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Kumar N, Tan JYH, Chen Z, Ravikumar N, Milavec H, Tan JH. Intraoperative cell-salvaged autologous blood transfusion is safe in metastatic spine tumour surgery: early outcomes of prospective clinical study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:2493-2502. [PMID: 37191676 DOI: 10.1007/s00586-023-07768-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 03/30/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE Allogeneic blood transfusion (ABT) is current standard of blood replenishment despite known complications. Salvaged blood transfusion (SBT) addresses majority of such complications. Surgeons remain reluctant to employ SBT in metastatic spine tumour surgery (MSTS), despite ample laboratory evidence. This prompted us to conduct a prospective clinical study to ascertain safety of intraoperative cell salvage (IOCS), in MSTS. METHODS Our prospective study included 73 patients who underwent MSTS from 2014 to 2017. Demographics, tumour histology and burden, clinical findings, modified Tokuhashi score, operative and blood transfusion (BT) details were recorded. Patients were divided based on BT type: no blood transfusion (NBT) and SBT/ABT. Primary outcomes assessed were overall survival (OS), and tumour progression was evaluated using RECIST (v1.1) employing follow-up radiological investigations at 6, 12 and 24 months, classifying patients with non-progressive and progressive disease. RESULTS Seventy-three patients [39:34(M/F)] had mean age of 61 years. Overall median follow-up and survival were 26 and 12 months, respectively. All three groups were comparable for demographics and tumour characteristics. Overall median blood loss was 500 mL, and BT was 1000 mL. Twenty-six (35.6%) patients received SBT, 27 (37.0%) ABT and 20 (27.4%) NBT. Females had lower OS and higher risk of tumour progression. SBT had better OS and reduced risk of tumour progression than ABT group. Total blood loss was not associated with tumour progression. Infective complications other than SSI were significantly (p = 0.027) higher in ABT than NBT/SBT groups. CONCLUSIONS Patients of SBT had OS and tumour progression better than ABT/NBT groups. This is the first prospective study to report of SBT in comparison with control groups in MSTS.
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Affiliation(s)
- Naresh Kumar
- Department of Orthopaedic Surgery, Hand & Reconstructive Microsurgery Cluster, University Orthopaedics, National University Health System (NUHS) - Tower Block, Level 11, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Joel Yong Hao Tan
- Department of Orthopaedic Surgery, Hand & Reconstructive Microsurgery Cluster, University Orthopaedics, National University Health System (NUHS) - Tower Block, Level 11, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Zhaojin Chen
- Investigational Medicine Unit, Center for Translational Medicine, 14 Medical Drive, #07-01, Singapore, 117599, Singapore
| | - Nivetha Ravikumar
- Department of Orthopaedic Surgery, Hand & Reconstructive Microsurgery Cluster, University Orthopaedics, National University Health System (NUHS) - Tower Block, Level 11, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Helena Milavec
- Department of Orthopaedic Surgery, Hand & Reconstructive Microsurgery Cluster, University Orthopaedics, National University Health System (NUHS) - Tower Block, Level 11, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Jiong Hao Tan
- Department of Orthopaedic Surgery, Hand & Reconstructive Microsurgery Cluster, University Orthopaedics, National University Health System (NUHS) - Tower Block, Level 11, 1E Kent Ridge Road, Singapore, 119228, Singapore
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Campbell I, Wetzig N, Ung O, Espinoza D, Farshid G, Collins J, Kollias J, Gebski V, Mister R, Simes RJ, Stockler MR, Gill G. 10-Year axillary recurrence in the RACS SNAC1 randomised trial of sentinel lymph node-based management versus routine axillary lymph node dissection. Breast 2023; 70:70-75. [PMID: 37393644 DOI: 10.1016/j.breast.2023.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/22/2023] [Indexed: 07/04/2023] Open
Abstract
BACKGROUND Sentinel node-based management (SNBM) is the international standard of care for early breast cancer that is clinically node-negative based on randomised trials comparing it with axillary lymph node dissection (ALND) and reporting similar rates of axillary recurrence (AR) without distant disease. We report all ARs, overall survival, and breast cancer-specific survival at 10-years in SNAC1. METHODS 1.088 women with clinically node-negative, unifocal breast cancers 3 cm or less in diameter were randomly assigned to either SNBM with ALND if the sentinel node (SN) was positive, or to SN biopsy followed by ALND regardless of SN involvement. RESULTS First ARs were more frequent in those assigned SNBM rather than ALND (11 events, cumulative risk at 10-years 1·85%, 95% CI 0·95-3.27% versus 2 events, 0·37%, 95% CI 0·08-1·26%; HR 5·47, 95% CI 1·21-24·63; p = 0·013). Disease-free survival, breast cancer-specific survival, and overall survival were similar in those assigned SNBM versus ALND. Lymphovascular invasion was an independent predictor of AR (HR 6·6, 95% CI 2·25-19·36, p < 0·001). CONCLUSION First ARs were more frequent with SNBM than ALND in women with small, unifocal breast cancers when all first axillary events were considered. We recommend that studies of axillary treatment should report all ARs to give an accurate indication of treatment effects. The absolute frequency of AR was low in women meeting our eligibility criteria, and SNBM should remain the treatment of choice in this group. However, for those with higher-risk breast cancers, further study is needed because the estimated risk of AR might alter their choice of axillary surgery.
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Affiliation(s)
- Ian Campbell
- Department of Surgery, University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand; Waikato Hospital, Hamilton, New Zealand.
| | - Neil Wetzig
- Princess Alexandra Hospital, Brisbane, Australia
| | - Owen Ung
- Royal Brisbane and Women's Hospital, Brisbane, Australia; Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Australia
| | - David Espinoza
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Gelareh Farshid
- South Australian Pathology, Royal Adelaide Hospital, Adelaide, Australia
| | - John Collins
- University of Melbourne, Department of Surgery, Royal Melbourne Hospital, Melbourne, Australia
| | - James Kollias
- Department of Surgery, University of Adelaide, Adelaide, Australia; Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Val Gebski
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Rebecca Mister
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - R John Simes
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Martin R Stockler
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Grantley Gill
- Emeritus Professor, University of Adelaide, Adelaide, Australia
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Gebski V, Obermair A, Janda M. Toward Incorporating Health-Related Quality of Life as Coprimary End Points in Clinical Trials: Time to Achieve Clinical Important Differences and QoL Profiles. J Clin Oncol 2022; 40:2378-2388. [PMID: 35576502 DOI: 10.1200/jco.21.02750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Besides morbidity and mortality, quality of life (QoL) is a key outcome of cancer treatments. Trials on the basis of clinical outcomes have expectations that QoL outcomes can be either tolerated or improved. Simultaneously considering QoL and clinical outcomes is challenging with lack of suitable metrics allowing incorporation of QoL as coprimary end points in clinical trial design and utilization of hierarchical hypothesis testing. METHOD We propose combining time to achieving a minimal clinically important difference (MCID) and probabilities of a MCID occurring in each QoL domain to provide QoL metrics analogous to those used for clinical end points. For QoL domains of interest, these yield QoL profiles, time to MCID, and number needed to treat. Incorporation of QoL as coprimary end points in clinical trial designs through hierarchical hypothesis testing can easily be achieved. The noninferiority designed Laparoscopic Approach to Carcinoma of the Endometrium trial, evaluating laparoscopic versus open abdominal surgery for endometrial cancer with Functional Assessment of Cancer Therapy-General QoL domains, is used to illustrate the usefulness of these metrics. RESULTS This analysis revealed that laparoscopic surgery had a significant shorter time to MCID for physical and functional well-being QoL domains (physical mean: 1.5 months, 95% CI, 0.5 to 2.6; P = .002; and functional mean: 1.4 months; 95% CI, 0.4 to 2.4; P = .003) than abdominal surgery, but little difference between the two approaches for psychologic social and emotion well-being. Probability profile plots show a consistent > 2-fold higher chance of attaining a MCID for physical and functional well-being over time for laparoscopic compared with abdominal surgery. CONCLUSION This analysis reinforces the potential value of novel MCID metrics and their usefulness in raising the profile of QoL outcomes to complement clinical end points. The methods will allow health professionals to counsel patients about QoL outcomes and clinical outcomes simultaneously.
