OBJECTIVE: To evaluate the benefits of surgical repair acute type A aortic dissection (ATAAD) on survival of octogenarians. METHODS: Patients who underwent surgery for acute ATAAD from the multicenter European Registry of Type A Aortic Dissection (ERTAAD) were the subjects of the present analysis. RESULTS: 326 (8.4%) patients were aged ≥ 80 years. Among 280 propensity score matched pairs, in-hospital mortality was 30.0% in patients aged ≥ 80 years and 20.0% in younger patients (P = 0.006), while 10-year mortality were 93.2% and 48.0%, respectively (P < 0.001). The hazard of mortality was higher among octogenarians up to two years after surgery, but it became comparable to that of younger patients up to 5 years. Among patients who survived 3 months after surgery, 10-year relative survival was 0.77 in patients aged < 80 years, and 0.46 in patients aged ≥ 80 years. Relative survival of octogenarians decreased markedly 5 years after surgery. Age ≥ 85 years, glomerular filtration rate, preoperative invasive ventilation, preoperative mesenteric mal-perfusion and aortic root replacement were independent predictors of in-hospital mortality among octogenarians (AUC = 0.792; E:O ratio = 0.991; CITL = 0.016; slope = 1.096). An additive score was developed. A risk score ≤ 1 was observed in 68.4% of patients, and their in-hospital mortality was 20.9%. CONCLUSIONS: Provided a thoughtful patient selection, surgery may provide a survival benefit in patients aged ≥ 80 years with ATAAD that, when compared to younger patients and the general population, may last up to 5 years after the procedure. These findings have significant epidemiologic and clinical relevance because of the increasing longevity of the population of the Western countries.
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BACKGROUND: Chest wall sarcomas are rare and pose significant technical challenges in surgical management, particularly in patients with advanced disease. In this study, we examined the extent of resection, reconstruction techniques, and oncological outcomes of patients with chest wall soft tissue and bone sarcomas. METHODS: This retrospective single-center series included patients who underwent surgery at our center between May 2014 and February 2022 for deep-seated/subfascial primary and recurrent soft tissue or bone sarcomas of the chest wall requiring significant resection and extensive reconstruction. We analyzed clinical and operative data, including extent of resection, reconstruction techniques, and oncological outcomes. Additionally, we compared survival outcomes between patients with primary and recurrent tumors, and examined how these were influenced by clinical factors using Cox proportional hazards regression analysis. RESULTS: Of the 38 patients included, 22 were treated for primary or recurrent soft tissue sarcoma (STS) and 16 for bone sarcoma. En bloc microscopic radical resection (R0) was achieved in 95.45% and 93.75% of patients with soft tissue and bone sarcomas, respectively. Nonetheless, local recurrence or distant metastases occurred in 40%, 58.33%, and 40% of patients with primary soft tissue, recurrent soft tissue, and bone sarcomas, respectively. Adherence to clinical guidelines and treatment in the reference center was high for bone sarcoma (93.75%), but notably low for STS, resulting in 54.55% of these patients requiring re-resection. Compared with those who underwent only one surgery, patients who underwent re-resection had poorer postoperative outcomes, more severe complications, and longer hospital stay. CONCLUSIONS: Chest wall sarcomas often require extensive resection and complex reconstruction. Although surgical treatment at reference sarcoma centers has significantly improved oncological and clinical outcomes, the prognosis of these patients remains guarded, necessitating further related research and continued refinement in surgical techniques, adjuvant therapies, and follow-up strategies.
