Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis in the Elderly: A Case-Controlled, Multicenter Study

Mohammad Alyami; Peter Lundberg; Vahan Kepenekian; Diane Goéré; Jean Marc Bereder; Simon Msika; Gérard Lorimier; François Quenet; Gwenaël Ferron; Emilie Thibaudeau; Karine Abboud; Réa Lo Dico; Delphine Delroeux; Cécile Brigand; Catherine Arvieux; Frédéric Marchal; Jean Jacques Tuech; Jean Marc Guilloit; Frédéric Guyon; Patrice Peyrat; Denis Pezet; Pablo Ortega-Deballon; Franck Zinzindohoue; Cécile de Chaisemartin; Reza Kianmanesh; Olivier Glehen; Guillaume Passot; behalf of the BIG-RENAPE on behalf of the BIG-RENAPE; Julio Abba; Naoual Bakrin; Gisèle Balagué; Vincent Barrau; Houda Ben Rejeb; Frédéric Bibeau; Isabelle Bonnefoy; Dominique Bouzard; Ivan Bricault; Sébastien Carrère; Michel Carretier; Madleen Chassang; Anne Chevallier; Thomas Courvoisier; Eddy Cotte; Peggy Dartigues; Grégoire Desolneux; Anthony Dohan; Clarisse Dromain; Julien Dubreuil; Frédéric Dumont; Sylvaine Durand-Fontanier; Dominique Elias; Clarisse Eveno; Serge Evrard; Olivier Facy; Marie Faruch-Bilfeld; Gwenaël Ferron; Johan Gagniere; Delphine Geffroy; François Noël Gilly; Juliette Fontaine; Nicolas Goasguen; Laurent Ghouti; Aymeric Guibal; Bruno Heyd; Constance Hordonneau; Sylvie Isaac; Peggy Jourdan-Enfer; Rachid Kaci; Mehdi Karoui; Catherine Labbé; Joëlle Lacroix; Gerlinde Lang-Averous; Marie Hélène Laverriere; Jérémie Lefevre; Bernard Lelong; Agnès Leroux; Valéria Loi; Caroline Malhaire; Antoine Mariani; Pascale Mariani; Christophe Mariette; Emilie Mathiotte; Pierre Meeus; Eliane Mery; Mathieu Messager; Cédric Nadeau; Olivier Pellet; Caroline Petorin; Guillaume Piessen; Nicolas Pirro; Marc Pocard; Flora Poizat; Jack Porcheron; Anaïs Poulet; Patrick Rat; Jean Marc Regimbeau; Pierre Rousselot; Pascal Rousset; Charles Sabbagh; Martine Serrano; Vincent Servois; Andrea Skanjeti; Magali Svrcek; Raphaël Tetreau; Pierre Jean Valette; Séverine Valmary-Degano; Delphine Vaudoyer; Stéphane Velasco; Véronique Verriele-Beurrier; Laurent Villeneuve; Romuald Wernert

doi:10.1245/s10434-016-5519-2

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis in the Elderly: A Case-Controlled, Multicenter Study

