Conventional and machine-learning based risk score for patients with early-stage hepatocellular carcinoma

Background/Aims

The performance of machine-learning (ML) in predicting the outcomes of patients with hepatocellular carcinoma (HCC) remains uncertain. We aimed to develop risk scores using conventional methods and ML to categorize early-stage HCC patients into distinct prognostic groups.

Methods

The study retrospectively enrolled 1411 consecutive treatment-naïve patients with the Barcelona Clinic Liver Cancer (BCLC) stage 0 to A HCC from 2012 to 2021. The patients were randomly divided into a training cohort (n=988) and validation cohort (n=423). Two risk scores (CATS-IF and CATS-INF) were developed to predict overall survival (OS) in the training cohort using the conventional methods (Cox proportional hazards model) and ML-based methods (LASSO Cox regression), respectively. They were then validated and compared in the validation cohort.

Results

In the training cohort, factors for the CATS-IF score were selected by the conventional method, including age, curative treatment, single large HCC, serum creatinine and alpha-fetoprotein levels, fibrosis-4 score, lymphocyte-to-monocyte ratio, and albumin bilirubin grade. The CATS-INF score, determined by ML-based methods, included the above factors and two additional ones (aspartate aminotransferase and prognostic nutritional index). In the validation cohort, both CATS-IF score and CATS-INF score outperformed other modern prognostic scores in predicting OS, with the CATS-INF score having the lowest Akaike information criterion value. A calibration plot exhibited good correlation between predicted and observed outcomes for both scores.

Conclusions

Both the conventional Cox-based CATS-IF score and ML-based CATS-INF score effectively stratified patients with early-stage HCC into distinct prognostic groups, with the CATS-INF score showing slightly superior performance.

Comparison of modified quick sequential organ failure assessment models as triage tools for febrile patients

Object

Effective triage of febrile patients in the emergency department is crucial during times of overcrowding to prioritize care and allocate resources, especially during pandemics. However, available triage tools often require laboratory data and lack accuracy. We aimed to develop a simple and accurate triage tool for febrile patients by modifying the qSOFA score.

Methods

We retrospectively analyzed data from 7,303 febrile patients and created modified versions of qSOFA using factors identified through multivariable analysis. The performance of these modified qSOFAs in predicting in hospital mortality and intensive care unit (ICU) admission was compared using the area under the receiver operating characteristic curve (AUROC).

Results

Through multivariable analysis, the identified factors were age (A), male sex (M), SpO2 (S), and lactate levels (L). The AUROCs of ASqSOFA (for in-hospital mortality: 0.812; 95% CI: 0.789-0.835, for ICU admission: 0.794; 95% CI: 0.771-0.817), which included age and SpO2 with qSOFA, were simple and not inferior to other more complex models (e.g., ASMqSOFA, ASLqSOFA, and ASMLqSOFA). ASqSOFA also displayed significantly higher AUROC than other triage scales, such as the modified early warning score and Korean triage and acuity scale. The optimal cut-off score of ASqSOFA for the outcome was 2 and the score for redistribution to a lower-level emergency department was 0.

Conclusion

We demonstrated that ASqSOFA can be employed as a simple and efficient triage tool for emergency febrile patients to aid in resource distribution during overcrowding. It may also be applicable in pre-hospital settings for febrile patient triage.

Prognostic utility of paraspinal muscle index in elderly patients with community-acquired pneumonia

Objective

This study aimed to investigate the association between paraspinal muscle measurements using chest computed tomography (CT) and the clinical outcomes of elderly patients with community-acquired pneumonia (CAP).

Methods

This was a single-center, retrospective, observational study that included elderly (≥65 years) patients with CAP hospitalized through an emergency department between March 2020 and December 2022. We collected their baseline characteristics and laboratory data at the time of admission. Paraspinal muscle index and attenuation were calculated at the level of the 12th thoracic vertebra using chest CT taken within 48 hours before and after admission. Univariable and multivariable logistic regression analyses were conducted to evaluate the association between paraspinal muscle measurements and 28-day mortality. Receiver operating characteristic (ROC) curve and area under the curve (AUC) analyses were used to evaluate the prognostic predictive power.