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Affiliation(s)
- Val Gebski
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Andreas Obermair
- Queensland Centre for Gynaecological Cancer Research, University of Queensland, Brisbane, Queensland, Australia
| | - Monika Janda
- Centre for Health Services Research, The University of Queensland, Brisbane, Queensland, Australia
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Pathak M, S Deo SNV, Dwivedi SN, Vishnubhatla S, Thakur B. Comparison of hazard models with and without consideration of competing risks to assess the effect of neoadjuvant chemotherapy on locoregional recurrence among breast cancer patients. J Cancer Res Ther 2021; 17:982-987. [PMID: 34528552 DOI: 10.4103/jcrt.jcrt_49_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Context While analyzing locoregional recurrences (LRRs), it is necessary to consider distant metastasis as a competing event. Because, later one is more fatal than LRR. It may change ongoing treatment of breast cancer and may alter the chance of LRR. Although some earlier studies assessed the effect of neoadjuvant chemotherapy (NACT) on LRR, they did not use competing risk regression model for it. Aims To identify the risk factors and predict LRR using competing risk hazard model and to compare them with those using conventional hazard model. Settings and Design This was a retrospective study from a tertiary care cancer hospital in India. Subjects and Methods Data of 2114 breast cancer patients undergoing surgery were used from patient's record files (1993-2014). Statistical Analysis Fine and Gray competing risk regression was used to model time from surgery to LRR, considering distant metastasis and death as the competing events. Further, cause-specific Cox regression was used to model time from surgery to LRR without considering competing risk. Results Greater than ten positive nodes (hazard ratio [HR] [95% confidence interval (CI)]: 2.19 [1.18-4.03]), skin involvement (HR [95% CI]: 2.75 [1.50-5.05]), NACT (HR [95% CI]: 1.90 [1.06-3.40]), invasive tumor in inner quadrant (HR [95% CI]: 1.78 [0.98-3.24]), and postoperative radiotherapy (HR [95% CI]: 0.52 [0.29-0.94]) were found to be significantly associated with LRR. However, conventional survival analysis ignoring competing risk overestimated cumulative incidence function and underestimated survival. Competing risk regression provided relatively more precise CI. Conclusions: Competing risks, if any, need to be incorporated in the survival analysis. NACT was found to be associated with higher risk for LRR, which may be because of administering it mainly to patients with bad prognosis. Conclusions Competing risks, if any, need to be incorporated in the survival analysis. NACT was found to be associated with higher risk for LRR, which may be because of administering it mainly to patients with bad prognosis.
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Affiliation(s)
- Mona Pathak
- Division of Biostatistics, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha; Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Surya Narayana V S Deo
- Department of Surgical Oncology, BRA Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sada Nand Dwivedi
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Bhaskar Thakur
- Division of Biostatistics, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Wang Y, Zhang J, Cai C, Lu W, Tang Y. Semiparametric estimation for proportional hazards mixture cure model allowing non-curable competing risk. J Stat Plan Inference 2021. [DOI: 10.1016/j.jspi.2020.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Honda T, Chen S, Hata J, Yoshida D, Hirakawa Y, Furuta Y, Shibata M, Sakata S, Kitazono T, Ninomiya T. Development and Validation of a Risk Prediction Model for Atherosclerotic Cardiovascular Disease in Japanese Adults: The Hisayama Study. J Atheroscler Thromb 2021; 29:345-361. [PMID: 33487620 PMCID: PMC8894117 DOI: 10.5551/jat.61960] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIM To develop and validate a new risk prediction model for predicting the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) in Japanese adults. METHODS A total of 2,454 participants aged 40-84 years without a history of cardiovascular disease (CVD) were prospectively followed up for 24 years. An incident ASCVD event was defined as the first occurrence of coronary heart disease or atherothrombotic brain infarction. A Cox proportional hazards regression model was used to construct the prediction model. In addition, a simplified scoring system was translated from the developed prediction model. The model performance was evaluated using Harrell's C statistics, a calibration plot with the Greenwood-Nam-D'Agostino test, and a bootstrap validation procedure. RESULTS During a median of a 24-year follow-up, 270 participants experienced the first ASCVD event. The predictors of the ASCVD events in the multivariable Cox model included age, sex, systolic blood pressure, diabetes, serum high-density lipoprotein cholesterol, serum low-density lipoprotein cholesterol, proteinuria, smoking habits, and regular exercise. The developed models exhibited good discrimination with negligible evidence of overfitting (Harrell's C statistics: 0.786 for the multivariable model and 0.789 for the simplified score) and good calibrations (the Greenwood-Nam-D'Agostino test: P=0.29 for the multivariable model, 0.52 for the simplified score). CONCLUSION We constructed a risk prediction model for the development of ASCVD in Japanese adults. This prediction model exhibits great potential as a tool for predicting the risk of ASCVD in clinical practice by enabling the identification of specific risk factors for ASCVD in individual patients.
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Affiliation(s)
- Takanori Honda
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University
| | - Sanmei Chen
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University
| | - Jun Hata
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University.,Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University.,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Daigo Yoshida
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University
| | - Yoichiro Hirakawa
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University.,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Yoshihiko Furuta
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University.,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University.,Department of Medical-Engineering Collaboration for Healthy Longevity, Graduate School of Medical Sciences, Kyushu University
| | - Mao Shibata
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University.,Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University
| | - Satoko Sakata
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University.,Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University.,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Takanari Kitazono
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University.,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Toshiharu Ninomiya
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University.,Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University
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Koo CY, Tai BC, Chan DKH, Tan LL, Tan KK, Lee CH. Chemotherapy and adverse cardiovascular events in colorectal cancer patients undergoing surgical resection. World J Surg Oncol 2021; 19:21. [PMID: 33478503 PMCID: PMC7819286 DOI: 10.1186/s12957-021-02125-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/11/2021] [Indexed: 02/07/2023] Open
Abstract
Abstract Background Colorectal cancer patients undergoing surgical resection are at increased short-term risk of post-operative adverse events. However, specific predictors for long-term major adverse cardiac and cerebrovascular events (MACCE) are unclear. We hypothesised that patients who receive chemotherapy are at higher risk of MACCE than those who did not. Methods In this retrospective study, 412 patients who underwent surgical resection for newly diagnosed colorectal cancer from January 2013 to April 2015 were grouped according to chemotherapy status. MACCE was defined as a composite of cardiovascular death, myocardial infarction, stroke, unplanned revascularisation, hospitalisation for heart failure or angina. Predictors of MACCE were identified using competing risks regression, with non-cardiovascular death a competing risk. Results There were 200 patients in the chemotherapy group and 212 patients in the non-chemotherapy group. The overall prevalence of prior cardiovascular disease was 20.9%. Over a median follow-up duration of 5.1 years from diagnosis, the incidence of MACCE was 13.3%. Diabetes mellitus and prior cardiovascular disease were associated with an increased risk of MACCE (subdistribution hazard ratio, 2.56; 95% CI, 1.48-4.42) and 2.38 (95% CI, 1.36-4.18) respectively. The chemotherapy group was associated with a lower risk of MACCE (subdistribution hazard ratio, 0.37; 95% CI, 0.19-0.75) compared to the non-chemotherapy group. Conclusions Amongst colorectal cancer patients undergoing surgical resection, there was a high incidence of MACCE. Diabetes mellitus and prior cardiovascular disease were associated with an increased risk of MACCE. Chemotherapy was associated with a lower risk of MACCE, but further research is required to clarify this association.
