Human Stem Cell-Derived Skin Progenitors Produce Alpha 2-HS Glycoprotein (Fetuin): A Revolutionary Cosmetic Ingredient.

These studies were designed to determine the effect of stem cell-derived skin lineage precursor secretions on the intrinsic and extrinsic symptoms of human skin aging.
Human stem cells cultivated in balanced conditions were differentiated into skin lineage precursors, and shown to secrete large amounts of fetuin as well as multiple growth factors beneficial for human skin development and maintenance. The cell secretions were incorporated in two simple cosmetic formulations (serum and lotion) and investigated in an IRB-approved 12-week human trial that included 25 subjects in each group. Subjects were examined at 2, 4, 8, and 12 weeks by a dermatologist to evaluate safety, trans-epidermal water loss, wrinkles, firmness, radiance, texture, softness, and overall appearance. A sub-group of subjects from each group consented for biopsies for histological analyses.
Protein analyses in the cell secretions revealed a high concentration of the multifunctional alpha 2-HS glycoprotein (fetuin) along with a multitude of protein factors involved in the development and maintenance of healthy human skin. Clinical investigation demonstrated significant amelioration of the clinical signs of intrinsic and extrinsic skin aging, findings that were confirmed by significant changes in skin morphology, filaggrin, aquaporin 3, and collagen I content.
Our data strongly support our hypothesis that cosmetic application of stem cell-derived skin lineage precursor secretions containing fetuin and growth factors beneficial for human skin development and maintenance, positively influence intrinsic and extrinsic aging.

J Drugs Dermatol. 2016;15(5):583-598.

Admixture analysis of age at onset in schizophrenia: evidence of three subgroups in a first-episode sample.

OBJECTIVE: The objective was to assess the presence of different subgroups, via age-at-onset (AAO) analysis, in a schizophrenia population consecutively recruited through an Early Psychosis Service in London, Canada. METHOD: Admixture analysis was applied in order to identify a model of separate normal distribution of AAO characterized by different means, variances and population proportions to allow for evaluation of different subgroups in a sample of 187 unrelated patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of schizophrenia. RESULTS: The best-fitting model suggested three subgroups with means and standard deviations of 16.8 ± 1.9, 22.3 ± 2.1 and 32.7 ± 5.9 years comprising 41%, 30% and 29% of the schizophrenia sample, respectively. These three subgroups were categorized as early, intermediate and late onset with cutoffs determined by admixture analysis to be 19 and 26 years of age, respectively. In our investigation, the definition of early-onset schizophrenia is the main outcome. We considered the clinical variables mainly related to the heritability and neurobiology of schizophrenia. Single status was strongly associated with early onset (P<.001). The male gender (P=.023), as well as a history of drug abuse (P=.004), was significantly associated with early onset. Interestingly, lower academic achievement was also associated with early-onset schizophrenia (P<.001). CONCLUSION: Overall, our study showed that a typical early-onset schizophrenia patient is more likely to be a single male, with a history of drug abuse and birth complications, and lower academic achievement as compared to the late-onset subgroup.

Comparative assessment of 2-dimensional echocardiography vs cardiac magnetic resonance imaging in measuring left ventricular mass in patients with and without end-stage renal disease.

BACKGROUND: While echocardiography (ECHO)-measured left ventricular mass (LVM) predicts adverse cardiovascular events that are common in hemodialysis (HD) recipients, cardiac magnetic resonance imaging (CMR) is now considered the reference standard for determination of LVM. This study aimed to evaluate concordance between LVM measurements across ECHO and CMR among chronic HD recipients and matched controls. METHODS: A single-centre, cross-sectional study of 41 chronic HD patients and 41 matched controls with normal kidney function was performed to compare LVM measurements and left ventricular hypertrophy (LVH) designation by ECHO and CMR. RESULTS: In both groups, ECHO, compared with CMR, overestimated LVM. Bland-Altman analysis demonstrated wider agreement limits in LVM measurements by ECHO and CMR in the chronic HD group (mean difference, 60.8 g; limits -23 g to 144.6 g) than in the group with normal renal function (mean difference, 51.4 g; limits -10.5 g to 113.3 g). LVH prevalence by ECHO and CMR in the chronic HD group was 37.5% and 22.5%, respectively, while 17.5% and 12.5% had LVH by ECHO and CMR, respectively, in the normal kidney function group. Intermodality agreement in the designation of LVH was modest in the chronic HD patients (κ = 0.42, P = 0.005) but strong (κ = 0.81, P < 0.001) in the patients with preserved kidney function. Agreement was strong in assessing LVH by ECHO and CMR only in those with normal kidney function. CONCLUSIONS: Our results suggest that the limitations of LVM measurement by ECHO may be more pronounced in patients receiving HD, and provide additional support for the use of CMR in research and clinical practice when rigourous assessment of LVM is essential.