Mohammad Alyami, Peter Lundberg, Vahan Kepenekian, Diane Goéré, Jean Marc Bereder, Simon Msika, Gérard Lorimier, François Quenet, Gwenaël Ferron, Emilie Thibaudeau, Karine Abboud, Réa Lo Dico, Delphine Delroeux, Cécile Brigand, Catherine Arvieux, Frédéric Marchal, Jean Jacques Tuech, Jean Marc Guilloit, Frédéric Guyon, Patrice PeyratDenis Pezet, Pablo Ortega-Deballon, Franck Zinzindohoue, Cécile de Chaisemartin, Reza Kianmanesh, Olivier Glehen, Guillaume Passot, behalf of the BIG-RENAPE on behalf of the BIG-RENAPE, Julio Abba, Naoual Bakrin, Gisèle Balagué, Vincent Barrau, Houda Ben Rejeb, Frédéric Bibeau, Isabelle Bonnefoy, Dominique Bouzard, Ivan Bricault, Sébastien Carrère, Michel Carretier, Madleen Chassang, Anne Chevallier, Thomas Courvoisier, Eddy Cotte, Peggy Dartigues, Grégoire Desolneux, Anthony Dohan, Clarisse Dromain, Julien Dubreuil, Frédéric Dumont, Sylvaine Durand-Fontanier, Dominique Elias, Clarisse Eveno, Serge Evrard, Olivier Facy, Marie Faruch-Bilfeld, Gwenaël Ferron, Johan Gagniere, Delphine Geffroy, François Noël Gilly, Juliette Fontaine, Nicolas Goasguen, Laurent Ghouti, Aymeric Guibal, Bruno Heyd, Constance Hordonneau, Sylvie Isaac, Peggy Jourdan-Enfer, Rachid Kaci, Mehdi Karoui, Catherine Labbé, Joëlle Lacroix, Gerlinde Lang-Averous, Marie Hélène Laverriere, Jérémie Lefevre, Bernard Lelong, Agnès Leroux, Valéria Loi, Caroline Malhaire, Antoine Mariani, Pascale Mariani, Christophe Mariette, Emilie Mathiotte, Pierre Meeus, Eliane Mery, Mathieu Messager, Cédric Nadeau, Olivier Pellet, Caroline Petorin, Guillaume Piessen, Nicolas Pirro, Marc Pocard, Flora Poizat, Jack Porcheron, Anaïs Poulet, Patrick Rat, Jean Marc Regimbeau, Pierre Rousselot, Pascal Rousset, Charles Sabbagh, Martine Serrano, Vincent Servois, Andrea Skanjeti, Magali Svrcek, Raphaël Tetreau, Pierre Jean Valette, Séverine Valmary-Degano, Delphine Vaudoyer, Stéphane Velasco, Véronique Verriele-Beurrier, Laurent Villeneuve, Romuald Wernert

Research output: Contribution to journal › Article › peer-review

23 Scopus citations

Abstract

Objective: This study was designed to identify factors associated with morbidity and mortality in patients older than 70 years who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC). Background: Major surgery is associated with higher morbidity and mortality in elderly patients. For PC, CRS and HIPEC is the only current potential curative therapy, but the risks inherent to this patient population have called its benefits into question. Methods: We retrospectively analyzed a multi-center database from 1989 to 2015. All patients who underwent CRS and HIPEC for PC were selected and patients older than 70 years were matched 1:4 with a younger cohort according to cancer origin, peritoneal cancer index (PCI), and completeness of cytoreduction. Major morbidity and mortality were analyzed. Results: Of 2328 patients, 188 patients older than aged 70 years were matched with 704 younger patients. Patients older than aged 70 years demonstrated a higher American Society of Anesthesiologist score (≥ASA III 10.8 vs. 6.6 %, p = 0.008). There was no difference in overall 90-day morbidity (≥70: 45.7 % vs. <70: 44.5 %; p = 0.171); however, patients older than 70 years had significantly more cardiovascular complications (13.8 vs. 9.2 %, p = 0.044). Differences between the older and younger cohorts failed to reach significance for 90-day mortality (5.4 and 2.7 %, respectively; p = 0.052), and failure-to-rescue (11.6 and 6.1 %, respectively; p = 0.078). In multivariate analysis, PCI > 7 (95 % CI 1.051–5.798, p = 0.038) and HIPEC duration (95 % CI 1.106–6.235, p = 0.028) were independent factors associated with morbidity in elderly patients. Conclusions: CRS and HIPEC appear feasible for selected patients older than aged 70 years, albeit with a higher risk of medical complications associated with increased mortality.