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Affiliation(s)
- Chieh Yang Koo
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore.
| | - Bee-Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Dedrick Kok Hong Chan
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System Singapore, Singapore, Singapore
| | - Li Ling Tan
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Ker Kan Tan
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System Singapore, Singapore, Singapore
| | - Chi-Hang Lee
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
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Extensive peritoneal lavage with saline after curative gastrectomy for gastric cancer (EXPEL): a multicentre randomised controlled trial. Lancet Gastroenterol Hepatol 2020; 6:120-127. [PMID: 33253659 DOI: 10.1016/s2468-1253(20)30315-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/18/2020] [Accepted: 09/22/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Peritoneal recurrence of gastric cancer after curative surgical resection is common and portends a poor prognosis. Early studies suggest that extensive intraoperative peritoneal lavage (EIPL) might reduce the risk of peritoneal recurrence and improve survival. We aimed to evaluate the survival benefit of EIPL in patients with gastric cancer undergoing curative gastrectomy. METHODS In this open-label, phase 3, multicentre randomised trial, patients aged 21-80 years with cT3 or cT4 gastric cancer undergoing curative resection were enrolled at 22 centres from South Korea, China, Japan, Malaysia, Hong Kong, and Singapore. Patients were randomly assigned to receive surgery and EIPL (EIPL group) or surgery alone (standard surgery group) via a web-based programme in random permuted blocks in varying block sizes of four and six, assuming equal allocation between treatment groups. Randomisation was stratified according to study site and the sequence was generated using a computer program and concealed until the interventions were assigned. After surgery in the EIPL group, peritoneal lavage was done with 1 L of warm (42°C) normal 0·9% saline followed by complete aspiration; this procedure was repeated ten times. The primary endpoint was overall survival. All analyses were done assuming intention to treat. This trial is registered with ClinicalTrials.gov, NCT02140034. FINDINGS Between Sept 16, 2012, and Aug 3, 2018, 800 patients were randomly assigned to the EIPL group (n=398) or the standard surgery group (n=402). Two patients in the EIPL group and one in the standard surgery group withdrew from the trial immediately after randomisation and were excluded from the intention-to-treat analysis. At the third interim analysis on Aug 28, 2019, the predictive probability of overall survival being significantly higher in the EIPL group was less than 0·5%; therefore, the trial was terminated on the basis of futility. With a median follow-up of 2·4 years (IQR 1·5-3·0), the two groups were similar in terms of overall survival (hazard ratio 1·09 [95% CI 0·78-1·52; p=0·62). 3-year overall survival was 77·0% (95% CI 71·4-81·6) for the EIPL group and 76·7% (71·0-81·5) for the standard surgery group. 60 adverse events were reported in the EIPL group and 41 were reported in the standard surgery group. The most common adverse events included anastomotic leak (ten [3%] of 346 patients in the EIPL group vs six [2%] of 362 patients in the standard surgery group), bleeding (six [2%] vs six [2%]), intra-abdominal abscess (four [1%] vs five [1%]), superficial wound infection (seven [2%] vs one [<1%]), and abnormal liver function (six [2%] vs one [<1%]). Ten of the reported adverse events (eight in the EIPL group and two in the standard surgery group) resulted in death. INTERPRETATION EIPL and surgery did not have a survival benefit compared with surgery alone and is not recommended for patients undergoing curative gastrectomy for gastric cancer. FUNDING National Medical Research Council, Singapore.
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Yoshida D, Ohara T, Hata J, Shibata M, Hirakawa Y, Honda T, Furuta Y, Oishi E, Sakata S, Kanba S, Kitazono T, Ninomiya T. Lifetime cumulative incidence of dementia in a community-dwelling elderly population in Japan. Neurology 2020; 95:e508-e518. [PMID: 32636320 PMCID: PMC7455343 DOI: 10.1212/wnl.0000000000009917] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 01/09/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To estimate the lifetime cumulative incidence of dementia and its subtypes from a community-dwelling elderly population in Japan. METHODS A total of 1,193 community-dwelling Japanese individuals without dementia, aged 60 years or older, were followed up prospectively for 17 years. The cumulative incidence of dementia was estimated based on a death- and dementia-free survival function and the hazard functions of dementia at each year, which were computed by using a Weibull proportional hazards model. The lifetime risk of dementia was defined as the cumulative incidence of dementia at the point in time when the survival probability of the population was estimated to be less than 0.5%. RESULTS During the follow-up, 350 participants experienced some type of dementia; among them, 191 participants developed Alzheimer disease (AD) and 117 developed vascular dementia (VaD). The lifetime risk of dementia was 55% (95% confidence interval, 49%-60%). Women had an approximately 1.5 times greater lifetime risk of dementia than men (65% [57%-72%] vs 41% [33%-49%]). The lifetime risks of developing AD and VaD were 42% (35%-50%) and 16% (12%-21%) in women vs 20% (7%-34%) and 18% (13%-23%) in men, respectively. CONCLUSION Lifetime risk of all dementia for Japanese elderly was substantial at approximately 50% or higher. This study suggests that the lifetime burden attributable to dementia in contemporary Japanese communities is immense.
