A global federated real-world data and analytics platform for research

Liraglutide for idiopathic intracranial hypertension: a real-world propensity score-matched study

OBJECTIVE

Idiopathic intracranial hypertension (IIH) is a neurological disorder predominantly affecting young women with obesity, characterized by elevated intracranial pressure. While current treatments include weight loss counseling, medical therapies, and surgical interventions, their limitations necessitate exploring novel therapeutic approaches. We investigated the efficacy of liraglutide as an adjunctive therapy in IIH management.

METHODS

We conducted a retrospective cohort study, analyzing adult patients with IIH. Through propensity score matching, we compared patients receiving liraglutide alongside standard therapy (n = 204) with those receiving standard therapy alone (n = 204). Primary outcomes included papilledema, headache manifestations, and visual disturbances, assessed at 3, 6, 12, and 24 months posttreatment initiation.

RESULTS

Our matched cohorts were predominantly female (95.1% vs. 97.1%) with comparable mean ages (37.6 vs. 37.3 years). Liraglutide treatment demonstrated significant reduction in papilledema risk at 3 months (RR 0.333, 95% CI 0.167-0.664, p = 0.001), with sustained benefits throughout 24 months (RR 0.524, 95% CI 0.325-0.845, p = 0.006). While improvements were observed in visual disturbances, headache symptoms, and refractory IIH cases, these did not reach statistical significance.

INTERPRETATION

Our findings suggest that liraglutide as an adjunctive therapy significantly improves papilledema outcomes in IIH patients, with the greatest effect observed at 3 months and sustained benefits over 2 years. This study provides promising evidence for liraglutide's role in IIH management, particularly in addressing papilledema.

Trends in Ancillary Procedures Following Staged Implant-Based Breast Reconstruction

BACKGROUND

The shift from submuscular to prepectoral breast reconstruction has contributed to anecdotal changes in practices around ancillary procedures, such as autologous fat grafting and nipple-areola complex (NAC) reconstruction. Although prepectoral reconstruction carries a lesser risk for muscular injury, postoperative pain and animation deformity, it is associated with decreased soft-tissue coverage and may necessitate ancillary procedures. This study examines operative trends following staged implant-based breast reconstruction to determine if tissue expander (TE) plane is associated with changes in the utilization of supplemental procedures.

METHODS

We conducted a retrospective review using the TriNetX research database of deidentified patient data. Using Current Procedural Terminology codes, we identified adult female patients who underwent (1) mastectomy, (2) TE placement between 2013 and 2020, and (3) implant exchange. We grouped patients by year of TE placement and collected postimplant procedure characteristics.

RESULTS

We identified 10,984 patients who underwent TE placement between 2013 and 2020 and subsequent implant exchange. There were 854 patients in the 2013 cohort and 1634 in the 2020 cohort. Fat grafting was 2.76-fold more prevalent in the 2020 cohort compared to the 2013 cohort (43.0% vs 15.6%, P < 0.001). Notably, the percentage of patients undergoing more than one round of fat grafting increased from 4.1% in the 2013 cohort to 11.9% in the 2020 cohort (P < 0.001). Fat grafting at the time of implant exchange was also more common in later cohorts, increasing from 6.6% of patients in the 2013 cohort to 32.0% in the 2020 cohort (P < 0.001). Over the study period, rates of NAC reconstruction were observed to decrease. A total of 10.3% of patients in the 2020 cohort underwent NAC reconstruction compared to 24.6% in the 2013 cohort (P < 0.001). Nipple tattooing procedures were also performed less frequently in recent cohorts.

CONCLUSIONS

In more recent cohorts, procedures aimed at correcting contour irregularities and rippling, specifically autologous fat grafting, have become more common. In contrast, the rates of NAC reconstruction and nipple tattooing have decreased, possibly because of challenges related to thin mastectomy skin flaps and limited soft-tissue coverage, which are more common in prepectoral reconstruction.

Outcomes of non-hospitalized patients with COVID-19 versus seasonal influenza during the fall-winter 2022-2023 period

BACKGROUND

The comparability of outcomes for non-hospitalized COVID-19 outpatients during the Omicron wave to outpatients with influenza remains uncertain. This study aims to compare the outcomes of non-hospitalized outpatients with COVID-19 and seasonal influenza during the fall-winter of 2022-2023.

METHODS

This is a retrospective cohort study using TriNetX, a collaborative clinical research platform. Non-hospitalized outpatients with COVID-19 and seasonal influenza between 01 October 2022 and 31 January 2023 were selected from TriNetX. Propensity score matching (PSM) was used to compare patients receiving corresponding outpatient antiviral treatments. Hazard ratios (HRs) with 95% confidence intervals (CIs) for the primary outcome-a composite of all-cause emergency department (ED) visits, hospitalizations, or mortality during the 30-day follow-up period-were calculated and compared.

RESULTS

After PSM, two well-balanced groups of 9,030 patients each were identified. Non-hospitalized COVID-19 patients had a lower risk of primary composites outcomes including all-cause ED visits, hospitalization, or mortality (5.9% vs. 9.2%, HR, 0.661[95% CI, 0.593-0.737]) compared to the influenza group. In addition, the COVID-19 group demonstrated a reduced risk of all-cause ED visits (4.4% vs. 6.6%, HR 0.683[0.601-0.776]), hospitalization (1.7% vs. 2.9%, HR 0.605[0.495-0.739]) and mortality (0.1% vs. 0.2%, HR 0.176[0.052-0.597]), respectively.

CONCLUSIONS

This study indicates a lower risk of all-cause ED visits, hospitalization, and mortality in the non-hospitalized COVID-19 patients compared to the seasonal influenza group, supporting the current public health strategy of adjusting COVID-19 management based on approaches used for seasonal influenza.

Effects and Complications of Apixaban versus Aspirin for Venous Thromboembolism Prophylaxis after Total Hip or Knee Arthroplasty

BACKGROUND

Major orthopaedic procedures, such as total hip arthroplasty (THA) and total knee arthroplasty (TKA), carry risk for thrombotic complications. To reduce the incidence of postoperative venous thromboembolism (VTE), surgical patients are often prescribed antiplatelet or anticoagulant treatment. The objective of this study was to compare rates of VTE events and complications between apixaban and aspirin for VTE prophylaxis following primary THA and TKA.

METHODS

We searched a research network using Current Procedural Terminology and International Classification of Diseases, Tenth Revision codes for patients who underwent a THA or TKA from 2018 to 2023. Patients were then categorized into cohorts of patients who received only aspirin (81 or 325 mg, twice daily) or patients who received only apixaban (2.5 mg, twice daily) for VTE prophylaxis. Odds ratios with 95% confidence intervals were calculated to compare the associations of selected prophylaxis with VTE events and complications, and Chi-square analyses were performed to determine the significance of differences. Statistical significance was defined as a two-sided alpha value < 0.05.

RESULTS

Patients who received apixaban after THA had increased odds of deep vein thrombosis (5.22, 4.60 to 5.93), pulmonary embolism (7.85, 6.55 to 9.41), transfusion (1.5, 1.27 to 1.81), hemarthrosis (1.87, 1.26 to 2.24), myocardial infarction (1.12, 1.03 to 1.23), and readmission (1.18, 1.09 to 1.28) within 90 days after surgery. Patients who received apixaban after TKA had increased odds of deep vein thrombosis (4.57, 4.15 to 5.02), pulmonary embolism (6.05, 5.33 to 6.88), transfusion (1.6, 1.36 to 1.96), hemarthrosis (1.48, 1.03 to 2.12), myocardial infarction (1.42, 1.29 to 1.63), stroke (1.16, 1.09 to 1.53), and readmission (1.84, 1.61 to 2.11) within 90 days after TKA.

CONCLUSIONS

Apixaban is associated with increased odds of thrombotic events and bleeding complications in the postoperative period of THA and TKA compared to aspirin. This highlights the potential risks associated with apixaban use and the importance of using data to guide patient management in the absence of standardized clinical guidelines.

The impact of sodium-glucose cotransporter-2 inhibitors on dialysis risk and mortality in kidney transplant patients with diabetes

Kidney transplantation is the optimal treatment for end-stage kidney disease, but many patients also have diabetes mellitus. This study compares long-term outcomes between new users of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and dipeptidyl peptidase-4 inhibitors (DPP-4i) in kidney transplant recipients with diabetes mellitus. Data from the TriNetX Collaborative Network, including 89,710 patients with diabetes mellitus who underwent kidney transplantation between January 1, 2015, and June 30, 2023, were analyzed. From this cohort, 1410 matched pairs of SGLT2i and DPP-4i users were selected based on propensity scores. The results showed that SGLT2i users had a lower risk of dialysis (hazards ratio: 0.694) and all-cause mortality (hazards ratio: 0.687) compared with DPP-4i users. There were no significant differences in the risk of posttransplant infections, transplant rejection, or hospitalization between the 2 groups. Additionally, SGLT2i users had significantly lower cumulative incidences of dialysis and mortality. In conclusion, this study, using data from TriNetX, demonstrated that SGLT2i treatment in kidney transplant recipients with diabetes mellitus is associated with lower risks of dialysis and mortality, suggesting it may help preserve kidney function and improve survival in this population.

A comprehensive review of methodologies and application to use the real-world data and analytics platform TriNetX

Randomized controlled trials (RCTs) are the gold standard for evaluating the efficacy and safety of both pharmacological and non-pharmacological interventions. However, while they are designed to control confounders and ensure internal validity, their usually stringent inclusion and exclusion criteria often limit the generalizability of findings to broader patient populations. Moreover, RCTs are resource-intensive, frequently underpowered to detect rare adverse events, and sometimes narrowly focused due to their highly controlled environments. In contrast, real-world data (RWD), typically derived from electronic health records (EHRs) and claims databases, offers a valuable counterpart for answering research questions that may be impractical to address through RCTs. Recognizing this, the US Food and Drug Administration (FDA) has increasingly relied on real-world evidence (RWE) from RWD to support regulatory decisions and post-market surveillance. Platforms like TriNetX, that leverage large-scale RWD, facilitate collaborations between academia, industry, and healthcare organizations, and constitute an in-depth tool for retrieval and analysis of RWD. TriNetX's federated network architecture allows real-time, privacy-compliant data access, significantly enhancing the ability to conduct retrospective studies and refine clinical trial designs. With access to currently over 150 million EHRs, TriNetX has proven particularly effective in filling gaps left by RCTs, especially in the context of rare diseases, rare endpoints, and diverse patient populations. As the role of RWD in healthcare continues to expand, TriNetX stands out as a critical tool that complements traditional clinical trials, bridging the gap between controlled research environments and real-world practice. This review provides a comprehensive analysis of the methodologies and applications of the TriNetX platform, highlighting its potential contribution to advance patient care and outcomes.

