Comparison of 2 methods for calculating adjusted survival curves from proportional hazards models

Association of postpartum medication practices with early breastfeeding cessation among mothers with chronic conditions: A prospective cohort study

INTRODUCTION

Use of medications is a common concern for breastfeeding women, particularly when they are strongly needed or unavoidable to manage maternal chronic conditions. Yet the influence of medication usage patterns on breastfeeding duration in mothers with chronic conditions is unclear. The objective of this study was to examine whether postpartum medication practices were associated with shorter breastfeeding duration or earlier than planned breastfeeding cessation among mothers with chronic conditions.

MATERIAL AND METHODS

We analyzed 346 mothers with chronic conditions enrolled in a prospective, community-based pregnancy cohort study (Alberta, Canada) who initiated breastfeeding after birth. Data were collected through self-report questionnaires spanning late pregnancy to 6 months postpartum. Based on reported use of preexisting medications while breastfeeding, women were classified as continuing medications (reference group), discontinuing one or more medications, or those who did not use preexisting medications. Cox proportional hazards regression was used to analyze the association of medication practices and overall breastfeeding duration in weeks. Logistic regression was used to analyze the association of medication practices and earlier than planned breastfeeding cessation. Multivariable models adjusted for demographic and health-related factors.

RESULTS

Overall, 30.6% of women with chronic conditions stopped breastfeeding in the first 6 months, almost all of whom did so earlier than planned. In multivariable models, medication discontinuation was significantly associated with shorter breastfeeding duration (adjusted hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.03-2.70) and earlier than planned breastfeeding cessation (adjusted odds ratio [OR] 1.85, 95% CI 1.01-3.42), whereas medication non-use was not associated with differences in breastfeeding outcomes.

CONCLUSIONS

Women with chronic conditions who discontinued preexisting medications while breastfeeding had significantly shorter breastfeeding duration and were less likely to meet their breastfeeding goals in the first 6 months postpartum compared to women who continued preexisting medications.

A comparison of different methods to adjust survival curves for confounders

Treatment specific survival curves are an important tool to illustrate the treatment effect in studies with time-to-event outcomes. In non-randomized studies, unadjusted estimates can lead to biased depictions due to confounding. Multiple methods to adjust survival curves for confounders exist. However, it is currently unclear which method is the most appropriate in which situation. Our goal is to compare forms of inverse probability of treatment weighting, the G-Formula, propensity score matching, empirical likelihood estimation and augmented estimators as well as their pseudo-values based counterparts in different scenarios with a focus on their bias and goodness-of-fit. We provide a short review of all methods and illustrate their usage by contrasting the survival of smokers and non-smokers, using data from the German Epidemiological Trial on Ankle-Brachial-Index. Subsequently, we compare the methods using a Monte-Carlo simulation. We consider scenarios in which correctly or incorrectly specified models for describing the treatment assignment and the time-to-event outcome are used with varying sample sizes. The bias and goodness-of-fit is determined by taking the entire survival curve into account. When used properly, all methods showed no systematic bias in medium to large samples. Cox regression based methods, however, showed systematic bias in small samples. The goodness-of-fit varied greatly between different methods and scenarios. Methods utilizing an outcome model were more efficient than other techniques, while augmented estimators using an additional treatment assignment model were unbiased when either model was correct with a goodness-of-fit comparable to other methods. These "doubly-robust" methods have important advantages in every considered scenario.

Prognostic Factors and Primary Healing on Root Perforation Repaired with MTA: A 14-year Longitudinal Study

INTRODUCTION

Few data are available on the long-term efficacy of mineral trioxide aggregate (MTA) in treating root canal perforations. This prospective cohort study builds on a previously reported trial to determine the outcome for teeth with root perforations treated with orthograde MTA after longer follow-up and identify potential prognostic factors.

METHODS

A prospective cohort study was performed, enrolling (1999-2009) patients with a single dental perforation treated with MTA. Preoperative, intraoperative, and postoperative information was evaluated, and the outcomes were dichotomized as healed or nonhealing. Patients were followed up yearly until 2018 for a maximum of 17 years after treatment, with controls carried out until 14 years. Clinical and radiographic outcomes were evaluated using standardized follow-up protocols.

RESULTS

Of the 124 entrolled patients (median age = 36.5 years, 53.2% male), 115 were healed at the first (n = 110, 89%) or second (n = 5, 4%) annual posttreatment checkup, while 9 subjects (7%, 4 females, 18-65 years old) did not heal. Characteristics significantly associated with nonhealing were gender, positive probing, size, and perforation site. Perforations recurred in 48 teeth during the follow-up with the estimated probability of reversal at 5, 10, and 14 years of 6% (95% confidence interval [CI], 2%-10%), 30% (95% CI, 20%-38%), and 62% (95% CI, 46%-73%), respectively. Positive probing had a higher reversal risk (hazard ratio = 3.3, P ≤ .001), and perforations >3 mm were more likely to have a reversal (hazard ratio = 4.1, P < .001).

CONCLUSIONS

The risk of reversal for healed MTA-treated root canal perforations, initially relatively low, vastly increases over time.

A SAS macro for estimating direct adjusted survival functions for time-to-event data with or without left truncation

There are several statistical programmes to compute direct adjusted survival estimates from results of the Cox proportional hazards model. However, when used to analyze observational databases with large sample sizes or highly stratified treatment groups such as in registry-related datasets, these programmes are inefficient or unable to generate confidence bands and simultaneous p values. Also, these programmes do not consider potential left-truncation in retrospectively collected data. To address these deficiencies we developed a new SAS macro %adjsurvlt() able to produce direct adjusted survival estimates based on a stratified Cox model. The macro has improved computational performance and is able to handle left-truncated and right-censored time-to-event data. Several mechanisms were implemented to improve computational efficiency including choosing matrix operations over do-loops and reducing dimensions of co-variate matrices. Compared to the latest SAS macro, %adjsurvlt() used < 0.1% computational time to process a dataset with 100 treatment cohorts and a sample size of 20,000 and showed similar computational efficiency when analyzing left-truncated and right-censored data. We illustrate use of %adjsurvlt() to compare retrospectively collected survival data of 2 transplant cohorts.

Adjusted Survival Curves Improve Understanding of Multivariable Cox Model Results

Kaplan-Meier survival curves are the most common methods for unadjusted group comparison of outcomes in orthopedic research. However, they may be misleading due to an imbalance of confounders between patient groups. The Cox model is frequently used to adjust for confounders, but graphical display of adjusted survival curves is not commonly utilized. We describe the circumstances when adjusted survival curves are useful in orthopedic research, describe and use 2 different methods to obtain adjusted curves, and illustrate how they can improve understanding of the multivariable Cox model results. We further provide practical strategies for identifying the need for and performing adjusted survival curves. Please visit the followinghttps://youtu.be/ys0hy2CiMCAfor a video that explains the highlights of the paper in practical terms.

Association of Labor Epidural Analgesia With Autism Spectrum Disorder in Children

IMPORTANCE

A recent cohort study found that epidural analgesia during labor was associated with an increased risk of autism in offspring.

OBJECTIVE

To investigate if labor epidural increases the risk of autism in offspring.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide retrospective cohort study identified all live-born children in Denmark between January 2006 and December 2013. Follow-up commenced at children's first birthday and ended in December 2017. Among 485 093 live-born children, 5915 were excluded because of occurrences during the first year of life including death, emigration, misregistration of birth, diagnosis of disease inherently linked to autism, or diagnosis of autism.

EXPOSURES

Administration of epidural analgesia during labor, as identified by procedure code.

MAIN OUTCOMES AND MEASURES

The main outcome of interest was incident diagnosis of autism spectrum disorder based on International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes in the Danish Psychiatric Central Register or National Patient Register. Hazard ratios were estimated using Cox regression, adjusted for covariates describing maternal comorbidity, sociodemographic factors, lifestyle, pregnancy, psychiatric illness, psychotropic medication, medical-seeking behavior, and family history of autism. A secondary analysis used a within-mother design including only children of mothers with both exposure and nonexposure to labor epidural analgesia in different deliveries.

RESULTS

The cohort included 479 178 children (233 405 girls [48.7%]; median maternal age at delivery, 30.9 [IQR, 27.6-34.2] years); of these, 92 900 (19.4%) were exposed to epidural analgesia during labor. Median follow-up was 7.0 years (IQR, 4.9-9.0 years), and by the end of follow-up, 6428 children (1.3%) had been diagnosed with autism. Exposed children had an autism diagnosis incidence rate of 23.1 per 10 000 person-years compared with 18.5 per 10 000 person-years in the unexposed group (crude hazard ratio, 1.29 [95% CI, 1.21-1.37]; adjusted hazard ratio, 1.05 [95% CI, 0.98-1.11]). A secondary within-mother analysis including 59 154 children (12.3%) estimated an autism diagnosis incidence rate of 20.8 per 10 000 person-years in the exposed group and 17.1 per 10 000 person-years in the unexposed group (adjusted hazard ratio, 1.05 [95% CI, 0.90-1.21]).

CONCLUSIONS AND RELEVANCE

In this nationwide cohort study of Danish children, maternal exposure to epidural analgesia during labor was not significantly associated with autism spectrum disorder in offspring.

Prediagnostic Inflammation and Pancreatic Cancer Survival

BACKGROUND

Chronic inflammation may promote initiation and progression of pancreatic cancer, but no studies have examined the association between inflammation in the period before diagnosis and pancreatic cancer survival.