Anatomy of the supratrochlear nerve: implications for the surgical treatment of migraine headaches.

BACKGROUND: Migraine headaches have been linked to compression, irritation, or entrapment of peripheral nerves in the head and neck at muscular, fascial, and vascular sites. The frontal region is a trigger for many patients' symptoms, and the possibility for compression of the supratrochlear nerve by the corrugator muscle has been indirectly implied. To further delineate their relationship, a fresh tissue anatomical study was designed. METHODS: Dissection of the brow region was undertaken in 25 fresh cadaveric heads. The corrugator muscle was identified on both sides, and its relationship with the supratrochlear nerve was investigated. RESULTS: The supratrochlear nerve was found in all 50 hemifaces. Three potential points of compression were uncovered in this investigation: the nerve entrance into the brow through the frontal notch or foramen, the entrance of the nerve into the corrugator muscle, and the exit of the nerve from the corrugator muscle. The nerve generally bifurcates within the retro-orbicularis oculi fat pad, and these branches enter into one of four relationships with the corrugator muscle: both branches enter the muscle, one branch enters the muscle and one remains deep, both branches remain deep, and the branches further branch into ever smaller filaments that cannot be identified cranially. CONCLUSIONS: Some patients are nonresponders to migraine decompression techniques that address the supraorbital nerve. The supratrochlear nerve may be compressed in these patients. A standard corrugator resection that comes more medially within 1.8 cm of the midline may be beneficial. The morphology of the frontal notch/foramen must be examined and addressed if necessary.

Defining the infratip lobule in rhinoplasty: anatomy, pathogenesis of abnormalities, and correction using an algorithmic approach.

BACKGROUND: Excess infratip lobule projection is often the result of deformities of the middle crus and lower lateral cartilage. The causes and correction of excess projection have not been well described. The classification of the deformities causing excess infratip lobule projection is defined and a surgical algorithm for addressing the infratip lobule is presented. METHODS: A retrospective review of primary rhinoplasties was combined with the use of a cadaver model to identify the causes of excess infratip lobule projection and develop an algorithm for its correction. Specific cases are presented to demonstrate the consistency and predictability of these techniques. RESULTS: The classification of excess infratip lobule projection is divided into intrinsic (i.e., long middle crus, wide middle crus, lower lateral malposition, and combination) and extrinsic causes (i.e., prominent septum). After correcting extrinsic causes, the algorithm progresses from medial to lateral, working from the medial crus to the lateral crus. Final refinement using transdomal sutures establishes the endpoint for infratip lobule projection and alar rim position when the cephalic and caudal edges (rotational orientation) of the lower lateral cartilage lie in the same plane. CONCLUSIONS: A simple classification and logical algorithm are established to help rhinoplasty surgeons achieve aesthetic and consistent infratip lobule projection in cosmetic rhinoplasty. Establishing appropriate infratip lobule projection is essential for an aesthetic result in the lower third of the nose. The appearance of this complex area with the tip, columella, ala, and lobule has great importance in the final outcome in rhinoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Hydrolytic mechanism of OXA-58 enzyme, a carbapenem-hydrolyzing class D ß-lactamase from Acinetobacter baumannii.

Carbapenem-hydrolyzing class D ß-lactamases (CHDLs) represent an emerging antibiotic resistance mechanism encountered among the most opportunistic Gram-negative bacterial pathogens. We report here the substrate kinetics and mechanistic characterization of a prominent CHDL, the OXA-58 enzyme, from Acinetobacter baumannii. OXA-58 uses a carbamylated lysine to activate the nucleophilic serine used for ß-lactam hydrolysis. The deacylating water molecule approaches the acyl-enzyme species, anchored at this serine (Ser-83), from the α-face. Our data show that OXA-58 retains the catalytic machinery found in class D ß-lactamases, of which OXA-10 is representative. Comparison of the homology model of OXA-58 and the recently solved crystal structures of OXA-24 and OXA-48 with the OXA-10 crystal structure suggests that these CHDLs have evolved the ability to hydrolyze imipenem, an important carbapenem in clinical use, by subtle structural changes in the active site. These changes may contribute to tighter binding of imipenem to the active site and removal of steric hindrances from the path of the deacylating water molecule.