Corticosteroid Injection up to 8 Weeks Before Anterior Cruciate Ligament Reconstruction Doubles the Incidence of Postoperative Infection

PURPOSE

To determine whether at least 1 corticosteroid injection (CSI) within 8 weeks before anterior cruciate ligament reconstruction (ACLR) increases the incidence of postoperative infection.

METHODS

A large globally federated research database (TriNetX) containing more than 200 million patient records was queried retrospectively for patients undergoing ACLR between October 1, 2010, and January 1, 2024, using diagnosis and procedure codes. A cohort of patients receiving CSI up to 8 weeks before ACLR were compared with a cohort of patients who did not receive a CSI before ACLR. One-to-one propensity score matching was performed on the basis of preoperative characteristics and comorbid diagnoses. Outcomes examined were incidence of postoperative infection at 90 days and 180 days. Postoperative infection was defined as a formal infection diagnosis or need for a washout surgery. Comparisons were performed using Pearson χ2 tests.

RESULTS

After matching, 2,439 patients were analyzed in each cohort with matched preoperative characteristics and comorbid diagnoses. Patients receiving a CSI in the 8 weeks before ACLR had a 90-day infection rate of 1.2% (30/2,439) compared with a control group infection rate of 0.6% (14/2,439) represented as an odds ratio of 2.1 (95% confidence interval 1.1-4.0, P = .015). After 180 days, the infection rates grew to 1.3% (33/2,439) for patients receiving CSI and 0.6% (15/2,439) for the control group with an odds ratio of 2.2 (95% confidence interval 1.2-4.1, P = .009).

CONCLUSIONS

CSIs given within 8 weeks of ACL-R approximately double the incidence of postoperative infection.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Incidence of arrhythmias in chronic obstructive pulmonary disease, obstructive sleep apnea, and overlap syndrome: A retrospective cohort study

BACKGROUND

New-onset arrhythmias are common in patients with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA). However, scarce data exist regarding arrhythmia risk in overlap syndrome (OS), encompassing COPD and OSA.

OBJECTIVE

We compared the incidence of new-onset atrial and ventricular arrhythmias in patients with COPD, OSA, and OS.

METHODS

We conducted a retrospective cohort study using the TriNetX Network, comprising >140 million patients to identify patients with COPD, OSA, and OS. Patients with pre-existing arrhythmias were excluded. Propensity score matching (PSM) was used to adjust for demographics, comorbidities, and medications. Adjusted odds ratios (aORs) were estimated to compare incidence of arrhythmias across cohorts.

RESULTS

Between 2010 and 2020, a total of 2,438,454 patients with COPD only, 1,960,845 patients with OSA only, and 440,018 patients with OS (age ≥18 years) were identified. After PSM, we included 359,496 patients per cohort for the OS vs OSA-only comparison and 399,235 patients per cohort for the OS vs COPD-only comparison. Over a mean follow-up of 5.3 years, incidence of new-onset atrial fibrillation/flutter was 10.0% in OS vs 7.0% in COPD (aOR 1.472, 95% confidence interval [CI] 1.449-1.496) and 6.4% in OSA (aOR 1.568, 95% CI 1.541-1.595). Patients with OS had higher incidence of new-onset ventricular tachycardia and cardiac arrest than those with COPD (aOR 1.442 and 1.189, respectively) and OSA (aOR 1.645 and 1.777, respectively). Patients with COPD preceding OSA diagnosis had higher odds of new-onset arrhythmias.

CONCLUSION

Patients with OS have a higher incidence of new-onset atrial fibrillation/flutter, ventricular tachycardia, and cardiac arrest compared with those with OSA and COPD alone.

Pulmonary outcomes of incretin-based therapies in COPD patients receiving single-inhaler triple therapy

Background

Patients with COPD on triple therapy often face exacerbations and comorbidities. Emerging evidence suggests that glucagon-like peptide-1 (GLP-1) analogues may reduce the risk of exacerbation in patients with COPD and type 2 diabetes mellitus (T2DM). This study investigates the impact of GLP-1 analogues on pulmonary outcomes in patients with COPD on single-inhaler triple therapy (SITT) and T2DM.

Methods

We conducted a retrospective cohort study using the TriNetX database and analysed adult patients with COPD and T2DM who received SITT between April 2005 and July 2023. Patients were categorised into GLP-1 analogue and dipeptidyl peptidase-4 inhibitor (DPP4i) cohorts. The primary efficacy outcome was COPD exacerbation, and the secondary efficacy outcomes were pneumonia, acute respiratory distress syndrome, intubation, oxygen dependence and all-cause mortality. The secondary outcomes were serious gastrointestinal adverse events.

Results

We included 6898 patients, with 4184 receiving GLP-1 analogues and 2714 receiving DPP4i. After matching, 1751 GLP-1 analogue users were matched with 1751 DPP4i users. GLP-1 analogue users had an 18% lower risk of COPD exacerbation (hazard ratio (HR) 0.82 (95% CI 0.71-0.94)), a 28% reduced risk of pneumonia (HR 0.72 (95% CI 0.61-0.85)), a 34% reduced risk of oxygen dependence (HR 0.66 (95% CI 0.47-0.91)) and a 40% decreased risk of all-cause mortality (HR 0.60 (95% CI 0.47-0.77)). No significant serious gastrointestinal adverse events were observed.

Conclusion

GLP-1 analogues may be associated with reduced COPD exacerbations, pulmonary comorbidities and mortality in patients with COPD receiving SITT and T2DM, with no significant serious gastrointestinal safety concerns.

Association between combined oral contraceptive prescription and cervical artery dissection: A retrospective cohort study

BACKGROUND

To date, research has identified positive associations between combined oral contraceptives (COCs) and adverse vascular events, however, evidence regarding the possible association with cervical artery dissection (CeAD) remains limited. We tested the hypothesis of a positive association between COCs and CeAD within one year following COC initiation compared to matched controls initiating intrauterine devices (IUDs), as measured by risk ratio (RR).

METHODS

We queried de-identified United States health records data (TriNetX, Inc.) from 2014 to 2024 for females aged 15-50 years without previous cerebrovascular disease or CeAD, creating mutually exclusive cohorts initiating either COCs or IUDs. We used propensity matching to control for variables associated with CeAD. Our primary outcome included the RR for CeAD within one year follow-up. We secondarily explored cumulative CeAD incidence and RR of stroke, also examining outcomes for females with ≥2 COC prescriptions (COC2).

RESULTS

After matching there were 214,020 patients per cohort (mean age 31 years). The incidence and risk of CeAD was greater among those prescribed COCs compared to matched controls with IUDs [95 % CI] (COCs: 0.016 %, IUDs: 0.008 %; RR 1.94 [1.10,3.43]; P = 0.0195). A similar association was observed for stroke (COCs: 0.106 %, IUDs: 0.057 %; RR = 1.86 [1.49,2.32]; P < 0.0001). The secondary COC2 analysis revealed similar findings.

CONCLUSIONS

The present findings suggest that females prescribed COCs have an increased risk of CeAD and stroke compared to matched controls using IUDs. These observations should be viewed as preliminary, require corroboration by other studies, and in isolation do not replace the broader clinical and shared decision-making regarding contraceptive use.

Inflammatory Bowel Disease and Joint Surgery: A 20-Year Cohort Study of Arthroplasty and Arthritis Risks

Background Patients with inflammatory bowel disease (IBD) have a higher risk of adverse outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA) compared to the general population. However, existing literature has not fully elucidated the risk of IBD patients to undergo arthroplasty for treatment of arthritis. Therefore, the purpose of this study is to understand the incidence of arthroplasty and osteoarthritis, enteropathic arthritis, or inflammatory polyarthropathies in patients with IBD compared to the general population. Methods A retrospective cohort analysis was conducted using the TriNetX research database to identify all patients who experienced the primary outcomes between 2004 and 2024. Two cohorts were stratified by a diagnosis of IBD and propensity score matched (1:1) to mitigate baseline differences in demographics and comorbidities. Results After propensity matching, each cohort contained 531,263 patients who were included for analysis. Patients with IBD were significantly less likely to undergo THA (OR 0.853, 95% CI 0.804-0.906) and TKA (OR 0.830, 95% CI 0.788-0.874) and less likely to incur a diagnosis of hip osteoarthritis (OR 0.943, 95% CI 0.922-0.965) or knee osteoarthritis (OR 0.794, 95% CI 0.780-0.808). Conversely, IBD patients were significantly more likely to incur a diagnosis of enteropathic arthropathy (OR 287.9, 95% CI 181.3-457.5) or inflammatory polyarthropathies (OR 1.390, 95% CI 1.365-1.414). Conclusions Patients with IBD are less likely to undergo THA and TKA despite the association between IBD and arthritis. These findings underscore the importance of tailored treatment strategies for joint-related complications in IBD patients and highlight the need for further research to optimize surgical outcomes in this population.

Effect of Cannabis Usage on Thyroid Eye Disease

PURPOSE

The purpose of this study is to investigate the association between cannabis usage and thyroid eye disease (TED) in patients with autoimmune hyperthyroidism. While the association between cigarette smoking and TED is well established, the effect of cannabis on TED is unclear.

METHODS

This cohort study examined data from TriNetX, an electronic health record platform, for patients with autoimmune hyperthyroidism between December 1, 2003, and December 1, 2023. Primary outcomes were TED presentation (exophthalmos, eyelid retraction, eyelid edema, orbital edema, strabismus, and optic neuropathy) and treatment (teprotumumab, methylprednisolone, tarsorrhaphy, and orbital decompression) in cannabis users, nicotine users, and control patients. Propensity matching was performed to control for characteristics such as age, sex, race, prior thyroidectomy, and/or radio ablation. Relative risk between cohorts was calculated for each outcome in 6-month, 1-year, and 2-year intervals following diagnosis of autoimmune hyperthyroidism.

