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Surgery for oligometastatic non-small cell lung cancer: Long-term results from a single center experience.

The role of surgery in the multimodal therapy for selected stage IV oligometastatic non-small cell lung cancer (NSCLC) is still a forum of open discussion.

METHODS: We have retrospectively analyzed the records of 53 patients with oligometastatic NSCLC who had been treated with curative intent in the period January 1997 to May 2010.

RESULTS: The mean age and the male/female ratio were 61 years and 32:21, respectively. A single metastatic lesion was present in 45 (84.9%) subjects, in 2 patients there were 2 different anatomic sites involved, and in 8 patients there were 2 metastases in the same site. The most common involved sites were brain (39), followed by adrenal gland (7), bone (3), vertebrae (3), liver (1), and contralateral supraclavicular lymph node (1). Distant disease was completely resected in 42 patients; 10 patients were treated with exclusive chemotherapy and/or radiotherapy and 1 with local laser therapy. Twenty-nine patients had been administered concurrent chemoradiation in a neoadjuvant setting before the surgical treatment at the lung or both sites (primary/distant). The pulmonary resection was complete (R0) in 42 patients (79.2%). Overall, 1-, and 5-year survivals were 73.1% and 24%, respectively (median follow-up, 28 months). Median overall survival, local disease-free survival, and distant disease-free survival, estimated using the Kaplan-Meier method, were respectively 19, 72, and 12 months. After stepwise multivariate analysis, the weight loss (P < .001), the completeness of pulmonary resection (P =.0019), and, interestingly, the performance of a positron emission tomography-computed tomography scan in preoperative staging (P = .05) maintained their independent prognostic value as overall survival determinants.

CONCLUSIONS: Surgical treatment for selected stage IV NSCLC is feasible and safe. Furthermore, good survival can be expected in those patients in whom a complete resection of the primary tumor and radical control of the distant diseases are accomplished.

Asthma and COPD - The C/EBP Connection.

Asthma and chronic obstructive pulmonary disease (COPD) are the two most prominent chronic inflammatory lung diseases with increasing prevalence. Both diseases are associated with mild or severe remodeling of the airways.

In this review, we postulate that the pathologies of asthma and COPD may result from inadequate responses and/or a deregulated balance of a group of cell differentiation regulating factors, the CCAAT/Enhancer Binding Proteins (C/EBPs). In addition, we will argue that the exposure to environmental factors, such as house dust mite and cigarette smoke, changes the response of C/EBPs and are different in diseased cells. These novel insights may lead to a better understanding of the etiology of the diseases and may provide new aspects for therapies.

Venous thromboembolism in the elderly: The result of comorbid conditions or a consequence of injury?

Venous thromboembolism (VTE) is a common complication in trauma patients. Several risk factors have been identified that may place patients at in increased risk for VTE including preexisting medical conditions, iatrogenic factors, and injury-related factors. Advanced age has also been implicated as a risk factor for VTE. The purpose of this study was to determine the incidence and outcomes of VTE in geriatric trauma patients as well as to identify risk factors for VTE in this population.

METHODS : We performed a 10-year retrospective review of all trauma patients aged 65 years or older discharged with a diagnosis of VTE. Demographic data, injuries, mechanism, Injury Severity Score, Abbreviated Injury Score, Glasgow Coma Scale, length of stay, and mortality were collected.

RESULTS : Of 2,521 trauma patients aged 65 years or older, 82 (3.2%) were diagnosed with VTE. Seventy-two of 82 patients were diagnosed with deep vein thrombosis, and pulmonary embolism was found in 8 patients. Two patients had both a deep vein thrombosis and pulmonary embolism. Independent predictors of VTE included traumatic brain injury (p < 0.05); chest Abbreviated Injury Score ≥3 (p < 0.001); mechanical ventilation (p < 0.001); major operation (p < 0.001); and history of VTE (p = 0.05). Other comorbid conditions were not significantly associated with VTE. Preinjury anticoagulation had a trend toward a protective effect. Although length of stay was longer in patients with VTE (adjusted mean difference 14.7 days, p < 0.001), mortality for patients with and without VTE was 8.5% and 7.0%, respectively (p = 0.59).

CONCLUSION : VTE is associated with prolonged length of stay and duration of mechanical ventilation as well as continued medical dependence after discharge. Several risk factors place the elderly trauma patient at an increased risk for VTE, and trauma or injury-related risk factors seem to have a greater impact on the development of VTE in comparison to underlying conditions or increasing patient age (>65 years).

Prospective Study of the Incidence of Contrast-induced Nephropathy Among Patients Evaluated for Pulmonary Embolism by Contrast-enhanced Computed Tomography.

Objectives:  Contrast-enhanced computed tomography (CECT) of the pulmonary arteries (CTPA) has become the mainstay to evaluate patients with suspected pulmonary embolism (PE) and is one of the most common CECT imaging studies performed in the emergency department (ED). While contrast-induced nephropathy (CIN) is a known complication, this risk is not well defined in the ED or other ambulatory setting. The aim of this study was to define the risk of CIN following CTPA.

Methods: The authors enrolled and followed a prospective, consecutive cohort (June 2007 through January 2009) of patients who received intravenous (IV) contrast for CTPA in the ED of a large, academic tertiary care center. Study outcomes included 1) CIN defined as an increase in serum creatinine (sCr) of 0.5ƒmg/dL or 25%, 2 to 7ƒdays following contrast administration; and 2) severe renal failure defined as an increase in sCr to 3.0ƒmg/dL or the need for dialysis within 45days and/or renal failure as a contributing cause of death at 45ƒdays, determined by the consensus of three independent physicians.

Results: A total of 174 patients underwent CTPA, which demonstrated acute PE in 12 (7%, 95% confidence interval [CI]ƒ=ƒ3% to 12%). Twenty-five patients developed CIN (14%, 95% CIƒ=ƒ10% to 20%) including one with acute PE. The development of CIN after CTPA significantly increased the risk of the composite outcome of severe renal failure or death from renal failure within 45ƒdays (relative riskƒ=ƒ36, 95% CIƒ=ƒ3 to 384). No severe adverse outcomes were directly attributable to complications of venous thromboembolism (VTE) or its treatment.

Conclusions:‚ In this population, CIN was at least as common as the diagnosis of PE after CTPA; the development of CIN was associated with an increased risk of severe renal failure and death within the subsequent 45ƒdays. Clinicians should consider the risk of CIN associated with CTPA and discuss this risk with patients.

Thromboembolic complications of heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is an adverse effect of heparin therapy which can be responsible for thrombotic events with embolic consequences. Although ischemic stroke is a well known consequence of HIT, few cases of cerebral ischemia of arterial origin have been reported so far.

A 38-year-old man was admitted because of acute multiple ischemic strokes and pulmonary embolism which occurred during treatment with low molecular weight heparin as prophylactic therapy for orthopedic surgery. Neuroimaging showed occlusion of the right common carotid artery with multiple acute cerebral infarcts. Testing for anti-platelet factor 4 antibodies confirmed the diagnosis.

Systematic review of the literature revealed 55 cases of arterial stroke and three cases of carotid artery occlusion caused by HIT. Although arterial ischemic stroke is a rare complication of HIT, a high level of suspicion and a prompt diagnosis of this coagulation disorder are necessary to avoid life-threatening thromboembolic complications.

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