Survival in breast cancer patients undergoing immediate breast reconstruction.

Immediate and early-delayed breast reconstruction are the preferred methods of reconstruction in breast cancer patients treated with mastectomy. These options for reconstruction allow for superior outcomes through peri-operative planning between the oncologic surgeon and reconstructive team. We used the Surveillance, Epidemiology, and End Results (SEER) database to study the overall survival of patients treated with immediate or early-delayed breast reconstruction after mastectomy. Population level de-identified data was abstracted from the National Cancer Institute's SEER cancer database. We obtained data for all female patients with breast cancer treated with mastectomy from 2000 to 2002. Patients with missing or incomplete data were excluded. Univariate and multivariate statistics were performed using Intercooled Stata 7.0 (College Station, TX). A total of 51,702 patients were included in the study. The mean age was 60.8 (range 20-104) years old. Reconstruction was performed in 16.7% of patients. Multivariate analysis showed that patients treated with mastectomy and reconstruction had a significantly lower hazard ratio of death (HR=0.62, p<0.001) compared with patients treated with mastectomy only, when controlling for demographic and oncologic covariates. Black patients comprised 7.5% of the total population, and multivariate analysis showed that black patients had a significantly increased hazard ratio of death (HR=1.43, p<0.001) when compared with white patients, when controlling for all other covariates including reconstruction status. We show that women with breast cancer who undergo breast reconstruction after mastectomy do not have a worse overall survival than those not undergoing breast reconstruction. This is true when patient age, race, income, and marital status; and tumor stage, histology, grade, use of radiotherapy, and mastectomy site (bilateral or unilateral) are controlled for.

The dorsal columellar strut: innovative use of dorsal hump removal for a columellar strut.

BACKGROUND: Dorsal hump reduction is a common complaint among primary cosmetic rhinoplasty patients. Newer techniques for addressing the dorsal hump focus on the preservation, reinforcement, or modification of existing structures. OBJECTIVES: The authors describe their technique of a "dorsal columellar strut," an innovative use of dorsal nasal cartilage from hump removal for a columellar strut. Combined with other cartilage-conserving techniques, this forgoes the morbidity and operative time of a septal cartilage harvest while preserving--and possibly increasing--tip support. METHODS: Candidates for this procedure are selected based on a number of criteria. Ideally, the patient is one who requires 3 mm or more of dorsal hump reduction with tip reshaping and refinement. Each patient is treated using the open technique with a stair-step columellar incision, combined with an infracartilaginous incision. RESULTS: With the addition of the authors' cartilage-conserving techniques (autospreader flap, lower lateral turnover, and tip suturing), patients experience successful reshaping of the middle vault and nasal tip. CONCLUSIONS: In well-selected patients, the authors have found their technique to be efficient, effective, and aesthetic. The precise dorsal reduction allows surgeons to use the cartilage fragment as a dorsal columellar strut, foregoing the standard septal harvest and reducing operative time and patient morbidity.

Disease relapse after segmental resection and free flap reconstruction for mandibular osteoradionecrosis.

OBJECTIVE: The objective of this study was to assess the outcomes, complications, and incidence of disease recurrence of mandibular osteoradionecrosis (ORN) after resection and microvascular free flap reconstruction. STUDY DESIGN: Case series with chart review. SETTING: Academic medical center. SUBJECTS AND METHODS: Retrospective patient data review of 40 patients with mandibular ORN who were treated by segmental mandibulectomy and microvascular reconstruction between 1995 and 2009. All patients received radiation therapy for previous head and neck cancer, and 12 of 40 patients received concurrent chemotherapy. All patients failed to respond to conservative management. There were 26 males and 14 females, with a median age of 62 years. Median follow-up was 17.4 months. RESULTS: There were no free flap failures. The incidence of wound-related complications was 55 percent. Median time to complication was 10.6 months. Ten (25%) patients developed symptoms of residual or recurrent ORN, with 70 percent of the recurrences arising in unresected condyles that were adjacent to the segmental mandibulectomy. Statistical analysis revealed that current smokers were at reduced risk to develop residual or recurrent ORN. CONCLUSION: This present study confirms that microvascular free flaps are reliable for treatment of advanced mandibular ORN. Nevertheless, there remains a 55 percent incidence of wound-healing complications. The lack of objective clinical criteria to judge the appropriate amount of mandible resection in patients with ORN remains an unresolved issue that resulted in the development of recurrent ORN in 25 percent of patients. Further investigations are needed to better understand the pathophysiology of ORN to prevent postoperative wound complications and disease recurrence.