Original language	English (US)
Pages (from-to)	737-745
Number of pages	9
Journal	Annals of surgical oncology
Volume	23
DOIs	https://doi.org/10.1245/s10434-016-5519-2
State	Published - Dec 1 2016
Externally published	Yes

ASJC Scopus subject areas

Surgery
Oncology

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10.1245/s10434-016-5519-2

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Alyami, M., Lundberg, P., Kepenekian, V., Goéré, D., Bereder, J. M., Msika, S., Lorimier, G., Quenet, F., Ferron, G., Thibaudeau, E., Abboud, K., Lo Dico, R., Delroeux, D., Brigand, C., Arvieux, C., Marchal, F., Tuech, J. J., Guilloit, J. M., Guyon, F., ... Wernert, R. (2016). Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis in the Elderly: A Case-Controlled, Multicenter Study. Annals of surgical oncology, 23, 737-745. https://doi.org/10.1245/s10434-016-5519-2

Alyami, M, Lundberg, P, Kepenekian, V, Goéré, D, Bereder, JM, Msika, S, Lorimier, G, Quenet, F, Ferron, G, Thibaudeau, E, Abboud, K, Lo Dico, R, Delroeux, D, Brigand, C, Arvieux, C, Marchal, F, Tuech, JJ, Guilloit, JM, Guyon, F, Peyrat, P, Pezet, D, Ortega-Deballon, P, Zinzindohoue, F, de Chaisemartin, C, Kianmanesh, R, Glehen, O, Passot, G, on behalf of the BIG-RENAPE, BOTBIG-RENAPE, Abba, J, Bakrin, N, Balagué, G, Barrau, V, Rejeb, HB, Bibeau, F, Bonnefoy, I, Bouzard, D, Bricault, I, Carrère, S, Carretier, M, Chassang, M, Chevallier, A, Courvoisier, T, Cotte, E, Dartigues, P, Desolneux, G, Dohan, A, Dromain, C, Dubreuil, J, Dumont, F, Durand-Fontanier, S, Elias, D, Eveno, C, Evrard, S, Facy, O, Faruch-Bilfeld, M, Ferron, G, Gagniere, J, Geffroy, D, Gilly, FN, Fontaine, J, Goasguen, N, Ghouti, L, Guibal, A, Heyd, B, Hordonneau, C, Isaac, S, Jourdan-Enfer, P, Kaci, R, Karoui, M, Labbé, C, Lacroix, J, Lang-Averous, G, Laverriere, MH, Lefevre, J, Lelong, B, Leroux, A, Loi, V, Malhaire, C, Mariani, A, Mariani, P, Mariette, C, Mathiotte, E, Meeus, P, Mery, E, Messager, M, Nadeau, C, Pellet, O, Petorin, C, Piessen, G, Pirro, N, Pocard, M, Poizat, F, Porcheron, J, Poulet, A, Rat, P, Regimbeau, JM, Rousselot, P, Rousset, P, Sabbagh, C, Serrano, M, Servois, V, Skanjeti, A, Svrcek, M, Tetreau, R, Valette, PJ, Valmary-Degano, S, Vaudoyer, D, Velasco, S, Verriele-Beurrier, V, Villeneuve, L & Wernert, R 2016, 'Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis in the Elderly: A Case-Controlled, Multicenter Study', Annals of surgical oncology, vol. 23, pp. 737-745. https://doi.org/10.1245/s10434-016-5519-2

@article{a403462eff1040ccb076515e581fb731,

title = "Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis in the Elderly: A Case-Controlled, Multicenter Study",

abstract = "Objective: This study was designed to identify factors associated with morbidity and mortality in patients older than 70 years who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC). Background: Major surgery is associated with higher morbidity and mortality in elderly patients. For PC, CRS and HIPEC is the only current potential curative therapy, but the risks inherent to this patient population have called its benefits into question. Methods: We retrospectively analyzed a multi-center database from 1989 to 2015. All patients who underwent CRS and HIPEC for PC were selected and patients older than 70 years were matched 1:4 with a younger cohort according to cancer origin, peritoneal cancer index (PCI), and completeness of cytoreduction. Major morbidity and mortality were analyzed. Results: Of 2328 patients, 188 patients older than aged 70 years were matched with 704 younger patients. Patients older than aged 70 years demonstrated a higher American Society of Anesthesiologist score (≥ASA III 10.8 vs. 6.6 %, p = 0.008). There was no difference in overall 90-day morbidity (≥70: 45.7 % vs. <70: 44.5 %; p = 0.171); however, patients older than 70 years had significantly more cardiovascular complications (13.8 vs. 9.2 %, p = 0.044). Differences between the older and younger cohorts failed to reach significance for 90-day mortality (5.4 and 2.7 %, respectively; p = 0.052), and failure-to-rescue (11.6 and 6.1 %, respectively; p = 0.078). In multivariate analysis, PCI > 7 (95 % CI 1.051–5.798, p = 0.038) and HIPEC duration (95 % CI 1.106–6.235, p = 0.028) were independent factors associated with morbidity in elderly patients. Conclusions: CRS and HIPEC appear feasible for selected patients older than aged 70 years, albeit with a higher risk of medical complications associated with increased mortality.",