RESULTS

Of 36,186 patients with autoimmune hyperthyroidism, 783 were cannabis users, 17,310 were nicotine users, and 18,093 were control patients without cannabis or nicotine usage. Compared with control patients, cannabis users were more likely to be younger, male, and Black/African American and have anxiety or depression. After propensity matching, cannabis users were 1.9 times more likely to develop exophthalmos ( p = 0.03) and 1.6 times more likely to develop any TED presentation ( p = 0.049) in the 1-year interval although these differences did not remain statistically significant in the 2-year interval.

CONCLUSIONS

Cannabis users had a significantly increased risk for TED outcomes in the 1-year interval. Further research is needed to inform TED management.

Early statin use is associated with improved survival and cardiovascular outcomes in patients with atrial fibrillation and recent ischaemic stroke: A propensity-matched analysis of a global federated health database

INTRODUCTION

Statins reduce recurrent stroke and cardiovascular events in patients with non-cardioembolic stroke. The benefits of statins in patients with AF and recent IS remain unclear. We aimed to investigate the benefits of statins in patients with AF and recent IS.

PATIENTS AND METHODS

This retrospective, cohort study was conducted using deidentified electronic medical records within TriNetX platform. Patients with AF and recent IS, who received statins within 28 days of their index stroke were propensity score-matched with those who did not. Patients were followed up for up to 2 years. Primary outcomes were the 2-year risk of recurrent IS, all-cause mortality and the composite outcome of all-cause mortality, recurrent IS, transient ischaemic attack (TIA), and acute myocardial infarction (MI). Secondary outcomes were the 2-year risk of TIA, intracranial haemorrhage (ICH), acute MI, and hospital readmission. Cox regression analyses were used to calculate hazard ratios (HRs) with 95% confidence intervals (95%CI).

RESULTS

Of 20,902 patients with AF and recent IS, 7500 (35.9%) received statins within 28 days of their stroke and 13,402 (64.1%) did not. 11,182 patients (mean age 73.7 ± 11.5; 5277 (47.2%) female) remained after propensity score matching. Patients who received early statins had significantly lower risk of recurrent IS (HR: 0.45, 95%CI: 0.41-0.48, p < 0.001), mortality (HR: 0.75, 95%CI: 0.66-0.84, p < 0.001), the composite outcome (HR: 0.48, 95%CI: 0.45-0.52, p < 0.001), TIA (HR: 0.37, 95%CI: 0.30-0.44, p < 0.001), ICH (HR: 0.59, 95%CI: 0.47-0.72, p < 0.001 ), acute MI (HR: 0.35, 95%CI: 0.30-0.42, p < 0.001) and hospital readmission (HR: 0.46, 95%CI: 0.42-0.50, <0.001). Beneficial effects of early statins were evident in the elderly, different ethnic groups, statin dose intensity, and AF subtypes, large vessel occlusion and embolic strokes and within the context of statin lipophilicity, optimal LDL-cholesterol levels, various cardiovascular comorbidities, treatment with intravenous thrombolysis or endovascular thrombectomy, and NIHSS 0-5 and NIHSS > 5 subgroups.

DISCUSSION AND CONCLUSION

Patients with AF and recent IS, who received early statins, had a lower risk of recurrent stroke, death, and other cardiovascular outcomes including ICH, compared to those who did not.

Efficacy of Tirzepatide Dual GIP/GLP-1 Receptor Agonist in Patients With Idiopathic Intracranial Hypertension. A Real-World Propensity Score-Matched Study

INTRODUCTION

Idiopathic intracranial hypertension (IIH) is a neurological disorder characterised by elevated intracranial pressure (ICP), predominantly affecting obese women of reproductive age. While GLP-1 receptor agonists have shown promise in IIH management, the potential of dual GIP/GLP-1 receptor activation through tirzepatide remains unexplored. This study aimed to evaluate tirzepatide's efficacy as an adjunctive therapy in IIH management.

METHODS

We conducted a retrospective cohort analysis using the TriNetX Global Health Research Network, analysing data through November 2024. Through propensity score matching, we compared 193 tirzepatide-exposed IIH patients with 193 controls receiving standard care. Primary outcomes included papilledema severity, visual function, headache frequency, and treatment resistance, monitored at multiple follow-up timepoints.

RESULTS

Our analysis revealed significant improvements across all measured outcomes in the tirzepatide group. At 24 months, we observed a 68% reduction in papilledema risk (RR 0.320, 95% CI 0.189-0.542, p < 0.001), a 73.9% reduction in visual disturbance and blindness risk (RR 0.261, 95% CI 0.143-0.477, p < 0.001), and a 19.7% reduction in headache risk (RR 0.803, 95% CI 0.668-0.966, p = 0.019). The tirzepatide group demonstrated significant body-mass index reductions, reaching -1.147 kg/m2 (95% CI [-1.415, -0.879], p < 0.001) at 24 months compared to controls.

CONCLUSIONS

Our results demonstrate that tirzepatide, when used as an adjunctive therapy, provides significant therapeutic benefits in IIH management, particularly in improving papilledema and visual outcomes. Our findings suggest that dual GIP/GLP-1 receptor activation may offer advantages over traditional single-receptor therapies, potentially through enhanced metabolic regulation and direct effects on ICP dynamics.

Effect of glucagon-like peptide-1 receptor agonists on vascular risk factors among adults with type 2 diabetes and established atherosclerotic cardiovascular disease

Introduction

Limited data exist on the cardiovascular effectiveness of once-weekly (OW) glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in real-world practice.

Methods

We assessed the OW GLP-1 RA effects on vascular risk factors in adults with type 2 diabetes and atherosclerotic cardiovascular disease using data from a large-scale US electronic health record database (index date = first prescription of OW GLP-1 RA). Exploratory analyses were performed on patients newly initiating OW GLP-1 RAs with semaglutide, OW GLP-1 RAs without semaglutide, and semaglutide. Changes in vascular risk factors were evaluated by comparing mean measures between the 12-month pre- and post-index periods. Analyses were conducted for all three cohorts and subpopulations including stratified by tercile of baseline vascular risk factor value.

Results

In the final cohorts ([1] OW GLP-1 RA including semaglutide: n = 20,084; [2] OW GLP-1 RA excluding semaglutide: n = 16,894; [3] semaglutide: n = 3,435), significant mean reductions (P < 0.001) were observed from baseline to post-index in hemoglobin A1c (%, [1] -1.1; [2] -1.1; [3] -1.2), low-density lipoprotein cholesterol (mg/dL, [1] -6.4; [2] -6.4; [3] -6.9), total cholesterol (mg/dL, [1] -11.0; [2] -11.1; [3] -10.7), triglycerides (mg/dL, [1] -31.8; [2] -31.4; [3] -33.1), systolic blood pressure (mmHg, [1] -1.5; [2] -1.2; [3] -3.1), body weight (kg, [1] -2.7; [2] -2.4; [3] -4.3) and body mass index (kg/m2; [1] -0.9; [2] -0.8; [3] -1.4). Largest reductions were observed in the top tercile.

Conclusion

Our data suggest GLP-1 RAs are associated with significant reductions in key vascular risk factors in real-world practice.

Glucagon-like peptide-1 receptor agonists and pancreatic cancer risk: target trial emulation using real-world data

BACKGROUND

Data on the effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on pancreatic cancer incidence are limited and inconsistent. Here we evaluate the association of GLP-1RAs, alone and in combinations, with incident pancreatic cancer risk in a real-world population, stratified by obesity and smoking status.

METHODS

This retrospective cohort included patients with type 2 diabetes mellitus who were prescribed GLP-1RAs or other nonglucagon-like peptide-1 receptor agonist antidiabetes medications between January 2013 and March 2019 and had no prior diagnosis of pancreatic cancer. The incident (first-time) diagnosis of pancreatic cancer during a 5-year follow-up was compared between propensity-score matched cohorts of patients prescribed GLP-1RAs vs other nonglucagon-like peptide-1 receptor agonist antidiabetes medications. Subgroup analyses were performed in patients stratified by the status of obesity and tobacco use disorder. We also compared GLP-1RA combination therapies with monotherapies. Time-to-first-event analysis was performed using Cox proportional hazards and Kaplan-Meier survival analysis, with the hazard ratio and 95% confidence interval calculated.

RESULTS

The study population comprised 1 636 056 eligible patients including 167 091 prescribed GLP-1RAs and 1 468 965 prescribed other antidiabetes medications. GLP-1RAs were associated with a statistically significant decreased risk for pancreatic cancer incidence compared with each of 6 nonglucagon-like peptide-1 receptor agonist antidiabetes medications with hazard ratios ranging from 0.42 to 0.82. The reduction was greater in patients with obesity and tobacco use disorder than in those without. GLP-1RA combination therapies were associated with lower pancreatic cancer risk compared with monotherapies.

CONCLUSIONS

GLP-1RAs were associated with reduced pancreatic cancer incidence in patients with type 2 diabetes mellitus. Further studies and trials are needed to explore mechanisms and confirm causal effects.

Developing a prototype for federated analysis to enhance privacy and enable trustworthy access to COVID-19 research data

BACKGROUND

The use of federated networks can reduce the risk of disclosure for sensitive datasets by removing the requirement to physically transfer data. Federated networks support federated analytics, a type of privacy-enhancing technology, enabling trustworthy data analysis without the movement of source data.

OBJECTIVES

To set out the methodology used by the International COVID-19 Data Alliance (ICODA) and its partners, the Secure Anonymised Information Linkage (SAIL) Databank and Aridhia Informatics in piloting a federated network infrastructure and consequently testing federated analytics using test data provided from an ICODA project, the International Perinatal Outcome in the Pandemic (iPOP) Study. To share the challenges and benefits of using a federated network infrastructure to enable trustworthy analysis of health-related data from multiple countries and sources.

RESULTS

This project successfully developed a federated network between the SAIL Databank and the ICODA Workbench and piloted the use of federated analysis using aggregate-level model outputs as test data from the iPOP Study, a one-year, multi-country COVID-19 research project. This integration is a first step in implementing the necessary technical, governance and user experiences for future research studies to build upon, including those using individual-level datasets from multiple data nodes.