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Affiliation(s)
- Daigo Yoshida
- From the Departments of Epidemiology and Public Health (D.Y., J.H., T.H., Y.F., E.O., T.N.), Neuropsychiatry (T.O., S.K.), Center for Cohort Studies (M.S., S.S.), and Medicine and Clinical Science (Y.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoyuki Ohara
- From the Departments of Epidemiology and Public Health (D.Y., J.H., T.H., Y.F., E.O., T.N.), Neuropsychiatry (T.O., S.K.), Center for Cohort Studies (M.S., S.S.), and Medicine and Clinical Science (Y.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun Hata
- From the Departments of Epidemiology and Public Health (D.Y., J.H., T.H., Y.F., E.O., T.N.), Neuropsychiatry (T.O., S.K.), Center for Cohort Studies (M.S., S.S.), and Medicine and Clinical Science (Y.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mao Shibata
- From the Departments of Epidemiology and Public Health (D.Y., J.H., T.H., Y.F., E.O., T.N.), Neuropsychiatry (T.O., S.K.), Center for Cohort Studies (M.S., S.S.), and Medicine and Clinical Science (Y.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoichiro Hirakawa
- From the Departments of Epidemiology and Public Health (D.Y., J.H., T.H., Y.F., E.O., T.N.), Neuropsychiatry (T.O., S.K.), Center for Cohort Studies (M.S., S.S.), and Medicine and Clinical Science (Y.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanori Honda
- From the Departments of Epidemiology and Public Health (D.Y., J.H., T.H., Y.F., E.O., T.N.), Neuropsychiatry (T.O., S.K.), Center for Cohort Studies (M.S., S.S.), and Medicine and Clinical Science (Y.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiko Furuta
- From the Departments of Epidemiology and Public Health (D.Y., J.H., T.H., Y.F., E.O., T.N.), Neuropsychiatry (T.O., S.K.), Center for Cohort Studies (M.S., S.S.), and Medicine and Clinical Science (Y.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Emi Oishi
- From the Departments of Epidemiology and Public Health (D.Y., J.H., T.H., Y.F., E.O., T.N.), Neuropsychiatry (T.O., S.K.), Center for Cohort Studies (M.S., S.S.), and Medicine and Clinical Science (Y.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Satoko Sakata
- From the Departments of Epidemiology and Public Health (D.Y., J.H., T.H., Y.F., E.O., T.N.), Neuropsychiatry (T.O., S.K.), Center for Cohort Studies (M.S., S.S.), and Medicine and Clinical Science (Y.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shigenobu Kanba
- From the Departments of Epidemiology and Public Health (D.Y., J.H., T.H., Y.F., E.O., T.N.), Neuropsychiatry (T.O., S.K.), Center for Cohort Studies (M.S., S.S.), and Medicine and Clinical Science (Y.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- From the Departments of Epidemiology and Public Health (D.Y., J.H., T.H., Y.F., E.O., T.N.), Neuropsychiatry (T.O., S.K.), Center for Cohort Studies (M.S., S.S.), and Medicine and Clinical Science (Y.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshiharu Ninomiya
- From the Departments of Epidemiology and Public Health (D.Y., J.H., T.H., Y.F., E.O., T.N.), Neuropsychiatry (T.O., S.K.), Center for Cohort Studies (M.S., S.S.), and Medicine and Clinical Science (Y.H., T.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Wang Y, Tang Y, Zhang J. Bayesian approach for proportional hazards mixture cure model allowing non-curable competing risk. J STAT COMPUT SIM 2019. [DOI: 10.1080/00949655.2019.1695798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Yijun Wang
- KLATASDS-MOE, School of Statistics, East China Normal University, Shanghai, People's Republic of China
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA
| | - Yincai Tang
- KLATASDS-MOE, School of Statistics, East China Normal University, Shanghai, People's Republic of China
| | - Jiajia Zhang
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA
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11
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Chowdhury RI, Islam MA. Prediction of risks of sequence of events using multistage proportional hazards model: a marginal-conditional modelling approach. STAT METHOD APPL-GER 2019. [DOI: 10.1007/s10260-019-00460-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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12
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Truche AS, Ragey SP, Souweine B, Bailly S, Zafrani L, Bouadma L, Clec'h C, Garrouste-Orgeas M, Lacave G, Schwebel C, Guebre-Egziabher F, Adrie C, Dumenil AS, Zaoui P, Argaud L, Jamali S, Goldran Toledano D, Marcotte G, Timsit JF, Darmon M. ICU survival and need of renal replacement therapy with respect to AKI duration in critically ill patients. Ann Intensive Care 2018; 8:127. [PMID: 30560526 PMCID: PMC6297118 DOI: 10.1186/s13613-018-0467-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 11/30/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Transient and persistent acute kidney injury (AKI) could share similar physiopathological mechanisms. The objective of our study was to assess prognostic impact of AKI duration on ICU mortality. DESIGN Retrospective analysis of a prospective database via cause-specific model, with 28-day ICU mortality as primary end point, considering discharge alive as a competing event and taking into account time-dependent nature of renal recovery. Renal recovery was defined as a decrease of at least one KDIGO class compared to the previous day. SETTING 23 French ICUs. PATIENTS Patients of a French multicentric observational cohort were included if they suffered from AKI at ICU admission between 1996 and 2015. INTERVENTION None. RESULTS A total of 5242 patients were included. Initial severity according to KDIGO creatinine definition was AKI stage 1 for 2458 patients (46.89%), AKI stage 2 for 1181 (22.53%) and AKI stage 3 for 1603 (30.58%). Crude 28-day ICU mortality according to AKI severity was 22.74% (n = 559), 27.69% (n = 327) and 26.26% (n = 421), respectively. Renal recovery was experienced by 3085 patients (58.85%), and its rate was significantly different between AKI severity stages (P < 0.01). Twenty-eight-day ICU mortality was independently lower in patients experiencing renal recovery [CSHR 0.54 (95% CI 0.46-0.63), P < 0.01]. Lastly, RRT requirement was strongly associated with persistent AKI whichever threshold was chosen between day 2 and 7 to delineate transient from persistent AKI. CONCLUSIONS Short-term renal recovery, according to several definitions, was independently associated with higher mortality and RRT requirement. Moreover, distinction between transient and persistent AKI is consequently a clinically relevant surrogate outcome variable for diagnostic testing in critically ill patients.
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Affiliation(s)
- A S Truche
- UMR 1137 - IAME Team 5 - DeSCID : Decision SCiences in Infectious Diseases, Control and Care, Inserm/Paris Diderot University, Sorbonne Paris Cité, Paris, France
- Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France
- Nephrology Dialysis Renal Transplantation, Grenoble University Hospital, La Tronche, France
| | - S Perinel Ragey
- Medical Intensive Care Unit, Croix Rousse Hospital, Lyon University Hospital, Lyon, France
| | - B Souweine
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - S Bailly
- UMR 1137 - IAME Team 5 - DeSCID : Decision SCiences in Infectious Diseases, Control and Care, Inserm/Paris Diderot University, Sorbonne Paris Cité, Paris, France
- Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France
| | - L Zafrani
- Medical Intensive Care Unit, AP-HP, Saint Louis Hospital, Paris, France
- Medicine University, Paris 7 University, Paris, France
| | - L Bouadma
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, 75018, Paris, France
| | - C Clec'h
- Intensive Care Unit, AP-HP, Avicenne Hospital, Paris, France
- Medicine University, Paris 13 University, Bobigny, France
| | - M Garrouste-Orgeas
- Intensive Care Unit, Saint Joseph Hospital Network, Paris, France
- Medicine University, Paris Descartes University, Sorbonne Cite, Paris, France
| | - G Lacave
- Medical Intensive Care Unit, André Mignot Hospital, Versailles, France
| | - C Schwebel
- Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France
| | - F Guebre-Egziabher
- Nephrology Dialysis Renal Transplantation, Grenoble University Hospital, La Tronche, France
| | - C Adrie
- Physiology Department, Cochin University Hospital, Assistance Publique, Hôpitaux de Paris (AP-HP), Paris Descartes University des, Sorbonne Cite, Paris, France
| | - A S Dumenil
- Medical-Surgical Intensive Care Unit, AP-HP, Antoine Béclère University Hospital, Clamart, France
| | - Ph Zaoui
- Nephrology Dialysis Renal Transplantation, Grenoble University Hospital, La Tronche, France
| | - L Argaud
- Medical Intensive Care Unit, Edouard Herriot University Hospital, Lyon, France
| | - S Jamali
- Critical Care Medicine Unit, Dourdan Hospital, Dourdan, France
| | | | - G Marcotte
- Surgical ICU, Edouard Herriot University Hospital, Lyon, France
| | - J F Timsit
- UMR 1137 - IAME Team 5 - DeSCID : Decision SCiences in Infectious Diseases, Control and Care, Inserm/Paris Diderot University, Sorbonne Paris Cité, Paris, France
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, 75018, Paris, France
| | - M Darmon
- Medical Intensive Care Unit, AP-HP, Saint Louis Hospital, Paris, France.