author = "Mohammad Alyami and Peter Lundberg and Vahan Kepenekian and Diane Go{\'e}r{\'e} and Bereder, {Jean Marc} and Simon Msika and G{\'e}rard Lorimier and Fran{\c c}ois Quenet and Gwena{\"e}l Ferron and Emilie Thibaudeau and Karine Abboud and {Lo Dico}, R{\'e}a and Delphine Delroeux and C{\'e}cile Brigand and Catherine Arvieux and Fr{\'e}d{\'e}ric Marchal and Tuech, {Jean Jacques} and Guilloit, {Jean Marc} and Fr{\'e}d{\'e}ric Guyon and Patrice Peyrat and Denis Pezet and Pablo Ortega-Deballon and Franck Zinzindohoue and {de Chaisemartin}, C{\'e}cile and Reza Kianmanesh and Olivier Glehen and Guillaume Passot and {on behalf of the BIG-RENAPE}, {behalf of the BIG-RENAPE} and Julio Abba and Naoual Bakrin and Gis{\`e}le Balagu{\'e} and Vincent Barrau and Rejeb, {Houda Ben} and Fr{\'e}d{\'e}ric Bibeau and Isabelle Bonnefoy and Dominique Bouzard and Ivan Bricault and S{\'e}bastien Carr{\`e}re and Michel Carretier and Madleen Chassang and Anne Chevallier and Thomas Courvoisier and Eddy Cotte and Peggy Dartigues and Gr{\'e}goire Desolneux and Anthony Dohan and Clarisse Dromain and Julien Dubreuil and Fr{\'e}d{\'e}ric Dumont and Sylvaine Durand-Fontanier and Dominique Elias and Clarisse Eveno and Serge Evrard and Olivier Facy and Marie Faruch-Bilfeld and Gwena{\"e}l Ferron and Johan Gagniere and Delphine Geffroy and Gilly, {Fran{\c c}ois No{\"e}l} and Juliette Fontaine and Nicolas Goasguen and Laurent Ghouti and Aymeric Guibal and Bruno Heyd and Constance Hordonneau and Sylvie Isaac and Peggy Jourdan-Enfer and Rachid Kaci and Mehdi Karoui and Catherine Labb{\'e} and Jo{\"e}lle Lacroix and Gerlinde Lang-Averous and Laverriere, {Marie H{\'e}l{\`e}ne} and J{\'e}r{\'e}mie Lefevre and Bernard Lelong and Agn{\`e}s Leroux and Val{\'e}ria Loi and Caroline Malhaire and Antoine Mariani and Pascale Mariani and Christophe Mariette and Emilie Mathiotte and Pierre Meeus and Eliane Mery and Mathieu Messager and C{\'e}dric Nadeau and Olivier Pellet and Caroline Petorin and Guillaume Piessen and Nicolas Pirro and Marc Pocard and Flora Poizat and Jack Porcheron and Ana{\"i}s Poulet and Patrick Rat and Regimbeau, {Jean Marc} and Pierre Rousselot and Pascal Rousset and Charles Sabbagh and Martine Serrano and Vincent Servois and Andrea Skanjeti and Magali Svrcek and Rapha{\"e}l Tetreau and Valette, {Pierre Jean} and S{\'e}verine Valmary-Degano and Delphine Vaudoyer and St{\'e}phane Velasco and V{\'e}ronique Verriele-Beurrier and Laurent Villeneuve and Romuald Wernert",

