioperative contralateral stroke. Urgency of operation, length of operation, and performance of a concomitant, ipsilateral endovascular procedure predict risk of contralateral stroke with CEA.TableUnivariate discriminants of perioperative contralateral stroke after carotid endarterectomy (CEA)FactorP valuePreoperative Urgency of operation.0001 Degree of ipsilateral (operated) carotid stenosis.004 Stress test performance.02 Preoperative facility need.03 Beta blocker use.04 Contralateral occlusion.06 Degree of contralateral carotid stenosis.14 Symptomatic.23 Aspirin use.26 Clopidogrel use.43 Dual antiplatelet therapy.46 ACE inhibitor/ARB.57 Statin use.62Operative CEA with coronary bypass (P = .001).0001 Length of operation.0001 CEA with other open arterial component (P = .01).01 Ipsilateral proximal endovascular procedure (P = .02).02 Shunt.19 Dextran.45 Protamine.85 Type of CEA (eversion/longitudinal).91Postoperative Dysrhythmia (P = .0001).0001 Return to OR (P = .0001).0001 Reperfusion syndrome (P = .006).006ACE, Angiotensin-converting enzyme; ARB, angiotensin receptor blocker; OR, operating room. Open table in a new tab

Image-guided adaptive brachytherapy in cervical cancer: Patterns of relapse by brachytherapy planning parameters

PurposeCervical cancer patients with a bulky high-risk clinical target volume (HR-CTV) get the largest benefit of dose escalation in terms of local control. However, the expected survival benefit could be lessened by a higher metastatic risk. We examined the patterns of relapse according to major prognostic factors: the HR-CTV volume and to the D90 HR-CTV. Methods and MaterialsThe clinical records of patients treated with pulsed-dose-rate image-guided adaptive brachytherapy after concurrent pelvic chemoradiation were reviewed. All patients had an optimal workup before treatment comprising a 18-fluorodeoxyglucose positron emission tomography/computed tomography and a para-aortic lymph node dissection. Patients with initial extrapelvic disease were excluded. ResultsA total of 109 patients fulfilled inclusion criteria. Median followup was 39 months. An HR-CTV volume ≥40 cm3 was associated with a poorer local failure-free survival. There was a strong inverse correlation between the HR-CTV volume and the D90 of the HR-CTV (correlation coefficient r = −0.696; p < 0.001) with increasing HR-CTV volume being associated with a decreasing D90 HR-CTV. A D90 HR-CTV <85 Gy and an HR-CTV volume ≥40 cm3 were significant univariate factors for experiencing nonlocal failure (p = 0.002 and 0.035, respectively), even after exclusion of local relapses. ConclusionA lower ability to reach the target D90 HR-CTV planning and an HR-CTV volume ≥ 40 cm3 correlated with a high propensity of relapsing at distance, these factors being interrelated. Next step of treatment personalization should design strategies integrating this risk, which is now the main cause of failure.

Smoldering multiple myeloma risk factors for progression: a Danish population‐based cohort study

Several risk scores for disease progression in patients with smoldering multiple myeloma (SMM) have been proposed; however, all have been developed using single-center registries. To examine risk factors for time to progression (TTP) to multiple myeloma (MM) for SMM, we analyzed a nationwide population-based cohort of 321 patients with newly diagnosed SMM registered within the Danish Multiple Myeloma Registry between 2005 and 2014. Significant univariable risk factors for TTP were selected for multivariable Cox regression analyses. We found that both an M-protein ≥30 g/L and immunoparesis significantly influenced TTP (HR 2.7, 95%CI (1.5;4.7), P = 0.001, and HR 3.3, 95%CI (1.4;7.8), P = 0.002, respectively). High free light chain (FLC) ratio did not significantly influence TTP in our cohort. Therefore, our data do not support recent IMWG proposal of identifying patients with FLC ratio above 100 as having ultra high-risk of transformation to MM. Using only immunoparesis and M-protein ≥30 g/L, we created a scoring system to identify low-, intermediate-, and high-risk SMM. This first population-based study of patients with SMM confirms that an M-protein ≥30 g/L and immunoparesis remain important risk factors for progression to MM.

Patient-reported geriatric symptoms as risk factors for hospitalization and emergency department visits.

