Jr-Rung Lin

Can neutrophil-to-lymphocyte ratio predict the survival of colorectal cancer patients who have received curative surgery electively?

PurposeWe evaluated the effect of neutrophil-to-lymphocyte ratio (NLR) on disease-free survival in patients with stages I to III colorectal cancer (CRC).MethodsThere were 3857 patients identified from our database. We used receiver operating characteristic (ROC) analysis to identify the best cutoff value of NLR. A 5-year disease-free survival was used as end point. Survival analysis was used to assess the NLR effect, after stratification by several clinopathologic factors.ResultsIn the ROC analysis, NLRu2009=u20093 had the highest sensitivity and specificity. Elevated NLR (>3) in colon cancer seemed to accompany larger tumor size (≧5xa0cm) and more advanced T stage. By multivariate analysis, elevated NLR in colon cancer was associated with an increased risk of disease progression or cancer death [hazard ratio (HR) 1.377, 95u2009xa0% confidence interval 1.104–1.717, Pu2009=u20090.014]. However, elevated NLR in rectal cancer lost its significance in multivariate analysis (HR 1.121, 95u2009xa0% confidence interval 0.941–1.336, Pu2009=u20090.200). Patients with elevated NLR had worse outcome, especially for colon cancer.ConclusionsPreoperative NLR influenced the disease-free survival in patients with stages I to III CRC. Elevated NLR (>3) was associated with worse outcome (5-year disease-free survival 66.3u2009xa0% vs. 78.9u2009xa0% in colon cancer, Pu2009<u20090.001; 60.u20095xa0% vs. 66.2u2009xa0% in rectal cancer, Pu2009=u20090.008). The difference was larger in colon cancer than in rectal cancer. NLR should be considered as a prognostic factor for stages I to III CRC patients after curative surgery.

Dehydration is an independent predictor of discharge outcome and admission cost in acute ischaemic stroke

Our aim was to investigate the influence of admission dehydration on the discharge outcome in acute ischaemic and hemorrhagic stroke.

Effects of aging and hypertension on cerebral ischemic susceptibility: Evidenced by MR diffusion-perfusion study in rat

Aging is the most significant non-modifiable risk factor and hypertension is the most significant modifiable risk factor for ischemic stroke. We used magnetic resonance imaging (MRI) to investigate the evidence of ischemic susceptibility after aging and hypertension. Four groups of rat were studied: young normotensive Wistar-Kyoto (WKY) rat, aged normotensive WKY rat, young spontaneously hypertensive rat (SHR) and aged SHR. Brain images were acquired at a 3.0T Tim-Trio MRI system. For diffusion-weighted images, apparent diffusion coefficient (ADC) was measured. Relative cerebral blood flow (CBF) was also calculated. Cerebral ischemic susceptibility was examined by using ischemic model of bilateral common carotid artery occlusion. In the MRI study of non-ischemic rat, aged SHR had significantly higher ADC (P<0.01) and significantly lower CBF (P<0.01) in the parietal cortex, but aged WKY rat had only significantly lower CBF (P<0.01) when compared with young WKY rat. The ADC/CBF ratio in the parietal cortex was significantly higher in aged SHR when compared with young WKY rat, young SHR and aged WKY rat (P<0.01, P<0.05, P<0.05, respectively) suggesting a significant diffusion-perfusion disparity in aged SHR. After bilateral common carotid artery occlusion, there was significantly larger damage in the parietal cortex of aged SHR when compared with young WKY rat, young SHR and aged WKY rat (all P<0.05), but not in the hippocampus and thalamus (P>0.05). Our study demonstrated a significantly increased ADC value and reduced CBF in the ischemia-vulnerable cortical area. This cerebral diffusion-perfusion disparity is seen mainly in aged rat and can be more evident if associated with hypertension indicating an increased susceptibility of brain tissue to ischemic injury.

Bispectral Index in Evaluating Effects of Sedation Depth on Drug-Induced Sleep Endoscopy.

