Wallace, Robert B.

Two cases of severe neurologic symptoms after a Blalock-Taussig anastomosis are presented in detail. The histories of 116 patients with cyanotic congenital heart disease who had such an anastomotic operation at the Mayo Clinic were reviewed. There was a low incidence (less than 1%) of postoperative neurologic complications in patients without evidence of focal dysfunction of the central nervous system prior to operation. The review suggested an increased incidence of complications in those patients with a cerebrovascular abnormality before surgery. It is likely that these complications are related to alterations in the vertebrobasilar arterial system associated with this procedure.

e19065 Background: Treatment decisions for patients with advanced stage (stages IIIB and IV) non-small cell lung cancer (AS NSCLC) are influenced by comorbidity at time of diagnosis. We studied the effects of comorbidity on survival and whether effects differ for short-term (120 days) vs. for long-term (>120 days) survival. Methods: Data were from surveys and medical records of 1498 patients withnewly diagnosed AS NSCLC in the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS). Respiratory disease severity and comorbidities at diagnosis were measured from the Adult Comorbidity Evaluation (ACE-27) index and model fitting used the Akaike Information Criteria. The log-rank test was used for univariable survival models, and Cox proportional hazards regression for multivariable survival models. Results: Five comorbidities were significantly associated with survival and 437 (29.2%) patients had one or more of these. Survival to 120 days was significantly poorer for patients with a baseline diagnosis of stroke [hazard ratio (HR) 1.92; 95% confidence interval (CI) 1.26–2.93], diabetes (HR 1.33, 95% CI 1.08–1.65), or congestive heart failure (HR 1.45, 95% CI 1.07–1.96), controlling for age, gender, smoking status, stage, severe respiratory disease, and brain metastases. Given survival to 120 days (885 pts, 59%), survival beyond that was significantly poorer only for patients with baseline arrhythmia (HR 1.47, 95% CI 1.15–1.87) or end stage renal disease (HR 1.82, 95% CI 1.09–3.04), controlling for the covariates above. Adjustment for chemotherapy use had no effect on these associations. Conclusions: Several comorbidities present at diagnosis affected survival for AS NSCLC, with some comorbidities having a more immediate relationship to survival than others. Our finding provides information that could be used to tailor treatment decisions to patients’ comorbidities at diagnosis.

BACKGROUNDPrior evidence of a possible link between vitamin D status and hematologic malignancy (HM) in humans comes from observational studies, leaving unresolved the question of whether a true causal relationship exists.METHODSThe authors performed a secondary analysis of data from the Women's Health Initiative Calcium/Vitamin D (CaD) trial, a large randomized controlled trial of CaD supplementation compared with placebo in older women. Kaplan‐Meier and Cox proportional hazards survival analysis methods were used to evaluate the relationship between treatment assignment and 1) incident HM and 2) HM‐specific mortality over 10 years following randomization. HMs were classified by cell type (lymphoid, myeloid, or plasma cell) and analyzed as distinct endpoints in secondary analyses.RESULTSA total of 34,763 Women's Health Initiative CaD trial participants (median age, 63 years) had complete baseline covariate data and were eligible for analysis. Women assigned to CaD supplementation had a significantly lower risk of incident HM (hazard ratio [HR], 0.80; 95% confidence interval [95% CI], 0.65‐0.99) but not HM‐specific mortality (HR, 0.77 [95% CI, 0.53‐1.11] for the entire cohort; and HR, 1.03 [95% CI, 0.70‐1.51] among incident HM cases after diagnosis). In secondary analyses, protective associations were found to be most robust for lymphoid malignancies, with HRs of 0.77 (95% CI, 0.59‐1.01) and 0.46 (95% CI, 0.24‐0.89), respectively, for cancer incidence and mortality in those assigned to CaD supplementation.CONCLUSIONSThe current post hoc analysis of data from a large and well‐executed randomized controlled trial demonstrates a protective association between modest CaD supplementation and HM risk in older women. Additional research concerning the relationship between vitamin D and HM is warranted. Cancer 2017;123:4168–4177. © 2017 American Cancer Society.

