Development of a model based on the age-adjusted Charlson comorbidity index to predict survival for resected perihilar cholangiocarcinoma

BACKGROUND Perihilar cholangiocarcinoma(pCCA)has a poor prognosis and urgently needs a better predictive method.The predictive value of the age-adjusted Charlson comorbidity index(ACCI)for the long-term prognosis of patients with multiple malignancies was recently reported.However,pCCA is one of the most surgically difficult gastrointestinal tumors with the poorest prognosis,and the value of the ACCI for the prognosis of pCCA patients after curative resection is unclear.AIM To evaluate the prognostic value of the ACCI and to design an online clinical model for pCCA patients.METHODS Consecutive pCCA patients after curative resection between 2010 and 2019 were enrolled from a multicenter database.The patients were randomly assigned 3:1 to training and validation cohorts.In the training and validation cohorts,all patients were divided into low-,moderate-,and high-ACCI groups.Kaplan-Meier curves were used to determine the impact of the ACCI on overall survival(OS)for pCCA patients,and multivariate Cox regression analysis was used to determine the independent risk factors affecting OS.An online clinical model based on the ACCI was developed and validated.The concordance index(C-index),calibration curve,and receiver operating characteristic(ROC)curve were used to evaluate the predictive performance and fit of this model.RESULTS A total of 325 patients were included.There were 244 patients in the training cohort and 81 patients in the validation cohort.In the training cohort,116,91 and 37 patients were classified into the low-,moderate-and high-ACCI groups.The Kaplan-Meier curves showed that patients in the moderate-and high-ACCI groups had worse survival rates than those in the low-ACCI group.Multivariable analysis revealed that moderate and high ACCI scores were independently associated with OS in pCCA patients after curative resection.In addition,an online clinical model was developed that had ideal C-indexes of 0.725 and 0.675 for predicting OS in the training and validation cohorts.The calibration curve and ROC curve indicated that the model had a good fit and prediction performance.CONCLUSION A high ACCI score may predict poor long-term survival in pCCA patients after curative resection.High-risk patients screened by the ACCI-based model should be given more clinical attention in terms of the management of comorbidities and postoperative follow-up.

Epidemiology of perforating peptic ulcer:A population-based retrospective study over 40 years

BACKGROUND The incidence of peptic ulcer disease has decreased during the last few decades,but the incidence of reported peptic ulcer complications has not decreased.Perforating peptic ulcer(PPU)is a severe form of the disease.AIM To assess trends in the incidence,presentation,and outcome of PPU over a period of 40 years.METHODS This was a single-centre,retrospective,cohort study of all patients admitted to Levanger Hospital,Norway,with PPU from 1978 to 2017.The patients were identified in the Patient Administrative System of the hospital using International Classification of Diseases(ICD),revision 8,ICD-9,and ICD-10 codes for perforated gastric and duodenal ulcers.We reviewed the medical records of the patients to retrieve data.Vital statistics were available for all patients.The incidence of PPU was analysed using Poisson regression with perforated ulcer as the dependent variable,and sex,age,and calendar year from 1978 to 2017 as covariates.Relative survival analysis was performed to compare long-term survival over the four decades.RESULTS Two hundred and nine patients were evaluated,including 113(54%)men.Fortysix(22%)patients were older than 80 years.Median age increased from the first to the last decade(from 63 to 72 years).The incidence rate increased with increasing age,but we measured a decline in recent decades for both sexes.A significant increase in the use of acetylsalicylic acid,from 5%(2/38)to 18%(8/45),was observed during the study period.Comorbidity increased significantly over the 40 years of the study,with 22%(10/45)of the patients having an American Society of Anaesthesiologists(ASA)score 4-5 in the last decade,compared to 5%(2/38)in the first decade.Thirty-nine percent(81/209)of the patients had one or more postoperative complications.Both 100-day mortality and long-term survival were associated with ASA score,without significant variations between the decades.CONCLUSION Declining incidence rates occurred in recent years,but the patients were older and had more comorbidity.The ASA score was associated with both short-term mortality and long-term survival.

