Clinical Outcomes after Intravenous Alteplase in Elderly Patients with Acute Ischaemic Stroke: A Retrospective Analysis of Patients Treated at a Tertiary Neurology Centre in England from 2013 to 2018

Intravenous thrombolysis with alteplase within 4.5 hours from symptom onset is a well-established treatment of acute ischaemic stroke (AIS). The aim was to compare alteplase for AIS between patients aged >80 and ≤80 years in our registry data, from 2013 to 2018. Mechanical thrombectomy cases were excluded. We assessed clinical outcomes over the six-year period and between patients aged over 80 and ≤80 years, using measures including the discharge modified Rankin Scale (mRS), 24-hour National Institutes of Health Stroke Scale (NIHSS) improvement, and symptomatic intracerebral haemorrhage (sICH) rate. Of a total of 805 AIS patients who received intravenous alteplase, 278 (34.5%) were over 80 years old, and 527 (65%) were younger. 616 (76.5%) received thrombolysis ≤ 3 hours after symptom onset and 189 (23.5%) within 3-4.5 hours. Median baseline mRS and NIHSS of the elderly cohort were 1 (IQR 0-5) and 13 (IQR 2-37), respectively, compared to the younger cohort 0 (IQR 0-5) and 9 (IQR 0-29). The sICH rate was 7.2% in the elderly and 4.6% in those ≤80 years, p = 0.05 . NIHSS improved within 24 hours in 34% of the elderly cohort compared to 35% in the younger cohort. At hospital discharge, the mortality rate was 9% in the elderly cohort compared to the 6% in the younger cohort, p = 0.154 . 25% of patients aged >80 years had mRS ≤ 2 compared to 47% in the younger patients ( p < 0.0001 ). In conclusion, thrombolysis in elderly patients results in clinical improvement comparable to younger patients.

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Typical Trigeminal Neuralgia: Comparison of Results between Patients Older and Younger than 65 Years Operated on with Microvascular Decompression by Retrosigmoid Approach

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0039-1693126 ◽

2019 ◽

Vol 81 (01) ◽

pp. 028-032 ◽

Cited By ~ 1

Author(s):

Luciano Mastronardi ◽

Franco Caputi ◽

Alessandro Rinaldi ◽

Guglielmo Cacciotti ◽

Raffaelino Roperto ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Elderly Patients ◽

Microvascular Decompression ◽

Cerebrospinal Fluid Leak ◽

The Elderly ◽

Retrosigmoid Approach ◽

Younger Patients ◽

Significant Difference ◽

Elderly Cohort

Abstract Objective The incidence of typical trigeminal neuralgia (TN) increases with age, and neurologists and neurosurgeons frequently observe patients with this disorder at age 65 years or older. Microvascular decompression (MVD) of the trigeminal root entry zone in the posterior cranial fossa represents the etiological treatment of typical TN with the highest efficacy and durability of all treatments. This procedure is associated with possible risks (cerebellar hematoma, cranial nerve injury, stroke, and death) not seen with the alternative ablative procedures. Thus the safety of MVD in the elderly remains a topic of discussion. This study was conducted to determine whether MVD is a safe and effective treatment in older patients with TN compared with younger patients. Methods In this retrospective study, 28 patients older than 65 years (elderly cohort: mean age 70.9 ± 3.6 years) and 38 patients < 65 years (younger cohort: mean age 51.7 ± 6.3 years) underwent MVD via the keyhole retrosigmoid approach for type 1 TN (typical) or type 2a TN (typically chronic) from November 2011 to November 2017. A 75-year-old patient and three nonelderly patients with type 2b TN (atypical) were excluded. Elderly and younger cohorts were compared for outcome and complications. Results At a mean follow-up 26.0 ± 5.5 months, 25 patients of the elderly cohort (89.3%) reported a good outcome without the need for any medication for pain versus 34 (89.5%) of the younger cohort. Twenty-three elderly patients with type 1 TN were compared with 30 younger patients with type 1 TN, and no significant difference in outcomes was found (p > 0.05). Five elderly patients with type 2a TN were compared with eight younger patients with type 2a TN, and no significant difference in outcomes was noted (p > 0.05). There was one case of cerebrospinal fluid leak and one of a cerebellar hematoma, both in the younger cohort. Mortality was zero in both cohorts. Conclusions On the basis of our experience and the international literature, age itself does not seem to represent a major contraindication of MVD for TN.