Results

Of 338 enrolled patients, 60 (17.8%) died within 28 days after admission. A high paraspinal muscle index was associated with a low 28-day mortality in elderly patients with CAP (adjusted odds ratio, 0.994; 95% confidence interval, 0.992-0.997). The area under the ROC curve for the muscle index was 0.75, which outperformed pneumonia severity index (PSI) and confusion, urea, respiratory rate, blood pressure, age ≥ 65 (CURB-65), both of which showed 0.64 in predicting mortality.

Conclusion

A high paraspinal muscle index was associated with a low 28-day mortality in patients aged 65 years or older with CAP.

Potential Role of Zinc Finger 365 rs10822013 and rs10995190 in Mammographic Density, Sporadic Breast Cancer Risk, and Prognosis

Background

Despite suggesting many genetic risk markers as the outcome of Genome-wide association studies (GWAS) for breast cancer, replicating the results in different populations has remained the main issue. In this regard, this study assessed the association of two variations in Zinc Finger 365 (ZNF365) in an Iranian population.

Methods

In a case-control study conducted at Mashhad University of Medical Sciences, Mashhad, Iran, between 2017 and 2020, ZNF365-rs10822013 and rs10995190 were genotyped using Allele-Specific PCR (AS-PCR). Breast density was assessed using mammography images. PHASE software module version 2 and SPSS version 16.0 were used for haplotype and statistical analyses. Quantitative and qualitative variables were compared between groups using independent t tests and Chi square tests, respectively. Binary logistic regression analysis was performed to calculate odds ratios. Multivariate analysis was then undertaken for the baseline variables, with a P<0.05 in the univariate analysis. The survival analysis was performed using the Kaplan-Meier method and the log-rank test.

Results

In this survey, 732 females, including 342 breast cancer patients and 390 healthy subjects, were enrolled. rs10822013-T allele (P=0.014), rs10995190-G allele (P=0.003), and TG haplotype (P=0.002) were significantly associated with the increased risk of breast cancer. Moreover, rs10995190-GG genotype (P=0.042) and C-G haplotype (P=0.019) revealed a significant association with better overall survival. However, considered polymorphisms and their haplotypes indicated no association with breast density and clinical features of breast cancer.

Conclusion

ZNF365 variants might be a potential risk marker of breast cancer in the Iranian population. The interaction between alleles in haplotypes may modulate the amount of the risk conferred by these variants. Further studies on different ethnic groups can validate these results.

Association between anogenital distance as a noninvasive index in the diagnosis and prognosis of reproductive disorder: A systematic review

Background

There are 2 measures of anogenital distance (AGD) in men and women. AGD has been used as an indicator of fetal androgen dysfunction and an adverse outcome in adulthood. Some studies have shown the association of AGD as a predictor in the diagnosis and prognosis of diseases and disorders.

Objective

To systematically summarize the latest evidence for presenting AGD as a new approach for prognosis and early diagnosis of diseases.

Materials and Methods

A systematic review of the available literature was performed using Medline via PubMed, Scopus, and ISI Web of Knowledge up to July 2021, using search terms "anogenital distance" OR "anogenital index" OR "ano genital distance" OR "ano genital index". Language restrictions were not imposed.

Results

After reviewing the retrieved articles, 47 unique studies were included in this systematic review. Different outcomes, including endometriosis, prostate cancer, polycystic ovary syndrome, pelvic organ prolapse, hypospadias, cryptorchidism, fertility and semen parameters, maternal and birth development, and ovarian and gynecological-related disorders, have been studied in the included evidence. A negative association was observed between AGD and endometriosis and hypospadias and a positive association between AGD and prostate cancer, polycystic ovary syndrome, male fetal gender, and fertility parameters.

Conclusion

Using quantitative indicators such as AGD may be a useful clinical tool for the diagnosis of diseases. Although many studies have shown an association between AGD and diseases, some factors, including different measurement methods, different measurement tools, age, and different definitions of AGD, can be involved in the variation of AGD.