CONCLUSIONS

Creating federated networks requires extensive investment from a data governance, technology, training, resources, timing and funding perspective. For future initiatives, the establishment of a federated network should be built into medium to long term plans to provide researchers with a secure and robust data analysis platform to perform joint multi-site collaboration. Federated networks can unlock the enormous potential of national and international health datasets through enabling collaborative research that addresses critical public health challenges, whilst maintaining privacy and trustworthiness by preventing direct access to the source data.

COVID-19 infection is associated with an elevated risk for autoimmune blistering diseases while COVID-19 vaccination decreases the risk: A large-scale population-based cohort study of 112 million individuals

BACKGROUND

Numerous diseases associated with COVID-19 infection and vaccination have been reported, including conditions such as the autoimmune blistering diseases (AIBDs) pemphigus and pemphigoid. However, robust evidence supporting these associations is lacking.

OBJECTIVE

To investigate the risk of developing AIBD following COVID-19 infection and vaccination.

METHODS

Population-based retrospective cohort study utilizing data from over 112 million patients. The risk of AIBD within 3 months was compared among 3 cohorts: COVID-19 infection, COVID-19 vaccination, and controls, along with 7 sensitivity analyses.

RESULTS

COVID-19 infection was associated with an increased risk of AIBD (hazard ratio [HR] 1.508, 95% CI 1.260-1.805), with the risk being more pronounced for pemphigus (HR 2.432, 1.618-3.657) compared to bullous pemphigoid (HR 1.376, 1.019-1.857). Conversely, COVID-19 vaccination was associated with an almost halved risk of AIBD (HR 0.514, 0.394-0.672), with the risk reduction most significant for pemphigus (HR 0.477, 0.241-0.946). Comparisons between COVID-19 infection and vaccination revealed a more than threefold increased risk of AIBD in the infection cohort (HR 3.130, 2.411-4.063), particularly for pemphigus (HR 5.508, 2.973-10.205).

LIMITATIONS

Retrospective design and potential under-reporting of COVID-19 cases and vaccinations.

CONCLUSION

COVID-19 infection significantly increases the risk of AIBD while vaccination appears to reduce this risk.

Association of glucagon-like peptide-1 receptor agonists with cardiovascular and kidney outcomes in type 2 diabetic kidney transplant recipients

BACKGROUND

Cardiovascular disease is a leading cause of post-transplant mortality in kidney transplant recipients (KTRs), especially those with diabetes. Although glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have demonstrated cardiovascular and kidney benefits in the general population with type 2 diabetes mellitus (T2DM), evidence regarding their effects in diabetic KTRs is limited.

METHODS

This retrospective cohort study utilized data from the Global Collaborative Network in TriNetX, spanning January 1, 2006, to June 1, 2023. Propensity score matching (PSM) with 1:1 ratio was employed to create balanced cohorts. Adult KTRs with T2DM who received GLP-1 RAs within 3 months post-transplant were compared to a matched cohort of KTRs who did not. The primary outcome was all-cause mortality, with secondary outcomes including major adverse cardiovascular events (MACEs) and major adverse kidney events (MAKEs).

RESULTS

A total of 35,488 adult KTRs with T2DM (mean [SD] age, 57.7 [12.2] years; 57.7% men) were identified and 9.8% patients used GLP-1 RAs among 3 months post-transplant. Following PSM, 3564 GLP-1 RAs users were matched with an equal number of nonusers. After a median follow-up of 2.5 years, GLP-1 RAs users had lower risks of mortality (adjusted hazard ratio (aHR), 0.39; 95% CI 0.31-0.50), MACEs (aHR 0.66; 95% CI 0.56-0.79), and MAKEs (aHR 0.66; 95% CI 0.58-0.75). Adverse effects included higher risks of nausea, vomiting and diarrhea, while risks of suicide, hypoglycemia, retinopathy, and pancreatitis were not increased.

CONCLUSIONS

In KTRs with T2DM, GLP-1 RAs use was associated with substantial reductions in all-cause mortality, MAKEs, and MACEs compared to nonuse without increasing complications. However, the underutilization of GLP-1 RAs represents a significant opportunity to improve post-transplant outcomes in this high-risk population.

Risk of Progression of Nonproliferative to Proliferative Diabetic Retinopathy after Cataract Surgery

PURPOSE

To assess the influence of modern cataract surgery on the progression from nonproliferative diabetic retinopathy (NPDR) to proliferative diabetic retinopathy (PDR) in patients with type 2 diabetes (T2D).

DESIGN

A retrospective analysis of aggregated healthcare data from June 2004 to June 2024 within the TriNetX U.S. collaborative research network.

SUBJECTS

Patients 18 years or older with T2D and NPDR who either underwent routine cataract surgery or did not receive cataract surgery.

METHODS

We used the TriNetX integrated analytics platform to analyze data from U.S. healthcare organizations and conducted propensity score matching (PSM) to balance baseline demographic and clinical characteristics. We performed analysis by eye. We calculated hazard ratios (HRs) with 95% confidence intervals (CIs) and performed a sensitivity analysis evaluating patients with at least 5 years of T2D before cataract surgery.

MAIN OUTCOME MEASURES

Risk of first-time PDR diagnosis, vitreous hemorrhage (VH), tractional retinal detachment (TRD) or combined tractional and rhegmatogenous retinal detachment (CTRD), and a composite outcome at 1 year in patients who underwent cataract surgery relative to those who did not.

RESULTS

Post-PSM, there were 7178 patients in the study (n = 3589) and control (n = 3589) cohorts for right eye analysis; increased 1-year risks of PDR without complications (HR, 1.45; 95% CI, 1.09-1.92), VH (HR, 1.92; 95% CI, 1.13-3.25), and the composite outcome (HR, 1.49; 95% CI, 1.13-1.96) were observed in operated eyes. Left eye analysis included 7232 patients in the study (n = 3616) and control (n = 3616) cohorts post-PSM; increased 1-year risks of PDR without complications (HR, 1.58; 95% CI, 1.17-2.13), VH (HR, 2.12; 95% CI, 1.23-3.66), and the composite outcome (HR, 1.60; 95% CI, 1.21-2.13) were observed in operated eyes. Sensitivity analysis of those with at least 5 years of T2D included 4976 patients in the study (n = 2488) and control (n = 2488) cohorts post-PSM; increased 1-year risks of PDR without complications (HR, 1.52; 95% CI, 1.06-2.19), VH (HR, 2.50; 95% CI, 1.20-5.20), and the composite outcome (HR, 1.75; 95% CI, 1.22-2.51) were observed in operated eyes. There was no significant difference in the risk for TRD or CTRD in all analyses (all P > 0.05).

CONCLUSIONS

Modern cataract surgery was associated with progression from T2D NPDR to PDR within 1 year postoperatively.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Clinical outcomes after immune checkpoint inhibitor-associated acute kidney injury: a cohort study

OBJECTIVES

Immune checkpoint inhibitors (ICPi) have significantly improved survival for patients with advanced cancers. However, the occurrence of ICPi-associated acute kidney injury (AKI) and its clinical impact remains unclear. This study evaluates the effects of ICPi-associated AKI (ICPi-AKI) on mortality, kidney and cardiovascular outcomes in patients undergoing ICPi treatments.

DESIGN

This multicentre retrospective cohort study with propensity score matching to balance baseline characteristics. The International Classification of Diseases, 10th Revision codes were used to identify individuals with cancer and treated with ICPi concurrently. Kaplan-Meier analyses coupled with log-rank tests were conducted to estimate the survival probabilities.

SETTING

Data were sourced from the TriNetX database spanning records from 25 March 2011 to 5 April 2024.

PARTICIPANTS

Patients with cancer aged ≥18 years treated with ICPi with or without AKI occurrence.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was all-cause mortality, and secondary outcomes included major adverse kidney events (MAKE), major adverse cardiovascular events (MACE), the composite of MAKE or MACE with death, and end-stage renal disease.

RESULTS

The study identified 926 patients with cancer who developed ICPi-AKI (mean age, 67.1±11.8 years; 57.4% men). The control group consisted of 48 147 patients treated with ICPi but did not develop AKI (mean age, 65.3±13.1 years; 53.7% men). After matching, the ICPi-AKI group exhibited a higher risk of all-cause mortality (HR=1.27; 95% CI 1.02 to 1.61), MAKE (HR=3.83; 95% CI 1.72 to 8.40), MACE (HR=1.35; 95% CI 1.03 to 1.75)) compared with the non-ICPi-AKI group. Subgroup analyses confirmed these findings across various patient's characteristics.

CONCLUSION

Individuals with ICPi-AKI are associated with an increased risk of all-cause mortality, MAKE and MACE. Enhancing awareness and timely intervention for ICPi-AKI are crucial for improving prognosis and reducing complications among patients with cancer.

Patterns of management for post-traumatic elbow stiffness: A comparative study of open and arthroscopic approaches

Background

Post-traumatic elbow stiffness (PTES) often results in significant functional impairment. Open elbow arthrolysis (OEA) and arthroscopic elbow arthrolysis (AEA) are two surgical management options. This study aimed to compare the incidence, demographics, and treatment patterns of patients with PTES undergoing OEA and AEA from 2014 to 2023.

Methods

A retrospective analysis was conducted using the TriNetX database. Patients diagnosed with elbow stiffness (ICD-10 codes M25.621, M25.622, M25.629) were included. Rates of OEA (CPT 24149, 24006) and AEA (CPT 29837, 29838) were identified. Demographic characteristics and simultaneous surgical procedures were assessed.

Results

A total of 30,624 patients were diagnosed with PTES, with 848 undergoing OEA (2.8%) and 361 undergoing AEA (1.2%). The mean age for OEA patients was 44.3 ± 17.6 years, while AEA patients had a mean age of 37.9 ± 18.9 years. OEA was more common in males (61.2%) and non-Hispanic/Latino patients (68.3%). AEA showed higher rates in younger patients and non-Hispanic/Latino individuals (72.7%).

Discussion

The study highlights a preference for OEA in older patients with complex conditions, while AEA is more common in younger patients. Despite the growing trend toward minimally invasive techniques, OEA remains prevalent. Further research is needed to understand the drivers of these trends.

