The efficacy of the American College of Surgeons Surgical Risk Calculator in the prediction of postoperative complications in oncogeriatric patients after curative surgery for abdominal tumors.

BACKGROUND: The American College of Surgeons (ACS) has developed a Surgical Risk Calculator (SRC) to predict postoperative surgical complications. No studies have reported the performance of the ACS-SRC in oncogeriatric patients. Our objective was to evaluate the predictive performance of the ACS-SRC in these patients, treated with curative surgery for an abdominal malignancy. METHODS: This is a retrospective study including 136 patients who underwent elective abdominal oncological surgery, between 2017 and 2019, at our institution. Postoperative complications were classified according to the ACS-SRC, and its predictive performance was analyzed by assessing discrimination and calibration and using receiver operating characteristics and area under the curve (AUC). RESULTS: Discrimination was adequate with AUC of 0.7113 (95% confidence interval [CI]: 1.062-1.202, p = 0.0001; Brier 0.198) for serious complications and 0.7230 (95% CI: 1.101-1.756, p = 0.0057; Brier 0.099) for pneumonia; and poor for sepsis, surgical site infection (SSI), and urinary tract infection (UTI) with AUCs of 0.6636 (95% CI: 1.016-1.353, p = 0.0299; Brier 0.142), 0.6167 (95% CI: 1.003-1.266, p = 0.0450; Brier 0.175), and 0.6598 (95% CI: 1.069-2.145, p = 0.0195; Brier 0.082), respectively. CONCLUSION: The ACS-SRC is an adequate predictor for serious complications and pneumonia in oncogeriatric patients treated surgically for abdominal cancer. However, the predictive power of the calculator appears to be low for sepsis, UTI, and SSI.

Evaluation of the Comprehensive Geriatric Assessment (CGA) tool as a predictor of postoperative complications following major oncological abdominal surgery in geriatric patients.

INTRODUCTION: The concept of frailty extends beyond chronological age. Identifying frailty using a two-step approach, starting with the use of a screening tool (G8) followed by comprehensive geriatric assessment (CGA), may be useful in guiding treatment decisions and follow-up. This study evaluated the association between G8 and CGA, and the risk of 90-day postoperative complications risk, in oncogeriatric patients. METHODS: Data on geriatric patients with major oncological abdominal surgery was retrospectively collected from our hospital records between 2016 and 2019. Patients with an impaired G8 screening score, who subsequently underwent CGA geriatric screening, were included. Postoperative complications were classified using the Clavien-Dindo classification (CD), and the Comprehensive Complication Index (CCI). The association between the individual components of the geriatric assessment tools and the 90-day postoperative complications risk was analyzed. RESULTS: One hundred and twelve patients, aged ≥ 70 years, operated for an intra-abdominal tumor with curative intent, were included. Seventy-six patients (67.9%) presented with an impaired G8, out of whom sixty-six (58.9%) had a CGA performed. On univariate analysis, altered nutritional status assessed by the Mini-Nutritional Assessment-Short Form was the only variable associated with higher postoperative total complication rate (p = 0.01). Patients with an impaired G8 had significantly more postoperative complications and higher 1-year mortality rates than patients with normal G8. Fifteen patients (13.4%) had grade III-IVb complications. A CCI > 50 was recorded in 16 patients (14.3%). All-cause 90-day postoperative mortality was 10.7%. CONCLUSION: Identifying an altered preoperative nutritional status, as part of the CGA, in patients screening positive for frailty, is a potentially modifiable risk factor that can enhance preoperative management and optimize treatment decision making. G8 may be a predictive factor for postoperative complications in oncogeriatric patients.

Prostate Cancer and Reactive Haemophagocytic Lymphohistiocytosis.