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Endovascular treatment of acute ischaemic stroke in octogenarians and nonagenarians compared with younger patients

The Neuroradiology Journal ◽

10.1177/1971400919840847 ◽

2019 ◽

Vol 32 (4) ◽

pp. 303-308 ◽

Cited By ~ 2

Author(s):

Yasuhiro Kawabata ◽

Norio Nakajima ◽

Hidenori Miyake ◽

Shunichi Fukuda ◽

Tetsuya Tsukahara

Keyword(s):

Ischaemic Stroke ◽

Functional Outcome ◽

Scale Score ◽

Endovascular Therapy ◽

Acute Ischaemic Stroke ◽

Intravenous Thrombolysis ◽

Favourable Outcome ◽

Modified Rankin Scale ◽

Very Elderly ◽

Younger Patients

Purpose: Endovascular therapy for emergent large vessel occlusion has been established as the standard approach for acute ischaemic stroke. However, the effectiveness and safety of endovascular therapy in the very elderly population has not been proved. Objective: To determine the safety and effectiveness of endovascular therapy in octogenarians and nonagenarians. Methods: We retrospectively reviewed all patients who underwent endovascular therapy at two stroke centres between April 2012 and July 2018. Functional outcome was assessed using the modified Rankin scale at 90 days after stroke or at discharge. A favourable outcome was defined as a modified Rankin scale score of 0–2 or not worsening of the modified Rankin scale score before stroke. Outcome was compared between younger patients (aged 46–79 years, n = 40) and octogenarians and nonagenarians (aged 80–97 years, n = 19). Results: Octogenarian and nonagenarian patients had pre-stroke functional deficit (modified Rankin scale score >1) more frequently than younger patients (57.9% vs. 20.0%, respectively, P = 0.0059). No difference was observed between very elderly and younger patients in the rate of successful reperfusion (89.5% vs. 67.5%, respectively, P = 0.11), favourable functional outcome (47.4% vs. 45.0%, respectively, P = 1.00) and mortality (21.1% vs. 27.5%, respectively, P = 1.00). On multiple regression analysis, successful reperfusion, concomitant use of intravenous thrombolysis, and out-of-hospital onset were independent predictors of favourable outcome ( P = 0.0003, 0.015 and 0.028, respectively). Conclusions: Successful reperfusion, concomitant use of intravenous thrombolysis, and out-of-hospital onset were clinical predictors of favourable outcome. However, we did not observe an age-dependent effect of clinical outcome after endovascular therapy.

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Intravenous thrombolysis for acute ischaemic stroke in the elderly: data from the Baden-Wuerttemberg stroke registry

European Journal of Neurology ◽

10.1111/ene.12829 ◽

2015 ◽

Vol 23 (1) ◽

pp. 13-20 ◽

Cited By ~ 13

Author(s):

B. Reuter ◽

C. Gumbinger ◽

T. Sauer ◽

H. Wiethölter ◽

I. Bruder ◽

...

Keyword(s):

Ischaemic Stroke ◽

Acute Ischaemic Stroke ◽

Intravenous Thrombolysis ◽

The Elderly ◽

Stroke Registry

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Increasing time to thrombolysis is associated with worse long-term outcomes in patients with ischaemic stroke: a nationwide study

European Heart Journal ◽

10.1093/ehjci/ehaa946.2416 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Yafasova ◽

E.L Fosboel ◽

S.P Johnsen ◽

C Kruuse ◽

J.K Petersen ◽

...