OBJECTIVEnTo evaluate the effect of sedation depth on drug-induced sleep endoscopy (DISE).nnnMETHODSnNinety patients with obstructive sleep apnea (OSA) and 18 snorers underwent polysomnography and DISE under bispectral index (BIS)-guided propofol infusion at two different sedation levels: BIS 65-75 (light sedation) and 50-60 (deep sedation).nnnRESULTSnFor the patients with OSA, the percentages of velopharynx, oropharynx, hypopharynx, and larynx obstructions under light sedation were 77.8%, 63.3%, 30%, and 33.3%, respectively. Sedation depth was associated with the severity of velopharynx and oropharynx obstruction, oropharynx obstruction pattern, tongue base obstruction, epiglottis anteroposterior prolapse and folding, and arytenoid prolapse. In comparison, OSA severity was associated with the severity of velopharynx obstruction, severity of oropharynx obstruction, and arytenoid prolapse (odds ratio (95% confidence interval); 14.3 (4.7-43.4), 11.7 (4.2-32.9), and 13.2 (2.8-62.3), respectively). A good agreement was noted between similar DISE findings at different times and different observers (kappa value 0.6 to 1, respectively). A high percentage of arytenoid prolapse (46.7% among the patients with OSA under light sedation) was noted.nnnCONCLUSIONSnGreater sedative depth increased upper airway collapsibility under DISE assessment. DISE under BIS-guided propofol infusion, and especially a level of 65-75, offers an objective and reproducible method to evaluate upper airway collapsibility. Some findings were induced by drug sedation and need careful interpretation. Specific arytenoid prolapse patterns were noted for which further investigations are warranted.nnnCLINICAL TRIALS REGISTRATIONnhttp://www.clinicaltrials.gov, identifier: NCT01100554.nnnCOMMENTARYnA commentary on this article appears in this issue on page 965.

Inference on treatment effects for targeted clinical trials under enrichment design

After completion of a human genome project, the disease targets at molecular level can be identified. As a result, treatment modality for molecular targets can be developed. In practice, targeted clinical trials are usually conducted for evaluation of the possibility and feasibility of the individualized treatment of patients. However, the accuracy of diagnostic devices for identification of such molecular targets is usually not perfect. Therefore, some of the patients enrolled in targeted clinical trials with a positive result by the diagnostic device might not have the specific molecular targets and hence the treatment effects of the targeted drugs estimated from targeted clinical trials could be biased for the patient population truly with the molecular targets. Under an enrichment design for targeted clinical trials, we propose to use the EM algorithm and bootstrap method for obtaining the inference of the treatment effects of the targeted drugs in the patient population truly with molecular targets. A simulation study was conducted to empirically investigate the bias and variability of the proposed estimator and the size and power of the proposed testing method. Simulation results demonstrate that the proposed estimator is unbiased with adequate precision and the confidence interval can provide satisfactory coverage probability. In addition, the proposed testing procedure can adequately control the size with sufficient power. A practical example illustrates the utility of the proposed method.

The use of complementary and alternative medicine by patients with chronic hepatitis C.

BACKGROUNDnThe use of complementary and alternative medicine (CAM) is expanding globally. However, prevalence of its use by patients with chronic hepatitis C (CHC) remains unclear.nnnMETHODSnAn exploratory, descriptive study was conducted using a questionnaire and interview to describe the use of CAM by patients with CHC attending a liver clinic in the United States.nnnRESULTSnEighty percent (n = 120) had used CAM in the last 12 months, most often prayer for health reasons (63%), multivitamins (56%) and herbal medicine (25%). A higher level of education (p < 0.005), poorer health status (p < 0.002) and prior use of anti-viral therapy (p < 0.02) were predictors of CAM use. Participants used CAM to promote general health, but herbal medicine was used to treat CHC symptoms and prevent liver disease.nnnCONCLUSIONnUse of CAM is common among patients with CHC. Failure to acknowledge the use of CAM as a management strategy may restrict the health providers ability to provide optimal care.

Recipient Age and Mortality Risk after Liver Transplantation: A Population-Based Cohort Study

The aim of the present large population-based cohort study is to explore the risk factors of age-related mortality in liver transplant recipients in Taiwan. Basic information and data on medical comorbidities for 2938 patients who received liver transplants between July 1, 1998, and December 31, 2012, were extracted from the National Health Insurance Research Database on the basis of ICD-9-codes. Mortality risks were analyzed after adjusting for preoperative comorbidities and compared among age cohorts. All patients were followed up until the study endpoint or death. This study finally included 2588 adults and 350 children [2068 (70.4%) male and 870 (29.6%) female patients]. The median age at transplantation was 52 (interquartile range, 43–58) years. Recipients were categorized into the following age cohorts: <20 (n = 350, 11.9%), 20–39 (n = 254, 8.6%), 40–59 (n = 1860, 63.3%), and ≥60 (n = 474, 16.1%) years. In the total population, 428 deaths occurred after liver transplantation, and the median follow-up period was 2.85 years (interquartile range, 1.2–5.5 years). Dialysis patients showed the highest risk of mortality irrespective of age. Further, the risk of death increased with an increase in the age at transplantation. Older liver transplant recipients (≥60 years), especially dialysis patients, have a higher mortality rate, possibly because they have more medical comorbidities. Our findings should make clinicians aware of the need for better risk stratification among elderly liver transplantation candidates.