Cardiac Biomarkers Predict Major Adverse Cardiac Events (MACE) in Incident Haemodialysis Patients: Results from a Global Federated Database

Background: Despite its many advantages, haemodialysis (HD) has been shown to be associated with significant cardiovascular events, especially in patients commencing HD. Currently, there is no specific method to risk-stratify incident HD patients. Blood-based biomarkers provide insight into myocardial injury and stress. We aimed to evaluate the association of increased circulating biomarker concentration in incident HD with incident major adverse cardiac events (MACE). Methods: This was a retrospective cohort study of incident haemodialysis cases within 3 months of treatment initiation (≥18 years) from the TriNetX database. Cohorts were grouped by biomarker thresholds: Troponin I: ≥50 ng/L, BNP ≥ 100 pg/mL and 1:1 propensity-score matched for demographic characteristics, baseline cardiovascular risk, laboratory values, and cardiovascular medication. Primary outcome: Incidence of major adverse cardiac events (MACE) censored prior to index event of HD. Secondary outcome: Risk of each individual component of the composite outcome. Cox regression reported hazard ratios (95% CI) for the outcomes. Results: In total, 62,206 and 10,476 patients were included in the troponin I and BNP cohorts, respectively. In the troponin I cohort, 5878 developed MACE (HR 1.33 (95% CI 1.26-1.41, p < 0.0001)). In the BNP cohort, 1050 developed MACE (HR 1.28 (95% CI 1.13-1.44, p < 0.0001)). Conclusions: In incident HD, routine clinical laboratory biomarkers can predict incident MACE. The results suggest the clinical need for CV mortality and morbidity risk profiling in incident HD using a combination of clinical and laboratory variables.

Glucagon-like Peptide-1 Agonists Reduce Cardiovascular Events in Cancer Patients on Immune Checkpoint Inhibitors

BACKGROUND

Immune checkpoint inhibitors (ICIs) are associated with an increased risk of major adverse cardiovascular events (MACE). Glucagon-like peptide-1 agonists (GLP1a), initially developed for type 2 diabetes mellitus (T2DM), have shown promising results in reducing cardiovascular events. We aimed to investigate the effect of GLP1a on cardiovascular events in patients receiving ICIs.

METHODS

We conducted a retrospective, propensity score-matched cohort study using the TriNetX database. We identified adults with cancer and T2DM who received ICIs between April 2013 and May 2023. The primary efficacy outcome was incident MACE, defined as a composite of myocardial infarction, need for coronary revascularization, heart failure, ischemic stroke, and cardiac arrest. The secondary efficacy outcomes were the individual components of MACE as well as myocarditis and pericarditis. Safety outcomes included the occurrence of immune-related adverse events, serious adverse events related to GLP1a use, and all-cause mortality.

RESULTS

We identified 7651 patients eligible for inclusion, among which 479 received GLP1a and 7172 received non-GLP1a diabetes medications. After matching (469 patients each), baseline characteristics were well-balanced. Over a median 12-month follow-up, the GLP1a cohort had a significantly lower MACE incidence than the non-GLP1a cohort (9.0 vs. 17.1 events per 100 patient-years) with a 54 % lower risk of MACE (Hazard ratio (HR),0.46 [95 % CI: 0.32-0.67]). There were reductions in myocardial infarction or need for coronary revascularization, heart failure, and all-cause mortality, with no differences in other cardiovascular events. GLP1a use did not increase risk of adverse events, including pancreatitis, biliary disease, bowel obstruction, gastroparesis, and immune-related adverse events.

CONCLUSION

GLP1a use in cancer patients with T2DM receiving ICIs was associated with reduced MACE and all-cause mortality without an increased risk in serious adverse events.

Large-scale analysis highlights obesity as a risk factor for chronic, non-communicable inflammatory diseases

Background

Overweight and obesity are a global pandemic, contributing to death and disability-adjusted life-years. Obesity is a major factor in the onset of chronic inflammatory diseases (CIDs). Yet, several knowledge gaps remain: For several CIDs, inconsistent results have been reported, relating to their obesity-imposed risk, data on most rare CIDs remain unavailable, sex differences and racial disparities remain mostly unaddressed.

Methods

A large-scale cohort study compared the risk of developing 46 CIDs in individuals with overweight/obesity (n=3,101,824) to an equal number of non-overweight/obese individuals. Propensity score matching optimized between-group comparability, and sensitivity analyses assessed study robustness.

Results

The risk of developing any CID was 28.48% in overweight/obese individuals versus 17.55% in non-overweight/obese controls, with a hazard ratio (95%-confidence interval) of 1.52 (1.509-1.521, p<0.0001). This risk was consistent across all sensitivity, sex-, and race-stratified analyses. Overweight and obesity were associated with an increased risk for 24 of 46 CIDs in the primary analysis and all sensitivity analyses. For 12 diseases, increased risks were confirmed to one of the two sensitivity analyses, while for 10 diseases, results were discordant. No increased risk was observed for one disease. In sex-stratified analysis, overweight and obesity posed a more pronounced risk for four CIDs in female individuals. In race-stratified analysis, overweight and obesity were linked to a higher risk for seven CIDs in White individuals and to one CID in "Black or African American" individuals.

Conclusion

Overweight and obesity increase the risk for the majority of CIDs in a sex- and race-specific manner.

The cumulative impact of type 2 diabetes and obstructive sleep apnoea on cardiovascular, liver, diabetes-related and cancer outcomes

AIM

A bidirectional relationship exists between obstructive sleep apnoea (OSA) and type 2 diabetes (T2D). We aimed to examine the cumulative impact of having both OSA and T2D on patient outcomes, relative to having either condition alone.

MATERIALS AND METHODS

Using TriNetX, a global federated research network (n = 128 million), we undertook two retrospective cohort studies, using time-to-event analysis. Analysis 1 compared OSA with T2D versus OSA alone; analysis 2 compared T2D with OSA versus T2D alone. Propensity score matching using greedy nearest neighbour (calliper 0.1) balanced the cohorts (1:1) for significant covariates. Primary outcomes were cardiovascular, liver, diabetes-related (microvascular) and cancer events over 1-5 years.

RESULTS

Analysis 1 (n = 179 688): A codiagnosis of T2D/OSA significantly increased risk of all-cause mortality (hazard ratio [HR] 1.52; confidence interval [CI]: 1.48, 1.57), dementia (HR 1.19; CI: 1.12, 1.26), liver (HR 2.20; CI: 1.77, 2.73), pancreatic (HR 1.62; CI: 1.35, 1.93), colon, renal and endometrial cancers; all cardiovascular, microvascular and liver related outcomes versus OSA alone over 1-5 5 years following OSA diagnosis. Analysis 2 (n = 240 094): A codiagnosis of OSA/T2D significantly increased the risk of peripheral (HR 1.39; CI: 1.36, 1.43) and autonomic (HR 1.63; CI: 1.51, 1.75) neuropathy; retinopathy (HR 1.13; CI: 1.09, 1.18), CKD (HR 1.21; CI: 1.18, 1.23); all cardiovascular and liver outcomes; all-cause mortality and several obesity related cancers versus T2D alone.

CONCLUSIONS

T2D significantly potentiates risk of cardiovascular, malignancy and liver-related outcomes in individuals with OSA. OSA, in individuals with T2D, significantly potentiates risk of cardiovascular disease, malignancy, death and several microvascular complications (retinopathy, CKD, peripheral/autonomic neuropathy).

National COVID Cohort Collaborative data enhancements: a path for expanding common data models

OBJECTIVE

To support long COVID research in National COVID Cohort Collaborative (N3C), the N3C Phenotype and Data Acquisition team created data designs to aid contributing sites in enhancing their data. Enhancements include long COVID specialty clinic indicator; Admission, Discharge, and Transfer transactions; patient-level social determinants of health; and in-hospital use of oxygen supplementation.

MATERIALS AND METHODS

For each enhancement, we defined the scope and wrote guidance on how to prepare and populate the data in a standardized way.

RESULTS

As of June 2024, 29 sites have added at least one data enhancement to their N3C pipeline.

DISCUSSION

The use of common data models is critical to the success of N3C; however, these data models cannot account for all needs. Project-driven data enhancement is required. This should be done in a standardized way in alignment with common data model specifications. Our approach offers a useful pathway for enhancing data to improve fit for purpose.

CONCLUSION

In this initiative, we rapidly produced project-specific data modeling guidance and documentation in support of long COVID research while maintaining a commitment to terminology standards and harmonized data.

Enhanced renoprotective effects of combined glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors in type 2 diabetes mellitus: Real-world evidence

INTRODUCTION

Developing a more effective treatment for the global impact of diabetic kidney disease is crucial. This study examined the renoprotective effects of combining glucagon-like peptide-1 receptor agonists (GLP-1 RA) with sodium-glucose cotransporter 2 inhibitors (SGLT2i) compared to SGLT2is alone in type 2 diabetes (DM).

MATERIALS AND METHODS

This retrospective cohort study used data from the TriNetX Global Collaborative Network. Type 2 DM patients with estimated glomerular filtration rates ≥60 mL/min/1.73 m2 who used GLP-1 RA or SGLT2i between January 1, 2013, and December 31, 2023. Propensity score matching balanced baseline characteristics, resulting in 71,186 patients in each group (combined GLP-1 RA and SGLT2i therapy vs SGLT2i alone). Cox regression model was adopted to compare outcomes over a 5-year period, including major adverse kidney events (MAKE), acute kidney injury (AKI), end-stage kidney disease (ESKD), and all-cause mortality.

RESULTS

After matching, the average age was 57.1 ± 10.8 years for the GLP-1 RA plus SGLT2i group and 57.2 ± 11.7 years for the SGLT2i-only group. The GLP-1 RA plus SGLT2i group had significantly lower risk of MAKE (hazard ratio [HR]: 0.73, 95% confidence interval [CI]: 0.69-0.77), AKI (HR: 0.82, 95% C0I: 0.77-0.87), ESKD (HR: 0.61, 95% CI: 0.47-0.78), and all-cause mortality (HR: 0.54, 95% CI: 0.50-0.58) compared to the SGLT2i-only group. Moreover, subgroup analyses showed consistent benefits across different subgroups.

CONCLUSIONS

Dual therapy with GLP-1 RA and SGLT2i is supported to enhance renal outcomes and address the growing burden of diabetic kidney disease.

