Preexisting anticoagulation is an independent predictor of mortality in geriatric trauma patients - a retrospective cohort study.

Introduction: Preexisting anticoagulation is common among geriatric trauma patients. Geriatric trauma patients have a higher risk of mortality compared to younger patients. We sought to evaluate the association of preexisting anticoagulation with mortality in a group of geriatric trauma patients. Methods: A retrospective review of geriatric trauma patients was conducted for those admitted to a Level 1 trauma center from January 2018 to December 2020. Vital signs, demographics, injury characteristics, laboratory data, and mortality were all collected. Multivariable logistic regression analysis was performed for the association of preexisting anticoagulation and a primary endpoint of all-cause mortality. These groups were controlled for preexisting comorbidities, injury severity scores, and systolic blood pressure in the emergency department. Results: Four thousand four hundred thirty-two geriatric patients were admitted during the study period. This cohort was made up of 36.9% men and 63.1% women. Three thousand eight hundred fifty-nine (87.2%) were white; the average age was 81±8.5 years, and the median injury severity score (ISS) was 5. The mean systolic blood pressure was 150±32 mmHg, mean heart rate was 81±16 bpm, mean lactate was 2.3±1.3, mean hematocrit was 37.3±8.8, and mean international normalized ratio (INR) was 1.7±10.3. One thousand five hundred ninety-two (35.9%) patients were on anticoagulation (AC) upon presentation. One hundred and sixty-five (3.7%) mortalities were recorded. Multivariable logistic regression analysis results show that preexisting anticoagulation [ odds ratio (OR) 1.92, 95% CI 1.36-2.72] was independently predictive of death. The analysis was adjusted for systolic BP in the emergency department less than90 mmHg (OR 5.55, 95% CI 2.83-10.9), having more than 1 comorbidity (OR 2.30, 95% CI 1.57-3.38) and ISS (OR 1.13, 95% CI 1.10-1.15). Conclusion: Our study indicates that preexisting anticoagulation is associated with mortality among geriatric trauma patients.

Intraoperative parathormone monitoring to predict operative success in patients with normohormonal hyperparathyroidism.

BACKGROUND: It is unclear whether parathyroidectomy guided by intraoperative parathormone (PTH) monitoring is predictive of operative success in patients with normohormonal hyperparathyroidism (nhHPT), a variant of primary hyperparathyroidism (pHPT) in which patients develop clinical manifestations similar to those of pHPT. This study examined intraoperative PTH monitoring in patients undergoing parathyroidectomy for nhHPT. METHODS: We performed a retrospective review of prospectively collected data from adult (age > 18 yr) patients who underwent parathyroidectomy for pHPT at 1 of 2 North American medical centres (in Calgary, Alberta, Canada, or Miami, Florida, United States) between 2007 and 2015. In patients with nhHPT, we used the criterion of an intraoperative decrease of more than 50% in PTH after abnormal gland excision. We defined operative success as continuous eucalcemia more than 6 months after parathyroidectomy. RESULTS: Of 333 patients, 38 (11.4%) had nhHPT, with mean preoperative calcium and PTH levels of 2.7 mmol/L and 53 pg/dL, respectively. An intraoperative decrease of more than 50% in PTH level was seen in 27 patients (71.0%) with nhHPT and 265 patients (89.8%) with classic pHPT at 5 minutes (p < 0.001); the corresponding values at 20 minutes were 35 (92.1%) and 286 (96.9%). Although 5 patients (13.2%) with nhHPT did not reach this criterion until 20 minutes, the rate of operative success was still 97.0% at long-term follow-up (mean 13 mo, range 6-67 mo). Of the 38 patients, 3 (7.9%) did not have an intraoperative decrease of more than 50% in PTH level by 20 minutes. Two of the 3 achieved operative success and remained normocalemic, and 1 developed recurrent disease at 12 months. CONCLUSION: Parathyroidectomy guided by intraoperative PTH monitoring accurately predicted operative success in patients with nhHPT. Intraoperative PTH monitoring may also help identify multiglandular disease in patients with nhHPT, using criteria similar to those in classic pHPT, with comparable operative success.