Prognostic significance of thyroid hormone T3 in patients with septic shock: a retrospective cohort study

Background

The role of thyroid hormones is crucial in the response to stress and critical illness, which has been reported to be closely associated with a poor prognosis in patients admitted to the intensive care unit (ICU). This study aimed to explore the relationship between thyroid hormone and prognosis in septic shock patients.

Methods

A total of 186 patients with septic shock were enrolled in the analytical study between December 2014 and September 2022. The baseline variables and thyroid hormone were collected. The patients were divided into survivor group and non-survivor group according to whether they died during the ICU hospitalization. Among 186 patients with septic shock, 123 (66.13%) were in the survivor group and 63 (33.87%) were in the non-survivor group.

Results

There were significant differences in the indictors of free triiodothyronine (FT3) (p = 0.000), triiodothyronine (T3) (p = 0.000), T3/FT3 (p = 0.000), acute physiology and chronic health evaluation II score (APACHE II) (p = 0.000), sequential organ failure assessment score (SOFA) (p = 0.000), pulse rate (p = 0.020), creatinine (p = 0.008), PaO2/FiO2 (p = 0.000), length of stay (p = 0.000) and hospitalization expenses (p = 0.000) in ICU between the two groups. FT3 [odds ratio (OR): 1.062, 95% confidence interval(CI): (0.021, 0.447), p = 0.003], T3 (OR: 0.291, 95% CI: 0.172-0.975, p = 0.037) and T3/FT3 (OR: 0.985, 95% CI:0.974-0.996, p = 0.006) were independent risk factors of the short-term prognosis of septic shock patients after adjustment. The areas under the receiver operating characteristic curves for T3 was associated with ICU mortality (AUC = 0.796, p < 0.05) and was higher than that for FT3 (AUC = 0.670, p < 0.05) and T3/FT3 (AUC = 0.712, p < 0.05). A Kaplan-Meier curve showed that patients with T3 greater than 0.48 nmol/L had a significantly higher survival rate than the patients with T3 less than 0.48 nmol/L.

Conclusions

The decrease in serum level of T3 in patients with septic shock is associated with ICU mortality. Early detection of serum T3 level could help clinicians to identify septic shock patients at high risk of clinical deterioration.

Prognostic value of the myeloperoxidase index for early prediction of neurologic outcome in acute carbon monoxide poisoning

Objective

Carbon monoxide (CO) activates intravascular neutrophils through platelet-neutrophil aggregates, which cause neutrophil degranulation. This process causes the release of myeloperoxidase (MPO), proteases, and reactive oxygen species. The MPO index (MPXI) is a newly reported inflammatory marker that reflects the MPO level within neutrophils. The MPXI in conditions associated with neutrophil activation depends on the net effect of azurophil degranulation. This study aimed to determine whether the MPXI can predict neurocognitive prognosis 1 month after acute CO poisoning.

Methods

We included patients aged ≥16 years with acute CO poisoning from a cohort at a single tertiary academic hospital in Wonju, Korea, between January 2010 and May 2021. Data from 699 patients were analyzed. The neurocognitive outcome was assessed using Global Deterioration Scale scores and classified as favorable (score, 1–3 points) or poor (score, 4–7 points). The MPXI was determined within 1 hour of arrival to the emergency department.

Results

Among the 699 patients, 52 (7.4%) showed poor outcomes. The median MPXI of the patients in the poor outcome group was higher than that of the favorable outcome group (0.85 vs. 0.2, P=0.189). However, a significant difference was not found between the favorable and poor outcome groups, and MPXI was not a significant variable in multivariate logistic regression.

Conclusion

The MPXI evaluated in the emergency department did not differ based on neurocognitive outcome at 1 month after acute CO poisoning.

Novel lncRNAs with diagnostic or prognostic value screened out from breast cancer via bioinformatics analyses

Background

Recent studies have shown that long non-coding RNAs (lncRNAs) may play key regulatory roles in many malignant tumors. This study investigated the use of novel lncRNA biomarkers in the diagnosis and prognosis of breast cancer.