We report the case of a 76-year-old man presenting with reactive haemophagocytic lymphohistiocytosis (rHLH) in the setting of disseminated prostate cancer. This often fatal syndrome must be diagnosed early in order to maximize survival. Treatment should be initiated whenever the clinical diagnosis is suspected, even if the HLH-2004 criteria are not met. The HScore is a useful diagnostic tool for rHLH. In case of neurological symptoms, an extensive assessment must be performed. The goal of this case report is to raise awareness of this rare syndrome among oncologists. LEARNING POINTS: The association of prostate cancer and reactive haemophagocytic lymphohistiocytosis (rHLH) has rarely been described.This often fatal syndrome must be recognized early in order to start specific treatment and maximize survival.Specific treatment for rHLH must be accompanied by treatment of the triggering factors.

Sarcoidosis Versus Lymphoma?

An association between lymphoma and sarcoidosis was first suggested in 1960. We report a case of sarcoidosis-lymphoma syndrome, which is a diagnostically challenging condition. We conclude that an associated lymphoma should be considered in all patients with suspected sarcoidosis, especially those who do not respond to treatment or who present with persistent haematological abnormalities. Splenomegaly should prompt splenectomy to rule out lymphoma if a less invasive approach has failed to confirm the diagnosis. LEARNING POINTS: Clinical consideration should be given to an associated lymphoma in all patients with sarcoidosis, especially those who do not respond to treatment or who present with persistent haematological abnormalities.Splenomegaly should raise the possibility of splenectomy to rule out associated lymphoma.

Identifying frailty in clinically fit patients diagnosed with hematological malignancies using a simple clinico-biological screening tool: The HEMA-4 study.

INTRODUCTION: This study aims to develop and validate a simple score to estimate survival in the older population suffering from malignant hemopathies. METHODS: We prospectively recruited 285 patients, aged ≥65 years, admitted to receive chemotherapy. At inclusion, a geriatric assessment was performed. Cox proportional hazards models were performed to assess correlations between vulnerabilities and one-year survival. We developed a frailty score, HEMA-4, based on the most powerful prognostic factors. It was externally confirmed with an independent cohort. RESULTS: In the development cohort, 206 patients were evaluable. Mean age was 76 years (range 65-90). The HEMA-4 score was created based on four independent predictive factors for survival: cognitive impairment (MMSE<27), comorbidities (≥2 on Charlson comorbidity index), CRP (≥10 mg/L) and low albumin level (<35 g/L). The population was stratified into three groups: good prognosis (score = 0-1, n = 141), intermediate prognosis (score = 2, n = 37) and poor prognosis (score = 3-4, n = 28). Their respective one-year survival was 74%, 51% (HR = 2.30; 95% CI =1.31-4.05; p < 0.01) and 36% (HR = 3.95; 95% CI =2.23-6.98; p < 0.01). In the validation cohort (n = 25), the one-year survival was 78% in the good prognosis group (n = 9) and 50% in the intermediate prognosis group (n = 6). The poor prognosis group had a median survival of four months in the development cohort and six months in the validation cohort (n = 10). CONCLUSION: The HEMA-4 score is a simple score that combines cognitive impairment, comorbidities, inflammation and low albumin level. Our data suggest that it predicts survival among older patients suffering from malignant hemopathies referred to receive chemotherapy regardless of their chronological age.

Rare Features of Dermatomyositis in a Patient with Ovarian Cancer.

Despite having a classic presentation of dermatomyositis, a patient with ovarian cancer demonstrated several uncommon features: (i) unexpected onset of dermatomyositis in spite of cancer remission, (ii) development of Evans' syndrome and subcutaneous oedema, and (iii) dysphagia. We discuss the occurrence of these conditions as well as their treatment. LEARNING POINTS: This case illustrates a mode of onset of dermatomyositis that could challenge its classification as a 'paraneoplastic' syndrome, as the dermatomyositis appeared when the patient was in complete metabolic remission.This case also raises questions about the observed relationship between IVIG administration and the onset of subcutaneous oedema and Evans' syndrome.

Analysis of inflammatory markers and hormones in old cancer patients: A descriptive study.