METHODS

We prospectively examined the association of prediagnostic plasma levels of C-reactive protein, interleukin-6, and tumor necrosis factor-α receptor 2 with survival among 492 participants from 5 large US prospective cohort studies who developed pancreatic cancer. Using an empirical dietary inflammatory pattern (EDIP) score, we evaluated whether long-term proinflammatory diets were associated with survival among 1153 patients from 2 of the 5 cohorts. Cox proportional hazards regression was used to estimate hazard ratios for death with adjustment for potential confounders. All statistical tests were 2-sided.

RESULTS

Higher prediagnostic levels of C-reactive protein, interleukin-6, and tumor necrosis factor-α receptor 2 were individually associated with reduced survival (Ptrend = .03, .01, and .04, respectively). Compared with patients with a combined inflammatory biomarker score of 0 (all 3 marker levels below medians), those with a score of 3 (all 3 marker levels above medians) had a hazard ratio for death of 1.57 (95% confidence interval = 1.16 to 2.12; Ptrend = .003), corresponding to median overall survival times of 8 vs 5 months. Patients consuming the most proinflammatory diets (EDIP quartile 4) in the prediagnostic period had a hazard ratio for death of 1.34 (95% confidence interval = 1.13 to 1.59; Ptrend = .01), compared with those consuming the least proinflammatory diets (EDIP quartile 1).

CONCLUSION

Prediagnostic levels of inflammatory biomarkers and long-term proinflammatory diets were inversely associated with pancreatic cancer survival.

Coronary Revascularization in the Past Two Decades in Japan (From the CREDO-Kyoto PCI/CABG Registries Cohort-1, -2, and -3)

The treatment of coronary artery disease has substantially changed over the past two decades. However, it is unknown whether and how much these changes have contributed to the improvement of long-term outcomes after coronary revascularization. We assessed trends in the demographics, practice patterns and long-term outcomes in 24,951 patients who underwent their first percutaneous coronary intervention (PCI) (n = 20,106), or isolated coronary artery bypass grafting (CABG) (n = 4,845) using the data in a series of the CREDO-Kyoto PCI/CABG Registries (Cohort-1 [2000 to 2002]: n = 7,435, Cohort-2 [2005 to 2007]: n = 8,435, and Cohort-3 [2011 to 2013]: n = 9,081). From Cohort-1 to Cohort-3, the patients got progressively older across subsequent cohorts (67.0 ± 10.0, 68.4 ± 9.9, and 69.8 ± 10.2 years, p_trend < 0.001). There was increased use of PCI over CABG (73.5%, 81.9%, and 85.2%, p_trend < 0.001) and increased prevalence of evidence-based medications use over time. The cumulative 3-year incidence of all-cause death was similar across the 3 cohorts (9.0%, 9.0%, and 9.3%, p = 0.74), while cardiovascular death decreased over time (5.7%, 5.1%, and 4.8%, p = 0.03). The adjusted risk for all-cause death and for cardiovascular death progressively decreased from Cohort-1 to Cohort-2 (HR:0.89, 95%CI:0.80 to 0.99, p = 0.03, and HR:0.80, 95%CI:0.70 to 0.92, p = 0.002, respectively), and from Cohort-2 to Cohort-3 (HR:0.86, 95%CI:0.78 to 0.95, p = 0.004, and HR:0.77, 95%CI:0.67-0.89, p < 0.001, respectively). The risks for stroke and repeated coronary revascularization also improved over time. In conclusions, we found a progressive and substantial reduction of adjusted risk for all-cause death, cardiovascular death, stroke, and repeated coronary revascularization over the past two decades in Japan.

Stage-dependent conditional survival and failure hazard of non-metastatic nasopharyngeal carcinoma after intensity-modulated radiation therapy: Clinical implications for treatment strategies and surveillance

Purpose

Conditional survival (CS) and failure hazard estimations can provide important dynamic prognostic information for clinical decision‐making and surveillance counseling. The current study aimed to investigate the CS and dynamic failure hazard in non‐metastatic nasopharyngeal carcinoma (NPC) treated with intensity‐modulated radiotherapy (IMRT).

Methods

Conditional overall survival (COS) and progression‐free survival (CPFS) estimates adjusted for age and gender against each AJCC 8th stage were calculated. Multivariable Cox regression (MCR) models were fitted in the entire population at baseline and subsequently separate MCR models were fitted in patients who have maintained event‐free time of 1 to 10 years to generate respective hazard ratio (HR). Annual hazard rates of death and progression over 10 years for each stage were also estimated.

Results

A total of 1993 patients were eligible for analysis. The estimated 5‐year OS and PFS for entire cohort were 79.0% and 70.7% at initial diagnosis. After 5 years of event‐free follow‐up, additional 5‐year COS and CPFS increased to 85.9% and 85.5%, respectively. Stage I/II maintained dramatically favorable CS and low hazard (< 5%) of death and progression over time. Relative to stage I/II, stage III manifested non‐significantly higher failure hazard for the first 3 years of survivorship and approached to similar level of stage I/II afterwards. Stage IVA presented most impressive improvement in terms of both COS (∆=9.8%) and CPFS (∆ = 16.8%) whereas still drastically inferior to that of stage I‐III across all conditional time points. After 4 years of follow‐up, progression hazard of stage IVA became relatively steady of approximate 6%.

Conclusions

Survival prospect of non‐metastatic NPC improves over years with distinct dynamic patterns across stages, providing important implications for personalized decision‐making in terms of both clinical management and surveillance counseling. Stage‐dependent and hazard‐adapted clinical management and surveillance are warranted.

Plasma irisin levels are associated with hemodynamic and clinical outcome in idiopathic pulmonary arterial hypertension patients

Irisin has been considered to reflect oxidative stress. This study aimed to show whether plasma irisin levels are correlated with hemodynamic dysfunction and predict the clinical outcome of patients with idiopathic pulmonary arterial hypertension (IPAH). A total of 68 adult IPAH patients were prospectively recruited in the present study. Plasma irisin levels were measured by the ELISA method in enrolled IPAH patients. Baseline clinical characteristics, and hemodynamic and clinical outcome were compared according to different plasma irisin levels. IPAH patients were divided into high irisin group (irisin ≥ 7.3 μg/ml) and low irisin group (irisin < 7.3 μg/ml) according to median values of irisin levels. Total plasma cholesterol levels (P = 0.027) and low-density lipoprotein cholesterol (LDL-C) levels (P = 0.042) were higher in high irisin group and were positively correlated with plasma irisin levels. IPAH patients in low irisin group had a significantly higher mean pulmonary artery pressure (mPAP, P = 0.047), systolic pulmonary artery pressure (sPAP, P = 0.022), systolic right-ventricular pressure (sRVP, P = 0.007), mean right atrial pressure (mRAP, P = 0.043), and systolic right atrial pressure (sRAP, P = 0.020). mRAP, sRAP, and diastolic right atrial pressure (dRAP) were negatively correlated with plasma irisin levels. Low irisin group predicts adverse hemodynamic status and poor free of event survival rate (P = 0.030, log-rank test). Multivariate analysis indicates plasma irisin levels to be an independent predictor of prognosis in IPAH patients after adjusting for related covariates (HR 0.786; 95% CI 0.584, 0.957; P = 0.038). Plasma irisin levels may serve as a novel biomarker in IPAH patients for hemodynamic severity assessment and clinical outcome evaluation.

Guideline-concordant treatment predicts survival: a National Cancer Database validation study of novel composite locoregional and systemic treatment scores among women with early stage breast cancer

BACKGROUND

The aim of this large nationwide study was to validate two novel composite treatment scores that address guideline-concordant locoregional and systemic breast cancer care. We examined the relationship between these two scores and their association with survival.

METHODS

Women with Stage I-III unilateral breast cancer were identified within the National Cancer Database. For each woman, a locoregional and a systemic treatment score (0, 1, 2) was assigned based on receipt of guideline-concordant care. Multivariable Cox regression models evaluated the association between the scores and survival.

RESULTS

623,756 women were treated at 1,221 different American College of Surgeons Commission on Cancer (CoC) facilities. Overall, 86% had a locoregional treatment score of 2 (most guideline-concordant), 75% had a systemic treatment score of 2, and 72% had both scores of 2. Median follow-up was 4.5 years. Compared to women with a locoregional treatment score of 2, those with a score of 1 or 0 had a 1.7-fold and 2.0-fold adjusted greater risk of death. Compared to women with a systemic treatment score of 2, those with a score of 1 or 0 had a 1.5-fold and 2.1-fold adjusted greater risk of death. Risk-adjusted 5-year overall survival was 91.6% when both scores were 2 compared to 73.4% when both scores were 0.

CONCLUSIONS

In this large national study of CoC facilities, two composite scores capturing guideline-concordant breast cancer care had independent and combined robust effects on survival. These clinically constructed novel scores are promising tools for health services research and quality-of-care studies.

Alteration of FBXW7 is Associated with Worse Survival in Patients Undergoing Resection of Colorectal Liver Metastases

BACKGROUND

For patients undergoing resection of colorectal liver metastases (CLMs), the prognostic role of somatic gene alterations is increasingly recognized. F-box/WD repeat-containing protein 7 (FBXW7) is a tumor suppressor gene found in approximately 10% of patients with colorectal cancer. The aim of this study is to assess the association of FBXW7 with overall survival after CLM resection.