Materials and Methods

The database subsets of The Cancer Genome Atlas (TCGA) by RNA-seq for comparing analysis of tissue samples between breast cancer and normal control groups were downloaded. Additionally, anticoagulant peripheral blood samples were collected and used in this cohort study. The extracellular vesicles (EVs) from the plasma were extracted and sequenced, then analyzed to determine the expressive profiles of the lncRNAs, and the cancer-related differentially expressed lncRNAs were screened out. The expressive profiles and associated downstream-mRNAs were assessed using bioinformatics (such as weighted correlation network analysis (WGCNA), Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genome (KEGG) enrichments, Receiver-Operating Characteristic (ROC) curve and survival analysis, etc.) to investigate the diagnostic and prognostic values of these EV lncRNAs and their effectors.

Results

In this study, 41 breast cancer-related lncRNAs were screen out from two datasets of tissue and fresh collected plasma samples of breast cancer via the transcriptomic and bioinformatics techniques. A total of 19 gene modules were identified with WGCNA analysis, of which five modules were significantly correlated with the clinical stage of breast cancer, including 28 lncRNA candidates. The ROC curves of these lncRNAs revealed that the area under the curve (AUC) of all candidates were great than 70%. However, eight lncRNAs had an AUC >70%, indicating that the combined one has a good diagnostic value. In addition, the results of survival analysis suggested that two lncRNAs with low expressive levels may indicate the poor prognosis of breast cancer. By tissue sample verification, C15orf54, AL157935.1, LINC01117, and SNHG3 were determined to have good diagnostic ability in breast cancer lesions, however, there was no significant difference in the plasma EVs of patients. Moreover, survival analysis data also showed that AL355974.2 may serve as an independent prognostic factor and as a protective factor.

Conclusion

A total of five lncRNAs found in this study could be developed as biomarkers for breast cancer patients, including four diagnostic markers (C15orf54, AL157935.1, LINC01117, and SNHG3) and a potential prognostic marker (AL355974.2).

Association of inferior vena cava diameter ratio with outcomes in patients with gastrointestinal bleeding

Objective

To examine the association of inferior vena cava (IVC) diameter ratio measured using computed tomography with outcomes in patients with gastrointestinal bleeding (GIB).

Methods

A single-center retrospective observational study was conducted on consecutive patients with GIB who presented to the emergency department. The IVC diameter ratio was calculated by dividing the maximum transverse and anteroposterior diameters perpendicular to it. The association of the IVC diameter ratio with outcomes was examined using multivariable logistic regression analysis. The primary outcome was in-hospital mortality. The area under the receiver operator characteristic curve (AUC) of the IVC diameter ratio was calculated, and the sensitivity and specificity, including the cutoff values, were computed.

Results

In total, 585 patients were included in the final analysis. The in-hospital mortality rate was 4.6% (n=27). The IVC diameter ratio was significantly associated with higher in-hospital mortality in multivariable logistic regression analysis (odds ratio, 1.793; 95% confidence interval [CI], 1.239–2.597; P=0.002). The AUC of the IVC diameter ratio for in-hospital mortality was 0.616 (95% CI, 0.498–0.735). With a cutoff of the IVC diameter ratio (≥2.1), the sensitivity and specificity for predicting in-hospital mortality were 44% (95% CI, 26%–65%) and 71% (95% CI, 67%–75%), respectively.

Conclusion

The IVC diameter ratio was independently associated with in-hospital mortality in patients with GIB. However, the AUC of the IVC diameter ratio for in-hospital mortality was low.

[Odontogenic cervical-facial cellulitis: report of 87 cases]