Keyword(s):

Thrombolytic Therapy ◽

Ischaemic Stroke ◽

Acute Ischaemic Stroke ◽

Symptom Onset ◽

Intravenous Thrombolysis ◽

Treatment Delay ◽

Composite Outcome ◽

Long Term Outcomes ◽

First Time

Abstract Background It is well-established that the short-term benefits of intravenous thrombolytic therapy are reduced with increasing treatment delay in patients with acute ischaemic stroke. However, there is a paucity of contemporary data on the association between time from symptom onset to initiation of thrombolysis and long-term outcomes. With improving post-stroke survival in the Western world, data on time to thrombolysis and subsequent long-term outcomes are warranted in order to provide further insight into the importance of time to treatment. Purpose To examine the long-term risk of adverse outcomes according to time from symptom onset to intravenous thrombolytic therapy in patients with acute ischaemic stroke. Methods In this observational cohort study, we identified all patients with first-time ischaemic stroke treated with intravenous thrombolysis between 2011–2015 and alive at discharge through the Danish National Stroke Registry. Patients who received thrombolysis after >270 min were excluded. Using multivariable Cox regression, we examined associations between time from symptom onset to thrombolysis and risks of the composite of death, recurrent ischaemic stroke, and dementia, as well as each of these components separately. Patients were followed until the outcome of interest, emigration, or December 31, 2017. Results Of the 4,313 patients with first-time ischaemic stroke treated with intravenous thrombolysis, 4,119 were alive at discharge (median age 69 years [25th-75th percentile 59–78 years], 60% males). The median follow-up was 3.3 years (25th-75th percentile 2.3–4.7 years). The median time from symptom onset to initiation of thrombolytic therapy was 140 min (25th-75th percentile 106–187 min), and the median National Institutes of Health Stroke Scale score at presentation was 5 (25th-75th percentile 3–10). The unadjusted absolute 3-year risks of the composite outcome, death, recurrent ischaemic stroke, and dementia according to time to thrombolysis are displayed in the figure. Compared with thrombolysis within 90 min, time to thrombolysis >90 min was associated with a higher relative risk of the composite outcome (91–180 min: adjusted hazard ratio [HR] 1.37 [95% confidence interval [CI], 1.13–1.68]; 181–270 min: adjusted HR 1.42 [95% CI 1.15–1.76]). The risks of each component of the composite outcome according to time to thrombolysis were similar to results for the composite endpoint, as illustrated in the figure. Conclusions In this nationwide cohort of patients with acute ischaemic stroke treated with thrombolysis, increasing time from symptom onset to initiation of intravenous thrombolytic therapy was associated with higher long-term risks of the composite of death, recurrent ischaemic stroke, and dementia, as well as all three outcomes separately. These data indicate that long-term outcomes of patients with ischaemic stroke treated with intravenous thrombolysis can be greatly improved by reducing treatment delay. Time to thrombolysis and outcomes Funding Acknowledgement Type of funding source: None

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The Genetic Landscape in Elderly DLBCL Aged > 75 Years in the Australasian Leukaemia & Lymphoma Group NHL29 Iric Trial Identifies New Targetable Mutations

Blood ◽

10.1182/blood-2020-141795 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 18-20

Author(s):

Sewa Rijal ◽

Jun Hee Lim ◽

Lillian Smyth ◽

Caitlin Coombes ◽

Sanjiv Jain ◽

...