- Medicine University, Paris 7 University, Paris, France.
- ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Paris, France.
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Focus on an infrequently used quantity in the context of competing risks: The conditional probability function. Comput Biol Med 2018; 101:70-81. [PMID: 30103091 DOI: 10.1016/j.compbiomed.2018.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/02/2018] [Accepted: 08/02/2018] [Indexed: 11/24/2022]
Abstract
In clinical studies of hematologic and oncologic diseases, the outcomes of interest are generally composite time to event endpoints which are usually defined by occurrence of different event types. Nonetheless, clinicians are interested in studying only one event type, which leads to a competing risks situation. In this context, Pepe and Mori presented a quantity directly derived from the cumulative incidence: the conditional probability. This function defines the probability that a given event occurs, conditionally on not having had a competing event by that time. The objective of this paper is to present this conditional cumulative incidence function and to compare its use to the cumulative incidence in different data sets. Different scenarios highlight the importance of the competing event on the interpretation of the conditional probability. Conditional probability needs to be interpreted jointly with the cumulative incidence. This quantity can be of interest especially when the risk of the competing event is large, strongly precludes the risk of the event of interest and provides useful additional information.
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14
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Hamada T, Nakai Y, Isayama H. TOKYO criteria: Standardized reporting system for endoscopic biliary stent placement. GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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15
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Bellach A, Kosorok MR, Rüschendorf L, Fine JP. Weighted NPMLE for the Subdistribution of a Competing Risk. J Am Stat Assoc 2018; 114:259-270. [PMID: 31073256 DOI: 10.1080/01621459.2017.1401540] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Direct regression modeling of the subdistribution has become popular for analyzing data with multiple, competing event types. All general approaches so far are based on non-likelihood based procedures and target covariate effects on the subdistribution. We introduce a novel weighted likelihood function that allows for a direct extension of the Fine-Gray model to a broad class of semiparametric regression models. The model accommodates time-dependent covariate effects on the subdistribution hazard. To motivate the proposed likelihood method, we derive standard nonparametric estimators and discuss a new interpretation based on pseudo risk sets. We establish consistency and asymptotic normality of the estimators and propose a sandwich estimator of the variance. In comprehensive simulation studies we demonstrate the solid performance of the weighted NPMLE in the presence of independent right censoring. We provide an application to a very large bone marrow transplant dataset, thereby illustrating its practical utility.
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Affiliation(s)
- Anna Bellach
- Department of Biostatistics at University of Copenhagen
| | - Michael R Kosorok
- Department of Biostatistics and Department of Statistics and Operations Research at University of North Carolina at Chapel Hill. These authors shared seniorauthorship
| | - Ludger Rüschendorf
- Department of Mathematics at Albert Ludwigs University of Freiburg im Breisgau
| | - Jason P Fine
- Department of Biostatistics and Department of Statistics and Operations Research at University of North Carolina at Chapel Hill. These authors shared seniorauthorship
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16
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Lacny S, Wilson T, Clement F, Roberts DJ, Faris P, Ghali WA, Marshall DA. Kaplan–Meier survival analysis overestimates cumulative incidence of health-related events in competing risk settings: a meta-analysis. J Clin Epidemiol 2018; 93:25-35. [DOI: 10.1016/j.jclinepi.2017.10.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 08/15/2017] [Accepted: 10/10/2017] [Indexed: 02/03/2023]
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17
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Li Z, Dong H, Li M, Wu Y, Liu Y, Zhao Y, Chen X, Ma M. Honokiol induces autophagy and apoptosis of osteosarcoma through PI3K/Akt/mTOR signaling pathway. Mol Med Rep 2017; 17:2719-2723. [PMID: 29207060 DOI: 10.3892/mmr.2017.8123] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 06/08/2017] [Indexed: 11/05/2022] Open
Abstract
Honokiol is the main active constituent of Magnolia officinalis. With effective and long‑term pharmacological functions of being antibacterial, anti‑oxidative, anti‑inflammatory, antitumor, anti‑spasmic, anti‑anxiety and anti‑viral, Honokiol is clinically used in the treatment of acute enteritis and chronic gastritis. The aim of the present study was to observe the possible anti‑effects of honokiol on autophagy and apoptosis of osteosarcoma, and to investigate the role of the PI3K/Akt/mTOR signaling pathway in its anticancer effects. MTT assay was used to evaluate cell proliferation and Annexin V‑fluorescein isothiocyanate/propidium iodide staining flow cytometry was used to analyze the apoptotic rate. The authors identified that honokiol could inhibit cell proliferation and induce the apoptotic rate of osteosarcoma cells. The expression level of Bcl‑2‑like protein 4, caspase‑3 and p53 protein expression were induced and cyclin D1 protein expression was suppressed in osteosarcoma cells by honokiol. Autophagy‑associated LC3II protein expression level was promoted, and PI3K, p‑Akt and p‑mTOR protein expression level was suppressed in osteosarcoma cells by honokiol. The present study demonstrated, to the best of the authors' knowledge, for the first time that honokiol induces autophagy and apoptosis of osteosarcoma cells through the PI3K/Akt/mTOR signaling pathway.
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Affiliation(s)
- Zhiquan Li
- PLA Institute of Orthopedics and Traumatology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Hui Dong
- Department of Orthopedics, The 474th Hospital of PLA, Urumqi, Xinjiang 830013, P.R. China
| | - Mo Li
- PLA Institute of Orthopedics and Traumatology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Yaoping Wu
- PLA Institute of Orthopedics and Traumatology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Yanwu Liu
- PLA Institute of Orthopedics and Traumatology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Yinan Zhao
- PLA Institute of Orthopedics and Traumatology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Xiaochao Chen
- PLA Institute of Orthopedics and Traumatology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Minliang Ma
- PLA Institute of Orthopedics and Traumatology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
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18
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Eichenauer DA, Becker I, Monsef I, Chadwick N, de Sanctis V, Federico M, Fortpied C, Gianni AM, Henry-Amar M, Hoskin P, Johnson P, Luminari S, Bellei M, Pulsoni A, Sydes MR, Valagussa P, Viviani S, Engert A, Franklin J. Secondary malignant neoplasms, progression-free survival and overall survival in patients treated for Hodgkin lymphoma: a systematic review and meta-analysis of randomized clinical trials. Haematologica 2017; 102:1748-1757. [PMID: 28912173 PMCID: PMC5622859 DOI: 10.3324/haematol.2017.167478] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 07/19/2017] [Indexed: 11/29/2022] Open
Abstract
Treatment intensification to maximize disease control and reduced intensity approaches to minimize the risk of late sequelae have been evaluated in newly diagnosed Hodgkin lymphoma. The influence of these interventions on the risk of secondary malignant neoplasms, progression-free survival and overall survival is reported in the meta-analysis herein, based on individual patient data from 9498 patients treated within 16 randomized controlled trials for newly diagnosed Hodgkin lymphoma between 1984 and 2007. Secondary malignant neoplasms were meta-analyzed using Peto’s method as time-to-event outcomes. For progression-free and overall survival, hazard ratios derived from each trial using Cox regression were combined by inverse-variance weighting. Five study questions (combined-modality treatment vs. chemotherapy alone; more extended vs. involved-field radiotherapy; radiation at higher doses vs. radiation at 20 Gy; more vs. fewer cycles of the same chemotherapy protocol; standard-dose chemotherapy vs. intensified chemotherapy) were investigated. After a median follow-up of 7.4 years, dose-intensified chemotherapy resulted in better progression-free survival rates (P=0.007) as compared with standard-dose chemotherapy, but was associated with an increased risk of therapy-related acute myeloid leukemia/myelodysplastic syndromes (P=0.0028). No progression-free or overall survival differences were observed between combined-modality treatment and chemotherapy alone, but more secondary malignant neoplasms were seen after combined-modality treatment (P=0.010). For the remaining three study questions, outcomes and secondary malignancy rates did not differ significantly between treatment strategies. The results of this meta-analysis help to weigh up efficacy and secondary malignancy risk for the choice of first-line treatment for Hodgkin lymphoma patients. However, final conclusions regarding secondary solid tumors require longer follow-up.