Combined modality therapy including cytoreductive surgery and heated intraperitoneal chemotherapy for synchronous low volume peritoneal carcinomatosis from adenocarcinoma of the tail of pancreas in a BRCA-2 carrier resulting in long-term disease-free survival: A case report.

INTRODUCTION: A BRCA-2 mutation carrier with a metachronous pancreatic adenocarcinoma (PC) and established peritoneal metastases is presented. Combined modality therapy including Cytoreductive Surgery (CS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) was associated with long-term disease-free survival. CASE PRESENTATION: A 62-yr. old female underwent successful treatment for stage IIIa carcinoma of the right breast at age 48. 11 years later a cystic adenocarcinoma of the tail of the pancreas with peritoneal metastases was diagnosed. Platin based neoadjuvant chemotherapy followed by definitive resection of the pancreatic mass with cytoreductive surgery (CS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) with mitomycin C was performed. Postoperatively, a retro-gastric fluid collection developed from a pancreatic duct leak, successfully managed non-operatively. Maintenance poly ADP ribose polymerase (PARP) inhibitor therapy was initiated after recovery from surgery. The patient experienced a 30-month disease free survival and was subsequently found to have oligometastases to the brain. DISCUSSION: CR and HIPEC have not been reported to be efficacious in patients with pancreatic carcinomatosis. However, PC arising in BRCA-2 carriers has a DNA repair defect, which is sensitive to platin based chemotherapy and mitomycin C. HIPEC has more severe postoperative complications following distal pancreatectomy. Isolated brain metastases from PC are rare. BRCA-2 mutation carriers are at significantly increased risk for PC. CONCLUSION: Leveraging the DNA Repair defect in BRCA-2 pancreatic adenocarcinoma, including CS and HIPEC, led to long-term disease-free survival and good locoregional control in this patient. Complications from HIPEC are more severe. BRCA-2 carriers should undergo annual pancreatic cancer screening.

The Usefulness of the Pretreatment Neutrophil/Lymphocyte Ratio as a Predictor of the 5-Year Survival in Stage 1-3 Triple Negative Breast Cancer Patients.

BACKGROUND: We have previously shown that the neutrophil/lymphocyte ratio (NLR) is a predictor of survival among breast cancer patients. The aim of this study was to determine the predictive value of NLR among different nodal and chemotherapy subgroups of triple negative breast cancer (TNBC). METHODS: Patients with stage 1-3 TNBC who underwent treatment from 2007 to 2014 and had blood counts prior to treatments were included. Patients were categorized into high (≥2) and low (<2) NLR groups. Primary outcomes were overall survival (OS) and disease-free survival (DFS). RESULTS: The average follow-up time was 54 months. The high NLR group had worse OS (HR 2.8, CI 1.3-5.9, p < 0.001) and DFS (HR 2.3, CI 1.2-4.2, p < 0.001) than the low NLR group. After adjusting for confounding variables, high NLR was an independent prognostic factor for both OS (HR 5.5, CI 2.2-13.7, p < 0.0001) and DFS (HR 5.2, CI 2.3-11.6, p < 0.0001). Categorization of TNBC patients by NLR (high vs. low) and nodal status (positive vs. negative) resulted in four groups with significantly different OS and DFS (log rank p < 0.0001). Significant improvements in OS (p < 0.001) and DFS (p < 0.001) were observed for patients who received chemotherapy and had high NLR but not for patients with low NLR (p = 0.65 and p = 0.07, respectively). CONCLUSION: High pretreatment NLR is an independent predictor of poor OS and DFS among TNBC patients. Combining NLR and pN provides better risk stratification for TNBC patients. Chemotherapy appears to be beneficial only in patients with high NLR. Larger prospective studies are needed to validate these findings.

The Impact of Prolonged Chemotherapy to Surgery Interval and Neoadjuvant Radiotherapy on Pathological Complete Response and Overall Survival in Pancreatic Cancer Patients.

