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L e t t e r t o t h e E d i t o r 225Dear Sir, Acute multi-coronary thrombotic occlusion is an uncommon presentation of ST-segment elevation myocardial infarction (STEMI). Only a few reports of this condition have been published to date and the appropriate management options are unclear.(1) The present report draws attention to simultaneous coronary thrombosis in the right coronary artery (RCA) and left anterior descending artery (LAD) and discusses the possible mechanism and treatment strategy.A 51-year-old man presented with typical chest pain of four hours' duration and pulmonary oedema. His cardiovascular risk factors included Type 2 diabetes mellitus, hypertension, dyslipidaemia and smoking (ten cigarettes per day for the past 20 years). The patient received intranasal oxygen therapy, intravenous morphine and furosemide in the emergency department. A loading dose of aspirin 300 mg and clopidogrel 600 mg was administered. Electrocardiography revealed ST-segment elevation in the inferior leads. Coronary angiograms showed a thrombotic occlusion of the mid-RCA and the proximal LAD, with thrombolysis in myocardial infarction (TIMI) 0 flow (Figs. 1a & b).Primary percutaneous coronary intervention (PCI) was performed via a 7 French (Fr) sheath in the right common femoral artery. The patient received heparin anticoagulation during PCI, guided by an activated clotting time. Initial results with plain balloon angioplasty were unsatisfactory for both the lesions, with a large thrombus burden. Thrombus was aspirated from the RCA and the LAD with a 7 Fr Thrombuster aspiration catheter (Kaneka Medix Corp, Shinagawa-ku, Tokyo, Japan). TIMI 3 flow was achieved in both the arteries, with a residual stenosis of 50%-60% in the mid-RCA and 60%-70% in the mid-LAD (Figs. 2a & b). The coronary arteries were ectatic. An intra-aortic balloon pump was inserted for haemodynamic stability. During PCI, the patient had also received two boluses of eptifibatide (180 µg/kg given ten minutes apart), followed by an infusion for 24 hours (2.0 µg/kg/min). As reperfusion was successful following the aspiration thrombectomy, stenting during primary PCI was deferred. Following PCI, low-molecular-weight heparin (1 mg/kg body weight, twice daily) was administered during the period of index hospitalisation. Investigations did not reveal

Background Synchronous multiple primary colorectal cancer (SMPCC) involves the simultaneous occurrence of 2 or more independent primary malignant tumors in the colon or rectum. Although SMPCC is rare, it results in a higher incidence of postoperative complications and mortality compared to patients with single primary colorectal cancer (SPCRC). Methods The clinical factors and survival outcomes of SMPCC patients registered on the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2017 were extracted. The patients were divided into the training and validation cohorts using a ratio of 7:3. Univariate and multivariate logistic regression analyses were used to identify the independent risk factors for early death. The performance of the nomogram was evaluated using the concordance index (C-index), calibration curves, and the area under the curve (AUC) of a receiver operating characteristics curve (ROC). A decision curve analysis (DCA) was used to evaluate the clinical utility of the nomogram and standard TNM system. Results A total of 4386 SMPCC patients were enrolled in the study and randomly assigned to the training (n = 3070) and validation (n = 1316) cohorts. The multivariate logistic analysis identified age, chemotherapy, radiotherapy, T stage, N stage, and M stage as independent risk factors for all-cause and cancer-specific early death. The marital status was associated with all-cause early death, and the tumor grade was associated with cancer-specific early death. In the training cohort, the nomogram achieved a C-index of 0.808 (95% CI, 0.784–0.832) and 0.843 (95% CI, 0.816–0.870) for all-cause and cancer-specific early death, respectively. Following validation, the C-index was 0.797 (95% CI, 0.758–0.837) for all-cause early death and 0.832 (95% CI, 0.789–0.875) for cancer-specific early death. The ROC and calibration curves indicated that the model had good stability and reliability. The DCA showed that the nomogram had a better clinical net value than the TNM staging system. Conclusion Our nomogram can provide a simple and accurate tool for clinicians to predict the risk of early death in SMPCC patients undergoing surgery and could be used to optimize the treatment according to the patient's needs.

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