There is an urgent need to identify predictors of adverse outcomes and increased health care utilization in the elderly. The Mayo Ambulatory Geriatric Evaluation (MAGE) is a symptom questionnaire that was completed by patients aged 65 years and older during office visits to Primary Care Internal Medicine at Mayo Clinic in Rochester, MN. It was introduced to improve screening for geriatric conditions. We conducted this study to explore the relationship between self-reported geriatric symptoms and hospitalization and emergency department (ED) visits within 1 year of completing the survey. This was a retrospective cohort study of patients who completed the MAGE from April 2008 to December 2010. The primary outcome was an ED visit or hospitalization within 1 year. Predictors included responses to individual questions in the MAGE. Data were obtained from the electronic medical record and administrative records. Logistic regression analyses were performed from significant univariate factors to determine predictors in a multivariable setting. A weighted scoring system was created based upon the odds ratios derived from a bootstrap process. The sensitivity, specificity, and AUC were calculated using this scoring system. The MAGE survey was completed by 7738 patients. The average age was 76.2 ± 7.68 years and 57% were women. Advanced age, a self-report of worse health, history of 2 or more falls, weight loss, and depressed mood were significantly associated with hospitalization or ED visits within 1 year. A score equal to or greater than 2 had a sensitivity of 0.74 and specificity of 0.45. The calculated AUC was 0.60. The MAGE questionnaire, which was completed by patients at an outpatient visit to screen for common geriatric issues, could also be used to assess risk for ED visits and hospitalization within 1 year.

P385: Predictors of dehydration in older people living in UK residential care

Introduction Dehydration is common in frail older people and associated with increased mortality, disability and morbidity. We explored factors associated with dehydration in older people living in residential care. Methods DRIE (Dehydration Recognition In our Elders, http://driestudy.appspot.com/) recruited people aged ≥65 years living in UK residential care without cardiac or renal failure. Blood samples were taken, serum osmolality >300mOsm/kg defined dehydration. Assessments included Mini-Mental State Exam (MMSE), sitting and standing blood pressure (BP) and nutritional status. Staff were asked about functional status (Barthel Index), chronic illness, health-professional contacts, continence, dementia stage and medications. We used univariate logistic regression to determine factors associated with dehydration, then multivariate stepwise backwards logistic regression, including statistically significant univariate factors, removing factors with the highest p-value one by one until all remaining factors were statistically significant. Results Analyses included 188 participants (66% women, mean age 85.7 years, range 65-105, mean MMSE 21 range 0-30, 31% needed consultee consent, 20% dehydrated). In univariate analyses a wide range of factors predicted dehydration. In the multivariate model, adjusting for age and all other factors at once, moderate or severe dementia, using diabetic medication, swollen feet, poor renal function, higher numbers of prescription medications and health professional contacts, and lower standing blood pressure were all associated with greater odds of dehydration (Table). Conclusions A range of diverse factors are moderate predictors of dehydration in care home residents, including markers of cognitive and physical frailty. We need to find ways of identifying individuals becoming dehydrated.

Triglycerides as a biological marker of repeated re-hospitalization resulting from deliberate self-harm in acute psychiatry patients: a prospective observational study

BackgroundBiological factors have been associated with deliberate self-harm (DSH) but have not been integrated with clinical factors in routine risk assessments.This study aimed to examine the incremental validity of lipid levels and platelet serotonin when combined with psychosocial factors in risk assessments for repeated admissions due to DSH.MethodsIn this prospective observational study of 196 acutely admitted patients, results of blood tests performed upon admission and the MINI Suicidal Scale and psychosocial DSH risk factor assessments performed at discharge were compared with the incidence of DSH recorded during the first 3 and 12 months after discharge.ResultsHigh triglyceride levels were found to be a significant marker for patients admitted 3 or more times due to DSH (repeated DSH, DSH-R) when tested against other significant risk factors. When all (9) significant univariate factors associated with 12-month post-discharge DSH-R were analyzed in a multivariate logistic regression, the MINI Suicidal Scale (p = 0.043), a lack of insight (p = 0.040), and triglyceride level (p = 0.020) remained significant. The estimated 12-month area under the curve of the receiver operator characteristic (ROC-AUC) for DSH-R was 0.74 for triglycerides, 0.81 for the MINI, 0.89 for the MINI + psychosocial factors, and 0.91 for the MINI + psychosocial factors + triglycerides. The applied multifaceted approach also significantly discriminated between 12-month post-discharge DSH-R patients and other DSH patients, and a lack of insight (p = 0.047) and triglycerides (p = 0.046) remained significant for DSH-R patients in a multivariate analysis in which other DSH patients served as the reference group (rather than non-DSH patients).ConclusionThe triglyceride values provided incremental validity to the MINI Suicidal Scale and psychosocial risk factors in the assessment of the risk of repeated DSH. Therefore, a bio-psychosocial approach appears promising, but further research is necessary to refine and validate this method.