BACKGROUND: We aimed to study the impact of neoadjuvant chemotherapy to surgery (NCT-S) interval and neoadjuvant radiotherapy (NRT) on pathological complete response (pCR) and overall survival (OS) in pancreatic cancer (pancreatic ductal adenocarcinoma [PDAC]). METHODS: National Cancer Data Base (NCDB)-pancreatectomy patients who underwent NCT/NRT were included. The NCT-S interval was divided into time quintiles in weeks: 8 to 11, 12 to 14, 15 to 19, 20 to 29, and >29 weeks. RESULTS: A total of 2093 patients with NCT were included with median follow-up of 74 months and 71% NRT. The pCR rate was 2.1% with higher median OS compared with non-pCR (41 vs 19 months, P = .03). The pCR rate increased with longer NCT-S interval (quintiles: 1%, 1.6%, 1.7%, 3%, and 6%, P < .001, respectively). In logistic regression, NRT (odds ratio [OR] = 2.5, 95% confidence interval [CI]: 1.1-6.1, P = .03) and NCT-S >29 weeks (OR = 6.1, 95% CI = 2.02-18.50, P < .001) were predictive of increased pCR. The prolonged NCT-S interval and pCR were independent predictors of OS, whereas NRT was not. CONCLUSIONS: Longer NCT-S interval and pCR were independent predictors of improved OS in patients with PDAC. The NRT predicted increased pCR but not OS.

Utility of Radiation After Neoadjuvant Chemotherapy for Surgically Resectable Esophageal Cancer.

INTRODUCTION: Neoadjuvant chemotherapy (NAC) ± radiation (NRT) is the "gold standard" approach for locally advanced esophageal cancer (EC). However, the benefits of RT on overall survival (OS) in patients with resectable EC undergoing neoadjuvant therapy followed by esophagectomy remain controversial. METHODS: The National Cancer Data Base was queried for patients with nonmetastatic EC between 2004 and 2014. Kaplan-Meier, log-rank, and Cox multivariable regression analysis were performed to analyze OS. Logistic regression analyzed factors associated with 90-day mortality, lymph node involvement, and complete pathological response (pCR). RESULTS: A total of 12,238 EC patients who underwent neoadjuvant therapy [neoadjuvant chemoradiation (NACR), 92.1% and NAC, 7.9%] followed by esophagectomy were included. OS was similar in patients undergoing NAC ± RT (35.9 vs. 37.6 mo, respectively, p = 0.393). pCR rate was 18.1% (19.2%, NACR vs. 6.3%, NAC, p < 0.001). NRT was an independent predictor for increased pCR (HR 2.593, p < 0.001). Patients with pCR had increased survival compared with those without pCR (62.3 vs. 34.4 mo, p < 0.001); however, no difference was found between NACR and NAC (61.7 mo vs. median not reached, p = 0.745) in pCR patients. In non-pCR patients, NAC had improved OS compared with NACR (37.3 vs. 30.8 mo, p = 0.002). NRT was associated with worse 90-day mortality (8.2% vs. 7.7%, HR1.872, p = 0.036) In Cox regression, NRT was an independent predictor of worse OS (HR 1.561, p < 0.001). CONCLUSIONS: Neoadjuvant RT is associated with improved pCR rates; however, it had deleterious effects in short- and long-term survival. Also, patients who did not achieve pCR had worse OS after neoadjuvant RT.

The Role of Completion Lymphadenectomy in Positive Regional Lymph Nodes in Melanoma: A Meta-analysis.