METHODS

Patients who underwent initial CLM resection during 2001-2016 and had genetic sequencing data were studied. Risk factors for overall survival (OS) were evaluated with Cox proportional hazards models using backward elimination.

RESULTS

Of 2045 patients who underwent CLM resection during the study period, 476 were included. The majority (90.5%) underwent prehepatectomy chemotherapy. A total of 27 patients (5.7%) had FBXW7 alteration, along with 240 (50.4%) RAS, 337 (70.8%) TP53, 51 (10.7%) SMAD4, and 27 (5.7%) BRAF. Cox proportional hazards model analyses including 5 somatic gene alteration status and 12 clinicopathologic factors revealed FBXW7(hazard ratio [HR] 1.99, P = 0.015), BRAF (HR 2.47, P = 0.023), RAS (HR 2.42, P < 0.001), TP53 (HR 2.00, P < 0.001), and SMAD4 alterations (HR 1.90, P = 0.004) as significantly associated with OS, together with three clinicopathologic factors, prehepatectomy chemotherapy > 6 cycles (HR 1.51, P = 0.021), number of CLM (HR 1.05, P = 0.007), and largest liver metastasis diameter (HR 1.07, P = 0.023). The covariate-adjusted 5-year OS was significantly lower in patients with FBXW7 alteration than in patients with FBXW7 wild-type (40.4% vs.59.4%, P = 0.015).

CONCLUSIONS

FBXW7 alterations are associated with worse survival after CLM resection. The information on multiple somatic gene alterations is imperative for risk stratification and patient selection for CLM resection.

Revascularization for Isolated Proximal Left Anterior Descending Artery Disease

BACKGROUND

Most studies of patients with isolated proximal left anterior descending (PLAD) coronary artery disease do not include all 3 procedural options: percutaneous coronary intervention (PCI), conventional coronary artery bypass graft (CABG) surgery, or minimally invasive CABG.

METHODS

New York's cardiac registries were used to identify patients who underwent revascularization for isolated PLAD disease between January 1, 2010, and November 30, 2016, in New York State. After exclusions, 14,327 patients, of whom 13,115 received PCI, 1001 of whom underwent CABG surgery, and 211 of whom underwent minimally invasive CABG were monitored through the end of 2017 to compare outcomes. Registry data were matched to vital statistics data to obtain deaths occurring after discharge and matched to claims data to obtain subsequent admissions for myocardial infarction and stroke.

RESULTS

There were no significant differences in mortality or in mortality/myocardial infarction/stroke after 7 years (with median follow-up times in excess of 4 years) among the 3 procedures after adjusting for differences in patient risk factors. However, conventional CABG surgery was associated with a lower subsequent revascularization rate than PCI (adjusted hazard ratio, 0.45; 95% confidence interval, 0.35-0.58) and minimally invasive CABG surgery (adjusted hazard ratio, 0.46; 95% confidence interval, 0.32-0.66).

CONCLUSIONS

Among patients with isolated PLAD disease undergoing any of 3 revascularization options (PCI, conventional CABG surgery, or minimally invasive CABG surgery), conventional CABG surgery was associated with lower subsequent revascularization rates, but there were no differences in mortality or mortality/myocardial infarction/stroke rates.

Five-Year Prognosis After TIA or Minor Ischemic Stroke in Asian and Non-Asian Populations

OBJECTIVE

To determine long-term vascular outcomes of Asian patients who experienced TIA or minor ischemic stroke and to compare the outcomes of Asian patients with those of non-Asian patients, in the context of modern guideline-based prevention strategies.

METHODS

This is a subanalysis of the TIAregistry.org project, in which 3,847 patients (882 from Asian and 2,965 from non-Asian countries) with a recent TIA or minor ischemic stroke were assessed and treated by specialists at 42 dedicated units from 14 countries and followed for 5 years. The primary outcome was a composite of cardiovascular death, nonfatal stroke, and nonfatal acute coronary syndrome.

RESULTS

No differences were observed in the 5-year risk of the primary outcome (14.0% vs 11.7%; hazard ratio [HR], 1.10; 95% confidence interval [CI], 0.88-1.37; p = 0.41) and stroke (10.7% vs 8.5%; HR, 1.17; 95% CI, 0.90-1.51; p = 0.24) between Asian and non-Asian patients. Asian participants were at higher risk of intracranial hemorrhage (1.8% vs 0.8%; HR, 2.23; 95% CI, 1.09-4.57; p = 0.029). Multivariable analysis showed that the presence of multiple acute infarctions on initial brain imaging was an independent predictor of primary outcome and modified Rankin Scale score of >1 in both Asian (HR, 1.91; 95% CI, 1.11-3.29; p = 0.020) and non-Asian (HR, 1.39; 95% CI, 1.02-1.90; p = 0.037) patients.

CONCLUSION

The long-term risk of vascular events in Asian patients was as low as that in non-Asian patients, while Asian participants had a 2.2-fold higher intracranial hemorrhage risk. Multiple acute infarctions were independently associated with future disability in both groups.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that among people who experienced TIA or minor stroke, Asian patients have a similar 5-year risk of cardiovascular death, stroke, and acute coronary syndrome as non-Asian patients.

Plasma irisin level associated with hemodynamic parameters and predict clinical outcome in patients with acute pulmonary embolism

BACKGROUND

The purpose of the present study is to investigate the correlation of plasma irisin level and hemodynamic parameters in patients with acute pulmonary embolism (APE) and to estimate clinical outcome prediction value of plasma irisin level.

METHODS

We prospectively recruited 86 adult patients with APE in the present study. All recruited patients conduct measurement of plasma irisin levels using ELISA kits. Baseline clinical characteristics, hemodynamic parameters and prognostic conditions were evaluated according to different plasma irisin levels.

RESULTS

According to median values of irisin levels, APE patients were divided into high irisin group (irisin≥6.9 μg/ml) and low irisin group (irisin<6.9 μg/ml). Plasma NT-proBNP (P = 0.044), mean pulmonary artery pressure (mPAP, P = 0.013), systolic pulmonary artery pressure (sPAP, P = 0.001), mean right ventricular pressure (mRVP, P = 0.021) and systolic right ventricular pressure (sPVP, P = 0.003) were higher in low irisin group compared with high irisin group. Hemodynamic parameters of mPAP, sPAP, mRVP and sRVP were negatively correlated with plasma irisin levels. Kaplan- Meier survival analysis showed that APE patients with lower plasma irisin levels had significantly higher clinical worsening event rate (P = 0.026) and could be the independent predictor of prognosis in multivariate analysis (P = 0.035).

CONCLUSION

Plasma irisin level was negatively correlated with hemodynamic parameters in patients with APE. Low irisin group patients had significantly higher clinical worsening event rate and could be the independent predictor of clinical outcome in multivariate analysis.

Current comments on contrast media administration in patients with renal insufficiency

Contrast media administration has been associated with complications such as nephropathy, cardiovascular morbidity, and neurovascular events, particularly in patients with renal insufficiency. This association has been questioned in recent studies. This review was performed to summarize the most current evidence on contrast induced nephropathy (CIN), contributing factors, and considerations in patients with renal insufficiency. The risk of CIN was over-estimated by the previous studies, due to a lack of control groups or presence of non-randomized control groups, which led to a selection bias. However, the thresholds associated with an increased risk of CIN are controversial and require risk-benefit analysis on an individual basis. Regarding the administration of contrast media (CM) in the emergency setting, the majority of studies suggested that CM exposure does not meaningfully increase the risk of acute kidney injury in critically ill patients (including trauma patients). Several strategies have been suggested to reduce the risk of CIN, including volume expansion to increase renal blood flow, sodium bicarbonate or N-acetylcysteine administration, and use of low-osmolal contrast media in end-stage renal disease.

Modelling Survival of Patients Treated with Adjuvant Nivolumab Who Have Melanoma with Lymph Node Involvement or Metastatic Disease After Complete Resection

INTRODUCTION

Nivolumab demonstrated significant recurrence-free survival (RFS) gains versus ipilimumab in the CheckMate-238 trial, whereas the CA184-029 trial showed superior RFS gains for ipilimumab versus placebo. No head-to-head trial data were available to compare the efficacy of nivolumab to that of observation, so indirect treatment comparisons were required. Additionally, overall survival (OS) data were not available from CheckMate-238, and the clinical pathway for melanoma has changed significantly over the last decade. Four modelling options were developed using different methods and evidence sources to estimate OS and the impact of nivolumab on predicted life-years in the adjuvant setting; however, this article focuses on two primary methods.

METHODS

RFS for nivolumab and observation were informed by a patient-level data meta-regression. The first model was a partitioned survival model, where the parametric OS curve for observation was derived from CA184-029 and nivolumab OS was based on a surrogacy relationship between RFS and OS specific to adjuvant melanoma. The other option used a state-transition model to estimate post-recurrence survival using different data sources.

RESULTS

The modelling options estimated different OS for both nivolumab and observation but demonstrated at least a 32% increase in life-years gained for nivolumab versus observation.

CONCLUSION

This analysis demonstrated the difficulties in modelling within the adjuvant setting. Each model produced different survival projections, showing the need to explore different techniques to address the extent of uncertainty. This also highlighted the importance of understanding the impact of RFS in the long term in a setting where the aim of treatment is to remain disease free.