Prevalence and associated factors of suicide among hospitalized schizophrenic patients

BACKGROUND Previous studies found several factors associated with suicide in schizophrenic patients,such as age,sex,education level,history of suicide attempts,psychotic symptoms,social factors,and substance abuse.However,there might be some additional factors that were not considered in previous studies but may be correlated with a greater likelihood of suicide attempts,such as medication and treatment.AIM To investigate the prevalence of suicide attempts and identify the risk of suicidality in hospitalized schizophrenia patients.METHODS This is a cross-sectional study of schizophrenic patients admitted to a psychiatric hospital who were 18 years of age or more.The outcomes and possible suicide risk factors in these patients were collated.The current suicide risk was evaluated using the mini-international neuropsychiatric interview module for suicidality and categorized as none(0 points),mild(1-8 points),moderate(9-16 points),or severe(17 or more points).This study used ordinal logistic regression to assess the association of potential risk factors with the current suicide risk in schizophrenic patients.RESULTS Of 228 hospitalized schizophrenia patients,214(93.9%)were included in this study.The majority(79.0%)of patients were males.Females appeared to have a slightly higher suicidality risk than males,with borderline significance.With regard to the current suicide risk assessed with the mini-international neuropsychiatric interview,172(80.4%)schizophrenic patients scored zero,20(9.4%)had a mild risk,8(3.7%)had a moderate risk,and 14(6.5%)had a severe risk.The total prevalence of current suicide risk in these schizophrenic patients was 19.6%.Based on multivariable ordinal logistic regression analysis with backward elimination,it was found that younger age,a current major depressive episode,receiving fluoxetine or lithium carbonate in the previous month,or a relatively higher Charlson comorbidity index score were all significantly and independently associated with a higher level of suicide risk.CONCLUSION The prevalence rate of suicide attempts in schizophrenia is high.Considering risk factors in routine clinical assessments,environmental manipulations and adequate treatment might prevent or decrease suicide in these patients.

Feasibility of gastric endoscopic submucosal dissection in elderly patients aged≥80 years

BACKGROUND Endoscopic resection,especially endoscopic submucosal dissection(ESD),is increasingly performed in elderly patients with early gastric cancer,and lesions beyond the expanded indications are also resected endoscopically in some patients.It is essential to assess whether gastric ESD is safe and suitable for elderly patients and investigate what type of lesions carry an increased risk of ESD-related complications.AIM To assess the efficacy and feasibility of gastric ESD for elderly patients,and define high-risk lesions and prognostic indicators.METHODS Among a total of 1169 sessions of gastric ESD performed in Kanagawa Cancer Center Hospital from 2006 to 2014,179 sessions(15.3%)were performed in patients aged≥80 years,and 172 of these sessions were done in patients with a final diagnosis of gastric cancer.These patients were studied retrospectively to evaluate short-term outcomes and survival.The short-term outcomes included the rates of en bloc resection and curative resection,complications,and procedurerelated mortality.Curability was assessed according to the Japanese Gastric Cancer Treatment Guidelines 2010.Fisher’s exact test was used to statistically analyze risk factors.Clinical characteristics of each group were compared using Fisher’s exact test and Mann-Whitney U test.Survival rates at each time point were based on Kaplan-Meier estimation.Overall survival rates were compared between patients with gastric cancer in each group with use of the log-rank test.To identify prognostic factors that jointly predict the hazard of death while controlling for model overfitting,we used the least absolute shrinkage and selection operator(LASSO)Cox regression model including factors curative/noncurative,age,gender,body mass index,prognostic nutritional index,Charlson comorbidity index(CCI),Glasgow prognostic score,neutrophil-to-lymphocyte ratio,and antithrombotic agent use.We selected the LASSO Cox regression model that resulted in minimal prediction error in 10-fold cross-validation.P<0.05 was considered statistically significant.RESULTS The en bloc dissection rate was 97.1%,indicating that a high quality of treatment was achieved even in elderly patients.As for complications,the rates of bleeding,perforation and aspiration pneumonitis were 3.4%,1.1%and 0.6%,respectively.These complication rates indicated that ESD was not associated with a particularly higher risk in elderly patients than in nonelderly patients.A dissection incision>40 mm,lesions associated with depressions,and lesions with ulcers were risk factors for post-ESD bleeding,and location of the lesion in the upper third of the stomach was a risk factor for perforation in elderly patients(P<0.05).Location of the lesion in the lower third of the stomach tended to be associated with a higher risk of bleeding.The overall survival(OS)did not differ significantly between curative and noncurative ESD(P=0.69).In patients without additional surgery,OS rate was significantly lower in patients with a high CCI(≥2)than in those with a low CCI(≤1)(P<0.001).CONCLUSION Gastric ESD is feasible even in patients aged≥80 years.Observation without additional surgery after noncurative ESD is reasonable,especially in elderly patients with CCI≥2.