Cervical-facial cellulitis are infections of the cellular fatty spaces of the face and neck with a tendency towards locoregional extension, septic and thromboembolic complications that can affect the patient's vital and/or functional prognosis. The management is multidisciplinary including a medical component, surgical drainage associated with the treatment of the causal tooth. This is a retrospective study including 87 cases of odontogenic head and neck cellulitis hospitalized in the ENT and head and neck surgery department at Fattouma Bourguiba Monastir hospital over a period of 4 years between January 2017 and December 2020. The study included 48 women and 39 men. The most affected age group was young adults (54 %). The main contributing factors were poor oral hygiene (76 %), tobacco (41 %) and alcohol (19 %). Anti-inflammatory medicines intake was found in 31 % of cases. The average consultation time was 5 days. The main reason for consultation was painful head and neck swelling associated with trismus (70 %) and fever (52 %). The cervical-facial scan was performed in 93 % of patients. It revealed suppurative cellulitis (64 %), extension to upper aerodigestive ways (20 %), compression of upper aero-digestive tract (11,5 %), Lemierre syndrome (4,6 %) and gangrenous cellulitis with mediastinal extension (1,1 %). All patients received large spectrum antibiotic, associated in 25 % of cases with surgical drainage. Treatment of the dental cause was performed in all patients. The evolution was favourable in 98,9 % of cases. There is only one death due to a septic shock (1,1 %), which is consistent with most of the results reported in the literature. Head and neck cellulitis can affect the functional and vital prognosis of the patient in the absence of rapid and adequate management. The treatment remains primarily preventive.

Signature identification of relapse-related overall survival of early lung adenocarcinoma after radical surgery

Background

The widespread use of low-dose chest CT screening has improved the detection of early lung adenocarcinoma. Radical surgery is the best treatment strategy for patients with early lung adenocarcinoma; however, some patients present with postoperative recurrence and poor prognosis. Through this study, we hope to establish a model that can identify patients that are prone to recurrence and have poor prognosis after surgery for early lung adenocarcinoma.

Materials and Methods

We screened prognostic and relapse-related genes using The Cancer Genome Atlas (TCGA) database and the GSE50081 dataset from the Gene Expression Omnibus (GEO) database. The GSE30219 dataset was used to further screen target genes and construct a risk prognosis signature. Time-dependent ROC analysis, calibration degree analysis, and DCA were used to evaluate the reliability of the model. We validated the TCGA dataset, GSE50081, and GSE30219 internally. External validation was conducted in the GSE31210 dataset.

Results

A novel four-gene signature (INPP5B, FOSL2, CDCA3, RASAL2) was established to predict relapse-related survival outcomes in patients with early lung adenocarcinoma after surgery. The discovery of these genes may reveal the molecular mechanism of recurrence and poor prognosis of early lung adenocarcinoma. In addition, ROC analysis, calibration analysis and DCA were used to verify the genetic signature internally and externally. Our results showed that our gene signature had a good predictive ability for recurrence and prognosis.

Conclusions

We established a four-gene signature and predictive model to predict the recurrence and corresponding survival rates in patients with early lung adenocarcinoma after surgery. These may be helpful for reforumulating post-operative consolidation treatment strategies.

[Epidemiology of patients presenting to the emergency room for dyspnea in Belgium]

Studies about patients' profile presenting to the emergency department for dyspnea are scarce in Europe, and even more in Belgium. We analyze here a cohort of patients with acute dyspnea in three Belgian centers, as to the epidemiology of this dyspnea, the tests carried out, the diagnoses retained, the treatments administered, the hospitalization and survival rates. The secondary objective is to compare this Belgian cohort with a European population resulting from a large multicenter study. The analysis of 131 patients showed that acute dyspnea in the emergency department corresponds to four main diagnoses (exacerbation of chronic obstructive pulmonary disease, infections of the lower respiratory tract, acute cardiac decompensation and asthma). The age of patients is over 80 years in a quarter of them, the hospitalization rate is 57 % and the mortality is 5 %. Our analysis also reveals that the check of vital parameters may be insufficiently realized, as may the use of non-invasive ventilation. Etiological diagnoses made in the emergency department are confirmed at the end of hospitalization in 75 % of cases. The Belgian population is younger than the European population (62 against 69 years), presents fewer infection of the lower respiratory tract (20 % against 31 %), and is comparable to the European population for the other parameters studied. The article ends with 10 key messages that will enlighten clinicians about the reality of acute dyspnea in emergency rooms in Belgium.

Independent Impact of Diabetes on the Severity of Coronavirus Disease 2019 in 5,307 Patients in South Korea: A Nationwide Cohort Study

Background

Inconsistent results have been observed regarding the independent effect of diabetes on the severity of coronavirus disease 2019 (COVID-19). We conducted a nationwide population-based cohort study to evaluate the relationship between diabetes and COVID-19 severity in South Korea.