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Affiliation(s)
- Dennis A Eichenauer
- First Department of Internal Medicine and German Hodgkin Study Group (GHSG), University Hospital Cologne, Germany
| | - Ingrid Becker
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Germany
| | - Ina Monsef
- Cochrane Haematological Malignancies Group, First Department of Internal Medicine, University Hospital Cologne, Germany
| | | | | | | | - Catherine Fortpied
- European Organisation of Research and Treatment of Cancer (EORTC), Brussels, Belgium
| | | | - Michel Henry-Amar
- Centre de Traitement des Données du Cancéropôle Nord-Ouest, Centre François Baclesse, Caen, France
| | | | - Peter Johnson
- Cancer Research UK Centre, University of Southampton, UK
| | | | - Monica Bellei
- University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandro Pulsoni
- Cellular Biotechnology and Hematology Department, University "La Sapienza", Rome, Italy
| | - Matthew R Sydes
- Medical Research Council (MRC), Clinical Trials Unit at University College London (UCL), UK
| | | | | | - Andreas Engert
- First Department of Internal Medicine and German Hodgkin Study Group (GHSG), University Hospital Cologne, Germany
| | - Jeremy Franklin
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Germany
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Franklin J, Eichenauer DA, Becker I, Monsef I, Engert A. Optimisation of chemotherapy and radiotherapy for untreated Hodgkin lymphoma patients with respect to second malignant neoplasms, overall and progression-free survival: individual participant data analysis. Cochrane Database Syst Rev 2017; 9:CD008814. [PMID: 28901021 PMCID: PMC6483617 DOI: 10.1002/14651858.cd008814.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Efficacy and the risk of severe late effects have to be well-balanced in treatment of Hodgkin lymphoma (HL). Late adverse effects include secondary malignancies which often have a poor prognosis. To synthesise evidence on the risk of secondary malignancies after current treatment approaches comprising chemotherapy and/or radiotherapy, we performed a meta-analysis based on individual patient data (IPD) from patients treated for newly diagnosed HL. OBJECTIVES We investigated several questions concerning possible changes in the risk of secondary malignancies when modifying chemotherapy or radiotherapy (omission of radiotherapy, reduction of the radiation field, reduction of the radiation dose, use of fewer chemotherapy cycles, intensification of chemotherapy). We also analysed whether these modifications affect progression-free survival (PFS) and overall survival (OS). SEARCH METHODS We searched MEDLINE and Cochrane CENTRAL trials databases comprehensively in June 2010 for all randomised trials in HL since 1984. Key international trials registries were also searched. The search was updated in March 2015 without collecting further IPD (one further eligible study found) and again in July 2017 (no further eligible studies). SELECTION CRITERIA We included randomised controlled trials (RCTs) for untreated HL patients which enrolled at least 50 patients per arm, completed recruitment by 2007 and performed a treatment comparison relevant to our objectives. DATA COLLECTION AND ANALYSIS Study groups submitted IPD, including age, sex, stage and the outcomes secondary malignant neoplasm (SMN), OS and PFS as time-to-event data. We meta-analysed these data using Petos method (SMN) and Cox regression with inverse-variance pooling (OS, PFS) for each of the five study questions, and performed subgroup and sensitivity analyses to assess the applicability and robustness of the results. MAIN RESULTS We identified 21 eligible trials and obtained IPD for 16. For four studies no data were supplied despite repeated efforts, while one study was only identified in 2015 and IPD were not sought. For each study question, between three and six trials with between 1101 and 2996 participants in total and median follow-up between 6.7 and 10.8 years were analysed. All participants were adults and mainly under 60 years. Risk of bias was assessed as low for the majority of studies and outcomes. Chemotherapy alone versus same chemotherapy plus radiotherapy. Omitting additional radiotherapy probably reduces secondary malignancy incidence (Peto odds ratio (OR) 0.43, 95% confidence interval (CI) 0.23 to 0.82, low quality of evidence), corresponding to an estimated reduction of eight-year SMN risk from 8% to 4%. This decrease was particularly true for secondary acute leukemias. However, we had insufficient evidence to determine whether OS rates differ between patients treated with chemotherapy alone versus combined-modality (hazard ratio (HR) 0.71, 95% CI 0.46 to 1.11, moderate quality of evidence). There was a slightly higher rate of PFS with combined modality, but our confidence in the results was limited by high levels of statistical heterogeneity between studies (HR 1.31, 95% CI 0.99 to 1.73, moderate quality of evidence). Chemotherapy plus involved-field radiation versus same chemotherapy plus extended-field radiation (early stages) . There is insufficient evidence to determine whether smaller radiation field reduces SMN risk (Peto OR 0.86, 95% CI 0.64 to 1.16, low quality of evidence), OS (HR 0.89, 95% C: 0.70 to 1.12, high quality of evidence) or PFS (HR 0.99, 95% CI 0.81 to 1.21, high quality of evidence). Chemotherapy plus lower-dose radiation versus same chemotherapy plus higher-dose radiation (early stages). There is insufficient evidence to determine the effect of lower-radiation dose on SMN risk (Peto OR 1.03, 95% CI 0.71 to 1.50, low quality of evidence), OS (HR 0.91, 95% CI 0.65 to 1.28, high quality of evidence) or PFS (HR 1.20, 95% CI 0.97 to 1.48, high quality of evidence). Fewer versus more courses of chemotherapy (each with or without radiotherapy; early stages). Fewer chemotherapy courses probably has little or no effect on SMN risk (Peto OR 1.10, 95% CI 0.74 to 1.62), OS (HR 0.99, 95% CI 0.73 to1.34) or PFS (HR 1.15, 95% CI 0.91 to 1.45).Outcomes had a moderate (SMN) or high (OS, PFS) quality of evidence. Dose-intensified versus ABVD-like chemotherapy (with or without radiotherapy in each case). In the mainly advanced-stage patients who were treated with intensified chemotherapy, the rate of secondary malignancies was low. There was insufficient evidence to determine the effect of chemotherapy intensification (Peto OR 1.37, CI 0.89 to 2.10, low quality of evidence). The rate of secondary acute leukemias (and for younger patients, all secondary malignancies) was probably higher than among those who had treatment with standard-dose ABVD-like protocols. In contrast, the intensified chemotherapy protocols probably improved PFS (eight-year PFS 75% versus 69% for ABVD-like treatment, HR 0.82, 95% CI 0.7 to 0.95, moderate quality of evidence). Evidence suggesting improved survival with intensified chemotherapy was not conclusive (HR: 0.85, CI 0.70 to 1.04), although escalated-dose BEACOPP appeared to lengthen survival compared to ABVD-like chemotherapy (HR 0.58, 95% CI 0.43 to 0.79, moderate quality of evidence).Generally, we could draw valid conclusions only in terms of secondary haematological malignancies, which usually occur less than 10 years after initial treatment, while follow-up within the present analysis was too short to record all solid tumours. AUTHORS' CONCLUSIONS The risk of secondary acute myeloid leukaemia and myelodysplastic syndrome (AML/MDS) is increased but efficacy is improved among patients treated with intensified chemotherapy protocols. Treatment decisions must be tailored for individual patients. Consolidating radiotherapy is associated with an increased rate of secondary malignancies; therefore it appears important to define which patients can safely be treated without radiotherapy after chemotherapy, both for early and advanced stages. For early stages, treatment optimisation methods such as use of fewer chemotherapy cycles and reduced field or reduced-dose radiotherapy did not appear to markedly affect efficacy or secondary malignancy risk. Due to the limited amount of long-term follow-up in this meta-analysis, further long-term investigations of late events are needed, particularly with respect to secondary solid tumours. Since many older studies have been included, possible improvement of radiotherapy techniques must be considered when interpreting these results.