Suicide and Self-Harm in Recent Immigrants in Ontario, Canada: A Population-Based Study

OBJECTIVE

To estimate the rates of suicide and self-harm among recent immigrants and to determine which immigrant-specific risk factors are associated with these outcomes.

METHODS

Population-based cohort study using linked health administrative data sets (2003 to 2017) in Ontario, Canada which included adults ≥18 years, living in Ontario (N = 9,055,079). The main exposure was immigrant status (long-term resident vs. recent immigrant). Immigrant-specific exposures included visa class and country of origin. Outcome measures were death by suicide or emergency department visit for self-harm. Cox proportional hazards estimated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

We included 590,289 recent immigrants and 8,464,790 long-term residents. Suicide rates were lower among immigrants (n = 130 suicides, 3.3/100,000) than long-term residents (n = 6,354 suicides, 11.8/100,000) with aHR 0.3, 95% CI, 0.2 to 0.3. Male-female ratios in suicide rates were attenuated in immigrants. Refugees had 2.1 (95% CI, 1.3 to 3.6; rate 6.1/100,000) and 2.8 (95% CI, 2.5 to 3.2) times the likelihood of suicide and self-harm, respectively, compared with nonrefugee immigrants. Self-harm rate was lower among immigrants (n = 2,256 events, 4.4/10,000) than long-term residents (n = 68,039 events, 9.7/10,000 person-years; aHR 0.3; 95% CI, 0.3 to 0.3). Unlike long-term residents, where low income was associated with high suicide rates, income was not associated with suicide among immigrants and there was an attenuated income gradient for self-harm. Country of origin-specific analyses showed wide ranges in suicide rates (1.4 to 9.9/100,000) and self-harm (1.8 to 14.9/10,000).

CONCLUSION

Recent immigrants have lower rates of suicide and self-harm and different sociodemographic predictors compared with long-term residents. Analysis of contextual factors including immigrant class, origin, and destination should be considered for all immigrant suicide risk assessment.

Prediagnostic Leukocyte Telomere Length and Pancreatic Cancer Survival

BACKGROUND

Leukocyte telomere length has been associated with risk of subsequent pancreatic cancer. Few prospective studies have evaluated the association of prediagnostic leukocyte telomere length with pancreatic cancer survival.

METHODS

We prospectively examined the association of prediagnostic leukocyte telomere length with overall survival (OS) time among 423 participants diagnosed with pancreatic adenocarcinoma between 1984 and 2008 within the Health Professionals Follow-up Study, Nurses' Health Study, Physicians' Health Study, and Women's Health Initiative. We measured prediagnostic leukocyte telomere length in banked blood samples using quantitative PCR. Cox proportional hazards models were used to estimate HRs for OS with adjustment for potential confounders. We also evaluated 10 SNPs at the telomerase reverse transcriptase locus.

RESULTS

Shorter prediagnostic leukocyte telomere length was associated with reduced OS among patients with pancreatic cancer (P trend = 0.04). The multivariable-adjusted HR for OS comparing the lowest with highest quintiles of leukocyte telomere length was 1.39 (95% confidence interval, 1.01-1.93), corresponding to a 3-month difference in median OS time. In an analysis excluding cases with blood collected within 2 years of cancer diagnosis, the association was moderately stronger (HR, 1.55; 95% confidence interval, 1.09-2.21; comparing the lowest with highest quintiles; P trend = 0.01). No prognostic association or effect modification for the prognostic association of prediagnostic leukocyte telomere length was noted in relation to the studied SNPs.

CONCLUSIONS

Prediagnostic leukocyte telomere length was associated with pancreatic cancer survival.

IMPACT

Prediagnostic leukocyte telomere length can be a prognostic biomarker in pancreatic cancer.

Long-Term Safety and Efficacy of Staged Percutaneous Coronary Intervention for Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Disease

The relative benefit of staged percutaneous coronary intervention (PCI) versus culprit-only PCI in patients with ST-segment elevation myocardial infarction and multivessel coronary disease remains disputable. Therefore, we conducted this study to compare the long-term outcomes of staged complete revascularization and culprit-only PCI in this population. A total of 1,205 patients were treated with staged PCI (n = 576) or culprit-only PCI (n = 629) from January 2006 to December 2015 in our center. After propensity-score matching, 415 pairs of patients were identified, and postmatching absolute standardized differences were <10% for all covariates. The primary endpoint was major adverse cardiac and cerebrovascular event (MACCE), defined as a composite of all-cause death, myocardial infarction (MI), stroke, or unplanned revascularization. The mean follow-up duration was 5 years. Overall, staged complete revascularization was associated with lower risks of MACCE, MI, unplanned revascularization, and a composite of cardiac death, MI or stroke compared with culprit-only PCI in both overall population and propensity-matched cohorts. In Cox proportional hazards regression analysis, the strategy of staged PCI was consistently a significant predictor of lower incidences of MACCE, MI, unplanned revascularization and a composite of cardiac death, MI, or stroke. However, there was no difference in the risks of MACCE, MI and unplanned revascularization between the 2 approaches for diabetic patients. In conclusion, among patients with ST-segment elevation myocardial infarction and multivessel disease who underwent primary PCI, an approach of staged complete revascularization is superior to culprit-only PCI at 5-year follow-up. Nevertheless, the advantage of staged PCI is attenuated in diabetic patients.

Mutation Status of RAS, TP53, and SMAD4 is Superior to Mutation Status of RAS Alone for Predicting Prognosis after Resection of Colorectal Liver Metastases

PURPOSE

Somatic gene mutations have been increasingly recognized to impact prognosis following resection of colorectal liver metastases (CLM). We aimed to determine the impact of combinations of somatic mutations on survival in patients undergoing CLM resection.

EXPERIMENTAL DESIGN

We identified patients who underwent initial CLM resection during 2007-2017 and had genetic sequencing data available. Risk factors for overall survival (OS) and recurrence-free survival (RFS) were determined using Cox proportional hazards models.

RESULTS

Of 1460 patients who underwent CLM resection during the study period, 507 met the inclusion criteria. Multigene testing revealed mutation rates greater than 10% for TP53 (mutated in 70.8% of patients), APC (53.5%), RAS (50.7%), PIK3CA (15.8%), and SMAD4 (11.0%). BRAF was mutated in 2.0% of patients. BRAF, RAS, TP53, and SMAD4 mutations were significantly associated with OS, and RAS, TP53, and SMAD4 mutations were significantly associated with RFS. Coexisting mutations in RAS, TP53, and SMAD4 were associated with significantly worse OS and RFS than coexisting mutations in any 2 of these genes and mutations in 1 or none of these genes. Coexisting mutations in 2 genes conferred significantly worse OS and RFS than single mutation or no mutations. OS and RFS did not differ significantly between patients with RAS mutation and wild-type TP53 and SMAD4 and patients with wild-type RAS (P = 0.858 and 0.729, respectively).

CONCLUSIONS

RAS mutation status alone is not sufficient for precisely predicting prognosis after CLM resection.

Cardiovascular Event Risk in Rheumatoid Arthritis Compared with Type 2 Diabetes: A 15-year Longitudinal Study

OBJECTIVE

Cardiovascular (CV) disease (CVD) risk is increased in rheumatoid arthritis (RA). However, longterm followup studies investigating this risk are scarce.

METHODS

The CARRÉ (CARdiovascular research and RhEumatoid arthritis) study is a prospective cohort study investigating CVD and its risk factors in 353 patients with longstanding RA. CV endpoints were assessed at baseline and 3, 10, and 15 years after the start of the study and are compared to a reference cohort (n = 2540), including a large number of patients with type 2 diabetes (DM).

RESULTS

Ninety-five patients with RA developed a CV event over 2973 person-years, resulting in an incidence rate of 3.20 per 100 person-years. Two hundred fifty-seven CV events were reported in the reference cohort during 18,874 person-years, resulting in an incidence rate of 1.36 per 100 person-years. Age- and sex-adjusted HR for CV events were increased for RA (HR 2.07, 95% CI 1.57-2.72, p < 0.01) and DM (HR 1.51, 95% CI 1.02-2.22, p = 0.04) compared to the nondiabetic participants. HR was still increased in RA (HR 1.82, 95% CI 1.32-2.50, p < 0.01) after additional adjustment for CV risk factors. Patients with both RA and DM or insulin resistance had the highest HR for developing CVD (2.21, 95% CI 1.01-4.80, p = 0.046 and 2.67, 95% CI 1.30-5.46, p < 0.01, respectively).

CONCLUSION

The incidence rate of CV events in established RA was more than double that of the general population. Patients with RA have an even higher risk of CVD than patients with DM. This risk remained after adjustment for traditional CV risk factors, suggesting that systemic inflammation is an independent contributor to CV risk.

Importance of Nonobstructive Coronary Artery Disease in the Prognosis of Patients With Heart Failure

OBJECTIVES

This study sought to examine the prognostic significance of nonobstructive coronary artery disease (CAD) in patients with heart failure (HF), as a distinct category apart from those with normal coronary arteries.

BACKGROUND

Individuals with HF are often dichotomized into ischemic versus nonischemic categories according to the underlying etiology. This binary classification creates a heterogeneous group, combining individuals with nonobstructive CAD with those with normal coronary arteries under the nonischemic label.

