ABSTRACT
Objective:To investigate the predictive value of Charlson comorbidity index (CCI) in the operative prognosis of colorectal cancer (CRC).Methods:The retrospective cohort study was conducted. The clinicopathological data of 1 337 CRC patients who underwent surgery in the First Affiliated Hospital of Xi'an Jiaotong University from January 2013 to February 2019 were collected. There were 774 males and 563 females, aged 62(range, 22?80)years. All patients were evaluated by CCI. Observation indicators: (1) clinicopathological characteristics of CRC patients undergoing operation; (2) follow-up and survival; (3) prognostic factors analysis of CRC patients undergoing operation; (4) establishment and evaluation of a nomogram prediction model based on CCI. Follow-up was conducted using the telephone interview or outpatient examination to detect the survival of patients up to March 2020. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the t test. Measurement data with skewed distribution were described as M(range) or M( Q1, Q3), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test. Non-para-meter rank sum test was used for comparison of ordinal data. The Kaplan‐Meier method was used to calculate survival rates and draw survival curves, and Log-Rank test was used for survival analysis. Univariate and multivariate analyses were performed using the COX proportional hazard regression model. The independent risk factors were included into R4.0.4 software to construct a nomogram prediction model. The receiver operating characteristic (ROC) curve was drawn, and the area under curve (AUC) was used to evaluate discrimination of the nomogram prediction model. The C-index and calibration chart were used to evaluate consistency of the nomogram prediction model. Results:(1) Clinicopathological characteristics of CRC patients undergoing operation. Of the 1 337 patients, there were 1 041 cases with CCI ≤3 and 296 cases with CCI ≥4. Age, cases with non-smoking history, smoking cessation or smoking history, cases without or with R 0 resection, cases with low, moderate, well differentiated tumor, cases in stage Ⅰ?Ⅱ or Ⅲ?Ⅳ of clinical TNM staging, preoperative carcinoembryonic antigen (CEA) were 61(53,68)years, 717, 43, 281, 12, 1 029, 123, 859, 59, 666, 375, 3.22(1.84,7.75)μg/L for the 1 041 patients with CCI ≤3, versus 70(61,75)years, 217, 19, 60, 43, 253, 48, 237, 11, 102, 194, 5.55(2.43,17.64)μg/L for the 296 patients with CCI ≥4, showing significant differences in the above indicators between them ( Z=?10.50, χ2=7.34, 104.51, Z=?2.31, χ2=82.14, Z=?5.78, P<0.05). (2) Follow-up and survival. All the 1 337 patients were followed up for 31(range, 1?84)months. Of the 1 337 patients, 1 024 cases survived and 313 cases died. The 1-, 3-, 5-year survival rates were 94.8%, 85.5%, 80.1% for the 1 041 patients with CCI ≤3, versus 73.6%, 46.9%, 34.0% for the 296 patients with CCI ≥4, showing significant differences between them ( χ2=181.93, P<0.05). (3) Prognostic factors analysis of CRC patients undergoing operation. Results of univariate analysis showed that age, smoking history (having a history of smoking), tumor location (decending colon-sigmoid colon, recto-sigmoid junction-rectum), R 0 resection, tumor differentiation degree (moderate differentiation, well differentiation), clinical TNM staging, postoperative radio-therapy and chemotherapy, preoperational CEA and CCI were related factors for operative prognosis of CRC patients ( odds ratios=1.76, 0.71, 0.72, 0.61, 0.08, 0.39, 0.13, 3.02, 0.60, 2.41, 4.96, 95% confidence intervals as 1.39?2.23, 0.53?0.93, 0.52?0.99, 0.47?0.78, 0.06?0.11, 0.30?0.50, 0.05?0.31, 2.39?3.81, 0.48?0.76, 1.92?3.01, 3.97?6.20, P<0.05). Results of multivariate analysis showed that age >60 years, clinical TNM staging as stage Ⅲ?Ⅳ, preoperational CEA >5 μg/L and CCI ≥4 were independent risk factors for operative prognosis of CRC patients ( odds ratios=1.29, 1.88, 1.77, 2.84, 95% confidence intervals as 1.00?1.65, 1.45?2.44, 1.40?2.23, 2.20?3.67, P<0.05);tumor located in descending colon to sigmoid colon and recto-sigmoid junction to rectum, R 0 resection,tumor differen-tiation degree as moderate and well differentiation, postoperative radiotherapy and chemotherapy were independent protect factors for operative prognosis of CRC patients ( odds ratios=0.71, 0.72, 0.27, 0.50, 0.25, 0.56, 95% confidence intervals as 0.51?0.98, 0.56?0.93, 0.19?0.37, 0.38?0.65, 0.10?0.62, 0.44?0.70, P<0.05) (4) Establishment and evaluation of a nomogram prediction model based on CCI. Based on age, tumor location, R 0 resection, tumor differentiation degree, clinical TNM staging, postoperative radiotherapy and chemotherapy, preoperational CEA and CCI of multivariate analysis results, a nomogram prediction model for operative prognosis of CRC patients was established. The nomogram score was 1.0 for age >60 years, 18.0 for tumor located in proximal colon, 9.0 for tumor located in distal colon, 53.0 for non-R 0 resection, 62.0 for low differentiated tumor, 31.0 for morderate differentiated tumor, 32.0 for stage Ⅲ?