Jungerman I, Toyota J, Montoni NP, Azevedo EHM, Guedes RLV, Damascena A, Lowe D, Vartanian JG, Rogers SN, Kowalski LP.

Patient Concerns Inventory for head and neck cancer: Brazilian cultural adaptation.

Rev Assoc Med Bras 2017; Apr;63(4):311-319.

doi: 10.1590/1806-9282.63.04.311. PubMed PMID:28614532

 

Vartanian JG, Rogers SN, Kowalski LP.

How to evaluate and assess quality of life issues in head and neck cancer patients.

Curr Opin Oncol. 2017 Mar 9.

doi:10.1097/CCO.0000000000000369. [Epub ahead of print] PubMed PMID: 28282344.

 

Br J Oral Maxillofac Surg. 2014 Sep;52(7):590-7.

Does elective neck dissection in T1/T2 carcinoma of the oral tongue and floor of the mouth influence recurrence and survival rates?

Kelner N, Vartanian JG, Pinto CA, Coutinho-Camillo CM, Kowalski LP

BACKGROUND: The aim of this study was to evaluate the results of elective neck dissection compared with observation (control group) in selected cases of early carcinoma of the oral tongue and floor of the mouth. It was a retrospective analysis of 222 patients who had the tumour resected (161 also had elective neck dissection). Occult lymph node metastases were detected in 33/161 (21%), and neck recurrences were diagnosed in 10 of the 61 patients in the control group (16%). Occult lymph node metastases reduced the 5-year disease-specific survival from 90% to 65% (p=0.001) and it was 96% among the controls. The 5-year disease-specific survival was 85% in the group treated by neck dissection and 96% in the observation group (p=0.09). Rigorous follow-up of selected low risk patients is associated with high rates of salvage, and overall survival was similar to the observed survival in patients treated by elective neck dissection. Observation is a reasonable option in the treatment of selected patients.

 

Head Neck. 2014 May 14. doi: 10.1002/hed.23765. [Epub ahead of print]

Head and neck squamous cell carcinoma lymphatic spread and survival: Relevance of vascular endothelial growth factor family for tumor evaluation.

de Sousa EA, Lourenço SV, Moraes FP, Vartanian JG, Gonçalves-Filho J, Kowalski LP, Soares FA, Coutinho-Camillo CM.

BACKGROUND: Head and neck squamous cell carcinoma (HNSCC) is primarily a locoregional disease in which the cervical lymph nodes are the chief site of metastasis. The purpose of this study was to examine the relationship between lymphangiogenesis and clinicopathological aspects of HNSCC and its metastasis. METHODS: Fifty-two patients with HNSCC and metastatic lymph nodes from 21 of these subjects were analyzed by mmunohistochemistry. RESULTS: The HNSCC samples were predominantly negative for vascular endothelial growth factor (VEGF)-C, VEGF-D, and vascular endothelial growth factor receptor (VEGFR)3. There was an association between the density of lymph vessels (measured by D2-40 staining) in the lymph nodes and advanced-stage tumors. There was no link between the expression of these proteins and survival rates. CONCLUSION: Although lymphatic spread is a significant event in the progression of HNSCC, the expression of VEGF-C, VEGF-D, and VEGFR3 does not correlate with clinicopathological characteristics, suggesting that other signaling pathways mediate lymphangiogenesis in HNSCC. © 2014 Wiley Periodicals, Inc. Head Neck, 2014.

 

Rev Col Bras Cir. 2014 Jan-Feb;41(1):68-71.

Protecting the skin during thyroidectomy.

Lira RB, de Carvalho GB, Vartanian JG, Kowalski LP.

BACKGROUND: In this note we describe the standard technical maneuver used in our department to protect the skin during thyroidectomy in order to get the best aesthetic result. We use surgical gloves to protect the skin during these operations to reduce the negative impact of thermal trauma and mechanical retractors and energy delivery devices at the edges of the skin incised. This practice is effective, inexpensive, rapid, reproducible and showed no complication in our experience of over 2,500 thyroidectomies.

 

Virchows Arch. 2013 Jul;463(1):31-9. doi: 10.1007/s00428-013-1438-9. Epub 2013 Jun 9.

Expression of PAR-4 and PHLDA1 is prognostic for overall and disease-free survival in oral squamous cell carcinomas.