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BACKGROUND: Improved prediction of prognosis among lung cancer patients could facilitate better clinical management. We aimed to study the prognostic significance of circulating proteins at the time of lung cancer diagnosis, among patients with and without smoking history. METHODS: We measured 91 proteins using the Olink Immune-Oncology panel in plasma samples that were collected at diagnosis from 244 never smoking and 742 ever smoking patients with stage I-IIIA non-small cell lung cancer (NSCLC). Patients were recruited from nine centres in Russian Federation, Poland, Serbia, Czechia, and Romania, between 2007-2016 and were prospectively followed through 2020. We used multivariable Survey-weighted Cox models to assess the relationship between overall survival and levels of proteins by adjusting for smoking, age at diagnosis, sex, education, alcohol intake, histology, and stage. RESULTS: The 5-year survival rate was higher among never than ever smoking patients (63.1% vs. 46.6%, P<0.001). In age- and sex-adjusted survival analysis, 23 proteins were nominally associated with overall survival, but after adjustment for potential confounders and correcting for multiple testing, none of the proteins showed a significant association with overall survival. In stratified analysis by smoking status, IL8 [hazard ratio (HR) per standard deviation (SD): 1.40, 95% confidence interval (CI): 1.18-1.65, P=1×10-4] and hepatocyte growth factor (HGF) (HR: 1.45, 95% CI: 1.18-1.79, P=5×10-4) were associated with survival among never smokers, but no protein was found associated with survival among ever smokers. Integrating proteins into the models with clinical risk factors did not improve the predictive performance of NSCLC prognosis [C-index of 0.63 (clinical) vs. 0.64 (clinical + proteins) for ever smokers, P=0.20; C-index of 0.68 (clinical) vs. 0.72 (clinical + proteins) for never smokers, P=0.28]. CONCLUSIONS: We found limited evidence of a potential for circulating immune- and cancer-related protein markers in lung cancer prognosis. Whereas some specific proteins appear to be uniquely associated with lung cancer survival in never smokers.
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Robotic coronary and intra-cardiac surgery has been available for more than 25 years. In this period, multiple studies have demonstrated the beneficial effects of robotic surgery over conventional open surgery. Throughout the years, technical developments have enabled us to perform totally endoscopic coronary artery bypass (TECAB) grafting. But these techniques remained in the hands of a small group of pioneers because of a lack of structured training programs and the absence of long-term results at that time. Currently, a renewed interest and a wide dispersion of robotic platforms, thanks to use of robotics in other disciplines, has led to an exponential increase in robotic cardiac centers both in Europe and USA. Nonetheless, this increase was slowed down in Europe as a result of the uncertainty introduced by the implementation of a revised regulatory framework for medical devices [Regulation 2017/745, 'Medical Device Regulation' ('MDR')]. The MDR was introduced with the goal of increasing patient safety and supporting innovation. Implementing the MDR has proven to be exceptionally challenging and risks to the supply of essential devices have been identified. Changes to both regulatory and market dynamics led to a circumstance where the only available robotic platform for cardiac surgery decided to cease marketing of essential accessories for conducting surgery. This resulted in the disappearance of dedicated tools such as the Endowrist stabilizer, essential for TECAB, and the atrial retractor which is essential for intra-cardiac surgery. In the mean-time, further clinical evidence was published demonstrating the superiority of robotic cardiac surgery over other minimally invasive approaches. This has demonstrated the need to better define the clinical evidence requirements for regulatory purposes to ensure that dedicated tools for evidence-based interventions in robotic coronary surgery remain available such that TECAB can continue in Europe.