Ⅳ of clinical TNM staging, 26.0 for no postoperative radiotherapy and chemotherapy, 4.6 for each increase of 100 μg/L in preoperative CEA and 12.6 for each increase of 1 score in CCI respectively. The total of different scores for risk factors was used to evaluate total 1, 3, 5-year survival rates. The ROC curve was drawn to evaluate the predictive ability for prognosis of nomogram model, with the AUC as 0.75 (95% confidence interval as 0.71?0.79, P<0.05). The C-index was 0.80 (95% confidence interval as 0.77?0.72). The calibration chart showed a good consistency between the probability of survival predicted by nomogram and the actual probability of survival. Conclusions:Age >60 years, stage Ⅲ?Ⅳ of clinical TNM staging, preoperational CEA >5 μg/L and CCI ≥4 are independent risk factors for operative prognosis of CRC patients. Tumor located in descending colon to sigmoid colon and recto-sigmoid junction to rectum, R 0 resection, tumor differentiation degree as moderate and well differentiation, postoperative radiotherapy and chemotherapy are independent protective factors for operative prognosis of CRC patients. The nomogram prediction model contributes to prediction of the survival of CRC patients.
ABSTRACT
Objective@#To investigate the effect of nimodipine combined with cerebrospinal fluid replacement on hemoglobin concentration, Toll-like receptor 4 (TLR4) expression level and cerebral vasospasm (CVS) in patients with CVS after aneurysmal subarachnoid hemorrhage (aSAH).@*Methods@#One hundred and twenty patients with CVS after aSAH admitted to the Department of Neurosurgery, the Sixth Medical Center of PLA General Hospital from May 2013 to May 2015 were selected. They were randomly divided into control group and observation group (n=60 in each group). The control group received conventional treatment and nimodipine infusion after embolization of the aneurysms, and the observation group underwent cerebrospinal fluid replacement by lumbar puncture on this basis. The clinical efficacy, Glasgow Coma Scale (GCS) scores, hemoglobin concentration and TLR4 expression levels before and after treatment, and adverse reactions were compared between the two groups.@*Results@#One month after treatment, the improvement rate of vasospasm in the observation group was significantly higher than that in the control group (86.7% vs. 60.0%; χ2=9.590, P=0.002). Three months after the treatment, the good rate of clinical outcome (the modified Rankin Scale score 0-2) was significantly higher than that of the control group (88.3% vs. 58.3%; χ2 =13.807, P<0.001). Before treatment, there were no significant differences in hemoglobin concentration and TLR4 expression levels between the two groups; after treatment, the hemoglobin concentration and TLR4 expression levels of both groups were significantly reduced (P<0.05). Compared with the control group, the hemoglobin concentration (119.9±19.8 g/L vs. 137.6±17.8 g/L; t=3.270, P=0.001) and TLR4 expression level (2.5±1.2 vs. 4.5±1.5; t=8.060, P<0.001) in the observation group decreased more significantly. Multivariate logistic regression analysis showed that hypertension (odds ratio [OR] 5.19, 95% confidence interval [CI] 2.31-6.71), hyperlipidemia (OR 2.70, 95% CI 1.93-4.86), previous history of stroke or transient ischemic attack (OR 6.29, 95% CI 3.23-7.32), smoking (OR 4.80, 95% CI 2.18-6.19), and the TLR4 expression level before treatment (OR 3.28, 95% CI 2.87-6.93) were independently correlated with the lack of improvement in CVS, and cerebrospinal fluid replacement was independently correlated with CVS improvement (OR 0.40, 95% CI 0.14-0.89). There was no significant difference in the incidence of adverse reactions such as blood pressure drop, obstructive hydrocephalus and gastrointestinal hemorrhage between the observation group and the control group, but the incidence of delayed CVS (13.3% vs. 36.7%; χ2=7.510, P=0.006) and secondary cerebral infarction (8.3% vs. 31.7%; χ2=8.800, P=0.003) in the observation group were significantly lower than those of the observation group.@*Conclusion@#Nimodipine infusion combined with cerebrospinal fluid replacement by lumbar puncture affected the hemoglobin concentration and TLR4 expression levels, improved the CVS improvement rate, and significantly improved the clinical outcome in patients with CVS after aSAH.