Reirradiation after salvage surgery and microvascular free flap reconstruction for recurrent head and neck carcinoma.

OBJECTIVE: To evaluate the outcome and complications of reirradiation of recurrent head and neck cancer after salvage surgery and microvascular reconstruction. STUDY DESIGN: Retrospective. SUBJECTS AND METHODS: Twelve patients underwent salvage surgery with microvascular reconstruction for recurrent or second primary head and neck cancer in a previously irradiated field. Median prior radiation therapy dose was 63.0 Gy. Patients then underwent postoperative reirradiation, and received a median total cumulative radiation dose of 115.0 Gy. RESULTS: Three (25%) patients experienced acute complications (<3 months) during reirradiation. Four (33%) patients developed grade 3 or 4 late reirradiation complications (>3 months). There were no incidences of free flap failure, brain necrosis, spinal cord injury, or carotid rupture. The incidence of soft tissue necrosis and osteoradionecrosis was 8%. Six (50%) patients are alive without evidence of recurrent disease a median of 40 months after reirradiation. CONCLUSION: Microvascular free flaps allow for maximal resection and reliable reconstruction of previously irradiated cancers before high dose reirradiation and may reduce the incidence of severe late complications and treatment related mortality.

Disparities in the utilization of high-volume hospitals for complex surgery.

CONTEXT: Referral to high-volume hospitals has been recommended for operations with a demonstrated volume-outcome relationship. The characteristics of patients who receive care at low-volume hospitals may be different from those of patients who receive care at high-volume hospitals. These differences may limit their ability to access or receive care at a high-volume hospital. OBJECTIVE: To identify patient characteristics associated with the use of high-volume hospitals, using California's Office of Statewide Health Planning and Development patient discharge database. DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of Californians receiving the following inpatient operations from 2000 through 2004: elective abdominal aortic aneurysm repair, coronary artery bypass grafting, carotid endarterectomy, esophageal cancer resection, hip fracture repair, lung cancer resection, cardiac valve replacement, coronary angioplasty, pancreatic cancer resection, and total knee replacement. MAIN OUTCOME MEASURES: Patient race/ethnicity and insurance status in high-volume (highest 20% of patients by mean annual volume) and in low-volume (lowest 20%) hospitals. RESULTS: A total of 719,608 patients received 1 of the 10 operations. Overall, nonwhites, Medicaid patients, and uninsured patients were less likely to receive care at high-volume hospitals and more likely to receive care at low-volume hospitals when controlling for other patient-level characteristics. Blacks were significantly (P<.05) less likely than whites to receive care at high-volume hospitals for 6 of the 10 operations (relative risk [RR] range, 0.40-0.72), while Asians and Hispanics were significantly less likely to receive care at high-volume hospitals for 5 (RR range, 0.60-0.91) and 9 (RR range, 0.46-0.88), respectively. Medicaid patients were significantly less likely than Medicare patients to receive care at high-volume hospitals for 7 of the operations (RR range, 0.22-0.66), while uninsured patients were less likely to be treated at high-volume hospitals for 9 (RR range, 0.20-0.81). CONCLUSIONS: There are substantial disparities in the characteristics of patients receiving care at high-volume hospitals. The interest in selective referral to high-volume hospitals should include explicit efforts to identify the patient and system factors required to reduce current inequities regarding their use.

A report card on outcomes for surgically treated gastrointestinal cancers: are we improving?

INTRODUCTION: Longitudinal analyses of cancer registries provide an opportunity for population-based explanations of epidemiology and survival-related outcomes. This study used two population-based data sets to report on nine surgery-related cancers over the past three decades. MATERIALS AND METHODS: Using the SEER cancer database (1973-1999), all patients (>18 years old) with adenocarcinoma of esophagus, gastric, biliary system, pancreas, small bowel, colon, rectum; esophageal squamous cell carcinoma (ESC), or hepatocellular (HCC) carcinoma (n = 379,640) were analyzed. Changes in incidence rates, stage at diagnosis, and 5-year cancer and stage-specific survivals were determined. A separate database, the California inpatient database (1990-2000), was concurrently used to evaluate inpatient mortality after surgical resection (n = 34,057). RESULTS: Incidence rates increased for three cancers (esophageal, HCC, small bowel); decreased for three (rectal, gastric, ESC); and stayed constant for three (biliary, pancreatic, colon). More patients presented with local/regional disease in the 1990s versus 1970s for eight tumors (except small bowel, P < 0.05). Five-year overall survival improved for all but small bowel (P < 0.05); and local stage survival was improved for all except small bowel and biliary (P < 0.05). Finally, inpatient mortality rates improved significantly for liver, esophageal, pancreatic, and gastric resections (P < 0.05) over the past decade. CONCLUSIONS: For these nine surgically treated cancers, we are detecting disease at earlier and therefore more treatable stages, and surgical care and outcomes also appear to have improved. Continued reexamination of longitudinal trends of surgically relevant outcomes is important for future improvement of surgical care.