Antiseizure medication prescribing in people with Dravet syndrome: An analysis of real-time administrative data

Since 2018, three new antiseizure medications (ASMs) received FDA approval for Dravet syndrome (DS) in the U.S: cannabidiol, stiripentol, and fenfluramine. Yet, the uptake of these ASMs in routine clinical practice is unknown. We use new ICD-10 codes for DS (implemented in 2020) to estimate ASM receipt in patients with DS. We analyzed the TriNetX Network, a real-time electronic health record-based dataset linked to prescription data encompassing all 50 states of the U.S. After identifying patients with health care encounters for DS in 2021 and 2022 (via ICD-10 codes), we examined ASM prescribing in the year following a DS claim: 2022 and 2023, respectively. We retrieved 387 and 451 patients receiving claims for DS in 2021 and 2022, respectively. Clobazam, diazepam, valproate, midazolam, clonazepam, levetiracetam, and cannabidiol were the most common ASMs used (29%-44%). Stiripentol and fenfluramine prescribing was limited (7%-16%); these two ASMs, considered second-line therapies in DS, were prescribed less often than ASMs considered third-line or beyond. Cannabidiol, stiripentol, and fenfluramine prescribing rates remained nearly identical in the 2021 and 2022 cohorts. Our data suggests that stiripentol, fenfluramine, and, to an extent, cannabidiol may be underused in a large, diverse, primarily U.S.-based population of patients with DS. PLAIN LANGUAGE SUMMARY: In an analysis of routinely-collected health care claims in the U.S., we found that the uptake of new antiseizure medications for Dravet Syndrome (i.e., stiripentol, fenfluramine, and cannabidiol) has been limited since 2022. Even though stiripentol and fenfluramine are considered second-line treatments for Dravet syndrome, we found they were prescribed less frequently than medicines considered third-line or beyond. These findings raise concern for underutilization of new antiseizure medications for Dravet syndrome in the United States.

Cardiovascular outcomes and mortality in diabetic multiple myeloma patients initiated on proteasome inhibitors according to prior use of glucagon-like peptide 1 agonists

Glucagon-like peptide 1 agonists may reduce the risk of major adverse cardiovascular events, heart failure, and all-cause mortality among patients with multiple myeloma and Type 2 diabetes mellitus receiving proteasome inhibitors. The use of glucagon-like peptide 1 agonist is associated with a reduction in cardiovascular events and mortality among patients with multiple myeloma and Type 2 diabetes mellitus receiving proteasome inhibitors. The use of glucagon-like peptide 1 agonist is not associated with an increased risk of adverse events among patients with multiple myeloma and Type 2 diabetes mellitus receiving proteasome inhibitors.

Artificial intelligence methods applied to longitudinal data from electronic health records for prediction of cancer: a scoping review

BACKGROUND

Early detection and diagnosis of cancer are vital to improving outcomes for patients. Artificial intelligence (AI) models have shown promise in the early detection and diagnosis of cancer, but there is limited evidence on methods that fully exploit the longitudinal data stored within electronic health records (EHRs). This review aims to summarise methods currently utilised for prediction of cancer from longitudinal data and provides recommendations on how such models should be developed.

METHODS

The review was conducted following PRISMA-ScR guidance. Six databases (MEDLINE, EMBASE, Web of Science, IEEE Xplore, PubMed and SCOPUS) were searched for relevant records published before 2/2/2024. Search terms related to the concepts "artificial intelligence", "prediction", "health records", "longitudinal", and "cancer". Data were extracted relating to several areas of the articles: (1) publication details, (2) study characteristics, (3) input data, (4) model characteristics, (4) reproducibility, and (5) quality assessment using the PROBAST tool. Models were evaluated against a framework for terminology relating to reporting of cancer detection and risk prediction models.

RESULTS

Of 653 records screened, 33 were included in the review; 10 predicted risk of cancer, 18 performed either cancer detection or early detection, 4 predicted recurrence, and 1 predicted metastasis. The most common cancers predicted in the studies were colorectal (n = 9) and pancreatic cancer (n = 9). 16 studies used feature engineering to represent temporal data, with the most common features representing trends. 18 used deep learning models which take a direct sequential input, most commonly recurrent neural networks, but also including convolutional neural networks and transformers. Prediction windows and lead times varied greatly between studies, even for models predicting the same cancer. High risk of bias was found in 90% of the studies. This risk was often introduced due to inappropriate study design (n = 26) and sample size (n = 26).

CONCLUSION

This review highlights the breadth of approaches to cancer prediction from longitudinal data. We identify areas where reporting of methods could be improved, particularly regarding where in a patients' trajectory the model is applied. The review shows opportunities for further work, including comparison of these approaches and their applications in other cancers.

Prevalence of Hepatitis C Virus Among Hospitalized Patients in a Tertiary Hospital in Italy: The Basis for a National Screening Assessment Model?

Free-of-charge hepatitis C virus antibody (HCV Ab) screening in some key populations and in 1969-1989 birth cohorts have been funded in Italy as the first step in confirming diagnosis in individuals who may be unaware of their infection. The purpose of this study is to leverage existing in-hospital routine screening data to better understand the distribution of HCV. A retrospective study of hospitalized patients (PTs) tested for HCV Ab for 5 years (from January 2017 to December 2022) in San Raffaele hospital was conducted according to age categories: birth year group before 1947 (patients older than 76 years old), birth year group 1947-1968, birth year group 1969-1989, and two other groups with birth year groups 1990-2000 and 2001-2022 (with patients younger than 33 years old) using the TriNetX platform. Among the 42,805 in-hospital PTs tested, 1297 (3.03%) were HCV Ab positive. The prevalence of HCV Ab was greater in PTs over the age of 76 (5.3%), whereas it was lower in the youngest birth year cohort (2000-2022, 0.16%). Among 1297 HCV Ab positive PTs, only 198 (15.3%) were tested for the presence of HCV RNA. The birth cohort 1969-1989 had a modest seroprevalence (1.5%), yet they were the most affected age group, with 44.4% being HCV RNA positive. The in-hospital HCV screening including birth year cohort 1947-1989 could be a more valuable option compared to the screening for birth year group 1969-1989 in the general population.

Robotic-assistance is associated with better joint outcomes compared to conventional techniques in surgically routine total hip arthroplasty: a propensity-matched large database study of 3948 patients

INTRODUCTION

The outcomes of total hip arthroplasty (THA) are highly dependent upon the restoration of native hip biomechanics and optimal component positioning. Robotic technologies for THA have rapidly improved the accuracy of component positioning and maintaining the planned center of rotation. While robotic-assisted THA (RA-THA) has primarily been employed in surgically intricate cases, its potential benefits in scenarios of diminished surgical complexity remain less explored. Therefore, the purpose of this study was to assess the odds of developing systemic and joint complications following RA-THA in cases of reduced surgical complexity.

METHODS

A retrospective cohort study was conducted using the TriNetX national database to identify patients who underwent primary THA (Current Procedural Terminology code 27,130) and more specifically RA-THA identified by ICD-10-PCS code 8E0Y0CZ and Healthcare Common Procedure Coding System code S2900 from 2013 to 2022. One-to-one propensity score matching was conducted to generate 2 cohorts: (1) RA-THA and (2) conventional THA (C-THA). Systemic and joint complications were assessed at the 30-day, 90-day, 1-year, and 5-year postoperative periods.

RESULTS

Patients undergoing RA-THA had a lower risk of needing a revision THA at the 90-day, 1-year, and 5-year time points. RA-THA was associated with a lower risk of prosthetic dislocation at 90 days and 1 year and prosthetic pain at 1 year and 5 years. Dislocation of the hip or fracture of the femur was significantly lower in the RA-THA cohort at all four-time points. Patients undergoing RA-THA had a lower risk of developing deep vein thrombosis at 5 years.

CONCLUSION

These findings suggest that RA-THA has comparable systemic and less joint complication risks at 30-day to 5-year timepoints between RA-THA and C-THA. Future studies with large sample sizes and long-term follow-up are needed to understand the patient-reported outcomes and functional outcomes of RA-THA for cases with reduced surgical complexity.

Systemic lupus erythematosus is associated with an increased risk of cervical artery dissection

Limited evidence suggests that autoimmune diseases are associated with an increased risk of cervical artery dissection (CeAD). We hypothesized individuals with systemic lupus erythematosus (SLE) would have an increased risk of CeAD following SLE diagnosis compared to matched non-lupus controls. We queried a de-identified United States electronic medical records network (TriNetX, Inc.) for individuals aged 10 and older from 2012 to 2020, for two cohorts: (1) SLE and (2) non-lupus controls, excluding those with prior CeAD. We used propensity matching to control for confounding variables and calculated the risk ratio (RR) for CeAD occurring over four years' follow-up, secondarily exploring cumulative incidence. After matching, both cohorts contained 77,008 patients, who were mostly female (89%). The incidence and risk of CeAD was significantly greater among those with SLE compared to matched non-lupus controls [95% CI] (0.08% vs. 0.04%; RR = 2.33 [1.49;3.66]; P < 0.0001). These findings support the hypothesis that SLE is a risk factor for CeAD. Additional research is needed to identify the mechanisms that may underly the SLE-CeAD association and examine the potential association between other autoimmune diseases and CeAD.

Enhancing real world data interoperability in healthcare: A methodological approach to laboratory unit harmonization

OBJECTIVE

The primary aim of this study is to address the critical issue of non-standardized units in clinical laboratory data, which poses significant challenges to data interoperability and secondary usage. Despite UCUM (Unified Code for Units of Measure) offering a unique representation for laboratory test units, nearly 60% of laboratory codes in healthcare organizations use non-standard units. We sought to design, implement and test a methodology for the harmonization of units to the UCUM standards across a large research network.

METHODS

Using dimensional analysis and a curated equivalence table, the proposed methodology harmonizes disparate units to UCUM standards. The process focused on identifying and converting non-UCUM conforming units, with the goal of enhancing data comparability and interoperability across different systems.

RESULTS

The methodology successfully achieved over 90% coverage of laboratory data with units in UCUM standards across the TriNetX research network, a significant improvement from baseline measurements. This enhancement in unit standardization directly contributed to increased interoperability of laboratory data, facilitating more reliable and comparable data analysis across various healthcare organizations.