Comparison of Charlson＇s weighted index of comorbidities with the chronic health score for the prediction of mortality in septic patients

Background Comorbidity is one of the most important determinants ot short-term and long-term outcomes in septic patients. Charlson＇s weighted index of comorbidities （WIC） and the chronic health score （CHS）, which is a component of the acute physiology and chronic health evaluation （APACHE） II, are two frequently-used measures of comorbidity. In this study, we assess the performance of WIC and CHS in predicting the hospital mortality of intensive care unit （ICU） patients with sepsis. Methods A total of 338 adult patients with sepsis were admitted to a multisystem ICU between October 2010 and August 2012. Clinical data were collected, including age, gender, underlying diseases, key predisposing causes, severity-of- sepsis, and hospital mortality. The APACHE II, CHS, acute physiology score （APS）, sequential organ failure assessment （SOFA） and WIC scores were assessed within the first 24 hours of admission. Univariate and multiple Logistic regression analyses were used to compare the performance of WlC and CHS. The area under the receiver operating characteristic curve （AUC） was used to predict hospital mortality over classes of risk. Results Of all the enrolled patients, 224 patients survived and 114 patients died. The surviving patients had significantly lower WlC, CHS, APACHE II, and SOFA scores than the non-surviving patients （P 〈0.05）. Combining WIC or CHS with other administrative data showed that the hospital mortality was significantly associated with age, severe sepsis, key predisposing causes such as pneumonia, a history of underlying diseases such as hypertension and congestive cardiac failure, and WlC, CHS and APS scores （P 〈0.05）. The AUC for the hospital mortality were 0.564 （95% confidence interval （CO 0.496-0.631） of CHS, 0.663 （95% CI 0.599-0.727） of WIC, 0.770 （95% CI 0.718-0.822） of APACHE II, 0.856 （95% Cl 0.815-0.897） of the CHS combined with other administrative data, and 0.857 （95% CI 0.817-0.897） of the WlC combined with other administrative data. The diagnostic value of WIC was better than that of CHS （P=0.0015）. Conclusions The WlC and CHS scores might be independent determinants for hospital mortality among ICU patients with sepsis. WlC might be an even better predictor of the mortality of septic patients with comorbidities than CHS. Chin Med J 2014;127 （14）： 2623-2627

Comorbidity Burden of Dementia:A Hospital-Based Retrospective Study from 2003 to 2012 in Seven Cities in China

Dementia is increasing dramatically and imposes a huge burden on society. To date, there is a lack of data on the health status of patients with dementia in China. In an attempt to investigate the comorbidity burden of dementia patients in China at the national level, we enrolled 2,938 patients with Alzheimer＇s disease（AD）, vascular dementia（Va D）, or other types of dementia, who were admitted to tertiary hospitals in seven regions of China from January2003 to December 2012. The Charlson Comorbidity Index（CCI） was used to evaluate the comorbidity burden of the patients with dementia. Among these patients, 53.4% had AD, 26.3% had Va D, and 20.3% had other types of dementia. The CCI was 3.0 ± 1.9 for all patients,3.4 ± 1.8 for those with Va D, and 3.0 ± 2.1 for those with AD. The CCI increased with age in all patients, andthe length of hospital stay and daily expenses rose with age and CCI. Males had a higher CCI and a longer stay than females. Moreover, patients admitted in the last 5 years of the study had a higher CCI than those admitted in the first 5 years. We found that the comorbidity burden of patients with dementia is heavy. These findings provide a better understanding of the overall health status of dementia patients, and help to increase the awareness of clinicians and policy-makers to improve medical care for patients.