METHODS

A cohort of individuals with HF and reduced ejection fraction undergoing invasive coronary angiography was examined and linked to administrative databases for outcomes evaluation. Patients were divided into those with normal coronary arteries, nonobstructive disease, and obstructive disease. The primary outcome was the composite of cardiovascular death, nonfatal acute myocardial infarction, nonfatal stroke, or HF hospitalization.

RESULTS

Of 12,814 individuals, 2,656 (20.7%) had normal coronary arteries, 2,254 (17.6%) had nonobstructive CAD, and 7,904 (61.7%) had obstructive CAD. The risk of the primary outcome was increased in the nonobstructive group (hazard ratio [HR]: 1.17; 95% confidence interval [CI]: 1.04 to 1.32; p = 0.01) relative to those with normal coronary arteries. Nonobstructive CAD was associated with an increased hazard of cardiovascular death (HR: 1.82; 95% CI: 1.27 to 2.62; p = 0.001) and death of any cause (HR: 1.18; 95% CI: 1.05 to 1.33; p = 0.005). There were no significant differences in the rate of acute myocardial infarction, stroke, or HF hospitalization.

CONCLUSIONS

Among HF patients with reduced ejection fraction, the presence of nonobstructive CAD was independently associated with an increased hazard of the primary composite outcome and death of any cause.

Modeling Covariate-Adjusted Survival for Economic Evaluations in Oncology

BACKGROUND AND OBJECTIVES

In economic evaluations in oncology, adjusted survival should be generated if imbalances in prognostic/predictive factors across treatment arms are present. To date, no formal guidance has been developed regarding how such adjustments should be made. We compared various covariate-adjusted survival modeling approaches, as applied to the ENDEAVOR trial in multiple myeloma that assessed carfilzomib plus dexamethasone (Cd) versus bortezomib plus dexamethasone (Vd).

METHODS

Overall survival (OS) data and baseline characteristics were used for a subgroup (bortezomib-naïve/one prior therapy). Four adjusted survival modeling approaches were compared: propensity score weighting followed by fitting a Weibull model to the two arms of the balanced data (weighted data approach); fitting a multiple Weibull regression model including prognostic/predictive covariates to the two arms to predict survival using the mean value of each covariate and using the average of patient-specific survival predictions; and applying an adjusted hazard ratio (HR) derived from a Cox proportional hazard model to the baseline risk estimated for Vd.

RESULTS

The mean OS estimated by the weighted data approach was 6.85 years (95% confidence interval [CI] 4.62-10.70) for Cd, 4.68 years (95% CI 3.46-6.74) for Vd, and 2.17 years (95% CI 0.18-5.06) for the difference. Although other approaches estimated similar differences, using the mean value of covariates appeared to yield skewed survival estimates (mean OS was 7.65 years for Cd and 5.40 years for Vd), using the average of individual predictions had limited external validity (implausible long-term OS predictions with > 10% of the Vd population alive after 30 years), and using the adjusted HR approach overestimated uncertainty (difference in mean OS was 2.03, 95% CI - 0.17 to 6.19).

CONCLUSIONS

Adjusted survival modeling based on weighted or matched data approaches provides a flexible and robust method to correct for covariate imbalances in economic evaluations. The conclusions of our study may be generalizable to other settings.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT01568866 (ENDEAVOR trial).

Associations between access to healthcare, environmental quality, and end-stage renal disease survival time: Proportional-hazards models of over 1,000,000 people over 14 years

Prevalence of end-stage renal disease (ESRD) in the US increased by 74% from 2000 to 2013. To investigate the role of the broader environment on ESRD survival time, we evaluated average distance to the nearest hospital by county (as a surrogate for access to healthcare) and the Environmental Quality Index (EQI), an aggregate measure of ambient environmental quality composed of five domains (air, water, land, built, and sociodemographic), at the county level across the US. Associations between average hospital distance, EQI, and survival time for 1,092,281 people diagnosed with ESRD between 2000 and 2013 (age 18+, without changes in county residence) from the US Renal Data System were evaluated using proportional-hazards models adjusting for gender, race, age at first ESRD service date, BMI, alcohol and tobacco use, and rurality. The models compared the average distance to the nearest hospital (<10, 10-20, >20 miles) and overall EQI percentiles [0-5), [5-20), [20-40), [40-60), [60-80), [80-95), and [95-100], where lower percentiles are interpreted as better EQI. In the full, non-stratified model with both distance and EQI, there was increased survival for patients over 20 miles from a hospital compared to those under 10 miles from a hospital (hazard ratio = 1.14, 95% confidence interval = 1.12-1.15) and no consistent direction of association across EQI strata. In the full model stratified by average hospital distance, under 10 miles from a hospital had increased survival in the worst EQI strata (median survival 3.0 vs. 3.5 years for best vs. worst EQI, respectively), however for people over 20 miles from a hospital, median survival was higher in the best (4.2 years) vs worst (3.4 years) EQI. This association held across different rural/urban categories and age groups. These results demonstrate the importance of considering multiple factors when studying ESRD survival and future efforts should consider additional components of the broader environment.

Long-term outcomes of in-hospital staged revascularization versus culprit-only intervention for patients with ST-segment elevation myocardial infarction and multivessel disease

BACKGROUND

The long-term relative benefit of culprit-only percutaneous coronary intervention (PCI) and staged PCI in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease remains disputable. This study aimed to compare the long-term outcomes of culprit-only PCI and in-hospital staged complete revascularization in real-world patients with STEMI and multivessel coronary artery disease.

PATIENTS AND METHODS

A total of 452 patients were treated with in-hospital staged complete revascularization (n=133) or culprit-only PCI (n=319) between May 2012 and December 2015 in our center. The primary end point was major adverse cardiac and cerebrovascular event (MACCE), defined as a composite of all-cause death, nonfatal myocardial infarction, stroke, and unplanned revascularization.

RESULTS

The median follow-up period was 3.2 years. Overall, treatment with in-hospital staged complete revascularization can reduce the incidence of the primary end point of MACCE in both the overall population [hazard ratio (HR): 0.48; 95% confidence interval (CI): 0.29-0.82] and the propensity-matched cohorts (HR: 0.51; 95% CI: 0.27-0.97). After correction of the possible confounders, staged PCI remained associated with decreased risk of MACCE (HR: 0.56; 95% CI: 0.33-0.96). Besides, the strategy of staged PCI tended to be associated with lower risk of a composite of cardiac death, myocardial infarction, and stroke than culprit-only PCI in multivariable-adjusted analysis (HR: 0.30; 95% CI: 0.09-1.01).

CONCLUSION

In patients with STEMI and multivessel disease undergoing primary PCI, an approach of in-hospital staged complete revascularization was associated with a better 3-year composite outcome compared with culprit-only PCI.

Femoral Tunnel Drilling Method: Risk of Reoperation and Revision After Anterior Cruciate Ligament Reconstruction

BACKGROUND

The femoral tunnel in anterior cruciate ligament reconstruction (ACLR) can be created by the transtibial (TT) or tibial-independent (TI) methods. An anatomically located femoral tunnel can be more consistently achieved by TI methods, which include the anteromedial portal and lateral (outside-in, retrodrill) techniques. Nonanatomic graft placement in ACLR can result in postoperative instability and meniscal or chondral injury. An anatomically located graft is subjected to higher postoperative physiologic forces than one placed nonanatomically.

PURPOSE

To examine isolated primary ACLR and determine the risk of aseptic revision and reoperation based on femoral tunnel drilling method.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

The ACLR registry of an integrated US health care system was used to identify primary isolated unilateral ACLRs from 2009 to 2014. Multivariable Cox proportional hazard regression models were used to evaluate risk for aseptic revision for graft failure and aseptic reoperation for meniscal or chondral injury according to femoral tunnel drilling method: TI versus TT. Models included age, sex, body mass index (BMI), race, graft type, and femoral fixation type as covariates.

RESULTS

The cohort included 19,059 patients with primary ACLR. The mean age was 28.9 years (SD, 11.5), 6991 patients (36.8%) were younger than 22 years, 11,795 patients (61.9%) were male, 7648 patients (40.1%) had a BMI less than 25 kg/m², 8913 patients (46.8%) were white, and 7357 patients (38.6%) received an allograft. Median follow-up was 2.30 years (interquartile range, 1.08-3.77). TI techniques were used for 12,342 (64.8%) of the ACLRs, and the TT method was used for 6717 (35.2%). Use of TI techniques increased from 33.6% of all ACLRs in 2009 to 83.4% in 2014. After adjustment for covariates, the TI group had a higher risk for aseptic revision than the TT group (hazard ratio [HR], 1.28; 95% CI, 1.04-1.56), and this risk was 1.41 times higher in patients younger than 22 years specifically. The 5-year cumulative reoperation probability was lower in the TI group (4.50%; 95% CI, 3.78%-5.36%) compared with the TT group (5.06%; 95% CI, 4.31-5.94%). After adjustment for the covariates, no difference in risk for aseptic reoperation was observed (HR, 1.08; 95% CI, 0.85-1.39).

CONCLUSION

In the largest known study of its type examining femoral tunnel drilling method for primary ACLR, after adjustment for age, sex, BMI, race, graft type, and femoral fixation, TI techniques were found to carry higher risk of aseptic revision compared with the TT method, while no difference was observed in risk for aseptic reoperation.