CONCLUSION

The successful harmonization of laboratory data units to UCUM standards represents a significant advancement in the field of biomedical informatics. By demonstrating a practical and effective approach to overcoming the challenges of non-standardized units, our study contributes to the broader efforts to improve data interoperability and usability for secondary purposes such as research and observational studies. Future work will focus on addressing the remaining gaps in unit standardization and exploring the implications of this methodology on clinical outcomes and research capabilities.

Is thymectomy necessary during parathyroidectomy for secondary hyperparathyroidism in patients with end-stage kidney disease?

BACKGROUND

Guidelines recommend thymectomy at the time of parathyroidectomy for secondary hyperparathyroidism to reduce the likelihood of persistent or recurrent disease. We sought to determine the frequency of thymectomy and explore its impact on recurrence of secondary hyperparathyroidism.

METHODS

Using TriNetX, a multi-institutional electronic health record and insurance claims network, we conducted a retrospective cohort study of adults with secondary hyperparathyroidism who underwent parathyroidectomy with or without thymectomy from 2005 to 2023. Rates of thymectomy, repeat parathyroidectomy, and calcimimetic use were compared between cohorts. Recurrence was defined by parathyroid hormone ≥600 pg/mL, reoperation, or calcimimetic use. Current Procedural Terminology and SNOMED codes for parathyroidectomy did not distinguish between subtotal compared with total parathyroidectomy.

RESULTS

Among 2,564 patients underwent surgery for secondary hyperparathyroidism, 2,272 (88.8%) underwent parathyroidectomy and 287 (11.2%) underwent parathyroidectomy + thymectomy. Rates of parathyroidectomy + thymectomydecreased over time, from 25.5% in 2005 to 10.1% in 2023. Preoperatively, there was no difference in mean preoperative parathyroid hormone levels, serum calcium or calcidiol, or cinacalcet use. Postoperatively, there was no difference in the mean parathyroid hormone level (183 pg/mL vs 180 pg/mL, P = .88), odds of calcimimetic use (odds ratio, 0.94, 95% confidence interval, 0.64-1.39), reoperation within 5 years postoperatively (odds ratio 0.72, 95% confidence interval 0.39-1.36), or rates of kidney transplantation (odds ratio 1.03, 95% confidence interval 0.67-1.60) between parathyroidectomy and parathyroidectomy + thymectomy groups.

CONCLUSION

Thymectomy is infrequently performed during parathyroidectomy for secondary hyperparathyroidism, and rates continue to decline. Although thymectomy at time of parathyroidectomy did not appear to decrease recurrence, future studies should include extent of parathyroidectomy to determine impact of thymectomy on recurrence in secondary hyperparathyroidism.

Exploring pharmacological treatment for trichotillomania: do we need better education?

BACKGROUND

Trichotillomania, also known as hair-pulling disorder, is a chronic psychiatric condition with a fluctuating course in which an individual pulls out their hair, leading to visible hair loss and psychosocial sequelae. Due to the unknown pathogenesis, the treatment of this disorder is complex and remains a challenge for dermatologists and psychiatrists. Since guidelines for treating trichotillomania are lacking and, consequently, no common treatment strategy exists, we decided to perform a large-scale, global retrospective cohort study to assess the characterized real-world prescription patterns in treating trichotillomania.

METHODS

The research used the TrinetX database for patients with trichotillomania (ICD 10 - F63.3) within the European and the United States Collaborative Network (EC and UC, respectively). After consulting with a psychodermatology expert, a list of 25 medications was investigated.

RESULTS

Data on the prescription drugs of 1,275 patients from the EC and 109,741 patients from the UC were collected. In both the EC and UC cohorts, benzodiazepine derivatives, particularly lorazepam and midazolam, were the most commonly prescribed sedatives/hypnotics. Antipsychotic prescriptions, primarily haloperidol, followed benzodiazepines. After the trichotillomania diagnosis, notable changes in drug prescriptions for the EC cohort, including an increased likelihood of receiving acetylcysteine, haloperidol, quetiapine, sertraline, olanzapine, and risperidone were observed. The UC cohort showed minimal changes. Overall, both cohorts leaned toward benzodiazepine prescriptions (37% UC, 21% EC) and had limited antidepressant usage. Haloperidol (19.3%) and quetiapine (15.1%) were commonly prescribed in both cohorts.

CONCLUSIONS

The results of our study indicate that the real-world prescription patterns for trichotillomania differ significantly from the expert-proposed therapeutic approach and point toward the necessity of creating standards of pharmacological care and better education.

The Impact of Contemporary Glucagon-like Peptide-1 Receptor Agonists on the Onset, Severity, and Conversion to Arthroplasty in Hip and Knee Osteoarthritis

Background

The growing popularity of glucagon-like peptide-1 receptor agonists (GLP-1-RAs) for weight loss could significantly impact joint preservation and arthroplasty. While this will in part be driven by the association between obesity, osteoarthritis (OA), and total joint arthroplasty (TJA), recent evidence also indicates that GLP-1-RAs may have direct joint-protective, anti-inflammatory effects.

Purpose

To evaluate the association between GLP-1-RA use and the onset and progression of hip and knee OA in an obese population.

Study Design

Cohort study; Level of evidence, 3.

Methods

A national health network was queried for patients with an index visit between June 1, 2021, and January 1, 2023, and a body mass index (BMI) ≥30. Patients were stratified into groups without (n = 1,092,225) and with(n = 237,043) preexisting hip and/or knee OA. One-to-one propensity score matching was used to balance GLP-1-RA use based on age, sex, race, BMI, and comorbid type 2 diabetes mellitus. Primary outcomes were incidence of hip OA, knee OA, major joint injections, total hip arthroplasty (THA), and total knee arthroplasty (TKA) within 1 year. Cox proportional hazards models were used to estimate hazard ratios (HRs) between cohorts prescribed and not prescribed GLP-1-RAs.

Results

In patients with preexisting OA, GLP-1-RA use correlated with reduced odds of conversion to THA (1.1% vs 2.2%; HR, 0.6; 95% CI, 0.5 to 0.8) and TKA (1.4% vs 2.1%; HR, 0.8; 95% CI, 0.6 to 0.9) within 1 year. In patients without preexisting OA, GLP-1-RA use was associated with an increased incidence of hip OA (0.9% vs 0.7%; HR, 1.4; 95% CI, 1.2 to 1.6), knee OA (2.1% vs 1.9%; HR, 1.3; 95% CI, 1.2 to 3.1), major joint injections (2.2% vs 1.8%; HR, 1.4; 95% CI, 1.3 to 1.5), and TKA (0.09% vs 0.04%; HR, 2.6; 95% CI, 1.6 to 4.3). Comparing cohorts without prior OA, patients who were prescribed a GLP-1-RA demonstrated slightly greater decreases in BMI (-1.00; 95% CI, -1.06 to -0.96) at 1-year after the index visit compared with patients not prescribed a GLP-1-RA (-0.90; 95% CI, -0.94 to -0.84). However, in patients with a prior diagnosis of hip or knee OA, there was no difference noted in BMI change.

Conclusion

GLP-1-RAs may provide direct disease-modifying behaviors in patients with preexisting OA diagnosis, per a reduced risk of conversion to TJA not attributable to weight loss. Further investigation is also needed to elucidate the association between GLP-1-RA use and the increased incidence of OA diagnosis and conversion to TKA in patients with no preexisting OA diagnosis.

Risk Factors and Outcomes Associated with Emergency Abdominal Surgery following Lower Extremity Total Joint Arthroplasty

Objectives

This study aims to identify potential risk factors and assess postoperative outcomes associated with requiring emergency abdominal surgery (EAS) within 30 days following total hip arthroplasty (THA) and total knee arthroplasty (TKA). We hypothesized that patients requiring EAS would carry a higher morbidity and mortality rates compared to patients that underwent the index operation alone.

Methods

We conducted a retrospective analysis using TriNetX, examining data from 2016-2024 from patients over 18 years old who underwent THA/TKA and required EAS within 30 days. Postoperative outcomes, including mortality and hospital readmission, were compared between patients requiring EAS and those who did not. Statistical analyses included measures of association and chi-squared tests. Patient demographic data, including age, sex, and comorbidities were analyzed.

Results

Patients requiring EAS within 30 days of a joint arthroplasty were significantly more likely to be older, overweight or obese, and to be diagnosed with comorbidities including diverticular disease, cholelithiasis, alcohol use disorders, and tobacco use. These patients had significantly higher mortality rates within 60 days of joint arthroplasty compared to patients without EAS, suggesting that the second operation contributed significantly to the increase in adverse outcomes.

Conclusion

This study emphasizes the importance of recognizing key risk factors for severe GI complications that require EAS. These findings highlight the need for careful patient selection, pre-operative evaluation of risk, and vigilant post-operative management, especially in those with many risk factors. Improved identification and management of high-risk patients may help reduce the likelihood of EAS and its associated mortality.

Biological, as opposed to classic antipsoriatic drug or apremilast, treatment mitigates the risk of death and cardiovascular disease in psoriasis

BACKGROUND

Cardiovascular comorbidity increases morbidity and mortality in psoriasis. Systemic treatments, particularly biologics, are effective in alleviating skin and joint inflammation. Conversely, the impact of systemic therapy on cardiovascular disease risk and mortality in psoriasis remains uncertain.

METHODS

Impact of systemic treatments on all-cause mortality and cardiovascular disease risk in psoriasis patients' electronic health records (EHRs) from TriNetX was assessed. Treatment categories included apremilast, IL-17 inhibitors (IL-17i), IL23i, TNFi, and classic antipsoriatic drugs. Index event was the first prescription of each treatment, requiring a two-year continuous treatment with exclusion of other systemic antipsoriatic drugs. Propensity-score matching was used to improve comparability. Sensitivity analyses ensured study robustness.