Statistical Methods for Targeted Clinical Trials under Enrichment Design

BACKGROUND/PURPOSEnAfter completion of the Human Genome Project, disease targets at the molecular level can be identified. Treatment for these specific targets can be developed with the individualized treatment of patients becoming a reality. However, the accuracy of diagnostic devices for molecular targets is not perfect and statistical inference for treatment effects of the targeted therapy is biased. We developed statistical methods for an unbiased inference for the targeted therapy in patients who truly have the molecular targets.nnnMETHODSnUnder the enrichment design, for binary data, we propose using the expectation maximization (EM) algorithm with the bootstrap method, to incorporate the inaccuracy of the diagnostic device for detection of the molecular targets for inference of the treatment effects. A simulation study was conducted to empirically investigate the performance of the proposed estimation and testing procedures. A numerical example illustrates the application of the proposed method.nnnRESULTSnSimulation results demonstrated that the proposed estimation method was unbiased, with adequate precision, and the confidence interval provided satisfactory coverage probability. The proposed testing procedure adequately controlled the size with sufficient power. The numerical example showed that a statistically significant treatment effect could be obtained when the inaccuracy of the diagnostic device was taken into account.nnnCONCLUSIONnOur proposed estimation and testing procedures are adequate statistical methods for the inference of the treatment effect for patients who truly have the molecular targets.

Incidence and Outcomes of Acute Renal Failure Following Liver Transplantation: A Population-Based Cohort Study.

AbstractThe aim of our large, population-based, cohort study was to explore the risk factors of acute renal failure (ARF) after liver transplant (LT) in Taiwan.From the Taiwanese National Health Insurance Research Database, 2862 patients who had undergone LT without pretransplant dialysis between July 1, 1998, and December 31, 2012, were identified. Preoperative, operative, and perioperative risks factors were considered and analyzed using logistic regression analysis, after adjusting for age and sex. All patients were followed up until the study endpoint or death.The final dataset included 214 patients with ARF and 2648 without ARF post-LT. Preoperative cerebrovascular diseases were the most important identifiable risk factor for ARF post-LT. Comparison of outcomes for patients “with” and “without” ARF indicated higher incidence rates of bacteremia, pneumonia, and postoperative bleeding, as well as longer stays in both intensive care unit and hospital. Kaplan–Meier mortality curves identified higher rates of mortality for patients’ developing ARF at 1-year post-LT and overall at 14.5 years postsurgery.We provide evidence of a high incidence of ARF post-LT in Taiwan, with documented association of ARF with higher incidence rates of morbidity and mortality in this clinical population. The most important identifiable risk factor for ARF in our study was cerebrovascular diseases.

An outcome prediction model for exsanguinating patients with blunt abdominal trauma after damage control laparotomy: a retrospective study

BackgroundWe present a series of patients with blunt abdominal trauma who underwent damage control laparotomy (DCL) and introduce a nomogram that we created to predict survival among these patients.MethodsThis was a retrospective study. From January 2002 to June 2012, 91 patients underwent DCL for hemorrhagic shock. We excluded patients with the following characteristics: a penetrating abdominal injury, age younger than 18 or older than 65xa0years, a severe or life-threatening brain injury (Abbreviated Injury Scale [AIS]u2009≥u20094), emergency department (ED) arrival more than 6xa0hours after injury, pregnancy, end-stage renal disease, or cirrhosis. In addition, we excluded patients who underwent DCL after ICU admission or later in the course of hospitalization.ResultsThe overall mortality rate was 61.5%: 35 patients survived and 56 died. We identified independent survival predictors, which included a preoperative Glasgow Coma Scale (GCS) scoreu2009<u20098 and a base excess (BE) valueu2009<u2009-13.9xa0mEq/L. We created a nomogram for outcome prediction that included four variables: preoperative GCS, initial BE, preoperative diastolic pressure, and preoperative cardiopulmonary cerebral resuscitation (CPCR).ConclusionsDCL is a life-saving procedure performed in critical patients, and devastating clinical outcomes can be expected under such dire circumstances as blunt abdominal trauma with exsanguination. The nomogram presented here may provide ED physicians and trauma surgeons with a tool for early stratification and risk evaluation in critical, exsanguinating patients.