METHODS

Patients with laboratory-confirmed COVID-19 aged ≥30 years were enrolled and medical claims data were obtained from the Korean Health Insurance Review and Assessment Service. Hospitalization, oxygen treatment, ventilator application, and mortality were assessed as severity outcomes. Multivariate logistic regression analyses were performed after adjusting for age, sex, and comorbidities.

RESULTS

Of 5,307 COVID-19 patients, the mean age was 56.0±14.4 years, 2,043 (38.5%) were male, and 770 (14.5%) had diabetes. The number of patients who were hospitalized, who received oxygen, who required ventilator support, and who died was 4,986 (94.0%), 884 (16.7%), 121 (2.3%), and 211 (4.0%), respectively. The proportion of patients with diabetes in the abovementioned outcome groups was 14.7%, 28.1%, 41.3%, 44.6%, showing an increasing trend according to outcome severity. In multivariate analyses, diabetes was associated with worse outcomes, with an adjusted odds ratio (aOR) of 1.349 (95% confidence interval [CI], 1.099 to 1.656; P=0.004) for oxygen treatment, an aOR of 1.930 (95% CI, 1.276 to 2.915; P<0.001) for ventilator use, and an aOR of 2.659 (95% CI, 1.896 to 3.729; P<0.001) for mortality.

CONCLUSION

Diabetes was associated with worse clinical outcomes in Korean patients with COVID-19, independent of other comorbidities. Therefore, patients with diabetes and COVID-19 should be treated with caution.

Development and Validation of a Risk Scoring System Derived from Meta-Analyses of Papillary Thyroid Cancer

BACKGROUND

The aim of this study was to develop a scoring system to stratify the risk of papillary thyroid cancer (PTC) and to select the proper management.

METHODS

We performed a systematic search of MEDLINE and Embase. Data regarding patients' prognoses were obtained from the included studies. Odds ratios (ORs) with statistical significance were extracted from the publications. To generate a risk scoring system (RSS), ORs were summed (RSS1), and summed after natural-logarithmic transformation (RSS2). RSS1 and RSS2 were compared to the eighth edition of the American Joint Committee on Cancer (AJCC) staging system and the 2015 American Thyroid Association (ATA) guidelines for thyroid nodules and differentiated thyroid carcinoma.

RESULTS

Five meta-analyses were eligible for inclusion in the study. Eight variables (sex, tumour size, extrathyroidal extension, BRAF mutation, TERT mutation, histologic subtype, lymph node metastasis, and distant metastasis) were included. RSS1 was the best of the analysed models.

CONCLUSION

We developed and validated a new RSS derived from previous meta-analyses for patients with PTC. This RSS seems to be superior to previously published systems.

Subclinical Hypothyroidism Affects the Long-Term Outcomes of Patients Who Undergo Coronary Artery Bypass Grafting Surgery but Not Heart Valve Surgery

BACKGROUND

The aim of this study was to determine the associations between subclinical hypothyroidism (SCH) and long-term cardiovascular outcomes after coronary artery bypass grafting (CABG) or heart valve surgery (HVS).

METHODS

We retrospectively reviewed and compared all-cause mortality, cardiovascular mortality, and cardiovascular events in 461 patients who underwent CABG and 104 patients who underwent HVS.

RESULTS

During a mean±standard deviation follow-up duration of 7.6±3.8 years, there were 187 all-cause deaths, 97 cardiovascular deaths, 127 major adverse cardiovascular events (MACE), 11 myocardial infarctions, one unstable angina, 70 strokes, 30 hospitalizations due to heart failure, 101 atrial fibrillation, and 33 coronary revascularizations. The incidence of all-cause mortality after CABG was significantly higher in patients with SCH (n=36, 55.4%) than in euthyroid patients (n=120, 30.3%), with a hazard ratio of 1.70 (95% confidence interval, 1.10 to 2.63; P=0.018) after adjustment for age, sex, current smoking status, body mass index, underlying diseases, left ventricular dysfunction, and emergency operation. Interestingly, low total triiodothyronine (T3) levels in euthyroid patients who underwent CABG were significantly associated with increased risks of all-cause mortality, cardiovascular mortality, and MACE, but those associations were not observed in HVS patients. Both free thyroxine and thyroid-stimulating hormone levels in euthyroid patients were not related with any cardiovascular outcomes in either the CABG or HVS group.