Assessment of sarcopenia and changes in body composition after neoadjuvant chemotherapy and associations with clinical outcomes in oesophageal cancer

Sarcopenia and changes in body composition following neoadjuvant chemotherapy (NAC) may affect clinical outcome. We assessed the associations between CT body composition changes following NAC and outcomes in oesophageal cancer. A total of 35 patients who received NAC followed by oesophagectomy, and underwent CT assessment pre- and post-NAC were included. Fat mass (FM), fat-free mass (FFM), subcutaneous fat to muscle ratio (FMR) and visceral to subcutaneous adipose tissue ratio (VA/SA) were derived from CT. Changes in FM, FFM, FMR, VA/SA and sarcopenia were correlated to chemotherapy dose reductions, postoperative complications, length of hospital stay (LOS), circumferential resection margin (CRM), pathological chemotherapy response, disease-free survival (DFS) and overall survival (OS). Nine (26 %) patients were sarcopenic before NAC and this increased to 15 (43 %) after NAC. Average weight loss was 3.7 % ± 6.4 (SD) in comparison to FM index (-1.2 ± 4.2), FFM index (-4.6 ± 6.8), FMR (-1.2 ± 24.3) and VA/SA (-62.3 ± 12.7). Changes in FM index (p = 0.022), FMR (p = 0.028), VA/SA (p = 0.024) and weight (p = 0.007) were significant univariable factors for CRM status. There was no significant association between changes in body composition and survival. Loss of FM, differential loss of VA/SA and skeletal muscle were associated with risk of CRM positivity. • Changes in CT body composition occur after neoadjuvant chemotherapy in oesophageal cancer. • Sarcopenia was more prevalent after neoadjuvant chemotherapy. • Fat mass, fat-free mass and weight decreased after neoadjuvant chemotherapy. • Changes in body composition were associated with CRM positivity. • Changes in body composition did not affect perioperative complications and survival.

Survival outcomes of schirrhus gastric cancer treated by multidisciplinary treatments: Putative impact on prognosis by DCS NAC.

128 Background: Among gastric cancer, schirrhus exhibited the poorest prognosis, and many patients die even after curative resection due to recurrence. Although progress of multidisciplinary treatments of advanced gastric cancer is outstanding, recent clinical outcome is obscure by such intensive treatments. Methods: Among the 5,664 gastric cancer patients who underwent gastrectomy between 1971 and 2013 in the Kitasato University Hospital, 287 of shirrhus gastric cancer were included (5%). We divided the total periods into early (1971-2004) and late period (2005-2013), and compared their prognosis. Multivariate proportional hazard model was applied to the significant univariate prognostic factors (p&lt;0.05), and identified independent prognostic factors (IPFs). Finally we compared the IPFs in terms of periods, and discuss the most appropriate treatments. Results: (1) Five-year survival rate was 13% and 31% in the early and late periods, respectively (p=0.0010). Between the periods, there were significant differences of pT (p=0.013), CY (p&lt;0.0001), and Margin status (p=0.041). (2) Univariate prognostic factors were age (p=0.032), pT (p=0.0009), pN (p&lt;0.0001), P (p=0.0033), CY (p=0.0002), and Margin status (p&lt;0.0001). Multivariate proportional hazard model elucidated IPFs of pN (pN0-2 vs pN3a-X, p&lt;0.0001) and Margin status (positive vs negative, p=0.0003). If the 2 factors were combined, patients with pN0-2 plus margin negative showed much better survival (about 40% of 5-year OS) than otherwise cases (below 10%)(p&lt;0.0001). (3) Comparison of the IPFs between early and late periods, margin positive cases were significantly less infrequent in the late period. This may be aggressive application of neoadjuvant chemotherapy of DCS (Docetaxel/CDDP/S1). Conclusions: Due to recent progress of multidisciplinary treatments of preoperative aggressive chemotherapy and surgery with curative intent for negative margin for schirrhus gastric cancer, its 5-year survival was dramatically improved. pN0-2 patients were promising for reasonable prognosis if negative margin is secured, so intraoperative diagnosis must be urgently developed.