Non-cardioembolic stroke/transient ischaemic attack in Asians and non-Asians: A post-hoc analysis of the PERFORM study

Introduction

We aimed to compare the characteristics and vascular outcomes between Asian and non-Asian patients with non-cardioembolic stroke/transient ischaemic attack receiving antiplatelet monotherapy and to identify population-specific predictors for recurrent events.

Patients and methods

We conducted a post-hoc analysis of data from the PERFORM study, in which 19,100 patients (mean age, 67.2 years; male, 63%; 2178 Asian and 16,922 non-Asian patients) with non-cardioembolic ischaemic stroke/transient ischaemic attack were randomised to aspirin or terutroban and followed for two years. The primary outcome was a composite of major adverse cardiovascular events (non-fatal myocardial infarction, non-fatal stroke and cardiovascular death).

Results

There was no difference in major adverse cardiovascular events risk between Asian and non-Asian populations (11.1% vs. 10.5%; p = 0.39). However, Asian patients were at significantly higher risk of intracranial haemorrhage (2.4% vs. 1.3%; hazard ratio (HR) 1.87; 95% confidence interval (CI) 1.34-2.60; p < 0.001) and major bleeding (5.4% vs. 4.1%; HR 1.30; 95% CI 1.04-1.61; p = 0.02). Stroke risk was significantly higher in Asian than in non-Asian populations among patients with lacunar stroke (7.4% vs. 4.5%; p = 0.02). In multivariable analysis, diastolic blood pressure (HR per 5 mm Hg 1.08; 95% CI 1.01-1.16; p = 0.03) and diabetes (HR 1.36; 95% CI 1.22-1.52; p < 0.001) were independent predictors of major adverse cardiovascular events for Asian and non-Asian patients, respectively.Conclusion: Compared with non-Asian patients, Asian patients had significantly higher risk of haemorrhagic events when given antiplatelet monotherapy for secondary prevention after non-cardioembolic stroke/transient ischaemic attack. Lacunar stroke and elevated diastolic blood pressure were more associated with recurrence risk in Asian patients.

Prediagnosis Use of Statins Associates With Increased Survival Times of Patients With Pancreatic Cancer

BACKGROUND & AIMS

Statin medications, most commonly prescribed to reduce lipid levels and prevent cardiovascular disease, may be associated with longer survival times of patients with cancer. However, the association of statins with outcomes of patients with pancreatic adenocarcinoma is not clear.

METHODS

We analyzed the association of statin use before a diagnosis of pancreatic cancer with survival times of 648 participants in the Nurses' Health Study and Health Professionals Follow-up Study who were diagnosed with pancreatic adenocarcinoma from 2000 through 2013. We estimated hazard ratios (HRs) for overall mortality using Cox proportional hazards models with adjustment for potential confounders. We assessed the temporal association between prediagnosis statin use and cancer survival by 2-year lag periods to account for a possible latency period between statin use and cancer survival.

RESULTS

Regular statin use before diagnosis of pancreatic cancer was associated with modestly prolonged survival compared with nonregular use (adjusted HR, 0.82; 95% CI, 0.69-0.97; P = .02). A 1-month longer median survival was observed in regular statin users compared with nonregular users. Regular statin use within the 2 years prior to cancer diagnosis was most strongly associated with longer survival. We observed no statistically significant effect modification by smoking status, body mass index, diabetes, or cancer stage (all P_interaction > .53). Regular statin use before diagnosis was similarly associated with survival in the Nurses' Health Study (HR, 0.79; 95% CI, 0.64-0.97) and Health Professionals Follow-up Study (HR, 0.86; 95% CI, 0.63-1.15).

CONCLUSIONS

Regular statin use before diagnosis of pancreatic cancer was associated with modest increases in survival times in 2 large prospective cohort studies.

Modeling the covariates effects on the hazard function by piecewise exponential artificial neural networks: an application to a controlled clinical trial on renal carcinoma

Background

In exploring the time course of a disease to support or generate biological hypotheses, the shape of the hazard function provides relevant information. For long follow-ups the shape of hazard function may be complex, with the presence of multiple peaks. In this paper we present the use of a neural network extension of the piecewise exponential model to study the shape of the hazard function in time in dependence of covariates. The technique is applied to a dataset of 247 renal cell carcinoma patients from a randomized clinical trial.

Results

An interaction effect of treatment with number of metastatic lymph nodes but not with pathologic T-stage is highlighted.

Conclusions

Piecewise Exponential Artificial Neural Networks demonstrate a clinically useful and flexible tool in assessing interaction or time-dependent effects of the prognostic factors on the hazard function.

Cervical Esophageal Cancer Treatment Strategies: A Cohort Study Appraising the Debated Role of Surgery

BACKGROUND

Few studies have examined optimal treatment specifically for cervical esophageal carcinoma. This study evaluated the outcome of three common treatment strategies with a focus on the debated role of surgery.

METHODS

All patients with cervical esophageal cancer treated at a single center were identified and their outcomes analyzed in terms of morbidity, mortality, and recurrence according to the treatment they received, i.e. surgery alone, definitive platinum-based chemoradiation (CRT), or CRT followed by surgery.

RESULTS

The study population included 148 patients with cervical esophageal cancer from a prospective database of 3445 patients. Primary surgery was the treatment of choice for 56 (37.83%) patients, definitive CRT was the treatment of choice for 52 (35.13%) patients, and CRT followed by surgery was the treatment of choice for 40 (27.02%) patients. CRT-treated patients obtained 36.96% complete clinical response, with overall morbidity and mortality rates of 36.95 and 2.17%, respectively. Surgical complete resection was achieved in 71.88% of surgically treated cases, with morbidity and mortality rates of 52.17 and 6.25%, respectively. No significant survival difference existed among the three treatments, but patients who underwent surgery alone had a significantly lower stage of disease (p = 0.031). Compared with patients with complete response after CRT, surgery did not confer any significant survival benefit, and overall 5-year survival was lower than definitive CRT alone. In contrast, surgery improved survival significantly in patients with non-complete response after definitive CRT (p = 0.023).

CONCLUSIONS

Definitive platinum-based CRT should be the treatment of choice for cervical esophageal cancer. Surgery has a role for patients with non-complete response as it adds significant survival benefit, with acceptable morbidity and mortality.

Mid-upper arm circumference, calf circumference and mortality in Chinese long-term care facility residents: a prospective cohort study

OBJECTIVE

To investigate the association between mid-upper arm circumference (MUAC), calf circumference (CC) and all-cause mortality in a Chinese population.

DESIGN

Prospective cohort study.

SETTING

Eight long-term care facilities in central Taiwan.

PARTICIPANTS

A total of 329 residents age 60 years and older (median 79.0 years, range 60-101; 139 men, 190 women) were enrolled.

METHODS

Anthropometrics and metabolic parameters were measured at the time of enrolment to the study. Mean MUAC and CC were 24.2±3.4 cm and 27.5±4.3 cm, respectively. Mortality data were obtained from the Department of Health in Taiwan.

MAIN OUTCOME MEASURE

To identify the association between all-cause mortality and MUAC or CC.

RESULTS

There were 255 deaths during the 7-year follow-up period. After adjusting for age, sex, cigarette smoking, betel nut chewing, alcohol use, Karnofsky Performance Status Scale score, serum albumin level, hypertension and diabetes mellitus, subjects in the highest tertile of MUAC (27.8±2.2 cm) and CC (32.1±2.6 cm) had a significantly lower mortality rate than did subjects in the lowest tertile (MUAC 20.6±1.7 cm; CC 22.8±1.9 cm). The adjusted HR for all-cause mortality in the highest versus lowest MUAC tertile was 0.64 (95% CI 0.45 to 0.90). The adjusted HR for all-cause mortality in the highest versus lowest CC tertile was 0.51 (95% CI 0.35 to 0.74).

CONCLUSIONS

MUAC and CC are negative predictors for all-cause mortality in older Chinese adults living in long-term care facilities. Participants with higher MUAC and CC had lower all-cause mortality.

Aortic valve replacement associated with survival in severe regurgitation and low ejection fraction

OBJECTIVES

Although guidelines support aortic valve replacement (AVR) in patients with severe aortic regurgitation (AR) and left ventricular ejection fraction (LVEF) <50%, severe left ventricular dysfunction (LVEF <35%) is thought to confer high surgical risk. We sought to determine if a survival benefit exists with AVR compared with medical management in this high-risk, relatively rare population.

METHODS

A large institutional echocardiography database was queried to identify patients with severe AR and LVEF <35%. Manual chart review was performed. Due to small sample size and population heterogeneity, corrected group prognosis method was applied, which calculates the adjusted survival curve for each individual using fitted Cox proportional hazard model. Average survival adjusted for comorbidities and age was then calculated using the weighted average of the individual survival curves.

RESULTS

Initially, 2 54 614 echocardiograms were considered, representing 1 45 785 unique patients, of which 40 patients met inclusion criteria. Of those, 18 (45.0%) underwent AVR and 22 (55.0%) were managed medically. Absolute mortality was 27.8% in the AVR group and 91.2% in the medical management group. After multivariate adjustment, end-stage renal disease (HR=17.633, p=0.0335) and peripheral arterial disease (HR=6.050, p=0.0180) were associated with higher mortality. AVR was associated with lower mortality (HR=0.143, p=0.0490). Mean follow-up time of the study cohort was 6.58 years, and mean survival for patients undergoing AVR was 6.31 years.