BACKGROUND: The optimal management of melanoma with positive sentinel lymph node (SLN) remains unclear. Completion lymph node dissection (CLND) only yields additional positive non-SLN in 20% of cases and its benefits on survival remains debatable. METHODS: An online database search of Medline was performed; key bibliographies were reviewed. Studies comparing outcomes after CLND versus observation were included. Odds ratios (ORs) with the corresponding 95% confidence intervals (CIs) by random fixed effects models of pooled data were calculated. The primary endpoints were disease-free survival (DFS), melanoma-specific survival (MSS), and overall survival (OS). RESULTS: Search strategy yielded 117 publications. Twelve studies were selected for inclusion, comprising 7966 SLN-positive patients. Among these patients, 5306 (66.6%) subjects underwent CLND and 2660 (33.4%) patients were observed. Median Breslow thickness and ulceration were similar between groups (2.8 ± 0.6 mm versus 2.5 ± 0.8 mm, P = 0.721; and 38.8% versus 37.2%, P = 0.136, CLND versus observation, respectively). CLND was associated with statistically significant improved 3-y (71.0% versus 66.2%, OR 0.82, 95% CI 0.69-0.97, P = 0.02) and 5-y DFS (48.3% versus 47.8%, OR 0.75, 95% CI 0.59-0.96, P = 0.02) compared with observation. However, no difference was demonstrated in 3-y MSS (83.7% versus 84.7%, OR 1.09, 95% CI 0.88-1.35, P = 0.41), 5-y MSS (68.4% versus 69.8%, OR 1.02, 95% CI 0.88-1.19, P = 0.78), or OS (68.2% versus 78.9%, OR 0.93, 95% CI 0.55-1.57, P = 0.78). CONCLUSIONS: Based on this large-scale analysis, CLND improved both 3- and 5-y DFS, possibly because of increased rates of local control; however, this did not translate in improved MSS or OS. Efforts toward the identification of molecular markers associated with poor outcomes in SLN-positive patients who undergo observation are warranted.

Impact of Chemoradiation-to-Surgery Interval on Pathological Complete Response and Short- and Long-Term Overall Survival in Esophageal Cancer Patients.

BACKGROUND: The impact of the neoadjuvant chemoradiation-to-surgery (CRT-S) interval in patients with esophageal cancer is not clear. We aimed to determine the relationship between CRT-S interval and pathological complete response rate (pCR) and overall survival (OS). METHODS: National Cancer Data Base patients with CRT followed by surgery were studied. CRT-S interval was studied as a continuous (weeks) and categorical variable (quintiles: 15-37, 38-45, 46-53, 54-64, and 65-90 days, with n = 1016, 1063, 1081, 1083, and 938 patients, respectively). RESULTS: A total of 5181 patients were included; 81% had adenocarcinoma. There was a significant increase of pCR rate across quintiles (18%, 21%, 24%, 25%, and 29%, p < 0.001) and per week increase of CRT-S interval [odds ratio (OR) 1.11, p < 0.001]. The 90-day mortality increased as CRT-S increased across quintiles (5.7%, 6.2%, 6.8%, 8.5%, and 8.2%, p = 0.02) and through weeks (OR 1.05, p = 0.03). Mean OS across CRT-S quintiles was 36.4, 35.1, 33.9, 33.2, and 30.7 months, respectively. Multivariate Cox regression showed significantly worse OS per week increase in CRT-S interval [hazard ratio (HR) 1.02, p = 0.02], especially among the last quintile (CRT-S = 65-90 days: HR 1.2, p = 0.009). The squamous cell carcinoma (SCC) and pCR groups had similar OS across CTR-S intervals. CONCLUSIONS: Despite the higher pCR rate with longer CRT-S interval, surgery is optimal less than 65 days after CRT to avoid worse 90-day mortality and achieve better OS. In patients with SCC and those with pCR, prolonged CRT-S interval had no impact on OS. Further studies are needed to consolidate our findings.

A large national comparative study of clinicopathological features and long-term survivals between esophageal gastrointestinal stromal tumor and leiomyosarcoma.

BACKGROUND: Esophageal gastrointestinal stromal tumors (E-GIST) and leiomyosarcoma (E-LMS) are rare tumors. Previous studies are limited to small number of patients. We sought to study these two tumors using a large national database. METHODS: The National Cancer Data Base 2004-2014 was queried for patients with E-GIST and E-LMS. The primary outcome was overall survival (OS). Univariate and multivariable Cox regression models were used to investigate OS predictors. RESULTS: We found 141 E-GIST and 38 E-LMS patients, with esophagectomy and systemic treatment rate of 55% and 49% for E-GIST and 50% and 26% for E-LMS. The 5-year OS of E-GIST and E-LMS were 62% and 23%, respectively, p < 0.001. In multivariable analysis, young age, tumor <10 cm, esophagectomy, and E-GIST were associated with superior OS. There was a higher median and mean OS with neoadjuvant vs. upfront surgery for E-GIST group (98 and 111 vs 79 and 80 months). CONCLUSION: E E-GIST has superior OS compared to E-LMS. Esophagectomy is the cornerstone treatment modality. Further studies are needed to evaluate the role of neoadjuvant therapy in E-GIST patients.