Advanced cancers are associated with a chronic inflammation, especially high interleukin-6 (IL-6) and with various levels of adipokines (leptin and adiponectin), while ghrelin counteracts the anorexigenic effect of leptin in cancer-induced anorexia-cachexia syndrome. We aimed to understand how IL-6, adipokines and ghrelin plasma levels could be influenced by cancer on the one hand, and by age, frailty, and nutritional status in old cancer patients on the other hand. Ninety-nine patients aged 79[76-83] years old were included. Sixty-six percent had advanced stages of cancer, and 34% had cachexia. Fifty percent were at risk of malnutrition, and 10% had overt malnutrition. None of the variables studied was significantly correlated with the advanced stage, or cachexia. In multiple regression, the only parameter significantly and positively associated with age was adiponectin (p = 0.008). Despite a high prevalence of frailty in our study, we did not find any independent association of frailty (assessed by G8) with IL-6, leptin, adiponectin, or ghrelin in multivariate analysis. We observed that a low albumin level was independently associated with a higher level of IL-6 (p < 0.0001), but not with the MNA score. However, leptin showed a positive correlation with BMI (p < 0.0001), confirming the persistence of a relationship between leptin and adiposity, even in older cancer patients. Finally, high IL-6 level was associated with a higher mortality rate (p = 0.027). In conclusion, IL-6, leptin, adiponectin, and ghrelin are not associated with advanced stages of cancer or cancer-induced cachexia in older subjects with cancer, but they are significantly correlated with anthropometric factors and body composition.

Advances in pain management for older patients with cancer.

The population of older patients is growing with a rising prevalence of cancer diagnoses and cancer-related pain syndromes. Older patients are also vulnerable to misleading pain evaluations and under treatment with opioids. Barriers to the effective and safe management of analgesics include pain assessments and the complex management of the best analgesic choice and dose-titration while achieving the fewest side effects. In this review, we will provide an overview of the challenges present in assessment and treatment choices, along with practical tips for routine clinical practice.

Baseline hepcidin measurement in the differential diagnosis of anaemia for elderly patients and its correlation with the increment of transferrin saturation following an oral iron absorption test.

Background Anaemia is often multifactorial in the elderly, with a frequent association between iron deficiency anaemia (IDA) and anaemia of chronic disease (ACD). The primary objective of our study was to investigate whether baseline hepcidin measurement could be useful for identifying iron deficiency (ID) in anaemic elderly patients. The secondary objective was to assess whether baseline hepcidin concentrations correlated with the relative increase of transferrin saturation (TS) after an oral iron absorption test (OIAT). Methods Blood samples were collected between 7:30 am and 10:00 am in 328 geriatric outpatients, 102 underwent the OIAT. Types of anaemia were classified according biochemical and clinical criteria. TS and hepcidin were measured at baseline and 4 h after the iron dose. The ability of baseline hepcidin measurement to highlight ID in elderly anaemic patients was assessed using a receiver operator curve (ROC) analysis. Correlations between baseline hepcidin levels and the increment of TS following the OIAT were investigated using the Spearman coefficient. Results Among 328 included patients, 78 (23.8%) suffered from anaemia; 13 (4.0%), 19 (5.8%), 27 (8.2%) and 19 (5.8%) patients fulfilled criteria for IDA, IDA/ACD, ACD and unexplained anaemia, respectively. By multivariable analysis, creatinine, C-reactive protein, ferritin, Delta TS and Delta hepcidin were independently associated with baseline hepcidin concentrations. The area under the ROC curve (95% confidence interval) was 0.900 (0.830-0.970) for baseline hepcidin measurement. Baseline hepcidin levels correlated negatively with the relative increase in TS with a Spearman coefficient of -0.742. Conclusions Baseline hepcidin levels could be a useful tool to identify ID in anaemic elderly patients and may predict acute iron response following OIAT.

Pregnancy outcomes are not altered by variation in thyroid function within the normal range in women free of thyroid disease.