CONCLUSIONS

Even after adjustment for clinical characteristics and patient age, AVR is associated with higher survival for patients with low LVEF and severe AR. Although treatment selection bias cannot be completely eliminated by this analysis, these results provide some evidence that surgery may be associated with prolonged survival in this high-risk patient group.

Circulating Levels of Inflammatory Proteins and Survival in Patients with Gallbladder Cancer

Although inflammation is central to gallbladder cancer (GBC) development and proliferation, no study has systematically investigated circulating inflammatory proteins and patient survival. We aimed to examine whether the circulating levels of inflammatory proteins is associated with all-cause mortality among such patients. We recruited 134 patients with newly diagnosed with GBC from 1997 to 2001 in a population-based study in Shanghai and an independent set of 35 patients from 2012 to 2013 in Chile. Cox proportional hazards regression models adjusted for covariates were used to evaluate the hazard ratios (HRs) for death by serum levels of 49 inflammatory proteins (quartiles). Of 49 evaluable proteins, eight were significantly associated with overall survival. Seven were associated with a poorer survival, while the highest levels of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) were associated with an increase in survival (HR = 0.26, 95% CI = 0.14, 0.47). No substantial difference in the magnitude of the association was observed between early- and late-stages of GBC. Of seven proteins, five were validated in the patients from Chile. Reducing inflammation and targeting pathways associated with increased survival might improve GBC outcomes. The potential for using a TRAIL-related anticancer drug for GBC treatment merits further investigation.

Survival benefit of glioblastoma patients after FDA approval of temozolomide concomitant with radiation and bevacizumab: A population-based study

Few population-based analyses have investigated survival change in glioblastoma multiforme (GBM) patients treated with concomitant radiotherapy-temozolomide (RT-TMZ) and adjuvant temozolomide (TMZ) and then bevacizumab (BEV) after Food and Drug Administration (FDA) approval, respectively. We aimed to explore the effects on survival with RT-TMZ, adjuvant TMZ and BEV in general GBM population based on the Surveillance, Epidemiology, and End Results (SEER) and Texas Cancer Registry (TCR) databases. A total of 28933 GBM patients from SEER (N = 24578) and TCR (N = 4355) between January 2000 and December 2013 were included. Patients were grouped into three calendar periods based on date of diagnosis: pre-RT-TMZ and pre-BEV (1/2000-2/2005, P1), post-RT-TMZ and pre-BEV (3/2005-4/2009, P2), and post-RT-TMZ and post-BEV (5/2009-12/2013, P3). The association between calendar period of diagnosis and survival was analyzed in SEER and TCR, separately, by the Kaplan-Meier method and Cox proportional hazards model. We found a significant increase in median overall survival (OS) across the three periods in both populations. In multivariate models, the risk of death was significantly reduced during P2 and further decreased in P3, which remained unchanged after stratification. Comparison and validation analysis were performed in the combined dataset, and consistent results were observed. We conclude that the OS of GBM patients in a "real-world" setting has been steadily improved from January 2000 to December 2013, which likely resulted from the administrations of TMZ concomitant with RT and adjuvant TMZ for newly diagnosed GBM and then BEV for recurrent GBM after respective FDA approval.

An application of restricted mean survival time in a competing risks setting: comparing time to ART initiation by injection drug use

Background

Restricted mean survival time (RMST) is an underutilized estimand in time-to-event analyses. Herein, we highlight its strengths by comparing time to (1) all-cause mortality and (2) initiation of antiretroviral therapy (ART) for HIV-infected persons who inject drugs (PWID) and persons who do not inject drugs.

Methods

RMST to death was determined by integrating the Kaplan-Meier survival curve to 5 years of follow-up. To account for the competing risks of death and loss-to-clinic when estimating time to ART, we calculated RMST to ART initiation by estimating the area between the survival curve for ART initiation and the cumulative incidence curve for death or loss-to-clinic. We standardized all curves using inverse probability of exposure weights.

Results

We followed 3044 HIV-positive, ART-naive persons from enrollment into the Johns Hopkins HIV Clinical Cohort from 1996 to 2014. PWID had a − 0.19 year (95% confidence interval (CI): − 0.29, − 0.10) difference in survival over 5 years of follow-up compared to persons who did not inject drugs. There was no difference between the two groups in time not on ART while alive and in clinic (RMST difference = 0.08, 95% CI: -0.10, 0.36).

Conclusions

PWID have similar expected time to ART initiation after properly accounting for their greater risk of death and loss-to-clinic.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0484-z) contains supplementary material, which is available to authorized users.

Impact of hospital volume on racial disparities and outcomes for endometrial cancer

OBJECTIVE

Little is known about the influence of hospital procedural volume on racial disparities for uterine cancer. We examined whether the magnitude of the survival differential between black and white women varied based on hospital procedural volume for endometrial cancer.

METHODS

We utilized the National Cancer Data Base to examine women with endometrial cancer from 1998 to 2012. Annualized hospital procedural volume was calculated and hospitals grouped into volume-based quartiles. Multivariable models were developed to examine differences in two and five-year survival between black and white women across the hospital volume categories. Patients were classified as early or advanced stage and as type I (low grade, endometrioid) or type II (high grade endometrioid, other histologies) cancers.

RESULTS

We identified 243,422 (75.0%) white and 27,764 (8.6%) black women treated at 1059 hospitals. Regardless of hospital volume, black women had decreased survival. For each tumor class, the absolute difference in adjusted two-year survival between black and white women decreased with increasing hospital volume. For example, for women with early-stage, type I tumors, the adjusted two-year survival differential between blacks and whites was -1.4% (95%CI, -2.4 to -0.5%) at low volume centers and decreased to -0.5% (95%CI, -0.9 to 0%) at high-volume hospitals (P<0.0001). For advanced stage, type I tumors, the adjusted survival differential decreased from -12.4% (95%CI, -24.0 to -0.9%) to 1.2% (95%CI, -2.9 to 5.3%) at high volume hospitals (P<0.0001).

CONCLUSION

Black race is an independent predictor of mortality. The impact of race on mortality is mitigated, albeit not eliminated, by increasing hospital volume.

Pomalidomide with Dexamethasone for Treating Relapsed and Refractory Multiple Myeloma Previously Treated with Lenalidomide and Bortezomib: An Evidence Review Group Perspective of an NICE Single Technology Appraisal

The National Institute for Health and Care Excellence (NICE), as part of the institute's single technology appraisal (STA) process, invited the manufacturer of pomalidomide (POM; Imnovid^®, Celgene) to submit evidence regarding the clinical and cost effectiveness of the drug in combination with dexamethasone (POM + LoDEX) for the treatment of relapsed and refractory multiple myeloma (RRMM) after at least two regimens including lenalidomide (LEN) and bortezomib (BOR). Kleijnen Systematic Reviews Ltd (KSR) and Erasmus University Rotterdam were commissioned as the Evidence Review Group (ERG) for this submission. The ERG reviewed the evidence submitted by the manufacturer, validated the manufacturer's decision analytic model, and conducted exploratory analyses in order to assess the robustness and validity of the presented clinical and cost-effectiveness results. This paper describes the company submission, the ERG assessment, and NICE's subsequent decisions. The company conducted a systematic review to identify studies comparing POM with comparators outlined in the NICE scope: panobinostat with bortezomib and dexamethasone (PANO + BOR + DEX), bendamustine with thalidomide and dexamethasone (BTD) and conventional chemotherapy (CC). The main clinical effectiveness evidence was obtained from MM-003, a randomized controlled trial (RCT) comparing POM + LoDEX with high-dose dexamethasone (HiDEX; used as a proxy for CC). Additional data from other studies were also used as nonrandomized observational data sources for the indirect treatment comparison of POM + LoDEX with BTD and PANO + BOR + DEX. Covariate or treatment switching adjustment methods were used for each comparison. The model developed in Microsoft^® Excel 2010 using a semi-Markov partitioned survival structure, submitted in the original submission to NICE for TA338, was adapted for the present assessment of the cost effectiveness of POM + LoDEX. Updated evidence from the clinical-effectiveness part was used for the survival modelling of progression-free survival and overall survival. For POM + LoDEX, the patient access scheme (PAS) discount was applied to the POM price. Three separate comparisons were conducted for each comparator, each comparison using a different dataset and adjustment methods. The ERG identified and corrected some errors, and the corrected incremental cost-effectiveness ratios (ICERs) for POM + LoDEX versus each comparator were presented: approximately £45,000 per quality-adjusted life-year (QALY) gained versus BTD, savings of approximately £143,000 per QALY lost versus PANO + BOR + DEX, and approximately £49,000 per QALY gained versus CC. The ERG also conducted full incremental analyses, which revealed that CC, POM + LoDEX and PANO + BOR + DEX were on the cost-effectiveness frontier. The committee's decision on the technology under analysis deemed that POM + LoDEX should be recommended as an option for treating multiple myeloma in adults at third or subsequent relapse of treatments including both LEN and BOR, contingent on the company providing POM with the discount agreed in the PAS.

Hospital Discharge Database as a Tool to Monitor Incidence, Survival and Burden of Cancer in Adolescents and Young Adults

Aims and Background

Cancer in young patients (15–39 years) is unique for the distribution of types, therapeutic options and clinical evolution. Administrative databases represent well-documented tools in epidemiology, and in oncology they are very important in those realities without cancer registries. Our study aimed to analyze the occurrence, outcomes and burden of cancer in young patients through the analysis of hospital discharge records.