Giant symptomatic gastric lipoma: A case report and literature review.

INTRODUCTION: Lipomas are uncommon tumors of the gastrointestinal tract; gastric lipomas account for <1% of all gastric tumors encountered (Nickloes and Sutphin [1]). Giant gastric lipomas, defined as ≥10 cm, are exceedingly rare with only 6 cases reported since 1980 (Cappell et al., Termos et al., Singh et al., Ramaraj et al., Rao et al., Priyadarshi et al., Neto et al. [3-9]). We hereby present a case of a giant gastric lipoma that became symptomatic seven years after its initial identification and was excised preserving gastric continuity. CASE PRESENTATION: Our patient is a 58-year-old African American male with a 3 cm gastric mass incidentally found on CT in 2010. In September of 2017, the patient presented with severe epigastric pain, nausea, and vomiting. Abdominal CT scan revealed an increase in size of the patient's gastric lesion to 7.2 × 10.3 × 7.3 cm. He underwent an exploratory laparotomy with transverse anterior gastrotomy and primary closure. Pathologic examination revealed a 12 cm submucosal, well-circumscribed, non-encapsulated mass comprised of mature adipose tissue without atypia or mitotic figures, consistent with lipoma. DISCUSSION: The majority of gastric lipomas are asymptomatic, identified on CT scan as round/ovoid masses with low attenuation and homogenous appearance, measuring -80 to -120 Hounsfield units. These findings are nearly pathognomonic. Due to the benign nature of gastric lipomas, circumferential excision with a clear margin of normal tissue is adequate for symptomatic resection. This is the second report of giant gastric lipoma excised with continuity preserving partial gastrectomy, avoiding gastrojejunostomy complications. CONCLUSION: Fatty tumors are rare in the gastrointestinal tract, yet lipomas must be on the differential when masses are found with Hounsfield units similar to peripheral fat.

Evolution of Minimally Invasive Coronary Artery Bypass Grafting: Learning Curve.

OBJECTIVE: Minimally invasive coronary surgery approach for coronary artery bypass grafting is a safe and reproducible procedure for multivessel revascularization. This study reviewed a single surgeon's experience with minimally invasive coronary surgery coronary artery bypass grafting, including operative time, number of bypasses, and conversion to sternotomy. METHODS: A prospective database of consecutive minimally invasive coronary surgery coronary artery bypass grafting procedures from 2005 to 2013 was reviewed. A small anterolateral left thoracotomy allowed left internal mammary artery harvest, proximal anastomoses on the ascending aorta, and distal coronary anastomoses. Early cases were compared with the later cases, focusing on grafting strategies that led to a standardized approach with Propensity Score Matching analysis. RESULTS: Seven hundred consecutive cases were divided into early (1-200) and late (201-700) groups. In the late group, the number of triple-vessel disease patients trended higher (50% vs. 57%, P = 0.0674) and the number of bypasses increased (2.3 ± 0.8 vs. 2.7 ± 1.0, P < 0.0001). Conversion to sternotomy significantly decreased between the groups (6% vs. 0.6%, P < 0.0001). There was no difference in rate of postoperative complications between the groups except for prolonged intubation (10% vs. 5%, P = 0.0236) and shortened length of stay (5.9 ± 6.7 vs. 5.5 ± 6.0, P = 0.0268). Propensity score matching analysis (n = 177) was significant for total bypass performed and time per bypass (P < 0.05). The late group was further divided into subgroups of one hundred each (subgroup 1 through 5). Operative times differed significantly (subgroup 1: 249 ± 71.2, subgroup 2: 259 ± 85.8, subgroup 3: 244 ± 71.0, subgroup 4: 270 ± 58.4, and subgroup 5: 246 ± 47.9, P < 0.005). CONCLUSIONS: As experience with minimally invasive coronary surgery coronary artery bypass grafting increased, the ideal sequence of steps to optimize surgical outcome was defined. The number of bypassed vessels increased and the operative time and conversion to sternotomy decreased.