584 Background: Standard therapy for stage II/III rectal cancer includes surgery, radiation, and chemotherapy. Multiple trials demonstrated neoadjuvant chemoradiation (CRT) provides better local control and decreased morbidity compared to adjuvant CRT, though differences in overall survival and long-term QoL have not been demonstrated. We examined impact of treatment (pre-op CRT/post-op CRT/no CRT) on long-term QoL. Methods: CanCORS patients with survey/medical record data diagnosed in 2003-2005 with stage II/III rectal (non-rectosigmoid) cancer had resection and survived > 7 years were included. QoL (SF-36, EQ-5D) measures and defecation problems were derived from surveys at 14 months and 7 years post-diagnosis. Mean scores were adjusted for the following when significant: age, gender, stage, sphincter preservation, comorbidities, and baseline self-reported health status and QoL scores. Results: Of 119 patients, 53% received pre-op CRT, 23% post-op CRT, and 24% no CRT. Of 114 patients with 14-month follow-up, Pre-op CRT and No CRT groups had better EQ-5D adjusted mean scores but worse defecation scale (DS) scores compared to the Post-op CRT group. Of 49 disease-free survivors with 7 years follow-up, there were no differences among groups in QoL scores, but the No CRT group had better DS scores than other groups. Conclusions: No major differences were detected in long-term QoL based on treatment aside from the DS, though sample sizes became small. Regardless of treatment, long term (7y) mental health and vitality were generally comparable to U.S. norms, while physical health and overall health status (EQ-5D) were somewhat lower. [Table: see text]

Neoadjuvant treatment may result in better quality of life and functional status 1 year after diagnosis.

Twenty-two patients had ventricular septal rupture complicating acute myocardial infarction. Sixteen of the 22 patients underwent surgical repair. The clinical findings, catheterization data, and operative results suggest that closure of the rupture should be delayed when possible from three to six weeks after the infarction to allow firm fibrous healing of the region. When surgery is thus delayed, the operative risks are smaller and the long-term results are good.

Six years have passed since the first successful surgical correction of truncus arteriosus. A review of our experience enables some conclusions regarding the operation. Patients with mild or moderate truncal valve incompetence do not need truncal valve replacement. Patients with severe truncal valve incompetence require valve replacement, which is associated with a significantly increased surgical mortality. The surgical mortality is not increased in hemodynamically favorable patients who have only one pulmonary artery. However, these patients are especially likely to have early development of severe pulmonary vascular disease. The surgical mortality for the patient with uncomplicated disease and two pulmonary arteries, with pulmonary resistance of less than 8.0 units m 2 , is 10%. In patients with pulmonary resistance between 8.0 and 12 units m 2 , the mortality is approximately three times greater. Patients with pulmonary resistances greater than 12.0 units m 2 are probably inoperable. Different hemodynamic criteria must be applied in assessing the operability of patients with a single pulmonary artery. A systemic arterial oxygen saturation less than 85% in a patient with two pulmonary arteries and without pulmonary artery stenosis or a pulmonary artery band usually indicates inoperability. Elective operation usually is deferred until a patient is four years old, but if the patient's clinical condition warrants, the procedure can be done at any time after the age of one year, with a good chance of success. Follow-up on most operated patients has been encouraging.

Fifty patients underwent correction of one or two valvular lesions with concomitant insertion of one to three aortocoronary vein bypass grafts. Hospital mortality was 14% and late mortality was 10%. Factors influencing operative mortality were: (1) mitral valve replacement after myocardial infarction; (2) complete obstruction of a coronary artery preoperatively; (3) high left ventricular end-diastolic pressure at rest preoperatively in patients with mitral valve disease; and (4) use of a single aortocoronary graft in the presence of multiple-vessel disease. For patients with significant associated valvular and coronary artery disease, combined correction yields results that appear sufficiently encouraging, judged by mortality and follow-up, to warrant its continued use in selected cases.

One hundred sixty-nine patients underwent replacement of the aortic valve with an aortic valve homograft; of these patients 17 had concomitant commissurotomy or annuloplasty for an associated mitral valve lesion. Homografts were prepared by sterilization with beta-propiolactone solution and stored in Hanks' solution, or were prepared by sterilization with irradiation and stored at -70 C. Operative mortality was 5.3%. Thirty (19%) of the 160 surviving patients had an aortic diastolic murmur at the time of hospital dismissal, and five of these patients had hemodynamically significant homograft incompetence. For 156 patients, follow-up was longer than 6 months; among the 147 patients who survived operation, there were 12 late deaths. Eighty-four per cent (132) of these 156 patients were alive and well 6 to 54 months after operation. Six patients have required reoperation for valve incompetence. An aortic diastolic murmur was present in 43% of patients. Five patients had significant valve incompetence; four of these patients are markedly improved over their preoperative status. Thromboembolism has been a rare complication despite the fact that anticoagulant therapy was not used. Late calcification of the homograft valve has been noted in only one patient.