Clinicopathological factors associated with positive circumferential margins in rectal cancers.

BACKGROUND: Positive circumferential resections are associated with local disease recurrence and reduced survival in rectal cancer. We studied a cohort of consecutive rectal cancer resections to assess for clinicopathological differences and survival in patients with positive and negative circumferential margins. METHODS: Rectal cancers were identified from a retrospective histopathology database of colorectal resections performed at five western Sydney hospitals from 2010 to 2016. Univariate and multivariate analysis with binary logistic regression were performed on histopathology data matched with survival times from the New South Wales Registry of Births Deaths and Marriages. RESULTS: A total of 502 rectal cancer patients were identified including 66 (13.1%) with involved circumferential margins. Patients with positive and negative circumferential margins had a similar distribution of age, gender and use of neoadjuvant radiotherapy. Tumours with involved circumferential margin comprised 98.5% T3 and T4 disease of which 51.5% received neoadjuvant radiotherapy. These were significantly associated with metastatic disease, increasing tumour size, circumferential and perforated tumours on univariate analysis. Multivariate analysis identified abdomino-perineal resection (odds ratio (OR) 3.35; P = 0.003), en-bloc multivisceral resection (OR 2.56; P = 0.032), T4 stage (OR 6.99; P < 0.001), perineural (OR 5.61; P < 0.001) and vascular invasion (OR 2.46; P = 0.022) as independent risk factors. Five-year survival was significantly worse for patients with involved circumferential margins (26% versus 69%; P < 0.001). CONCLUSION: Circumferential margin status reflects not only technical success but also aggressive disease phenotypes which require adjuvant therapy. Further work is needed to determine whether omission of radiotherapy has had an effect on long-term outcomes in some of our at-risk patients.

Addressing Multimorbidity and Polypharmacy in Individuals With Atrial Fibrillation.

PURPOSE OF REVIEW: The objectives of this review were to (1) discuss how multimorbidity and polypharmacy contributes to the complexity of management among individuals with AF and (2) identify any interventions to manage polypharmacy in relation to AF. RECENT FINDINGS: Based on the four landmark clinical trials of novel anticoagulants, the most common comorbidities with AF are hypertension, heart failure, diabetes, stroke and myocardial infarction. Polypharmacy was also found prevalent in 76.5% of patients with AF, with a median of six drugs per patient. Despite the consequences of polypharmacy in AF, there is very little evidence-based intervention designed to manage it. Hence, there is a need for further research to examine interventions to manage polypharmacy in relation to AF. Atrial fibrillation (AF) is the most common type of cardiac arrhythmia requiring treatment in adults. Due to the structural and/or electrophysiological abnormalities that occur in AF, patients are managed through the use of prophylactic anticoagulant and rate and/or rhythm control medications. However, these medications are considered high risk and can increase the chances of medication misadventure. Additionally, AF rarely occurs in isolation and is known to coexist with multiple other medical comorbidities, i.e. multimorbidity. This also increases the number of medications, i.e. polypharmacy and pill burden which results in treatment non-compliance to prescribed therapy.