Low-grade appendiceal mucinous neoplasm and endometriosis of the appendix.

BACKGROUND: A distended, mucous-filled appendix is known as an appendiceal mucocele. They are a rare form of an appendiceal mass and develop from both benign and malignant processes. Mucoceles can develop secondarily to an obstruction, such as from a fecalith, scarring or, rarely, endometriosis. Only 12 cases of non-neoplastic appendiceal mucoceles caused by endometriosis have been previously described. The association between neoplastic appendiceal mucoceles in the presence of endometriosis is described for the first time in this report. CASE PRESENTATION: A 57-year-old woman presented with a chief complaint of worsening abdominal pain over the past 3 months. Imaging studies revealed an appendiceal mass. Laparoscopic evaluation confirmed an appendiceal mucocele, and the patient underwent complete appendectomy. No evidence of mucinous or endometrial deposits were present within the abdominal cavity. Pathological diagnosis revealed low-grade appendiceal mucinous neoplasm (LAMN) with evidence of endometriosis within the muscularis propria of the appendix. The patient recovered without complications and her abdominal pain completely resolved. CONCLUSIONS: Endometriosis of the appendix is a rare manifestation and is most often identified as an incidental finding. Endometriosis leading to an obstructive mucocele of the appendix is an exceedingly rare finding, having only been described 12 times in the medical literature. LAMN in the presence of endometriosis of the appendix is described for the first time in this report. The association between appendiceal neoplasms in the presence of endometriosis requires further research in order to optimize operative treatment.

Large, extra-abdominal leiomyoma of the round ligament with carneous degeneration.

Round ligament tumours represent a rare entity that can present similarly to an incarcerated hernia. Basic understanding and appropriate preoperative management is imperative in order to differentiate between the two diagnoses. Leiomyoma is the most common type of round ligament tumour. It is associated with oestrogen exposure and is more common in the presence of uterine leiomyomas. Here we discuss a 68-year-old woman who presented with a palpable left inguinal mass that progressively grew in size, associated with pelvic pressure and discomfort. On surgical resection, the mass was found to be derived from the round ligament at the entrance of the external inguinal ring. Pathology confirmed a round ligament leiomyoma, measuring 25×9×8.5 cm. This case is the largest round ligament leiomyoma recorded to date and the first to exhibit carneous degeneration. A review of the current literature is also provided.

CT scan incidental findings in trauma patients: does it impact hospital length of stay?

BACKGROUND: CT scans are heavily relied on for assessment of solid organ injuries complementing clinical examination. These CT scans could also reveal pathologies not related to trauma called incidental findings. We aimed to evaluate the frequency of these findings and their outcome on hospital services. METHODS: A retrospective chart review of prospectively collected data of the emergency department's trauma database from January 2005 to December 2011 to evaluate incidental findings on CT scans on trauma admissions. These incidental findings were divided into three classes: class 1-minor degenerative, non-degenerative, normal variants or congenital finding that does not require further investigation or workup; class 2-findings not requiring urgent intervention with scheduled outpatient follow-up and class 3-all findings that require urgent evaluation/further investigation during the same hospital admission. One-year follow-up was done to review hospital length of stay, trauma clinic follow-up and post-trauma surgery. RESULTS: Of 1000 charts reviewed, 957 were selected after 43 patients were excluded due to incomplete documentation. Of the 957 patients, 385 (40%) were found to have incidental findings. A total of 560 incidental findings were found on the CT scan reports with one-third of patients having multiple findings (144 patients, 37.4%). The largest number of incidental findings were in class 2. The incidental group had significantly longer length of stay after adjusted multivariate analysis (8.7±0.48 vs 6.7±0.55, p=0.005). CONCLUSION: The incidental findings are commonly found during CT imaging in trauma centers and our rate was 40%. Appropriate documentation, communication and follow-up of those findings is necessary. A classification system for these findings practiced nationwide will aid in categorizing the urgency of continued follow-up. This also will help decrease the length of hospital stay and healthcare cost. LEVEL OF EVIDENCE: Level 4.