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This state-of-the-art review aimed to synthesize evidence from various sex-stratified studies on aortic stenosis (AS), focusing on the difference in clinical presentation, anatomical characteristics, pathophysiology, and management of AS. In comparison to men, women with AS are present at later stages, are older, more symptomatic, frailer, and exhibit higher operative risk [Society of Thoracic Surgeons (STS) score]. Women tend to have smaller aortic valve (AV) areas and left ventricular (LV) outflow tract, leading to lower stroke volumes (SVs) than men and have a higher prevalence of paradoxical, low-flow, low-gradient AS. In women, chronic pressure overload due to AS results in concentric LV remodelling and hypertrophy, characterized by reduced LV cavities, higher filling pressures, lower wall stress, and more diastolic dysfunction. Conversely, men exhibit more dilated eccentric LV remodelling and hypertrophy. AVs in women are less calcified but more fibrotic. Moreover, women are often underdiagnosed, have severity underestimated, and experience delays or receive fewer referrals for AV replacement (AVR). However, women tend to benefit from transcatheter AVR (TAVR) with a long-term survival advantage over men, although the incidence of vascular complications and bleeding events in 30 days after TAVR is higher in women. Surgical AVR (SAVR) in women has high operative risk, is technically demanding and has poorer outcomes with increased mortality at 30 days compared to men. According to the STS score and EuroSCORE, the female sex itself is considered a risk factor for SAVR. Therefore, addressing sex-related disparities in AS and increasing awareness among physicians promises improved diagnosis and treatment, facilitating equitable care and the development of sex-specific personalized medicine.
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- přehledy MeSH
BACKGROUND: Lung cancer is the leading cause of cancer-associated mortality worldwide. In the United Kingdom (UK), there has been a major reduction in smoking, the leading risk factor for lung cancer. Therefore, an up-to-date assessment of the trends of lung cancer is required in the UK. This study aims to describe lung cancer burden and trends in terms of incidence, prevalence, and survival from 2000-2021, using two UK primary care databases. METHODS: We performed a population-based cohort study using the UK primary care Clinical Practice Research Datalink (CPRD) GOLD database, compared with CPRD Aurum. Participants aged 18+ years, with 1-year of prior data availability, were included. We estimated lung cancer incidence rates (IRs), period prevalence (PP), and survival at 1, 5 and 10 years after diagnosis using the Kaplan-Meier (KM) method. RESULTS: Overall, 11,388,117 participants, with 45,563 lung cancer cases were studied. The IR of lung cancer was 52.0 [95% confidence interval (CI): 51.5 to 52.5] per 100,000 person-years, with incidence increasing from 2000 to 2021. Females aged over 50 years of age showed increases in incidence over the study period, ranging from increases of 8 to 123 per 100,000 person-years, with the greatest increase in females aged 80-89 years. Alternatively, for males, only cohorts aged over 80 years showed increases in incidence over the study period. The highest IR was observed in people aged 80-89 years. PP in 2021 was 0.18%, with the largest rise seen in participants aged over 60 years. Median survival post-diagnosis increased from 6.6 months in those diagnosed between 2000-2004 to 10.0 months between 2015-2019. Both short and long-term survival was higher in younger cohorts, with 82.7% 1-year survival in those aged 18-29 years, versus 24.2% in the age 90+ years cohort. Throughout the study period, survival was longer in females, with a larger increase in survival over time than in males. CONCLUSIONS: The incidence and prevalence of lung cancer diagnoses in the UK have increased, especially in female and older populations, with a small increase in median survival. This study will enable future comparisons of overall disease burden, so the overall impact may be seen.