CONCLUSION

SCH or low total T3 might be associated with a poor prognosis after CABG, but not after HVS, implying that preoperative thyroid hormonal status may be important in ischemic heart disease patients.

[Influence of clinical and pathological factors on lymph node harvesting in surgical specimens of colorectal cancer]

In colorectal cancer staging, pathologic lymph node analysis is a crucial information for the clinician and must be performed with a maximal level of accuracy. Therefore, the surgical sample analysis needs harvesting of as many lymph nodes as possible from the mesentery. In this study, we analysed the influence of a series of clinical and pathological factors which could influence lymph node harvesting. A total of 239 patients were included in our study. The factors with a statistically significant influence on lymph node collection (pinferior to0.05) were the age, gender of the patient, size of the primitive neoplasm, size of the surgical specimen, expertise of the surgeon and the pathology department. The presence of a radiochimiotherapy did not have any influence on the lymph node collection. This study highlights the importance of lymph node harvesting in colorectal surgical specimens of colo-rectal cancers.

Use of amplitude-integrated electroencephalography in decision-making for extracorporeal membrane oxygenation in comatose cardiac arrest patients whose eventual neurologic recovery is uncertain

Comatose cardiac arrest patients frequently experience cardiogenic shock or recurrent arrest. Extracorporeal membrane oxygenation (ECMO) can be used to salvage patients with cardiogenic shock or cardiac arrest refractory to conventional therapies. However, in comatose cardiac arrest patients whose neurologic recovery is uncertain, the use of ECMO is restricted because it requires considerable financial and human resources. Amplitude-integrated electroencephalography is an easily applicable, real-time electroencephalography monitoring tool that has been increasingly used to monitor brain activity in comatose cardiac arrest patients. We describe our experience of using amplitude-integrated electroencephalography in decision-making to place ECMO for comatose cardiac arrest patients whose eventual neurologic recovery appeared uncertain at the time of ECMO placement.

Low Skeletal Muscle Density Is Associated with Early Death in Patients with Perihilar Cholangiocarcinoma Regardless of Subsequent Treatment

BACKGROUND

Low skeletal muscle mass is associated with increased postoperative morbidity and worse survival following resection for perihilar cholangiocarcinoma (PHC). We investigated the predictive value of skeletal muscle mass and density for overall survival (OS) of all patients with suspected PHC, regardless of treatment.

METHODS

Baseline characteristics and parameters regarding disease and treatment were collected from all patients with PHC from 2002 to 2014. Skeletal muscle mass and density were measured at the level of the third lumbar vertebra on CT. The association between skeletal muscle mass and density with OS was investigated using the Kaplan-Meier method and Cox survival.

RESULTS

Median OS in 233 included patients did not differ between those with and without low skeletal muscle mass (p = 0.203), whereas a significantly different median OS (months) was observed between patients with low (HR 7.0, 95% CI 4.7-9.3) and high (HR 12.1, 95% CI 8.1-16.1) skeletal muscle density (p = 0.004). Low skeletal muscle density was independently associated with decreased OS (HR 1.78, 95% CI 1.03-3.07, p = 0.040) within the first 6 months but not after 6 months (HR 0.68, 95% CI 0.44-1.07, p = 0.093), after adjusting for age, tumour size and suspected peritoneal or other distant metastases on imaging.

CONCLUSION

A time-dependent effect of skeletal muscle density on OS was found in patients with PHC, regardless of subsequent treatment. Low skeletal muscle density may identify patients at risk for early death.

Prognostic Factors of Neurological Complications in Spinal Surgeries

Study Design

Retrospective study.

Purpose

To determine prognostic factors of neurological complications (NCs) of posterior thoracolumbar surgeries.