Long-term Outcome after Percutaneous Coronary Intervention Compared with Minimally Invasive Coronary Artery Bypass Surgery in the Elderly.

BACKGROUND: Elderly patients with unstable coronary artery disease (CAD) have better outcomes with coronary revascularization than conservative treatment. With the improvement in percutaneous coronary intervention (PCI) techniques using drug eluting-stents, this became an attractive option in elderly. Minimally invasive coronary artery bypass grafting (MICS-CABG) is a safe and effective alternative to conventional CABG. We aimed to explore the long-term outcomes after PCI vs MICS-CABG in ≥75 year-old patients with severe CAD. METHODS: A total of 1454 elderly patients (≥75 year-old patients) underwent coronary artery revascularization between January 2005 and December 2009. Patients were selected in the study if they have one of the Class-I indications for CABG. Groups were divided according to the type of procedure, PCI or MICS-CABG, and 5 year follow-up. RESULTS: Among 175 elderly patients, 109 underwent PCI and 66 had MICS-CABG. There was no significant difference observed in both groups with long-term all-cause mortality (31 PCI vs 21% MICS-CABG, p=0.151) and the overall 5 year survival was similar on Kaplan-Meier curve (Log rank p=0.318). The average length of stay in hospital was significantly shorter in the PCI than in the MICS-CABG group (4.3 vs 7.8 days, p<0.001). Only 4.7% of the PCI group were discharged to rehabilitation facility compared with 43.9% of the MICS-CABG group (p<0.001). The rate of repeat revascularization was significantly higher in the PCI group than in the MICS-CABG group (15 vs 3%, p=0.014). CONCLUSION: Among elderly patients, long-term all-cause mortality is similar after PCI and MICS-CABG. However, there is a significantly higher rate of repeat revascularization after PCI.

Hypoalbuminemia in colorectal cancer prognosis: Nutritional marker or inflammatory surrogate?

Albumin is the single most abundant protein in the human serum. Its roles in physiology and pathology are diverse. Serum albumin levels have been classically thought to reflect the nutritional status of patients. This concept has been challenged in the last two decades as multiple factors, such as inflammation, appeared to affect albumin levels independent of nutrition. In general, cancer patients have a high prevalence of hypoalbuminemia. As such, the role of hypoalbuminemia in patients with colorectal cancer has received significant interest. We reviewed the English literature on the prognostic value of pretreatment albumin levels in colorectal cancer. We also consolidated the evidence that led to the current understanding of hypoalbuminemia as an inflammatory marker rather than as a nutritional one among patients with colorectal cancer.

Long-term mortality in minimally invasive compared with sternotomy coronary artery bypass surgery in the geriatric population (75 years and older patients).

OBJECTIVES: Ischaemic heart disease is the leading cause of death in the elderly population. Coronary artery bypass graft (CABG) surgery via sternotomy remains the standard of care for patients with multivessel coronary artery disease (CAD). Minimally invasive cardiac surgery (MICS)-CABG via left thoracotomy has been used as an alternative to sternotomy. The aim of our study was to assess the overall survival after MICS-CABG and sternotomy-CABG in elderly patients with CAD. METHODS: This observational study included patients who underwent coronary bypass from 2005 to 2008. Patients 75 years and older (n = 159) were included in the final analysis. Each arm was further divided into the MICS-CABG group or sternotomy-CABG group. Primary outcome and overall survival were obtained from our records and the social security death index. RESULTS: Among patients 75 years and older (159 patients), MICS-CABG had a significantly lower 5-year all-cause mortality than sternotomy-CABG (19.7 vs 47.7%, P < 0.001). Similarly, Kaplan-Meier curves showed significantly higher overall survival in the MICS-CABG group compared with sternotomy-CABG (log-rank P = 0.014). After adjusting for confounders, MICS-CABG demonstrated a lower mortality than sternotomy-CABG (HR 0.51, 95% confidence interval 0.26-0.97, P = 0.04). For patients less than 75 years old, MICS and sternotomy groups had similar survival according to both uni- and multivariate analyses. CONCLUSIONS: The adjusted models demonstrated that MICS-CABG has a significantly better long-term survival than sternotomy-CABG despite slightly differing baseline characteristics. Further studies are needed to compare the short- and long-term outcomes of the two approaches among the elderly population.