Methods

Hospital discharge databases and civil registries were analyzed through record linkage technique. Annual incidence rate (AIR), standardized incidence rate (SR), overall survival, hospitalization rate, and mean number of hospitalizations were evaluated.

Results

Among 2,330,459 young adults, 1846 new cancer patients had been hospitalized in the analyzed period. The SR was 69.3/100,000/year: 1051, 56.9%, were females (AIR 91.0 and SR 76.0) and 795, 43.1%, were males (AIR 67.6 and SR 62.5). Hematological disease was more frequent in males than females (25.5% vs 14.7%, P <0.0001), whereas solid tumors were more frequent among females (85.3% vs 74.5, P <0.0001). The distribution by diagnostic group showed that among females breast cancer was the most frequent (n = 272, SR 17.2), whereas among males genitourinary tract cancer (n = 245, SR 19.2), especially testicular cancer (n = 187, SR 15.1), was the most frequent. Metastatic disease at diagnosis was already present in 198 patients with a solid cancer (13.3%), whereas 213 (11.5%) developed metastasis in the following years. At 12 months from the diagnosis, 87 of 1488 patients with solid cancers and 35 of 358 patients with hematologic disease failed: overall survival was 94% and 90%, respectively. Patients with a new diagnosis of cancer had produced 6663 hospitalizations, 4640 (69.6%) of which were due to solid tumors, 3992 (59.9%) produced by patients over 29 years old, and 3606 (54.1%) by females. The percentage of day hospital admissions increased proportionally with patient age: 25.7% of all hospitalizations among older adolescents (15–20 years) and 32.9% among young adults of 34–39 years.

Conclusions

Administrative data have clear advantages in terms of availability and large numbers. Comparison of our results with the literature showed that a health care delivery database can provide useful information for clinical-epidemiologic evaluations in oncology as well as for the analysis of health services utilization.

Postdischarge service utilisation and outcomes among Chinese and South Asian psychiatric inpatients in Ontario, Canada: a population-based cohort study

OBJECTIVE

We sought to examine the short-term and long-term impacts of psychiatric hospitalisations among patients of Chinese and South Asian origin.

DESIGN

Retrospective population-based cohort study using linked health administrative data.

SETTING

We examined all adult psychiatric inpatients discharged between 1 April 2006 and 31 March 2014 in Ontario, Canada, who were classified as Chinese, South Asian and all other ethnicities (ie, 'general population') using a validated algorithm. We identified 2552 Chinese, 2439 South Asian and 127 142 general population patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

We examined psychiatric severity measures at admission and discharge and performed multivariable logistic regression analyses to examine 30-day, 180-day and 365-day postdischarge service utilisation and outcomes, comparing each of the ethnic groups with the reference population, after adjustment for age, sex, income, education, marital status, immigration status, community size and discharge diagnosis.

RESULTS

Despite presenting to hospital with greater illness severity, Asian psychiatric inpatients had shorter lengths of hospital stay and greater absolute improvements in mental health and functional status at discharge compared with other inpatients. After hospitalisation, Chinese patients were more likely to visit psychiatrists and South Asian patients were more likely to seek mental healthcare from general practitioners. They were also less likely to have a psychiatric readmission or die 1 year following hospitalisation (adjusted OR_Chinese=0.87; 95% CI 0.79 to 0.97; adjusted OR_{South Asian}=0.82, 95% CI 0.73 to 0.91). Findings were consistent across genders, psychiatric diagnoses and immigrant groups.

CONCLUSION

Once hospitalised, patients of Chinese and South Asian origin fared as well as or better than general population patients at discharge and following discharge, and had a positive trajectory of psychiatric service utilisation.

Temporal Trends in the Use and Comparative Effectiveness of Direct Oral Anticoagulant Agents Versus Warfarin for Nonvalvular Atrial Fibrillation: A Canadian Population-Based Study

BACKGROUND

Direct oral anticoagulants (DOACs) are noninferior to warfarin for stroke prevention in atrial fibrillation (AF). We aimed to determine the population risk of stroke and death in incident AF, stratified by anticoagulation status and type, and the temporal trends of oral anticoagulation practice in the post-DOAC approval period.

METHODS AND RESULTS

We conducted a population-based cohort study of incident nonvalvular AF cases using administrative health data in Alberta, Canada. We used Cox proportional hazards modeling with anticoagulation status as a time-varying exposure and adjusted for age (continuous), sex, congestive heart failure, hypertension, diabetes mellitus, prior transient ischemic attack or ischemic stroke, myocardial infarction, peripheral artery disease, and chronic kidney disease. Primary outcome was the composite of stroke and death. Among 34 965 patients with incident AF (56.0% male, median age 73 years), relative to warfarin, DOAC use was associated with decreased risk of all stroke and death (hazard ratio: 0.90; 95% confidence interval, 0.83-0.97) and decreased hemorrhagic stroke (hazard ratio: 0.60; 95% confidence interval, 0.40-0.91]) but a similar risk of ischemic stroke (hazard ratio: 1.12; 95% confidence interval, 0.94-1.34]). During this time period, DOAC use increased rapidly, surpassing warfarin, but the total oral anticoagulation use in the population remained stable, even in the subgroup with the highest thromboembolic risk.

CONCLUSIONS

In a real-world population-based study of patients with incident AF, anticoagulation with DOACs was associated with decreased risk of stroke and death compared with warfarin. Despite a rapid uptake of DOACs in clinical practice, the total proportion of AF patients on anticoagulation has remained stable, even in high-risk patients.

Differences in Characteristics and Outcomes Between Asian and Non-Asian Patients in the TIAregistry.org

Background and Purpose—

This study provides the contemporary causes and prognosis of transient ischemic attack (TIA) and minor stroke in Asians and the direct comparisons with non-Asians.

Methods—

The TIAregistry.org enrolled 4789 patients (1149 Asians and 3640 non-Asians) with a TIA or minor ischemic stroke within 7 days of onset. Every participating facility had systems dedicated to urgent intervention of TIA/stroke patients by specialists. The primary outcome was a composite of cardiovascular death, nonfatal stroke, and nonfatal acute coronary syndrome.

Results—

Approximately 80% of patients were evaluated within 24 hours of symptom onset. At 1 year, there were no differences in the rates of composite cardiovascular events (6.8% versus 6.0%; P =0.38) and stroke (6.0% versus 4.8%; P =0.11) between Asians and non-Asians. Asians had a lower risk of cerebrovascular disease (stroke or TIA) than non-Asians (adjusted hazard ratio, 0.79; 95% confidence interval, 0.63–0.98; P =0.03); the difference was primarily driven by a lower rate of TIA in Asians (4.2% versus 8.3%; P <0.001). Moderately severe bleeding was more frequent in Asians (0.8% versus 0.3%; P =0.02). In multivariable analysis, multiple acute infarcts ( P =0.005) and alcohol consumption ( P =0.02) were independent predictors of stroke recurrence in Asians, whereas intracranial stenosis ( P <0.001), ABCD 2 score ( P <0.001), atrial fibrillation ( P =0.008), extracranial stenosis ( P =0.03), and previous stroke or TIA ( P =0.03) were independent predictors in non-Asians.

Conclusions—

The short-term stroke risk after a TIA or minor stroke was lower than expected when urgent evidence-based care was delivered, irrespective of race/ethnicity or region. However, the predictors of stroke were different for Asians and non-Asians.

Cigarette Smoking and Pancreatic Cancer Survival

Purpose Cigarette smoking is associated with increased incidence of pancreatic cancer. However, few studies have prospectively evaluated the association of smoking with patient survival. Patients and Methods We analyzed survival by smoking status among 1,037 patients from two large US prospective cohort studies diagnosed from 1986 to 2013. Among 485 patients from four prospective US cohorts, we also evaluated survival by prediagnostic circulating levels of cotinine, a metabolite of nicotine that is proportional to tobacco smoke exposure. On the basis of prediagnosis cotinine levels, we classified patients as nonsmokers (< 3.1 ng/mL), light smokers (3.1-20.9 ng/mL), or heavy smokers (≥ 21.0 ng/mL). We estimated hazard ratios (HRs) for death by using Cox proportional hazards models, with adjustment for age, sex, race/ethnicity, body mass index, diabetes status, diagnosis year, and cancer stage. Results The multivariable-adjusted HR for death was 1.37 (95% CI, 1.11 to 1.69) comparing current smokers with never smokers ( P = .003). A statistically significant negative trend in survival was observed for increasing pack-years of smoking ( P_trend = .008), with HR for death of 1.49 (95% CI, 1.05 to 2.10) for > 60 pack-years of smoking versus never smoking. Survival among former smokers was similar to that for never smokers, regardless of time since quitting. Heavy smokers defined by prediagnostic circulating cotinine levels had a multivariable-adjusted HR for death of 1.76 (95% CI, 1.23 to 2.51) compared with nonsmokers. Among patients with circulating cotinine levels measured within 5 years before diagnosis, heavy smokers had a multivariable-adjusted HR for death of 2.47 (95% CI, 1.24 to 4.92) compared with nonsmokers. Conclusion Cigarette smoking was associated with a reduction in survival among patients with pancreatic cancer.