ABSTRACT
Objective To investigate the effect of nimodipine combined with cerebrospinal fluid replacement on hemoglobin concentration,Toll-like receptor 4 (TLR4) expression level and cerebral vasospasm (CVS) in patients with CVS after aneurysmal subarachnoid hemorrhage (aSAH).Methods One hundred and twenty patients with CVS after aSAH admitted to the Department of Neurosurgery,the Sixth Medical Center of PLA General Hospital from May 2013 to May 2015 were selected.They were randomly divided into control group and observation group (n =60 in each group).The control group received conventional treatment and nimodipine infusion after embolization of the aneurysms,and the observation group underwent cerebrospinal fluid replacement by lumbar puncture on this basis.The clinical efficacy,Glasgow Coma Scale (GCS) scores,hemoglobin concentration and TLR4 expression levels before and after treatment,and adverse reactions were compared between the two groups.Results One month after treatment,the improvement rate of vasospasm in the observation group was significantly higher than that in the control group (86.7％ vs.60.0％;x2 =9.590,P =0.002).Three months after the treatment,the good rate of clirnical outcome (the modified Rankin Scale score 0-2) was significantly higher than that of the control group (88.3％ vs.58.3％;x2 =13.807,P＜0.001).Before treatment,there were no significant differences in hemoglobin concentration and TLR4 expression levels between the two groups;after treatment,the hemoglobin concentration and TLR4 expression levels of both groups were significantly reduced (P ＜0.05).Compared with the control group,the hemoglobin concentration (119.9 ± 19.8 g/L vs.137.6 ± 17.8 g/L;t =3.270,P =0.001) and TLR4 expression level (2.5 ± 1.2 vs.4.5 ± 1.5;t =8.060,P ＜0.001) in the observation group decreased more significantly.Multivariate logistic regression analysis showed that hypertension (odds ratio [OR] 5.19,95％ confidence interval [CI] 2.31-6.71),hyperlipidemia (OR 2.70,95％ CI 1.93-4.86),previous history of stroke or transient ischemic attack (OR 6.29,95％ CI 3.23-7.32),smoking (OR 4.80,95％ CI 2.18-6.19),and the TLR4 expression level before treatment (OR 3.28,95％ CI 2.87-6.93) were independently correlated with the lack of improvement in CVS,and cerebrospinal fluid replacement was independently correlated with CVS improvement (OR 0.40,95％ CI 0.14-0.89).There was no significant difference in the incidence of adverse reactions such as blood pressure drop,obstructive hydrocephalus and gastrointestinal hemorrhage betw een the observation group and the control group,but the incidence of delayed CVS (13.3％ vs.36.7％;x2 =7.510,P =0.006) and secondary cerebral infarction (8.3％ vs.31.7％;x2 =8.800,P =0.003) in the observation group were significantly lower than those of the observation group.Conclusion Nimodipine infusion combined with cerebrospinal fluid replacement by lumbar puncture affected the hemoglobin concentration and TLR4 expression levels,improved the CVS improvement rate,and significantly improved the clinical outcome in patients with CVS after aSAH.