O08.2 Use and Effectiveness of an Online Partner Notification Tool For STI, Called Suggest-A-Test

BackgroundPartner notification (PN) is crucial for STI control. We developed SuggestATest.nl (SAT), an internet-based notification system for verified diagnoses of STI/HIV, that uses an index-chosen method per partner (email, text...

Descemet Membrane Detachment After Phacoemulsification Surgery

To evaluate the efficacy of air bubble (AB) tamponade for Descemet membrane detachment (DMD) after clear corneal incision phacoemulsification surgery and to evaluate the risk factors for DMD. This is a retrospective analysis of patients with DMD managed with AB tamponade, within 42 postoperative days (PODs), over a 4-year period. Data collected were as follows: demographics, cataract density (Lens Opacities Classification System III), visual acuity, AB technique, clinical outcome, and total surgeries over the time period. Successful end points were DM reattachment and corneal clarity. Risk factors were assessed using a case-control study, with univariate and multivariate logistic regression analyses (significance at P < 0.05). Incidence rate of DMD was 0.044% per year. Sixteen patients (mean age of 76 years) had AB tamponade for DMD, with corneal clarity restored in 14 cases (87.5%; n = 11 with 1 AB procedure, n = 3 with 2 AB procedures). The main clear corneal incision was the major site of DMD (n = 14, 87.5%). Pre-AB visual acuity was 20/100 and at 1 month, 20/40. Corneal clarity occurred by 30 days (range: 4-82 days) and remained clear throughout the median follow-up of 12.9 months. Significant univariate factors were as follows: age >65 years, nuclear sclerosis grade ≥4 (Lens Opacities Classification System III), preexisting endothelial disease, and first POD corneal edema. Multivariate logistic regression analyses revealed endothelial disease (odds ratio = 18.66) and first POD edema (odds ratio = 7.88) as significant independent risk factors for DMD occurrence (P < 0.05). AB tamponade for DMD effectively restored corneal clarity in 87.5% of cases (14 of 16 eyes). Significant risk factors included endothelial disease and first POD corneal edema.

Value of N-terminal pro-brain natriuretic peptide on evaluating heart failure in neonates with respiratory distress syndrome

Objective To explore the value of plasma N-terminal pro-brain natriuretic peptide(NT-proBNP) in diagnosing or excluding concurrent heart failure (HF) in neonates with respiratory distress syndrome (RDS). Methods One hundred and fifteen preterm infants with RDS, admitted to Neonatal Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University from Jan.2011 to Oct.2012, were classified into 2 groups: HF group (56 cases) and non-HF group (59 cases). Differences in cardiac biomarkers and parameters of ultrasonic cardiogram for cardiac function between the 2 groups were analyzed within 24 hours after birth through univariate factors.To evaluate independent factors for HF, logistic regression analysis was performed including significant univariate factors.Receiver operator characteristic curve (ROC) was used to determine the best cutoff for diagnosis of HF with sensitivity and specificity of more than 90%. Results The level of plasma troponin and CK-MB showed no significant difference between the 2 groups(all P>0.05). Compared with the non-HF group, the incidence of patent ductus arteriosus, patent foramen ovale and pulmonary hypertension, as well as plasma NT-proBNP level and pulmonary artery pressure were significantly higher in the HF group(all P<0.05). In contrast, left ventricular ejection fraction and E/A ratio were significantly lower in the HF group(all P<0.05). Logistic regression analysis, which was performed using the 7 significant univariate factors, showed that only plasma NT-proBNP was the independent factor for evaluating HF(OR=1.359, P=0.000). The area under ROC for NT-proBNP levels for diagnosis of HF in RDS neonates was 0.997 (95% CI 0.962-1.000, P=0.000). A cutoff value of at least 16 379 ng/L had a sensitivity of 91.1% and specificity of 98.3%.All the 8 neonates who died had a plasma NT-proBNP level of 35 000 ng/L in 24 hours after birth, significantly higher than that in survival neonates(P=0.000). Conclusions Plasma NT-proBNP level proved to have the value for independently determining or excluding HF in RDS neonates, and dynamic observation for NT-proBNP level may be used for early prediction of mortality risk in neonates with HF. Key words: Respiratory distress syndrome; N-terminal pro-brain natriuretic peptide; Heart failure; Diagnosis