Coutinho-Camillo CMLourenço SVNonogaki SVartanian JGNagai MAKowalski LPSoares FA.

Department of Anatomic Pathology, AC Camargo Cancer Center, São Paulo, Brazil. claumcc@terra.com.br

Abstract

PAR-4 is a tumor suppressor protein with a pro-apoptotic function and down-regulation of PAR-4 is seen in a variety of tumors. PHLDA1 gene overexpression has been shown to reduce cell proliferation and induce cell death in a variety of cell types. In this study, 229 cases of oral squamous cell carcinoma (OSCC), arranged in a tissue microarray, were analyzed by immunohistochemistry. PAR-4 expression was predominantly moderate to strong and expression of PHLDA1 was predominantly negative or weak. Cytoplasmic expression of PAR-4 was associated with advanced clinical stage. Expression of PHLDA1 was associated with advanced clinical stage of the tumour. Five-year overall and disease-free survival rates differed significantly between cases that did and cases that did not express PHLDA1, and by multivariate analysis, expression of PHLDA1 and PAR-4 were independent prognostic factors in OSCC patients. Expression of PAR-4 and PHLDA1 is altered in OSCC and might be a valuable prognostic indicator for this disease.

PMID: 23748915 [PubMed – indexed for MEDLINE]
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Curr Opin Otolaryngol Head Neck Surg. 2013 Jun;21(3):212-7. doi: 10.1097/MOO.0b013e328361067b.

Practice of laryngectomy rehabilitation interventions: a perspective from South America.

Vartanian JGCarrara-de-Angelis EKowalski LP.

Head and Neck Surgery and Otorhinolaryngology Department, Hospital A.C. Camargo, Sao Paulo, Brazil.

Abstract

PURPOSE OF REVIEW:

Treatment of laryngeal cancer will depend on several factors, including tumor factors, patient factors, as well as the technical resource and expertise of the surgical team and treatment center. In developing countries, most patients have their diagnosis performed at advanced stages, with a significant proportion at very advanced locoregionally, which results in a limitation to the use of organ-preserving approaches. A total laryngectomy is still the most frequent treatment for larynx cancer patients. The rehabilitation in such scenarios can be more demanding and can cost more compared with developed countries.

RECENT FINDINGS:

For early-stage tumors, function-preserving strategies are mandatory, and can include partial laryngectomies and radiation therapy. In such cases, functional rehabilitation usually is easily achieved, with lower negative impact on the patient’s daily life. For advanced tumor stages, a treatment shift toward a more conservative management has been observed. However, the success rates of organ-preserving strategies, mainly with chemoradiation approaches, will rely on a rigorous patient selection process.

SUMMARY:

The rehabilitation of laryngectomy patients in developing countries can be more demanding and can cost more compared with developed countries. In such scenarios, some strategies can be employed by the multidisciplinary team, mainly by the surgical and speech-pathology teams, aiming to decrease the costs involved in the rehabilitation of total laryngectomy patients in developing countries.

PMID: 23619427 [PubMed – in process]
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Thyroid. 2012 Aug;22(8):814-9. doi: 10.1089/thy.2011.0118. Epub 2012 Jul 10.

Prevalence of upper aerodigestive symptoms in patients who underwent thyroidectomy with and without the use of intraoperative laryngeal nerve monitoring.

Silva ICNetto Ide PVartanian JGKowalski LPCarrara-de Angelis E.

Department of Voice, Speech, and Swallowing Rehabilitation, A.C. Camargo Hospital, Sao Paulo, Brazil.

Abstract

BACKGROUND:

Upper aerodigestive symptoms (UADS) have been reported by patients who have had thyroidectomies. This study evaluated the long-term prevalence of UADS after thyroidectomy in patients who did and who did not have intraoperative neuromonitoring (IONM).

METHODS:

This was a cross-sectional study of patients with normal vocal fold mobility who had a thyroidectomy. It included patients who did and did not have this surgery with IONM. All patients answered a questionnaire regarding UADS occurring one or more years after thyroidectomy. The questionnaire dealt with UADS relating to voice and swallowing symptoms and sought to quantify their severity. The 208 patients who underwent thyroidectomy without IONM were designated the control group (CG). The 100 patients who underwent thyroidectomy with IONM were designated the neuromonitored group (NMG).