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Affiliation(s)
- Jeremy Franklin
- University Hospital of CologneInstitute of Medical Statistics, Informatics and EpidemiologyKerpener Str. 62CologneGermany50937
| | - Dennis A. Eichenauer
- University Hospital of CologneDepartment I of Internal Medicine, Center of Integrated Oncology Köln BonnCologneGermany50924
| | - Ingrid Becker
- University Hospital of CologneInstitute of Medical Statistics, Informatics and EpidemiologyKerpener Str. 62CologneGermany50937
| | - Ina Monsef
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50924
| | - Andreas Engert
- University Hospital of CologneDepartment I of Internal MedicineKerpener Str. 62CologneGermany50924
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Sasahira N, Hamada T, Togawa O, Yamamoto R, Iwai T, Tamada K, Kawaguchi Y, Shimura K, Koike T, Yoshida Y, Sugimori K, Ryozawa S, Kakimoto T, Nishikawa K, Kitamura K, Imamura T, Mizuide M, Toda N, Maetani I, Sakai Y, Itoi T, Nagahama M, Nakai Y, Isayama H. Multicenter study of endoscopic preoperative biliary drainage for malignant distal biliary obstruction. World J Gastroenterol 2016; 22:3793-3802. [PMID: 27076764 PMCID: PMC4814742 DOI: 10.3748/wjg.v22.i14.3793] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/03/2016] [Accepted: 01/30/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.
METHODS: Multicenter retrospective study was conducted in patients who underwent plastic stent (PS) or nasobiliary catheter (NBC) placement for resectable malignant distal biliary obstruction followed by surgery between January 2010 and March 2012. Procedure-related adverse events, stent/catheter dysfunction (occlusion or migration of PS/NBC, development of cholangitis, or other conditions that required repeat endoscopic biliary intervention), and jaundice resolution (bilirubin level < 3.0 mg/dL) were evaluated. Cumulative incidence of jaundice resolution and dysfunction of PS/NBC were estimated using competing risk analysis. Patient characteristics and preoperative biliary drainage were also evaluated for association with the time to jaundice resolution and PS/NBC dysfunction using competing risk regression analysis.
RESULTS: In total, 419 patients were included in the study (PS, 253 and NBC, 166). Primary cancers included pancreatic cancer in 194 patients (46%), bile duct cancer in 172 (41%), gallbladder cancer in three (1%), and ampullary cancer in 50 (12%). The median serum total bilirubin was 7.8 mg/dL and 324 patients (77%) had ≥ 3.0 mg/dL. During the median time to surgery of 29 d [interquartile range (IQR), 30-39 d]. PS/NBC dysfunction rate was 35% for PS and 18% for NBC [Subdistribution hazard ratio (SHR) = 4.76; 95%CI: 2.44-10.0, P < 0.001]; the pig-tailed tip was a risk factor for PS dysfunction. Jaundice resolution was achieved in 85% of patients and did not depend on the drainage method (PS or NBC).
CONCLUSION: PS has insufficient patency for preoperative biliary drainage. Given the drawbacks of external drainage via NBC, an alternative method of internal drainage should be explored.
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Tai BC, Chen ZJ, Machin D. Estimating sample size in the presence of competing risks – Cause-specific hazard or cumulative incidence approach? Stat Methods Med Res 2015; 27:114-125. [DOI: 10.1177/0962280215623107] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In designing randomised clinical trials involving competing risks endpoints, it is important to consider competing events to ensure appropriate determination of sample size. We conduct a simulation study to compare sample sizes obtained from the cause-specific hazard and cumulative incidence (CMI) approaches, by first assuming exponential event times. As the proportional subdistribution hazard assumption does not hold for the CMI exponential (CMIExponential) model, we further investigate the impact of violation of such an assumption by comparing the results obtained from the CMI exponential model with those of a CMI model assuming a Gompertz distribution (CMIGompertz) where the proportional assumption is tenable. The simulation suggests that the CMIExponential approach requires a considerably larger sample size when treatment reduces the hazards of both the main event, A, and the competing risk, B. When treatment has a beneficial effect on A but no effect on B, the sample sizes required by both methods are largely similar, especially for large reduction in the main risk. If treatment has a protective effect on A but adversely affects B, then the sample size required by CMIExponential is notably smaller than cause-specific hazard for small to moderate reduction in the main risk. Further, a smaller sample size is required for CMIGompertz as compared with CMIExponential. The choice between a cause-specific hazard or CMI model in competing risks outcomes has implications on the study design. This should be made on the basis of the clinical question of interest and the validity of the associated model assumption.
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Affiliation(s)
- BC Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - ZJ Chen
- Investigational Medicine Unit, National University Health System, Singapore
| | - D Machin
- Medical Statistics Unit, School of Health and Related Sciences, University of Sheffield, UK
- Department of Cancer Studies and Molecular Medicine, University of Leicester, UK
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Lim R, Chen C, Naidoo N, Gay G, Tang W, Seah D, Chen R, Tan N, Lee J, Tai E, Chia K, Lim W. Anthropometrics indices of obesity, and all-cause and cardiovascular disease-related mortality, in an Asian cohort with type 2 diabetes mellitus. DIABETES & METABOLISM 2015; 41:291-300. [DOI: 10.1016/j.diabet.2014.12.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Revised: 12/02/2014] [Accepted: 12/07/2014] [Indexed: 10/24/2022]
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Cabarrou B, Jouin A, Boher JM, Kramar A, Filleron T. Assessment of health status over time by Prevalence and Weighted Prevalence functions: Interface in R. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2015; 118:298-308. [PMID: 25622568 DOI: 10.1016/j.cmpb.2014.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/10/2014] [Accepted: 12/30/2014] [Indexed: 06/04/2023]
Abstract
The importance of evaluating complications and toxicity during and following treatment has been stressed in many publications. In most studies, these endpoints are presented descriptively and summarized by numbers and percentages but descriptive methods are rarely sufficient to evaluate treatment-related complications. Pepe and Lancar developed Prevalence and Weighted Prevalence functions which take into account the duration and the severity of complication unlike conventional methods of survival analysis or competing risks which are limited to the time to first event. The purpose of this paper is to describe features and use of two R functions, main.preval.func and main.wpreval.func, which were designed for the analysis of survival adjusted for quality of life. These functions compute descriptive statistics, survival and competing risks analysis and especially Prevalence and Weighted Prevalence estimations with confidence intervals and associated test statistics. The use of these functions is illustrated by several examples.