note = "Publisher Copyright: {\textcopyright} 2016, Society of Surgical Oncology.",

year = "2016",

month = dec,

day = "1",

doi = "10.1245/s10434-016-5519-2",

language = "English (US)",

volume = "23",

pages = "737--745",

journal = "Annals of surgical oncology",

issn = "1068-9265",

publisher = "Springer New York",

}

TY - JOUR

T1 - Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis in the Elderly

T2 - A Case-Controlled, Multicenter Study

AU - Alyami, Mohammad

AU - Lundberg, Peter

AU - Kepenekian, Vahan

AU - Goéré, Diane

AU - Bereder, Jean Marc

AU - Msika, Simon

AU - Lorimier, Gérard

AU - Quenet, François

AU - Ferron, Gwenaël

AU - Thibaudeau, Emilie

AU - Abboud, Karine

AU - Lo Dico, Réa

AU - Delroeux, Delphine

AU - Brigand, Cécile

AU - Arvieux, Catherine

AU - Marchal, Frédéric

AU - Tuech, Jean Jacques

AU - Guilloit, Jean Marc

AU - Guyon, Frédéric

AU - Peyrat, Patrice

AU - Pezet, Denis

AU - Ortega-Deballon, Pablo

AU - Zinzindohoue, Franck

AU - de Chaisemartin, Cécile

AU - Kianmanesh, Reza

AU - Glehen, Olivier

AU - Passot, Guillaume

AU - on behalf of the BIG-RENAPE, behalf of the BIG-RENAPE

AU - Abba, Julio

AU - Bakrin, Naoual

AU - Balagué, Gisèle

AU - Barrau, Vincent

AU - Rejeb, Houda Ben

AU - Bibeau, Frédéric

AU - Bonnefoy, Isabelle

AU - Bouzard, Dominique

AU - Bricault, Ivan

AU - Carrère, Sébastien

AU - Carretier, Michel

AU - Chassang, Madleen

AU - Chevallier, Anne

AU - Courvoisier, Thomas

AU - Cotte, Eddy

AU - Dartigues, Peggy

AU - Desolneux, Grégoire

AU - Dohan, Anthony

AU - Dromain, Clarisse

AU - Dubreuil, Julien

AU - Dumont, Frédéric

AU - Durand-Fontanier, Sylvaine

AU - Elias, Dominique

AU - Eveno, Clarisse

AU - Evrard, Serge

AU - Facy, Olivier

AU - Faruch-Bilfeld, Marie

AU - Ferron, Gwenaël

AU - Gagniere, Johan

AU - Geffroy, Delphine

AU - Gilly, François Noël

AU - Fontaine, Juliette

AU - Goasguen, Nicolas

AU - Ghouti, Laurent

AU - Guibal, Aymeric

AU - Heyd, Bruno

AU - Hordonneau, Constance

AU - Isaac, Sylvie

AU - Jourdan-Enfer, Peggy

AU - Kaci, Rachid

AU - Karoui, Mehdi

AU - Labbé, Catherine

AU - Lacroix, Joëlle

AU - Lang-Averous, Gerlinde

AU - Laverriere, Marie Hélène

AU - Lefevre, Jérémie

AU - Lelong, Bernard

AU - Leroux, Agnès

AU - Loi, Valéria

AU - Malhaire, Caroline

AU - Mariani, Antoine

AU - Mariani, Pascale

AU - Mariette, Christophe

AU - Mathiotte, Emilie

AU - Meeus, Pierre

AU - Mery, Eliane

AU - Messager, Mathieu

AU - Nadeau, Cédric

AU - Pellet, Olivier

AU - Petorin, Caroline

AU - Piessen, Guillaume

AU - Pirro, Nicolas

AU - Pocard, Marc

AU - Poizat, Flora

AU - Porcheron, Jack

AU - Poulet, Anaïs

AU - Rat, Patrick

AU - Regimbeau, Jean Marc

AU - Rousselot, Pierre

AU - Rousset, Pascal

AU - Sabbagh, Charles

AU - Serrano, Martine

AU - Servois, Vincent

AU - Skanjeti, Andrea

AU - Svrcek, Magali

AU - Tetreau, Raphaël

AU - Valette, Pierre Jean

AU - Valmary-Degano, Séverine

AU - Vaudoyer, Delphine

AU - Velasco, Stéphane

AU - Verriele-Beurrier, Véronique

AU - Villeneuve, Laurent

AU - Wernert, Romuald

PY - 2016/12/1

Y1 - 2016/12/1