RESULTS:

The proportion of patients in the CG who reported UADS was 45%; 25.9% of these patients reported voice symptoms, and 33.6% reported swallowing symptoms. The proportion of patients in the NMG who reported UADS was 39%; 27% of these patients reported voice symptoms, and 22% reported swallowing symptoms. Thus, patients in the CG had more swallowing symptoms and a greater severity of UADS-related symptoms than patients in the NMG.

CONCLUSIONS:

In this study, IONM had a favorable effect in terms of decreasing the prevalence and severity of UADS occurring one year or more after thyroidectomy.

PMID: 22780215 [PubMed – indexed for MEDLINE]
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Dysphagia. 2013 Mar;28(1):24-32. doi: 10.1007/s00455-012-9409-x. Epub 2012 Jun 9.

Validation and application of the M.D. Anderson Dysphagia Inventory in patients treated for head and neck cancer in Brazil.

Guedes RLAngelis ECChen AYKowalski LPVartanian JG.

Voice, Speech and Swallowing Rehabilitation Department, A. C. Camargo Hospital, São Paulo, Brazil.

Abstract

Analysis of quality of life (QOL) has revealed that preservation of swallowing, speech, and breathing functions has a direct impact on QOL and that these functions are important patient-reported outcomes. The purposes of this study were to adapt and culturally validate the M.D. Anderson Dysphagia Inventory (MDADI) to the Brazilian Portuguese language and to evaluate QOL related to dysphagia in patients treated for head and neck cancer. This was a cross-sectional study that included 72 adult patients with a mean age of 63 years who were treated for head and neck cancer. Construct validity and reliability analyses were performed through the comparison of the MDADI with three other health-related QOL questionnaires administered at the time of enrollment and MDADI application 2 weeks thereafter, respectively. Reliability was established by assuring both internal consistency (Cronbach’s α) and test-retest reliability (intraclass correlation coefficient, ICC). Test-retest reliability for the total score in the MDADI had an ICC greater than 0.795 (p < 0.001). The MDADI had significant statistical correlations with the other questionnaires. Patients treated for head and neck cancer had a mean total score of 83 on the MDADI, which is indicative of minimal limitation in overall QOL. In conclusion, the present study validates the adaptation of the MDADI to the Brazilian Portuguese language and provides another tool to evaluate the impact of dysphagia on the QOL of head and neck cancer patients.

PMID: 22684923 [PubMed – in process]
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Head Neck. 2012 Jun;34(6):805-12. doi: 10.1002/hed.21815. Epub 2012 Feb 2.

Total thyroidectomy with ultrasonic scalpel: a multicenter, randomized controlled trial.

Kowalski LPSanabria AVartanian JGLima RAde Mendonca UBdos Santos CRBoldrini D Jrde Mello LEPinto FPLehn CNCorrea LADedivitis RAGuimarães AVPedruzzi PARamos GHGonçalves AJSuehara ABKanda JLCapuzzo Rde Cde Oliveira JCCurado MPde Góis Filho JFFukuyama EBeserra IM Jrde Carvalho Neto PBCarvalho AL.

Department of Head and Neck Surgery and Otorhinolaryngology, Hospital AC Camargo, São Paulo, Brazil. lp_kowalski@uol.com.br

Abstract

BACKGROUND:

The ultrasonic scalpel is a recently introduced device in head and neck surgery. Total thyroidectomy is the most common endocrine procedure performed by surgeons.

METHODS:

This was an open, phase IV, multicenter, randomized controlled trial (RCT) that compared the use of an ultrasonic scalpel with a conventional technique in patients who underwent total thyroidectomy. The outcomes were surgical complication rate, operative time, drainage volume, postoperative pain, and costs.

RESULTS:

In all, 261 patients were included in 11 centers. There was a mean difference of 17% of operative time in favor of the ultrasonic scalpel group. There were no differences in postoperative complications. There was a difference in costs of 14% in favor of the ultrasonic scalpel group, but it was not statistically significant.

CONCLUSIONS:

The use of an ultrasonic scalpel was as safe as that of the conventional technique and had the advantage of a shorter operative time and lower postoperative drainage. Costs were not different between groups.

Copyright © 2012 Wiley Periodicals, Inc.

PMID: 22302518 [PubMed – indexed for MEDLINE]
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Int J Cancer. 2012 Apr 15;130(8):1726-32. doi: 10.1002/ijc.26185. Epub 2011 Aug 5.