Do young colon cancer patients have worse outcomes?

Previous studies on colon cancer have noted rising incidence rates among young individuals and suggest that they may have more aggressive disease and worse 5-year survivals than their older counterparts. Our study uses a nationwide population-based cancer registry to analyze colon cancer presentations and outcomes in a young versus an older population. The records of patients with colon carcinoma were obtained from the Surveillance, Epidemiology, and End Results (SEER) national cancer database (1991-1999). Two cohorts based on age at diagnosis (20-40 years, n = 1334 vs. 60-80 years, n = 46,457) were compared for patient and tumor characteristics, treatment, and 5-year cancer-specific survival. A multivariate Cox regression was performed to identify predictors of survival. The young group had a higher proportion of black and Hispanic patients than did the older group (p < 0.001). Young patients had less stage I or II disease, more stage III or IV disease (p < 0.001), and worse-grade (poorly differentiated or anaplastic) tumors (p < 0.001). The 5-year stage-specific survival was similar for stage I and III disease (p = NS) but was significantly better for young patients with stage II and IV disease (p < 0.01). Using a nationally representative cancer registry, we found that young colon cancer patients tend to have later-stage and higher-grade tumors. However, they have equivalent or better 5-year cancer-specific survival compared to older patients. This population-based finding contradicts prior single-institution reports.

The increasing workload of general surgery.

BACKGROUND: With the aging of the baby boomers, individuals aged 65 years and older make up the fastest-growing segment of the US population. This aging of the population will lead to new challenges for the US health care system because older individuals are the largest consumers of health care. HYPOTHESIS: The general surgery workload will increase dramatically by 2020 as a result of the aging population. DATA SOURCES: The National Hospital Discharge Survey, National Survey of Ambulatory Surgery, US Census Bureau, and Centers for Medicare and Medicaid Services. SETTING: A nationally representative random sample of inpatient and outpatient general surgical operations performed in 1996 in the United States. METHODS: Age- and procedure-specific rates of general surgery were obtained from the National Hospital Discharge Survey and National Survey of Ambulatory Surgery. Population projections were derived from the census bureau. We used relative-value units as a proxy for surgical work. By linking these 3 data sources, we predicted the future general surgery workload by analyzing the rates of surgery and modeling both the aging and expansion of the population. RESULTS: General surgery operations (n = 63) were classified into 5 procedure categories. Whereas the population will grow by 18% between 2000 and 2020, the workload of general surgeons will increase by 31.5%. The amount of growth (19.9%-40.3%) varies among different categories of operations. CONCLUSIONS: To our knowledge, this is one of the only studies to analyze the future workload of general surgery. We project a dramatic increase in workload in the next 20 years, largely as a result of the aging US population. Our baseline assumptions are relatively conservative, so this forecast may be an underestimation. Hence, the challenge for general surgeons is to develop strategies to address this problem while maintaining quality of care for our patients.

Surgery for hepatocellular carcinoma: does it improve survival?

BACKGROUND: The incidence and mortality of hepatocellular carcinoma (HCC) are increasing in the United States. Whether surgery is associated with improved survival at the population level is relatively unknown. To address this question, we used a population-based cancer registry to compare survival outcomes between patients receiving and not receiving surgery with similar tumor sizes and health status. METHODS: By using the Surveillance, Epidemiology, and End Results database, we identified HCC patients who had surgically resectable disease as defined by published expert guidelines. After excluding patients with contraindications to surgery, we performed both survival analysis and Cox regression to identify predictors of improved survival. RESULTS: Of the 4008 patients diagnosed with HCC between 1988 and 1998, 417 were candidates for surgical resection. The mean age was 63.6 years; mean tumor size was 3.3 cm. The 5-year overall survival with surgery was 33% with a mean of 47.1 months; without surgery, the 5-year overall survival was 7% with a mean of 17.9 months (P <.001). In the multivariate Cox regression, surgery was significantly associated with improved survival (P <.001). Specifically, patients who received surgery had a 55% decreased rate of death compared with patients who did not have surgery, even after controlling for tumor size, age, sex, and race. CONCLUSIONS: This study shows that surgical therapy is associated with improved survival in patients with unifocal, nonmetastatic HCC tumors <5 cm. If this is confirmed in future studies, efforts should be made to ensure that appropriate patients with resectable HCC receive high-quality care, as well as the opportunity for potentially curative surgery.