OBJECTIVE: In the recently revised guidelines on the management of thyroid dysfunction during pregnancy, treatment with thyroid hormone (LT4) is not recommended in women without thyroid autoimmunity (TAI) and TSH levels in the range 2.5-4.0 mIU/L, and in a recent study in that particular group of pregnant women, more complications were observed when a treatment with LT4 was given. The objective of the study was therefore to investigate whether variation in thyroid function within the normal (non-pregnant) range in women free of thyroid disease was associated with altered pregnancy outcomes? DESIGN: Cross-sectional data analysis of 1321 pregnant women nested within an ongoing prospective collection of pregnant women's data in a single centre in Brussels, Belgium. METHODS: Thyroid peroxidase antibodies (TPO-abs), thyroid-stimulating hormone (TSH), free T4 (FT4) and ferritin levels were measured and baseline characteristics were recorded. Women taking LT4, with TAI and thyroid function outside the normal non-pregnant range were excluded. Pregnancy outcomes and baseline characteristics were correlated with all TSH and FT4 levels within the normal range and compared between two groups (TSH cut-off < and ≥2.5 mIU/L). RESULTS: Tobacco use was associated with higher serum TSH levels (OR: 1.38; CI 95%: 1.08-1.74); P = 0.009. FT4 levels were inversely correlated with age and BMI (rho = -0.096 and -0.089; P < 0.001 and 0.001 respectively) and positively correlated with ferritin levels (rho = 0.097; P < 0.001). Postpartum haemorrhage (>500 mL) was inversely associated with serum FT4 levels (OR: 0.35; CI 95%: 0.13-0.96); P = 0.040. Also 10% of women free of thyroid disease had serum TSH levels ≥2.5 mIU/L. CONCLUSIONS: Variation in thyroid function during the first trimester within the normal (non-pregnant) range in women free of thyroid disease was not associated with altered pregnancy outcomes. These results add evidence to the recommendation against LT4 treatment in pregnant women with high normal TSH levels and without TPO antibodies.

Prevalence of thyroid autoimmunity and dysfunction in women with iron deficiency during early pregnancy: is it altered?

OBJECTIVE: Thyroid disorders and iron deficiency (ID) are associated with obstetrical and fetal complications. Iron is essential for the normal functioning of thyroid peroxidase (TPO-abs) and ID is frequent during pregnancy. The aim of this study was to compare the prevalence of thyroid autoimmunity (TAI) and dysfunction during the first trimester of pregnancy in women with and without ID. DESIGN: Cross-sectional data analysis of 1900 pregnant women nested within an ongoing prospective collection of pregnant women's data. METHOD: The study was performed in a single, tertiary referral center. During the first antenatal visit, ferritin, TPO-abs, thyroid-stimulating hormone (TSH) and free T4 (FT4) were measured and age and BMI were recorded. ID was defined as ferritin <15µg/L, TAI when TPO-abs was >60kIU/L, and subclinical hypothyroidism (SCH) when TSH was >2.5mIU/L. RESULTS: ID was present in 35% of women. Age and BMI were comparable between both groups. In the ID group, the prevalence of TAI and SCH was significantly higher, compared with that in the non-ID group (10% vs 6% and 20% vs 16%; P=0.011 and 0.049 respectively). Ferritin was inversely correlated with serum TSH (ρ=-0.076; P=0.001) and positive with FT4 levels (ρ=0.112; P<0.001). In the logistic regression model, ID remained associated with TAI after correction for confounding factors (P=0.017). The association with SCH was absent after correction for the confounders in the logistic regression model (P=0.082), but remained present in the linear regression model (P=0.035). CONCLUSIONS: ID was frequent during the first trimester of pregnancy and was associated with a higher prevalence of TAI, higher serum TSH, and lower FT4 levels.

Drugs prescribed for patients hospitalized in a geriatric oncology unit: Potentially inappropriate medications and impact of a clinical pharmacist.