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BACKGROUND: Lumbar paraspinal muscles (LPM) are a part of the deep spinal stabilisation system and play an important role in stabilising the lumbar spine and trunk. Inadequate function of these muscles is thought to be an essential aetiological factor in low back pain, and several neuromuscular diseases are characterised by dysfunction of LPM. The main aims of our study were to develop a methodology for LPM assessment using advanced magnetic resonance imaging (MRI) methods, including a manual segmentation process, to confirm the measurement reliability, to evaluate the LPM morphological parameters [fat fraction (FF), total muscle volume (TMV) and functional muscle volume (FMV)] in a healthy population, to study the influence of physiological factors on muscle morphology, and to build equations to predict LPM morphological parameters in a healthy population. METHODS: This prospective cross-sectional observational comparative single-centre study was conducted at the University Hospital in Brno, enrolling healthy volunteers from April 2021 to March 2023. MRI of the lumbar spine and LPM (erector spinae muscle and multifidus muscle) were performed using a 6-point Dixon gradient echo sequence. The segmentation of the LPM and the control muscle (psoas muscle) was done manually to obtain FF and TMV in a range from Th12/L1 to L5/S1. Intra-rater and inter-rater reliability were evaluated. Linear regression models were constructed to assess the effect of physiological factors on muscle FF, TMV and FMV. RESULTS: We enrolled 90 healthy volunteers (median age 38 years, 45 men). The creation of segmentation masks and the assessment of FF and TMV proved reliable (Dice coefficient 84% to 99%, intraclass correlation coefficient ≥0.97). The univariable models showed that FF of LPM was influenced the most by age (39.6% to 44.8% of variability, P<0.001); TMV and FMV by subject weight (34.9% to 67.6% of variability, P<0.001) and sex (24.7% to 64.1% of variability, P<0.001). Multivariable linear regression models for FF of LPM included age, body mass index and sex, with R-squared values ranging from 45.4% to 51.1%. Models for volumes of LPM included weight, age and sex, with R-squared values ranged from 37.4% to 76.8%. Equations were developed to calculate predicted FF, TMV and FMV for each muscle. CONCLUSIONS: A reliable methodology has been developed to assess the morphological parameters (biomarkers) of the LPM. The morphological parameters of the LPM are significantly influenced by physiological factors. Equations were constructed to calculate the predicted FF, TMV and FMV of individual muscles in relation to anthropometric parameters, age, and sex. This study, which presented LPM assessment methodology and predicted values of LPM morphological parameters in a healthy population, could improve our understanding of diseases involving LPM (low back pain and some neuromuscular diseases).
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BACKGROUND: This study highlights an unusual and previously unreported adverse event (AE) following the minimally invasive treatment of pancreatic walled-off necrosis (WON). The standard treatment for WON currently involves primary drainage via an ultrasound-guided endoscopic, typically transgastric, approach. This method is associated with lower mortality and morbidity rates compared to traditional surgery. However, emerging AEs from these procedures may necessitate the involvement of a multidisciplinary team. Our case highlights the potential for gastrovesical fistula development as a rare AE following endoscopic drainage. Treatment for our patient prioritized individualized and non-surgical strategy, although surgical revision was also considered. CASE DESCRIPTION: A 42-year-old male presented with a large symptomatic pancreatic WON refractory to conservative management, necessitating transgastric drainage. Despite the gradual evacuation of the WON contents, treatment was complicated by stent-related issues, including inadvertent bladder penetration. Rather than surgical correction, a collaborative approach among urology, gastroenterology, and surgery teams was employed, focusing on conservative treatment strategies. This approach successfully resolved the fistula, leading to the patient's full recovery. CONCLUSIONS: Given the increasing use of endoscopic transluminal drainage in (peri)pancreatic collections, it is crucial to be aware of all potential AEs. To our knowledge, this is the first documented case of gastrovesical fistula following drainage of WON. Early recognition and a multidisciplinary approach are vital to manage this event.