Are survival rates different for young and older patients with rectal cancer?

PURPOSE: Although it is generally believed that young patients with rectal cancer have worse survival rates, no comprehensive analysis has been reported. This study uses a national-level, population-based cancer registry to compare rectal cancer outcomes between young vs. older populations. METHODS: All patients with rectal carcinoma in the Surveillance, Epidemiology, and End Results cancer database from 1991 to 1999 were evaluated. Young (range, 20-40 years; n = 466) and older groups (range, 60-80 years; n = 11,312) were compared for patient and tumor characteristics, treatment patterns, and five-year overall and stage-specific survival. Cox multivariate regression analysis was performed to identify predictors of survival. RESULTS: Mean ages for the groups were 34.1 and 70 years. The young group was comprised of more black and Hispanic patients compared with the older group (P < 0.001). Young patients were more likely to present with late-stage disease (young vs. older: Stage III, 27 vs. 20 percent respectively, P < 0.001; Stage IV, 17.4 vs. 13.6 percent respectively, P < 0.02). The younger group also had worse grade tumors (poorly differentiated 24.3 vs. 14 percent respectively, P < 0.001). Although the majority of both groups received surgery (85 percent for each), significantly more young patients received radiation (P < 0.001). Importantly, overall and stage-specific, five-year survival rates were similar for both groups (P = not significant). CONCLUSIONS: Although previous studies have found young rectal cancer patients to have poorer survival compared with older patients, this population-based study shows that young rectal cancer patients seem to have equivalent overall and stage-specific survival.

Elderly patients in surgical workloads: a population-based analysis.

Elderly (80+ year old) individuals are the fastest-growing segment of the U.S. population. The objective of this study was to use population-based data to examine trends in the number of elderly undergoing major general, vascular, and cardiothoracic surgical procedures. California inpatient data from 1990-2000 was used to identify patients undergoing six procedures: abdominal aortic aneurysm repair (AAA), coronary artery bypass graft (CABG), carotid endarterectomy (CEA), colon resections, lung resections, and pancreatic resections. Despite comprising only 2.7 per cent of the California population, elderly patients were a significant percentage (6-22%) of the caseloads for the six procedures examined. For all six procedures, the percentage of patients that were elderly increased during the study period. The age-specific incidence rates for elderly individuals increased significantly for three of these procedures (CABG, CEA, lung resection), remained unchanged for two (AAA, pancreas resection), and decreased for one (colon resection). Elderly patients are a large and growing part of surgical caseloads. In the near future, the number of elderly individuals in the California state and the U.S. populations will increase dramatically (41% and 35% between 2000 and 2020). To provide the best quality of care, surgeons should embrace research, training, and educational opportunities regarding the treatment of elderly patients.

What predicts serious complications in colorectal cancer resection?

Virtually all volume-outcome studies use mortality as their outcome measure, yet most general surgical procedures have low in-patient death rates. We examined whether hospital surgical volume impacts other colorectal cancer resection outcomes and complications. Colorectal cancer (CRC) resections from 1996 to 2000 were identified using the California hospital discharge database. Comorbidity was graded using a modified Charlson index. Hospital CRC resection volume was calculated. Serious medical complications were defined as life-threatening cardiac or respiratory events, renal failure, or shock. Serious surgical complications were defined as vascular events, need for reoperation, or bleeding. Multivariate logistic regression analyses were performed to estimate the impact of predictors on complications. We identified 56,621 resections. Median age was 70 to 74 years. Eighty-one per cent of patients were white. Most had localized (57%) versus distant (22%) disease. Serious medical (17.5%) and surgical (9.8%) complications were not infrequent. In multivariate analyses, greater annual CRC surgical volume predicted lower odds of serious complication, but patient characteristics (age, comorbidity, and acuity of surgery) were more important. Although patients receiving CRC resection at lower-volume hospitals have greater odds of complication than patients treated at higher-volume institutions, patient factors remain the most important determinants of complication.