Keyword(s):

Elderly Patients ◽

Board Of Directors ◽

Clinical Outcomes ◽

Research Funding ◽

B Cell Lymphoma ◽

The Elderly ◽

Gender Ratio ◽

Advisory Committees ◽

Genetic Landscape ◽

Elderly Cohort

Background: Approximately 40% of patients with diffuse large B-cell lymphoma (DLBCL) are >70 years old and have poor clinical outcomes attributable to treatment-related factors or to disease biology. Genotyping data in elderly DLBCL patients is limited because of lack of representation in clinical trials. R-mini-CHOP is better tolerated than R-CHOP in elderly DLBCL but with reduced efficacy. The addition of ibrutinib to R-CHOP has been shown to be effective in younger pts aged < 60 years but is associated with poor tolerability and outcomes in older patients. The ALLG Ibrutinib with R-mini-CHOP (IRiC) study, a prospective multicentre single-arm phase II study in elderly (≥ 75 years) DLBCL patients provided an opportunity to genotype this uncommon cohort. We therefore aimed to map the genetic landscape of mutations in elderly DLBCL and compare them to a non-trial younger cohort. Methods: Mutations in genes commonly associated with DLBCL were assessed in 55 IRIC study patients with a median age of 81 years (75-91 years) and a gender ratio of 1.0 (27 M/28 F). A cohort of 51 non-trial patients withde novoDLBCL treated with anthracycline-based regimens was also genotyped. The median age of the control group was 65 years (29-91 years) with a gender ratio of 1.2:1 (28 M/23 F). The cell of origin (COO) measured using gene expression profiling on 39/55 trial patients (non-GC=13, GC= 22, unclassified= 4), and Hans algorithm on 45/51 non-trial patients (non-GC=14, GC=31) was comparable (p=0.571). Outcome data was available at a median follow-up of 18 and 40 months for the trial and non-trial cohorts respectively. We extracted genomic DNA from and performed next generation sequencing on diagnostic formalin-fixed paraffin-embedded or fresh frozen tissue samples using a customized capture library (SureSelectXT Target Enrichment System, Aqilent Technologies) covering genes involved in lymphomagenesis. The purified libraries were sequenced on the Illumina NextSeq500 platform at AGRF (Australian Genome Research Facility, Australia). Mutations in the following genes were compared across the two cohorts: ARID1A, BCL2, BTG1, BTG2, CARD11, CCND3, DTX1, EP300, ETS1, EZH2, FOXO1, GNA13, HIST1H1C, IKBKB, IRF8, KDM2B, KLHL6, MYC, MYD88, NOTCH1, NOTCH2, PIK3CD, PIM1, PRDM1, PTEN, PTPN21, SGK1, SPEN, STAT3, TET2, TNFAIP3, TNFRSF11A, TNFRSF14, TP53 and TRAF5. Statistical analysis for nominal data was done using the chi-square test and for ordinal data using the Kruskal-Wallis test (p < 0.05= significant). Kaplan-Meier curves were calculated for patients with and without each mutation and the curves compared using a log-rank approach. Results: Patients were divided into 2 groups, IRiC trial cohort aged >75 years (n=55) + non-trial elderly patients >75 years (n=9) =elderly cohort(n=64) and non-trialnon-elderly cohortof patients < 75 years (n=42). As expected, elderly patients were more likely to have high-risk disease with higher IPI of ≥ 3 (n=42, n=17, p=0.009). There was no significant difference in gender or COO. The frequency of mutations in the elderly (n=64) was compared to the non-elderly cohort (n=42). NOTCH2 was the most common mutation irrespective of age (34 [53%]; 16 [38%], p=0.129). Notably, we found that mutations in MYC (8 [12.5%]; 0, p= 0.021), PTEN (17 [26.5%]; 4 [9%], p=0.045) and TET2 (28 [43.7%]); 7 [16.6%], p=0.004) were more frequent in the elderly. As expected, MYD88 and CD79B mutations were more frequently associated with non-GC subtype (p=0.001). No other associations with COO were identified. No clear prognostic individual genes or gene clusters could be identified in the trial or the elderly cohort. Ibrutinib-responsive (MYD88 [L265P n=7] and CD79B [n=11]) and ibrutinib-resistant mutations (CARD11 [n=6] or PIM1 [n=12]) did not show clear associations with response rate, overall survival or progression-free survival. Conclusions: Our study found that the mutational profile of elderly DLBCL patients aged ≥ 75 years is enriched for targetable mutations in MYC, PTEN and TET2 compared to those < 75 years. PTEN and TET2 are tumour suppressors and MYC is an oncogene with an important regulatory role in cell growth and proliferation. We hypothesize that hypo-methylating agents targeting TET2, BET inhibitors in MYC mutated tumours and PI3K inhibitors to target PTEN deficient lymphoma may help improve clinical outcomes in elderly DLBCL. No clear prognostic markers were identified in this small cohort. Disclosures Trotman: Celgene:Research Funding;BeiGene:Research Funding;Takeda:Research Funding;PCYC:Research Funding;F. Hoffmann-La Roche:Research Funding.Verner:Janssen Cilag Pty Ltd.:Research Funding.Gandhi:Celgene:Research Funding;Bristol-Myers Squibb:Research Funding;Mater Research:Current Employment;Janssen-Cilag:Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding;Roche:Other: Travel, accommodation, expenses ;Genentech:Honoraria;Gilead Sciences:Honoraria;Amgen:Honoraria;Merck Sharp & Dohme:Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees.Gandhi:Integrated Sciences:Current Employment.Talaulikar:Takeda:Research Funding;Amgen:Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding;Janssen:Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau;Roche:Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