FINDINGS

In descriptive analysis, all-cause mortality rates were 0.61% (classic antipsoriatics, n = 7929), 0.91% (apremilast, n = 1101), 0.00% (IL17i, n = 677), 0.81% (IL23i, n = 1242), and 0.20% (TNFi, n = 6468). Major adverse cardiac events (MACE) were documented in 8.49% (classic antipsoriatics), 5.14% (apremilast), 2.99% (IL17i), 2.09% (IL23i), and 3.74% (TNFi) EHRs. Propensity-score matching showed all-cause mortality rates of 0.23% for any biologic vs. 0.49% for classic antipsoriatics or apremilast, resulting in an HR of 2.21 (95% CI 1.21-3.71, p = 0.0073). MACE risk was also higher with classic antipsoriatics or apremilast (HR 1.66, CI 1.43-1.93, p < 0.0001). The majority of findings were consistent across all four sensitivity analyses. No significant differences in all-cause mortality or MACE risk were observed among biologics.

INTERPRETATION

Biological treatment, as opposed to classic antipsoriatic drugs or apremilast, reduces risk of death and cardiovascular disease in psoriasis. Prospective trials are required to validate these findings.

FUNDING

DFG: EXC 2167 and LU 877/25-1. State of Schleswig Holstein: Excellence-Chair Program.

Effect of Ketorolac Administration on the Rate of Nonunion of Operatively Treated Pediatric Long-Bone Fractures: A Matched Cohort Analysis

BACKGROUND

Nonunion is a rare yet serious complication in pediatric fracture healing that can lead to patient morbidity and economic burden. The administration of nonsteroidal anti-inflammatory drugs (NSAIDs) has been associated with an increased risk of fracture nonunion in adults, but data are lacking in the pediatric population. This study examines the relationship between postoperative ketorolac administration and nonunion in operatively managed pediatric long-bone fractures.

METHODS

A retrospective cohort study was conducted with use of TriNetX, a research network that encompasses data from the United States, Canada, and Western Europe. A total of 462,260 patients from 52 health-care organizations met the inclusion criteria. Patients <18 years old with operatively managed upper or lower-extremity long-bone fractures were included. The exposure of interest was ketorolac administration within 30 days postoperatively between 2003 and 2023. Nonunion was identified and verified with use of the pertinent medical codes. Absolute risks and hazard ratios (HRs) were calculated for both study groups. Significance was set at p < 0.05.

RESULTS

After propensity score matching, 48,778 patients were identified per group. The incidence of nonunion was 2.19% in the ketorolac group and 0.93% in the non-ketorolac group (HR, 2.71; 95% confidence interval [CI]: 2.46, 3.21; p < 0.0001). Subgroup analyses demonstrated a higher risk of nonunion in patients with lower-extremity fractures (HR, 3.45; 95% CI: 3.14, 3.75; p < 0.0001) than in those with upper-extremity fractures (HR, 2.11; 95% CI: 1.84, 2.32; p < 0.0001). Among the fracture location subgroups, the greatest HR for nonunion was observed in patients with femoral fractures, followed sequentially by those with tibial and/or fibular fractures, humeral fractures, and radial and/or ulnar fractures.

CONCLUSIONS

To our knowledge, this is the largest study to date to explore postoperative ketorolac use and nonunion in the setting of operatively managed pediatric long-bone fractures. Nonunion in children was rare, occurring in <1% of all included patients. Ketorolac administration was associated with a 2 to 3-fold increase in nonunion risks, with pronounced implications for patients with lower-extremity fractures, particularly those with femoral fractures. Clinicians should weigh the therapeutic advantages of non-opiate analgesia with ketorolac against the risk of nonunion in order to optimize postoperative pain management and recovery.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Health outcomes in chronic kidney disease patients with cognitive impairment or dementia: a global collaborative analysis

Background and hypothesis

Mild cognitive impairment and dementia (CI) are common in patients with CKD. We aim to clarify whether and how CKD and CI coexistence increases adverse health outcomes.

Methods

This retrospective observational cohort study was conducted on CKD patients (stages 3-5) from the TriNetX platform. CKD patients with and without pre-existing CI were included from 115 healthcare organizations, and their outcomes were compared. The two cohorts were propensity score matched (PSM) for age, sex, ethnicity, comorbidities, BMI, blood parameters, and medications. The proportional hazard assumption was tested with a 95% confidence interval. Kaplan-Meier analysis was used to calculate survival probability. Outcomes were included from 1 day after the CKD diagnosis until 10 years afterwards.

Results

We identified 533 772 CKD patients, and 8184 had co-existent CI. Two cohorts of 8170 PSM patients each were generated. The mean age was 60.5 ± 7.0 years and the eGFR was 52.1±19 mL/min. Mean follow-up was 23.2 months. CKD patients with CI had higher all-cause mortality (18.5% vs 12.6%), higher risk of cerebrovascular disease (11.3% vs 6.9%), transient cerebral ischemic attacks (2.7% vs 1.6%), hypotension (16.5%-12.5%), malnutrition (6.7% vs 4.0%), pneumonia (10.7% vs 7.9%), urinary infections (13.2% vs 9.3%), encephalopathy (9.9% vs 5.0%), mood disorders (13.6% vs 9.7%), psychosis (9.8% vs 4.6%), and epilepsy (4.3% vs 1.5%). Higher use of antidepressants (26.3% vs 16.3%), anticonvulsants (19.5% vs 15.1%), antipsychotics (18.6% vs 9.1%), anticholinesterase (5.6% vs 0.1%), and benzodiazepines (30.6% vs 26.6%) was noted in those with CI. All these findings were statistically significant.

Conclusion

Despite the limitations of a retrospective study, real-world data demonstrate that concomitant CI is a decisive risk factor for higher mortality and increased adverse outcomes in patients with CKD. These results highlight the need for routine comprehensive cognitive assessments in patients at any stage of CKD.

With big data comes big responsibility: Strategies for utilizing aggregated, standardized, de-identified electronic health record data for research

Electronic health records (EHRs), though they are maintained and utilized for clinical and billing purposes, may provide a wealth of information for research. Currently, sources are available that offer insight into the health histories of well over a quarter of a billion people. Their use, however, is fraught with hazards, including introduction or reinforcement of biases, clarity of disease definitions, protection of patient privacy, definitions of covariates or confounders, accuracy of medication usage compared with prescriptions, the need to introduce other data sources such as vaccination or death records and the ensuing potential for inaccuracy, duplicative records, and understanding and interpreting the outcomes of data queries. On the other hand, the possibility of study of rare disorders or the ability to link apparently disparate events are extremely valuable. Strategies for avoiding the worst pitfalls and hewing to conservative interpretations are essential. This article summarizes many of the approaches that have been used to avoid the most common pitfalls and extract the maximum information from aggregated, standardized, and de-identified EHR data. This article describes 26 topics broken into three major areas: (1) 14 topics related to design issues for observational study using EHR data, (2) 7 topics related to analysis issues when analyzing EHR data, and (3) 5 topics related to reporting studies using EHR data.

Differential Effects of GLP-1 Receptor Agonists on Cancer Risk in Obesity: A Nationwide Analysis of 1.1 Million Patients

Background: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have demonstrated significant efficacy in obesity treatment beyond their original development for type-2 diabetes management. This comprehensive study investigated the relationship between GLP-1RA use and cancer incidence in individuals with obesity across a 5-year follow-up period. Methods: We conducted a large-scale cohort study using the TriNetX US Collaborative Network database (2013-2023) examining adult patients with obesity. The study utilized propensity score matching to pair GLP-1RA-treated patients with controls (1:1) using the nearest neighbor method. Cancer incidence served as the primary outcome measure over the 5-year follow-up, with subgroup analyses considering individual GLP-1RA agents, patient sex, and BMI categories. Results: Analysis revealed significant cancer-risk reductions associated with GLP-1RA use across multiple cancer types compared to matched controls. Notable risk reductions were observed in gastrointestinal (HR 0.67, 95% CI 0.59-0.75), skin (HR 0.62, 95% CI 0.55-0.70), breast (HR 0.72, 95% CI 0.64-0.82), female genital (HR 0.61, 95% CI 0.53-0.71), prostate (HR 0.68, 95% CI 0.58-0.80), and lymphoid/hematopoietic cancers (HR 0.69, 95% CI 0.60-0.80). Semaglutide demonstrated superior protective effects, particularly in gastrointestinal cancers (HR 0.45, 95% CI 0.37-0.53). Conversely, liraglutide showed increased risks for thyroid (HR 1.70, 95% CI 1.03-2.82) and respiratory cancers (HR 1.62, 95% CI 1.13-2.32). Conclusions: This research provides compelling evidence for GLP-1RA's potential role in cancer-risk reduction, with semaglutide showing particularly promising results. The differential effects observed among GLP-1RA agents emphasize the importance of personalized medicine approaches. These findings suggest significant implications for clinical practice and future research in both obesity management and cancer prevention.

Adverse Pregnancy Outcomes in Patients with Polycystic Ovary Syndrome with Pre-Conceptional Hyperandrogenism: A Multi-Institutional Registry-Based Retrospective Cohort Study

Background/Objectives: Women with polycystic ovarian syndrome (PCOS) are at higher risk for pregnancy complications. The PCOS population is heterogeneous, with different phenotypes linked to varying risks of adverse outcomes. However, literature on pre-conceptional hyperandrogenism is limited and based on small sample sizes. Methods: This multi-institutional registry-based retrospective cohort study included pregnant patients diagnosed with PCOS with or without pre-conceptional hyperandrogenism. Utilizing the TriNetX platform, one-to-one propensity score matching was conducted to adjust for confounding factors. Exclusion criteria included multiple pregnancies and patients who received assisted reproductive technology, oral contraceptives, or spironolactone. 571 patients with PCOS and pre-conceptional hyperandrogenism and 13,465 patients with PCOS without hyperandrogenism were identified. Post-propensity matching, each cohort consisted of 564 patients. Results: Pregnant women diagnosed with PCOS and pre-conceptional hyperandrogenism showed a higher risk of large for gestational age (6.6% vs. 3.9%, OR = 1.73, 95% CI [1.007-2.972], p-value = 0.045) and preterm birth (10.3% vs. 5.9%, OR = 1.844, 95% CI [1.183-2.876], p-value = 0.006), but had no significant increase in the risk of gestational hypertension, preeclampsia/eclampsia, gestational diabetes, missed abortion, intrauterine growth restriction, placenta abruption, or cesarean section. Conclusions: Women with PCOS and pre-conceptional hyperandrogenism have an increased risk of pregnancy complications, especially large for gestational age and preterm birth. Further research is needed to clarify the underlying mechanisms, and whether treatment can improve outcomes.