High-risk human papillomavirus in oral squamous cell carcinoma of young patients.

Kaminagakura EVilla LLAndreoli MASobrinho JSVartanian JGSoares FANishimoto INRocha RKowalski LP.

Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Hospital, São Paulo, Brazil.

Abstract

The aim of this study was to investigate a possible relation between oral squamous cell carcinoma (SCC), the presence of high-risk human papillomavirus (HR-HPV) DNA and p16 expression in young patients. Paraffin-embedded tumor blocks from 47 oral SCC of young (≤40-year old) patients were evaluated. The presence of HPV DNA in tumor specimens was analyzed by polymerase chain reaction (PCR) using GP5+/GP6+ generic primers (L1 region) followed by dot blot hybridization for HPV typing. When necessary, the HPV16 positivity was confirmed by PCR HPV16 E7-specific primers. Cases involving young patients were compared with 67 oral SCC from patients ≥50-year old (controls). Demographic and clinical data were collected to analyze patient outcomes. p16(ink4) expression was evaluated by immunostaining of tissue microarrays. HPV16 was detected in 22 (19.2%) cases; 15 (68.2%) young and 7 (31.8%) control patients, a statistically significant difference (p = 0.01). In 1 (1.7%) young group specimen, HPV DNA 16 and 18 was detected. p16 expression was observed in 11 (25.6%) cases from the young group and in 11 (19.6%) controls (p = 0.48). Association between HPV and p16 was verified, and it was statistically significant (p = 0.002). The higher prevalence of high-risk HPV types, especially HPV16, may be a contributing factor to oral carcinogenesis in younger individuals.

Copyright © 2011 UICC.

PMID: 21618514 [PubMed – indexed for MEDLINE]
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Curr Opin Otolaryngol Head Neck Surg. 2010 Apr;18(2):95-100. doi: 10.1097/MOO.0b013e3283376c3f.

Total glossectomy in the organ preservation era.

Vartanian JGMagrin JKowalski LP.

Head and Neck Surgery and Otorhinolaryngology Department, A.C. Camargo Hospital, Sao Paulo, Brazil.

Abstract

PURPOSE OF REVIEW:

Total or subtotal glossectomy is considered a highly morbid procedure. However, in some institutions and in selected cases of unsuccessful chemoradiation regimens, it is performed with acceptable oncological and functional outcomes.

RECENT FINDINGS:

Chemoradiation for advanced oral and oropharyngeal cancers is also highly morbid and some authors reported reasonable functional results after major glossectomies. Also, there is a lack of prospective trials comparing the long-term outcome between chemoradiation and major glossectomies.

SUMMARY:

Total and/or subtotal glossectomies with immediate reconstruction can be performed in highly selected patients with advanced oral or base of the tongue carcinomas, as a primary or salvage procedure, with acceptable outcomes.

PMID: 20234211 [PubMed – indexed for MEDLINE]
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Head Neck. 2010 Nov;32(11):1460-6. doi: 10.1002/hed.21347.

Case-control study on prognostic factors in oral squamous cell carcinoma in young patients.

Kaminagakura EVartanian JGda Silva SDdos Santos CRKowalski LP.

Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Hospital, São Paulo, Brazil.

Abstract

BACKGROUND:

Oral squamous cell carcinoma affects mainly patients between the fifth and sixth decades of life, being rare in the young (≤40 years old).

METHODS:

Demographic, clinical, and pathologic features, and the long-term survival of 125 patients younger than 41 years of age were compared with 250 control patients older than 50 years old. Data were submitted to Kaplan-Meier and log-rank tests.

RESULTS:

The percentage of nonsmokers was higher in the younger patients (p = .04). In the younger patients, tumors at advanced clinical stage (p < .01) and poorly differentiated tumors (p = .01) were associated with a higher risk of recurrence. The relapse rate was higher in the younger patients (p = .02); however, there was no significant difference on overall survival (p = .86). The younger patients diagnosed after the 1990s had less advanced clinical stage tumors, had an increase in the use of combination of surgery, radiotherapy, and chemotherapy, and their overall survival was improved.

CONCLUSION:

This study emphasizes the importance of early diagnosis and aggressive treatment of oral squamous cell carcinoma.