OBJECTIVES: The aim of this study was to assess the prevalence of potentially inappropriate medication (PIM) use upon admission and at discharge in a geriatric oncology unit after involving a clinical pharmacist. Although the few studies conducted in geriatric oncology units used the 2003 Beers criteria, this study used START and STOPP criteria, a more appropriate tool for European formularies. MATERIALS AND METHODS: Prospective study in older (≥70years) patients consecutively admitted to a geriatric oncology unit in a cancer center from July 2011 to April 2012. Clinical pharmacist conducted a complete comprehensive medication review including non-prescription and complementary (herbals) medications. This information coupled with the patient's medical history allows identifying PIMs using the STOPP and START criteria. The number of PIMs at admission and at discharge from the hospital was compared after clinical pharmacist intervention. RESULTS: Ninety-one older patients with cancer (mean age±SD=79±6years) were included in the study. START criteria identified 41 PIMs for 31 persons (34%) at admission compared to 7 PIMs for 6 persons (7%) at discharge. STOPP criteria identified 50 PIMs at admission for 29 persons (32%) compared to 16 PIMs at discharge for 14 persons (16%). Results showed significantly lower START scores at discharge than at admission (p<0.001); similarly, STOPP criteria demonstrated fewer PIMs at discharge than at admission (p<0.001). CONCLUSION: The use of START and STOPP criteria by a clinical pharmacist allows identifying PIMs and changing prescriptions for older patients with cancer in agreement with the oncologist and geriatrician of the team.

Comprehensive geriatric assessment and comorbidities predict survival in geriatric oncology.

OBJECTIVES: The comprehensive geriatric assessment (CGA) can detect geriatric problems and potentially improve survival, physical, and cognitive state of patients, as well as increase an older person's chances of staying at home longer. In older people, the number and severity of comorbidity increase with age and are an important determinant of survival. The aim of the study was to assess to which extent CGA and comorbidities could be seen as determinants of survival. MATERIALS AND METHODS: This study analyzed data from two hospitals that included geriatric assessments of patients aged 70 years and more with cancer linked to mortality. Logistic regression was used to model survival predictors. RESULTS: Two hundred and five various cancer patients (47% females) with a median age of 79 were included. They presented with a lot of undiagnosed geriatric problems. Screening scales (G8, SEGA), cognitive, and psychological disorders, and low albumin levels appeared to be independent survival factors. A frailty profile classification was associated with higher mortality. The average comorbidity was graded 2 according to the Charlson scale. By the geriatric cumulative illness rating scale (CIRS-G), the arithmetic average number of affected organ systems was 5 (range 0-10) in all patients. Cardiovascular disorders were the most common comorbidity. Renal insufficiency and anaemia were negatively associated with survival. CONCLUSION: Old cancer patients present a lot of comorbidities and newly diagnosed geriatric problems. Several tools provide determinants of survival in old cancer patients. Prospective trials evaluating the utility of a CGA to guide interventions to improve quality of cancer care in older adults are justified.

Study of the association of total and differential white blood cell counts with geriatric conditions, cardio-vascular diseases, seric IL-6 levels and telomere length.

BACKGROUND/OBJECTIVES: Geriatric patients are highly susceptible to infections. While reduced lymphocyte count has been associated with age, other studies found no change in WBC counts with age. Increased circulating white blood cell (WBC) count has been associated with cardiovascular (CV) diseases and frailty but there are discrepancies. Frailty, geriatric conditions, cardiovascular diseases and WBC count have also been associated with low grade inflammation. Association between geriatric conditions and WBC has been scarcely studied. The aim of the study is to assess the association between WBC and geriatric conditions, CV diseases, and seric IL-6 levels. DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS: We recruited 100 subjects in the general population and hospitalized for chronic medical conditions (age, 23-96years). We collected information on clinical status (medical history, comorbidities, treatments and geriatric syndromes), biological parameters (hematological tests, cytomegalovirus serology) and cytokine production (basal IL-6). Using stepwise backward multivariate analyses, we defined which set of clinical and biological variables could be predictive of increased total and differential WBC counts. RESULTS: We found that low-grade inflammation is independently associated with total WBC, monocyte and neutrophil counts, but not geriatric conditions. CV diseases were the only significant associated factor for high monocyte count. CONCLUSION: In this study, we observed that differential and total WBC counts do not seem to be associated with geriatric conditions but with CV diseases, low-grade inflammation and telomere length.