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Safety and efficacy of 90y resin microspheres in elderly (≥70 years) compared to younger patients with colorectal liver metastases (mCRC).

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.e14545 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. e14545-e14545

Author(s):

Andrew S. Kennedy ◽

David Ball ◽

Steven J. Cohen ◽

Michael Cohn ◽

Douglas M. Coldwell ◽

...

Keyword(s):

Abdominal Pain ◽

Adverse Events ◽

Elderly Patients ◽

Liver Metastases ◽

Clinical Outcomes ◽

Performance Status ◽

The Elderly ◽

Younger Patients ◽

Resin Microspheres ◽

Grade 3

e14545 Background: The effects of advanced age on the clinical outcomes following 90Y treatment in elderly patients with mCRC are relatively unknown. Methods: A retrospective review was conducted to evaluate clinical outcomes among 160 elderly (≥70 years) and 446 younger (<70 years) patients with unresectable mCRC consecutively treated using 90Y resin microspheres (SIR-Spheres; Sirtex) from July 2002 to December 2011 at 11 US institutions. Data on background characteristics, prior chemotherapy or other procedures, 90Y therapy, subsequent adverse events and survival were documented. Results: The mean age (+ SD) of the elderly patients was 77.2 + 4.85 years and 55.9 + 9.45 years in the younger cohort. Regardless of age, patients receiving 90Y treatment were very similar in the elderly and younger cohorts in terms of sex, race, ECOG performance status and other characteristics. However, elderly patients were more likely to have had their primary resected (7.1% vs. 15.1%; p=0.009), received fewer lines of chemotherapy (p=0.036; 13.1% vs. 2.8% had no prior chemo, p<0.001), a longer period between diagnosis and 90Y therapy (median 26.9 vs. 20.5 months; p=0.011), and received only one 90Y treatment (58.8% vs. 46.4%; p=0.007). Overall survival following 90Y therapy did not deteriorate in elderly patients (median 9.3 vs. 9.7 months; p=0.335). 90Y treatment was equally well tolerated in both cohorts, with no significant increase in grade 3+ adverse events in elderly patients, but significantly fewer grade 1+ events for abdominal pain (26.3% vs. 41.3%; p<0.001) and nausea (20.6% vs. 29.4%; p=0.038). The most common grade 3+ events included: abdominal pain (3.1% vs. 6.1%), GI ulceration 0.6% vs. 1.3%), nausea (0.6% vs. 1.3%), vomiting (1.3% vs. 1.3%), fatigue (5.6% vs. 4.5%), ascites (1.3% vs. 2.0%), hyperbilirubinemia (3.8% vs. 2.7%) and anorexia (0.6% vs. 0.9%). Analysis of the 98 patients ≥75 years compared to younger patients confirmed equivalent outcomes for survival and toxicity. Conclusions: For patients with unresectable mCRC liver metastases that meet eligibility criteria, 90Y therapy appears to be as effective and well-tolerated for the elderly as it is for younger candidates.