PMID: 20175200 [PubMed – indexed for MEDLINE]
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Int J Oral Maxillofac Surg. 2009 Aug;38(8):850-4. doi: 10.1016/j.ijom.2009.03.709. Epub 2009 May 29.

Reconstruction after extended orbital exenteration using a fronto-lateral flap.

Rodrigues MLKöhler HFFaria JCIkeda MKVartanian JGKowalski LP.

Department of Head and Neck Surgery and Otolaryngology, Hospital A C Camargo, Rua Antônio Prudente 211, São Paulo, Brazil.

Abstract

Orbital exanteration is usually performed for advanced neoplasms of the eyelids and is associated with significant distress for patients. Its reconstruction should aim for functional and aesthetic results and safety for further oncological treatment. The ideal reconstruction should provide adequate cutaneous covering, short healing time, obliteration and closure of communication with facial sinuses and nasal cavity, resistance to radiotherapy, low morbidity and favorable rehabilitation. In 10 patients, a flap based on the frontal branch of the temporal artery was used for immediate reconstruction after orbital exenteration. Flap demarcation began through the frontal midline from the glabella to 0.5 cm above the hairline. Its elevation was performed in a plane above the periosteum and galea, including skin, subcutaneous tissue and frontal muscle. It was rotated tension-free over the defect. In all patients, adequate closure of the defect and obliteration of the orbital cavity was achieved. There was no flap loss or major complications. The lateral frontal flap is easy and fast to execute, with a reliable blood supply and reproducible technique. Its main applicability is for patients with orbital defects and high surgical risks with contraindications for microsurgical reconstruction.

PMID: 19481906 [PubMed – indexed for MEDLINE]
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Arch Otolaryngol Head Neck Surg. 2009 Apr;135(4):376-9. doi: 10.1001/archoto.2009.5.

Acceptance of major surgical procedures and quality of life among long-term survivors of advanced head and neck cancer.

Vartanian JGKowalski LP.

Department of Head and Neck Surgery and Otorhinolaryngology, Hospital A. C. Camargo, Rua Professor Antonio Prudente, 211-01509-900, São Paulo, Brazil. jgvartanian@uol.com.br

Abstract

OBJECTIVE:

To evaluate the acceptance of major surgical procedures and quality of life among long-term survivors of advanced head and neck cancer treated at a single institution.

DESIGN:

Cross-sectional analysis of a consecutive series of patients.

SETTING:

Tertiary care cancer center.

PATIENTS:

Participants had advanced (T3 and T4) head and neck cancer, had undergone a surgical procedure with or without postoperative radiotherapy, and had a minimum disease-free survival duration of 1 year. Eligible participants completed a questionnaire about their attitudes toward long-term outcomes and the University of Washington Quality of Life Questionnaire (UW-QOL).

MAIN OUTCOME MEASURE:

Descriptive analyses of the results and comparisons of the scores for each UW-QOL domain.

RESULTS:

A total of 273 patients were included in the study. Most were men (74.4%), with a median age of 56 years. The tumor site was the oral cavity in 101 patients (37.0%), larynx in 91 (33.3%), oropharynx in 64 (23.4%), and hypopharynx in 17 (6.2%). There were 167 patients (61.2%) with T3 tumors and 106 (38.8%) with T4 tumors. Adjuvant radiotherapy was performed in 153 patients (56.0%). Global quality of life was considered good to excellent by 162 patients (59.3%), and the mean UW-QOL composite score was 79.3. Most patients (91.2%) reported that they would undergo the same treatment if they had it to do again, and 95.6% reported that they would not like to exchange their present outcome for another treatment option with a lower chance of cure but with a possibly improved quality of life.

CONCLUSION:

In this series, the vast majority of patients considered a radical surgical procedure an acceptable treatment and reported a good quality of life.

PMID: 19380360 [PubMed – indexed for MEDLINE]
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Arch Otolaryngol Head Neck Surg. 2009 Apr;135(4):342-6. doi: 10.1001/archoto.2009.16.

Clinical predictors of quality of life in patients with initial differentiated thyroid cancers.

Almeida JPVartanian JGKowalski LP.

Department of Head and Neck Surgery and Otorhinolaryngology, Hospital A. C. Camargo, Rua Professor Antônio Prudente, 211, 01509-900 São Paulo, Brazil. lp_kowalski@uol.com.br

Erratum in

  • Arch Otolaryngol Head Neck Surg. 2009 Jul;135(7):636. Almeida, Juliana [corrected to Almeida, Juliana Pereira].