Multicenter implementation of geriatric assessment in Belgian patients with cancer: a survey on treating physicians' general experiences and expectations.

OBJECTIVES: The aim of this study is to identify treating physicians' general experiences and expectations regarding geriatric assessment (GA) in older patients with cancer. MATERIALS AND METHODS: A survey was carried out in 9 Belgian hospitals, which participated in a national GA implementation project focusing on older patients with cancer. A newly developed questionnaire was completed by their treating physicians. Data collection comprised of reviewing hospital data, general respondent data, and treating physicians' general experiences and expectations regarding GA. Descriptive statistics were calculated. RESULTS: Eighty-two physicians from 9 hospitals participated. The GA team composition can vary substantially, with a nurse as core member. Ideally, all older patients with cancer in whom a treatment decision is necessary, should benefit from the GA. Nearly all GA domains are reported as very important. Availability of GA results can be improved. Treating physicians want geriatricians to coordinate geriatric recommendations related to the identified GA problems, and expect from trained healthcare workers (THCWs) to collect GA data, to report GA results, and to follow-up the implementation of geriatric recommendations. CONCLUSION: This study identifies relevant information for improving the implementation of GA in older patients with cancer in Belgium and reveals priorities for a THCW from the treating physician's point of view. To increase the effectiveness of GA, further efforts are needed to improve the implementation of geriatric recommendations.

Dying in hospital: a study of incidence and factors related to hospital death using death certificate data.

BACKGROUND: Most people prefer not to die in a hospital, and for those with palliative care needs, doing so may result in inappropriate care and poor outcomes. We examined place of death and factors associated with hospital death in a population eligible for palliative care. METHODS: We used death certificate data to identify deaths from conditions eligible for palliative care and to examine place of death and demographic, socioeconomic and environmental characteristics associated with hospital death in Belgium in 2008. RESULTS: Of all people eligible for palliative care (N = 44 229, i.e. 43.5% of all deaths), 51% died in hospital, 25% at home and 24% in long-term care settings. Of those officially living at home at the time of death, hospital death occurred in >60%; of those living in long-term care settings, this was 16%. Nine percent of those living at home alone at the time of death died in long-term care settings; of those living with others, this was 5%. In both, those living at home and those living in long-term care settings, hospital death was more likely in areas with higher availability of hospital beds and less likely in areas with higher availability of skilled nursing beds in long-term care settings. CONCLUSIONS: Hospital death is still common among those eligible for palliative care. The significant proportion of people living at home and dying in long-term care settings indicates the need for additional inpatient beds for terminal care in palliative care institutions.

Increased basal and alum-induced interleukin-6 levels in geriatric patients are associated with cardiovascular morbidity.

BACKGROUND/AIM OF THE STUDY: Low-grade systemic inflammation was suggested to participate to the decline of physiological functions and increased vulnerability encountered in older patients. Geriatric syndromes encompass various features such as functional dependence, polymorbidity, depression and malnutrition. There is a strong prevalence of cardiovascular diseases and related risk factors and chronic cytomegalovirus infections in the geriatric population. As these underlying conditions were proposed to influence the inflammatory state, the aim of this study was to assess their potential contribution to the association of geriatric syndromes with inflammatory parameters. METHODOLOGY: We recruited 100 subjects in the general population or hospitalized for chronic medical conditions (age, 23-96 years). We collected information on clinical status (medical history, ongoing comorbidities, treatments and geriatric scales), biological parameters (hematological tests, cytomegalovirus serology) and cytokines production (basal and alum-induced interleukin (IL)-1ß and IL-6 levels). Using stepwise backward multivariate analyses, we defined which set of clinical and biological variables could be predictive for increased inflammatory markers. PRINCIPAL FINDINGS: We confirmed the age-associated increase of circulating IL-6 levels. In contrast to geriatric scales, we found history of cardiovascular diseases to be strongly associated for this parameter as for high IL-6 production upon ex vivo stimulation with alum. CONCLUSIONS: Association between low-grade inflammation and geriatric conditions could be linked to underlying cardiovascular diseases.