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BACKGROUND: Stage III non-small cell lung cancer (NSCLC) is a highly heterogeneous stage due to its subgroups (IIIA-IIIC) comprising both resectable and unresectable tumors. Accurate determination of the extent of the disease is essential for excluding stage IV and choosing the optimal treatment regimen. Whole body positron emission tomography and computed tomography scan (PET/CT) is recommended as an initial staging imaging in locally advanced NSCLC. Despite international guidelines for NSCLC diagnosis and treatment, they are not always adhered to due to various reasons. Even in such a groundbreaking study, the phase 3 trial PACIFIC investigating the efficacy of durvalumab as consolidation therapy in patients with stage III NSCLC PET/CT was not mandatory. With the premise that whole body PET/CT of the trunk is essential for diagnosing stage III NSCLC, we performed a retrospective study evaluating the relationship of the use of PET/CT versus conventional staging with CT of the chest and abdomen, in terms of survival. METHODS: This retrospective study of stage III NSCLC patients used the Czech lung cancer registry LUCAS, which was established in June 2018. As of the data export (up to February 9, 2022), a total of 703 patients were eligible for the analysis. Overall survival (OS) was compared using Kaplan-Meier analysis and a Cox regression model. Continuous variables were tested using the Mann-Whitney test, and categorical variables using the Pearson's Chi-square or Fisher's exact test. RESULTS: A total of 703 patients were included in the cohort with an average age of 69 years. PET/CT was performed on 354 patients, and conventional staging using chest and abdominal CT on 349 patients. The median OS among patients with PET/CT was 20.9 months [95% confidence interval (CI): 18.1-23.7], and it was statistically significantly higher (P<0.001) than among patients without PET/CT, where the median OS was 9.0 months (95% CI: 7.3-10.6). The observed effect of PET/CT was also statistically significant when comparing individual stages (IIIA, IIIB, IIIC). The multivariate Cox model confirmed the use of PET/CT as an independent prognostic factor. The most common reason for omission of PET/CT was the local or time unavailability of the examination. CONCLUSIONS: Omission of PET/CT can mean a significant decrement in survival for the patients in stage III NSCLC, likely due to poor staging and suboptimal treatment. Routine use of PET/CT is strictly recommended for the optimal management of stage III NSCLC patients even outside the high-income countries.
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BACKGROUND: Changes in both the vascular system and brain tissues can occur after a prior episode of coronavirus disease 2019 (COVID-19), detectable through modifications in diffusion parameters using magnetic resonance imaging (MRI) techniques. These changes in diffusion parameters may be particularly prominent in highly organized structures such as the corpus callosum (CC), including its major components, which have not been adequately studied following COVID-19 infection. Therefore, the study aimed to evaluate microstructural changes in whole-brain (WB) diffusion, with a specific focus on the CC. METHODS: A total of 101 probands (age range from 18 to 69 years) participated in this retrospective study, consisting of 55 volunteers and 46 post-COVID-19 patients experiencing neurological symptoms. The participants were recruited from April 2022 to September 2023 at the Institute for Clinical and Experimental Medicine in Prague, Czech Republic. All participants underwent MRI examinations on a 3T MR scanner with a diffusion protocol, complemented by additional MRI techniques. Two volunteers and five patients were excluded from the study due to motion artefacts, severe hypoperfusion or the presence of lesions. Participants were selected by a neurologist based on clinical examination and a serological test for COVID-19 antibodies. They were then divided into three groups: a control group of healthy volunteers (n=28), an asymptomatic group (n=25) with a history of infection but no symptoms, and a symptomatic group (n=41) with a history of COVID-19 and neurological symptoms. Symptomatic patients did not exhibit neurological symptoms before contracting COVID-19. Diffusion data underwent eddy current and susceptibility distortion corrections, and fiber tracking was performed using default parameters in DSI studio. Subsequently, various diffusion metrics, were computed within the reconstructed tracts of the WB and CC. To assess the impact of COVID-19 and its associated symptoms on diffusion indices within the white matter of the WB and CC regions, while considering age, we employed a statistical analysis using a linear mixed-effects model within the R framework. RESULTS: Statistical analysis revealed a significant difference in mean diffusivity (MD) between the symptomatic and control groups in the forceps minor (P=0.001) and CC body (P=0.003). In addition to changes in diffusion, alterations in brain perfusion were observed in two post-COVID-19 patients who experienced a severe course. Furthermore, hyperintense lesions were identified in subcortical and deep white matter areas in the vast majority of symptomatic patients. CONCLUSIONS: The main finding of our study was that post-COVID-19 patients exhibit increased MD in the forceps minor and body of the CC. This finding suggests a potential association between microstructural brain changes in post-COVID-19 patients and reported neurological symptoms, with significant implications for research and clinical applications.
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