Abstract

BACKGROUND:

Patients with differentiated thyroid cancer (DTC) usually have a good prognosis. Traditionally, treatment success in patients with cancer has been evaluated by survival time. Recently, it has been observed that the diagnosis and treatment of cancer also have a strong effect on the quality of life (QOL) of these patients.

OBJECTIVE:

To assess the QOL of patients with DTC and its potential clinical predictors.

DESIGN:

Cross-sectional analysis.

SETTING:

A tertiary cancer institution.

PATIENTS:

One hundred fifty-four patients submitted to thyroidectomy (1997-2006) were evaluated using the University of Washington Quality of Life questionnaire.

MAIN OUTCOME MEASURES:

Descriptive analysis of the results was done, as bivariate and multivariate analyses to compare each independent variable with each of 13 QOL domains.

RESULTS:

Patients 45 years or younger had better recreation scores than did patients older than 45 years (P = .04). Thirty-eight patients were submitted to neck dissection. Patients submitted to modified radical neck dissection reported worse chewing and shoulder scores than did patients submitted to selective paratracheal lymph node dissection only and those without neck dissection (P = .003 and P = .004, respectively). Patients who received more than 150 mCi of radioactive iodine therapy (RIT) reported significantly worse pain, swallowing, chewing, speech, taste, anxiety, and composite scores. Comorbidities showed significant effect on recreation, activity, speech, saliva, and composite scores (P = .02, P = .046, P = .02, P = .01, and P = .008, respectively). In multivariate analysis, RIT is the only variable associated with a worse composite score (P = .003).

CONCLUSION:

Although QOL after treatment of thyroid cancer can be considered good for most patients, those submitted to RIT at doses higher than 150 mCi are at risk for poor QOL and, therefore, may need more intensive follow-up and treatment.

PMID: 19380354 [PubMed – indexed for MEDLINE]
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Arch Otolaryngol Head Neck Surg. 2008 Jun;134(6):603-7. doi: 10.1001/archotol.134.6.603.

Validation of the Washington University Head and Neck Comorbidity Index in a cohort of older patients.

Sanabria ACarvalho ALVartanian JGMagrin JIkeda MKKowalski LP.

Department of Surgery, School of Medicine, Universidad de La Sabana, Fundación Abood Shaio, Campus Puente del Comun, Km 21 Autopista Norte, Bogotá Colombia. alvarosanabria@gmail.com

Abstract

OBJECTIVES:

To validate the prognostic ability of the Washington University Head and Neck Comorbidity Index (WUHNCI) relative to 5-year survival in a cohort of older patients with head and neck cancer and to compare it with that of the Adult Comorbidity Evaluation 27 (ACE-27).

DESIGN:

Validation study.

SETTING:

Academic research.

PATIENTS:

Three hundred twenty-one patients older than 70 years with head and neck cancer in a tertiary cancer center. Comorbidity was measured using the ACE-27, WUHNCI, and National Cancer Institute (NCI) comorbidity index.

MAIN OUTCOME MEASURE:

Five-year overall survival.

RESULTS:

Five-year overall and cancer-specific survival, respectively, were as follows: Using the WUHNCI, 52.2% and 62.9% for a score of 0; 25.1% and 41.7% for a score of 1; 39.3% and 64.9% for a score of 2; and 19.5% and 45.0% for a score of 3 or higher. Using the ACE-27, 54.4% and 61.7% for a score of 0 (no comorbidity); 46.8% and 61.7% for a score of 1 (mild comorbidity); 31.7% and 51.6% for a score of 2 (moderate comorbidity); and 13.8% and 43.7% for a score of 3 (severe comorbidity). The C statistics were 0.641 for the NCI comorbidity index, 0.656 for the ACE-27, and 0.686 for the WUHNCI.

CONCLUSIONS:

The WUHNCI did not demonstrate good discriminative power compared with the ACE-27 in a cohort of older patients. To be widely used, instruments developed to measure comorbidities must be reliable in any population. We believe that the ACE-27 is still the best index to assess comorbidities and that it should be used in studies evaluating the prognostic effect of comorbidities.

PMID: 18559726 [PubMed – indexed for MEDLINE]
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