N2 - Objective: This study was designed to identify factors associated with morbidity and mortality in patients older than 70 years who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC). Background: Major surgery is associated with higher morbidity and mortality in elderly patients. For PC, CRS and HIPEC is the only current potential curative therapy, but the risks inherent to this patient population have called its benefits into question. Methods: We retrospectively analyzed a multi-center database from 1989 to 2015. All patients who underwent CRS and HIPEC for PC were selected and patients older than 70 years were matched 1:4 with a younger cohort according to cancer origin, peritoneal cancer index (PCI), and completeness of cytoreduction. Major morbidity and mortality were analyzed. Results: Of 2328 patients, 188 patients older than aged 70 years were matched with 704 younger patients. Patients older than aged 70 years demonstrated a higher American Society of Anesthesiologist score (≥ASA III 10.8 vs. 6.6 %, p = 0.008). There was no difference in overall 90-day morbidity (≥70: 45.7 % vs. <70: 44.5 %; p = 0.171); however, patients older than 70 years had significantly more cardiovascular complications (13.8 vs. 9.2 %, p = 0.044). Differences between the older and younger cohorts failed to reach significance for 90-day mortality (5.4 and 2.7 %, respectively; p = 0.052), and failure-to-rescue (11.6 and 6.1 %, respectively; p = 0.078). In multivariate analysis, PCI > 7 (95 % CI 1.051–5.798, p = 0.038) and HIPEC duration (95 % CI 1.106–6.235, p = 0.028) were independent factors associated with morbidity in elderly patients. Conclusions: CRS and HIPEC appear feasible for selected patients older than aged 70 years, albeit with a higher risk of medical complications associated with increased mortality.

AB - Objective: This study was designed to identify factors associated with morbidity and mortality in patients older than 70 years who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC). Background: Major surgery is associated with higher morbidity and mortality in elderly patients. For PC, CRS and HIPEC is the only current potential curative therapy, but the risks inherent to this patient population have called its benefits into question. Methods: We retrospectively analyzed a multi-center database from 1989 to 2015. All patients who underwent CRS and HIPEC for PC were selected and patients older than 70 years were matched 1:4 with a younger cohort according to cancer origin, peritoneal cancer index (PCI), and completeness of cytoreduction. Major morbidity and mortality were analyzed. Results: Of 2328 patients, 188 patients older than aged 70 years were matched with 704 younger patients. Patients older than aged 70 years demonstrated a higher American Society of Anesthesiologist score (≥ASA III 10.8 vs. 6.6 %, p = 0.008). There was no difference in overall 90-day morbidity (≥70: 45.7 % vs. <70: 44.5 %; p = 0.171); however, patients older than 70 years had significantly more cardiovascular complications (13.8 vs. 9.2 %, p = 0.044). Differences between the older and younger cohorts failed to reach significance for 90-day mortality (5.4 and 2.7 %, respectively; p = 0.052), and failure-to-rescue (11.6 and 6.1 %, respectively; p = 0.078). In multivariate analysis, PCI > 7 (95 % CI 1.051–5.798, p = 0.038) and HIPEC duration (95 % CI 1.106–6.235, p = 0.028) were independent factors associated with morbidity in elderly patients. Conclusions: CRS and HIPEC appear feasible for selected patients older than aged 70 years, albeit with a higher risk of medical complications associated with increased mortality.

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U2 - 10.1245/s10434-016-5519-2

DO - 10.1245/s10434-016-5519-2

M3 - Article

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SN - 1068-9265

VL - 23

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JO - Annals of surgical oncology

JF - Annals of surgical oncology

ER -

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis in the Elderly: A Case-Controlled, Multicenter Study

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