Overview of Literature

There have been few reports on the prognosis of NCs according to the causes and treatment methods.

Methods

The subjects were 65 patients who had NCs for 19 years (1995–2013) after posterior thoracolumbar surgeries in Seoul Sacred Heart General Hospital. The degree of neurological injury was assessed using numeric scales as follows: G1, increased leg pain or sensory loss; G2, hemiparesis; G3, paraparesis; G4, cauda equine syndrome; and G5, complete paraplegia. The relative degree of neurological recovery was evaluated using four numeric scales as follows: Gr1, complete recovery; Gr2, almost complete recovery with residual sensory loss or numbness; Gr3, partial recovery with apparent neurological deficit; and Gr4, no recovery. The prognostic factors were investigated in terms of demographic and surgical variables that were available in a retrospective review.

Results

The causes were as follows: epidural hematoma (EH), 25 patients (38.5%); insufficient decompression and fusion, 14 patients (21.5%); mechanical injury, 11 patients (16.9%); insufficient discectomy, four patients (6.2%); and unknown, 11 patients (23.1%). The grade of neurological injury was as follows: G1, 11 patients (16.9%); G2, 34 patients (52.3%); G3, 15 patients (23.1%); G4, three patients (4.6%); and G5, two patients (3.1%). Thirteen patients received conservative treatment, and 52 underwent revision surgeries. Neurological recovery was as follows: Gr1, 21 patients (32.3%); Gr2, 17 patients (26.2%); Gr3, 20 patients (30.8%); and Gr4, seven patients (10.8%). The prognosis depended on the causes (p =0.041). The subgroup analysis of the revision group revealed a significant correlation between the degree of neurological recovery and the timing of revision, irrespective of causes (r =0.413, p =0.002).

Conclusions

The prognosis of NC depended on the causes. EH was the best and unknown was the worst prognostic factor. Revision should be performed as soon as possible for a better prognosis.

Combination of Tumor Volume and Epstein-Barr Virus DNA Improved Prognostic Stratification of Stage II Nasopharyngeal Carcinoma in the Intensity Modulated Radiotherapy Era: A Large-Scale Cohort Study

PURPOSE

Little is known about combination of the circulating Epstein-Barr viral (EBV) DNA and tumor volume in prognosis of stage II nasopharyngeal carcinoma (NPC) patients in the intensity modulated radiotherapy (IMRT) era. We conducted this cohort study to evaluate the prognostic values of combining these two factors.

MATERIALS AND METHODS

By Kaplan-Meier, we compare the differences of survival curves between 385 patients with different EBV DNA or tumor volume levels, or with the combination of two biomarkers mentioned above.

RESULTS

Gross tumor volume of cervical lymph nodes (GTVnd, p < 0.001) and total tumor volume (GTVtotal, p < 0.001) were both closely related to pretreatment EBV DNA, while gross tumor volume of nasopharynx (GTVnx, p=0.047) was weakly related to EBV DNA. EBV DNA was significantly correlated with progress-free survival (PFS, p=0.005), locoregional-free survival (LRFS, p=0.039), and distant metastasis-free survival (DMFS, p=0.017), while GTVtotal, regardless of GTVnx and GTVnd, had a significant correlation with PFS and LRFS. The p-values of GTVtotal for PFS and LRFS were 0.008 and 0.001, respectively. According to GTVtotal and pretreatment EBV DNA level, patients were divided into a low-risk group (EBV DNA 0 copy/mL, GTVtotal < 30 cm3; EBV DNA 0 copy/mL, GTVtotal ≥ 30 cm3; or EBV DNA > 0 copy/mL, GTVtotal < 30 cm3) and a high-risk group (EBV DNA > 0 copy/mL, GTVtotal ≥ 30 cm3). When patients in the low-risk group were compared with those in the high-risk group, 3-year PFS (p=0.003), LRFS (p=0.010), and DMFS (p=0.031) rates were statistically significant.

CONCLUSION

Pretreatment plasma EBV DNA and tumor volume were both closely correlated with prognosis of stage II NPC patients in the IMRT era. Combination of EBV DNA and tumor volume can refine prognosis and indicate for clinical therapy.