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Dabigatran initiation in patients with non-valvular AF and first acute ischaemic stroke: a retrospective observational study from the SITS registry

BMJ Open ◽

10.1136/bmjopen-2020-037234 ◽

2020 ◽

Vol 10 (5) ◽

pp. e037234

Author(s):

Irene Escudero-Martinez ◽

Michael Mazya ◽

Christine Teutsch ◽

Norbert Lesko ◽

Zuzana Gdovinova ◽

...

Keyword(s):

Ischaemic Stroke ◽

Clinical Outcomes ◽

Acute Ischaemic Stroke ◽

Demographic Data ◽

Intravenous Thrombolysis ◽

Optimal Timing ◽

Stroke Severity ◽

Stroke Index ◽

Index Event ◽

Registration Number

Background and objectiveThe optimal timing for initiation of dabigatran after acute ischaemic stroke (AIS) is not established. We aimed to evaluate initiation timing and clinical outcomes of dabigatran in AIS patients with non-valvular atrial fibrillation (NVAF).DesignRetrospective study based on prospectively collected data in SITS (Safe Implementation of Treatment in Stroke) Thrombolysis and Thrombectomy Registry from July 2014 to July 2018.ParticipantsEuropean NVAF patients (≥18 years) hospitalised after first-ever ischaemic stroke.SettingA multinational, observational monitoring register.InterventionDabigatran initiation within 3 months after the ischaemic stroke.Primary and secondary outcomesThe primary outcome was time from first-ever ischaemic stroke (index event) to dabigatran initiation. Additional outcomes included physicians’ reasons for delaying dabigatran initiation beyond acute hospital discharge and outcomes within 3 months of index event.MethodsWe identified patients with NVAF who received dabigatran within 3 months of the index event. We performed descriptive statistics for baseline and demographic data and clinical outcomes after dabigatran initiation.ResultsIn total, 1489 patients with NVAF received dabigatran after AIS treated with thrombolysis and/or thrombectomy. Of these, 1240 had available initiation time. At baseline, median age was 75 years; 53% of patients were women, 15% were receiving an oral anticoagulant, 29% acetylsalicylic acid and 4% clopidogrel. Most patients (82%) initiated dabigatran within 14 days after the index event. Patients initiating earlier had lower stroke severity from median NIHSS 8 (IQR 6–13) if initiated within 7 days to NIHSS 15 (9–19) if initiated between 28 days and 3 months. Most common reasons for delaying initiation were haemorrhagic transformation or intracranial haemorrhage, stroke severity and infarct size. Few thrombotic/haemorrhagic events occurred within 3 months after the index event (20 of 926 patients, 2.2% with the available data).ConclusionsOur findings, together with previous observational studies, indicate that dabigatran initiated within the first days after an AIS is safe in patients treated with intravenous thrombolysis, endovascular thrombectomy or both.Trial registration numberSITS Thrombolysis and Thrombectomy Registry (NCT03258645).

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Endovascular Thrombectomy in the Elderly: Do Radiological and Clinical Outcomes Differ from Those in Younger Patients? A Prospective Single-Center Experience

Cerebrovascular Diseases ◽

10.1159/000497315 ◽

2019 ◽

Vol 47 (1-2) ◽

pp. 65-71 ◽

Cited By ~ 5

Author(s):

Mehdi K. Rezai ◽

Rajiv Advani ◽

Ingvild Dalen ◽

Lars Fjetland ◽

Kathinka D. Kurz ◽

...