Average values and racial differences of neutrophil lymphocyte ratio among a nationally representative sample of United States subjects.

INTRODUCTION: Several studies reported the negative impact of elevated neutrophil/lymphocyte ratio (NLR) on outcomes in many surgical and medical conditions. Previous studies used arbitrary NLR cut-off points according to the average of the populations under study. There is no data on the average NLR in the general population. The aim of this study is to explore the average values of NLR and according to race in adult non-institutional United States individuals by using national data. METHODS: The National Health and Nutrition Examination Survey (NHANES) of aggregated cross-sectional data collected from 2007 to 2010 was analyzed; data extracted included markers of systemic inflammation (neutrophil count, lymphocyte count, and NLR), demographic variables and other comorbidities. Subjects who were prescribed steroids, chemotherapy, immunomodulators and antibiotics were excluded. Adjusted linear regression models were used to examine the association between demographic and clinical characteristics and neutrophil counts, lymphocyte counts, and NLR. RESULTS: Overall 9427 subjects are included in this study. The average value of neutrophils is 4.3 k cells/mL, of lymphocytes 2.1k cells/mL; the average NLR is 2.15. Non-Hispanic Black and Hispanic participants have significantly lower mean NLR values (1.76, 95% CI 1.71-1.81 and 2.08, 95% CI 2.04-2.12 respectively) when compared to non-Hispanic Whites (2.24, 95% CI 2.19-2.28-p<0.0001). Subjects who reported diabetes, cardiovascular disease, and smoking had significantly higher NLR than subjects who did not. Racial differences regarding the association of smoking and BMI with NLR were observed. CONCLUSIONS: This study is providing preliminary data on racial disparities in a marker of inflammation, NLR, that has been associated with several chronic diseases outcome, suggesting that different cut-off points should be set according to race. It also suggests that racial differences exist in the inflammatory response to environmental and behavioral risk factors.

The value of the pretreatment neutrophil lymphocyte ratio vs. platelet lymphocyte ratio in predicting the long-term survival in colorectal cancer.

BACKGROUND: The neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) have been well studied as inflammatory markers and predictors for outcomes in colorectal cancer patients. Our aim was to determine the predictive value of both above ratios in colorectal cancer patients. METHODS: This is a longitudinal retrospective study of a prospectively maintained database, included 580 patients, who had a complete blood count recorded before treatment (surgery or chemotherapy). We excluded patients presented with obstruction, infection, active hematological disease or those receiving steroid. The primary outcome (4-year cancer-related mortality) was obtained from our cancer registry. RESULTS: The 4-year cancer-related mortality rate in the 3rd tertile of NLR was 37% in comparison with 13% and 19% in lower tertiles, P value < 0.001. Similarly the 3rd tertile of PLR was 32% with 18% and 19% in lower tertiles, P value < 0.0005. In the multivariate survival analyses, elevated NLR was associated with higher mortality (a hazard ratio of 2.31(1.4-3.8) for the highest tertile and 5% increase in mortality for each unit increase in NLR, p < 0.001). Similarly, elevated NLR was a significant predictor for a worse disease-free survival. However, PLR was not significant predictor of mortality when adjusted for other confounding variables. CONCLUSION: Elevated pretreatment NLR is an independent predictor of both worse overall and disease free survival in colorectal cancer, whereas PLR was not after adjusting for confounding variables.