Keyword(s):

Elderly Patients ◽

Clinical Outcomes ◽

The Elderly ◽

Similar Efficacy ◽

Complication Rates ◽

Vessel Occlusion ◽

Younger Patients ◽

Neurological Improvement ◽

Single Center Experience ◽

Procedural Complication

Objectives: Endovascular treatment (EVT) has emerged as the gold standard therapy for stroke due to large vessel occlusion (LVO). There is however limited evidence to suggest that similar efficacy can be expected in elderly patients. We aimed to assess the efficacy and safety of EVT in elderly patients (aged > 80), comparing outcomes to younger patients (aged < 80). Material and Methods: A total of 195 patients with LVO stroke treated with EVT were included and dichotomized by age. We compared neurological improvement, clinical 90 day outcome, technical recanalization rates, procedure-related complications, and mortality in between the groups. Results: Both groups showed equally marked neurological improvement. A favorable outcome modified Rankin Scale (mRS < 2) was seen in 28% of the elderly patients compared to 46% of the younger patients (p = 0.01). mRS 0–3 was seen in 46% of the elderly patients and 58% of the younger patients (p = 0.09). The rates of successful technical recanalization did not differ between the groups and there were no differences in procedural complication rates or incidence of symptomatic intracranial bleeding. Three-month mortality rates were however higher in the elderly group. Conclusions: EVT in the elderly resulted in equally notable neurological improvement as compared to younger patients. Although the elderly had a higher mortality rate and fewer favorable clinical outcomes at 3 month follow-up, a strict upper age limit for EVT seems unjustified.

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Outcomes of endoscopic submucosal dissection for superficial esophageal cancer in an elderly population: a retrospective single center cohort study

Endoscopy International Open ◽

10.1055/a-0832-8257 ◽

2019 ◽

Vol 07 (03) ◽

pp. E355-E360 ◽

Cited By ~ 2

Author(s):

Toshiro Iizuka ◽

Daisuke Kikuchi ◽

Shu Hoteya

Keyword(s):

Esophageal Cancer ◽

Elderly Patients ◽

Endoscopic Submucosal Dissection ◽

Clinical Outcomes ◽

The Elderly ◽

Superficial Esophageal Cancer ◽

Younger Patients ◽

Submucosal Dissection ◽

Significant Difference

Abstract Background and study aims Endoscopic submucosal dissection (ESD) is increasingly being used to treat superficial esophageal cancer in the elderly. However, data on clinical outcomes in this age group are limited. The aim of this study was to evaluate the safety and efficacy of ESD in treatment of superficial esophageal cancer and its effect on long-term outcome in the elderly. Patients and methods In total, 664 consecutive patients with a histological diagnosis of squamous cell carcinoma or high-grade intraepithelial neoplasia who underwent ESD between April 2008 and March 2016 at our institution were enrolled. Clinical outcomes and prognostic factors were compared retrospectively between those aged 75 years or older (n = 162) and those aged younger than 75 years (n = 502). Results There was no significant difference in post-ESD bleeding (0 vs. 0.8 %, P = 0.27) and perforation rates (1.8 vs. 1.2 %, P = 0.47) between the two age groups; however, stricture rate was higher in younger patients than in elderly patients (20.8 % vs 11 %; P = 0.036). There was no significant difference in the rate of locoregional recurrence between the two groups. Overall survival was significantly different between the two groups, but cause-specific survival was similar. Conclusion These findings confirm the efficacy of ESD for superficial esophageal cancer in selected elderly patients (75 years or older) who were fit for the treatment because they can achieve similar long-term survival to younger patients.

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P1343DOES “FISTULA FIRST” FITS TO ELDERLY?

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p1343 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Valerio Patricia ◽

Elsa Soares ◽

Ana Farinha ◽

Teresa Furtado ◽

Catarina Abrantes ◽

...

Keyword(s):

Elderly Patients ◽

Clinical Outcomes ◽

Median Survival ◽

The Elderly ◽

Elderly Group ◽

Disease Etiology ◽

Younger Patients ◽

Surgical Interventions ◽

Comorbidity Burden ◽

The Impact

Abstract Background and Aims The incident patients on hemodialysis (HD) are becoming older. However, the optimal type of initial permanent vascular access (VA) among the elderly is controversial. Patient comorbidities and life expectancy are important considerations in whether to place an arteriovenous fistula (AVF) or graft (AVG). We design an observational study to compare clinical outcomes of elderly (≥65 year old) versus younger patients, who underwent for first VA placement before initiation of renal replacement therapy, between January 2014 and December 2018. Method We evaluated successful use of VA, requirement of surgical interventions before successful use, VA in use after the first and third months on HD and clinical outcomes, until December 2019. The comorbidity burden was calculated through age-adjusted Charlson Comorbidity Index (aCCI). We also evaluated the impact of comorbidity burden on the VA type on HD start and mortality after HD initiation. Results We identified 252 predialysis patients who underwent for VA placement in our center. We created two groups based on age at the time of VA placement: there were 199 (79,0%) with age ≥ 65 years (the elderly group), and 53 (21,0%) younger patients. The elderly group presented a mean age of 76,3 ± 6,4 (maximum of 92) years on first VA placement; in the younger group, the mean age was 54,5 ± 9,1 (minimum of 26) years. The following analysis are presented for elderly versus younger group. On both groups there were a predominance of male gender (66,8%; 73,6%; p=0,498) and caucasian race (95,0%; 88,7%; p=0,193). At time of referral for AV placement, both groups presented similar mean estimated glomerular filtration rate by CKD-EPI equation (11,7 ± 3,2; 11,2 ± 3,2 mL/Kg/1,72m2; p=0,391). Elderly group presented a significant higher aCCI (7,3 ± 1,74; 9,0 ± 1,9; p<0,001). The groups were also different in smoking status (6,0%; 30,8%; p<0,001). There were no differences on kidney disease etiology between groups, with diabetes being the most prevalent (23,1%; 24,5%; p=0,856). For all patients, the first VA placed was AVF. Only two patient placed an AVG on second and third vascular accesses. The median number of VA placed were similar between the two groups [1,0 (1 to 4); 1,0 (1 to 2); p= 0,811], likewise the occurrence of early complications (9,5%; 5,7%; p=0,583) and the need for surgical interventions (46,7%; 47,2%; p=1,000). In both groups, the majority of patients started HD (80,4%; 90,6%; p=0,103), with similar successful use of the VA (68,1%; 75,0%; p=0,474). In multivariate logistic regression, proteinuria (measured at time of referral for AV placement) and heart failure (HF) were predictors to HD initiation through a central venous catheter (CVC). This model classified correctly 74,9% of cases, with an HF odds ratio (OR) of 4,149 [confident interval (CI) of 1,721 to 10,000] and a proteinuria OR of 1,148 (CI: 1,047 to 1,259). After the first month on HD, 34,8% of elderly patients needed a CVC, a number significantly different from the younger group (15,9%; p=0,023). The same result was observed after the third month (22,2%; 7,1%; p=0,028). During the time of follow-up, the mortality rate was higher in the elderly group who started HD (log Rank test = 0,004), with a median survival of 29,3 (0,1 to 89,8) months, when compared to the younger group [median survival of 38,3 (0,1 to 76,9) months]. Conclusion There were no difference in the kind of VA on HD start (definitive VA versus CVC) between the two groups. However, elderly patients presented more fistula failure in the first three months after HD initiation. The need of CVC due to nonfunctioning AVF on the first and three months after HD initiation was higher in the elderly. The analysis of the patients who started HD showed that the elderly group presented a significant reduced survival when compared to the youngest patients.

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