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Affiliation(s)
- B Cabarrou
- Institut Claudius Regaud, IUCT-O, Bureau des Essais Cliniques, Cellule Biostatistique, Toulouse F-31059, France
| | - A Jouin
- Centre Oscar Lambret, Lille, France
| | - J M Boher
- Institut Paoli Calmettes, Marseille, France
| | - A Kramar
- Centre Oscar Lambret, Lille, France
| | - T Filleron
- Institut Claudius Regaud, IUCT-O, Bureau des Essais Cliniques, Cellule Biostatistique, Toulouse F-31059, France.
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Risk factors for hospital and long-term mortality of critically ill elderly patients admitted to an intensive care unit. BIOMED RESEARCH INTERNATIONAL 2014; 2014:960575. [PMID: 25580439 PMCID: PMC4280808 DOI: 10.1155/2014/960575] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 09/26/2014] [Indexed: 11/17/2022]
Abstract
Background. Data on long-term outcomes of elderly (≥65 years) patients in ICU are sparse. Materials and Methods. Adult patients (n = 1563, 45.4% elderly) admitted over 28 months were analyzed by competing risks regression model to determine independent factors related to in-hospital and long-term mortality. Results. 414 (26.5%) and 337 (21.6%) patients died in-hospital and during the 52 months following discharge, respectively; the elderly group had higher mortality during both periods. After discharge, elderly patients had 2.3 times higher mortality compared to the general population of the same age-group. In-hospital mortality was independently associated with mechanical ventilation (subdistribution hazard ratio (SHR) 2.74), vasopressors (SHR 2.56), neurological disease (SHR 1.77), and Mortality Prediction Model II score (SHR 1.01) regardless of age and with malignancy (SHR, hematological 3.65, nonhematological 3.4) and prior renal replacement therapy (RRT, SHR 2.21) only in the elderly. Long-term mortality was associated with low hemoglobin concentration (SHR 0.94), airway disease (SHR 2.23), and malignancy (SHR hematological 1.11, nonhematological 2.31) regardless of age and with comorbidities especially among the nonelderly. Conclusions. Following discharge, elderly ICU patients have higher mortality compared to the nonelderly and general population. In the elderly group, prior RRT and malignancy contribute additionally to in-hospital mortality risk. In the long-term, comorbidities (age-related), anemia, airway disease, and malignancy were significantly associated with mortality.
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Franklin JM, Gebski V, Poston GJ, Sharma RA. Clinical trials of interventional oncology—moving from efficacy to outcomes. Nat Rev Clin Oncol 2014; 12:93-104. [DOI: 10.1038/nrclinonc.2014.199] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Dorsey S, Pullmann MD, Berliner L, Koschmann E, McKay M, Deblinger E. Engaging foster parents in treatment: a randomized trial of supplementing trauma-focused cognitive behavioral therapy with evidence-based engagement strategies. CHILD ABUSE & NEGLECT 2014; 38:1508-20. [PMID: 24791605 PMCID: PMC4160402 DOI: 10.1016/j.chiabu.2014.03.020] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 03/25/2014] [Accepted: 03/29/2014] [Indexed: 05/03/2023]
Abstract
The goal of this study was to examine the impact of supplementing Trauma-focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al., 2006) with evidence-based engagement strategies on foster parent and foster youth engagement in treatment, given challenges engaging foster parents in treatment. A randomized controlled trial of TF-CBT standard delivery compared to TF-CBT plus evidence-based engagement strategies was conducted with 47 children and adolescents in foster care and one of their foster parents. Attendance, engagement, and clinical outcomes were assessed 1 month into treatment, end of treatment, and 3 months post-treatment. Youth and foster parents who received TF-CBT plus evidence-based engagement strategies were more likely to be retained in treatment through four sessions and were less likely to drop out of treatment prematurely. The engagement strategies did not appear to have an effect on the number of canceled or no-show sessions or on treatment satisfaction. Clinical outcomes did not differ by study condition, but exploratory analyses suggest that youth had significant improvements with treatment. Strategies that specifically target engagement may hold promise for increasing access to evidence-based treatments and for increasing likelihood of treatment completion.
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Affiliation(s)
- Shannon Dorsey
- Department of Psychology, University of Washington, 335 Guthrie Hall, Seattle, WA 98195 USA
| | - Michael D. Pullmann
- Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 2815
| | - Lucy Berliner
- Eastlake Avenue East, Suite 200, Seattle, WA 98102 USA, Harborview Center for Sexual Assault and Traumatic Stress, 401 Broadway, Suite 2027, Seattle, WA 98122 USA
| | - Elizabeth Koschmann
- Department of Psychiatry, University of Michigan Medical School, Rachel Upjohn Building, 4250 Plymouth Rd, Ann Arbor, MI 48108 USA
| | - Mary McKay
- Silver School of Social Work, New York University, 1 Washington Square North, Room 205, New York, NY 10003 USA
| | - Esther Deblinger
- Rowan University, School of Osteopathic Medicine, 42 E. Laurel Road, Stratford, NJ 08084 USA
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Hamada T, Nakai Y, Isayama H, Togawa O, Kogure H, Kawakubo K, Tsujino T, Sasahira N, Hirano K, Yamamoto N, Ito Y, Sasaki T, Mizuno S, Toda N, Tada M, Koike K. Estimation and comparison of cumulative incidences of biliary self-expandable metallic stent dysfunction accounting for competing risks. Dig Endosc 2014; 26:270-5. [PMID: 23650933 DOI: 10.1111/den.12120] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Accepted: 03/22/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Self-expandable metallic stent (SEMS) placement is widely carried out for distal malignant biliary obstruction, and survival analysis is used to evaluate the cumulative incidences of SEMS dysfunction (e.g. the Kaplan-Meier [KM] method and the log-rank test). However, these statistical methods might be inappropriate in the presence of 'competing risks' (here, death without SEMS dysfunction), which affects the probability of experiencing the event of interest (SEMS dysfunction); that is, SEMS dysfunction can no longer be observed after death. A competing risk analysis has rarely been done in studies on SEMS. PATIENTS AND METHODS We introduced the concept of a competing risk analysis and illustrated its impact on the evaluation of SEMS outcomes using hypothetical and actual data. Our illustrative study included 476 consecutive patients who underwent SEMS placement for unresectable distal malignant biliary obstruction. RESULTS A significant difference between cumulative incidences of SEMS dysfunction in male and female patients via theKM method (P = 0.044 by the log-rank test) disappeared after applying a competing risk analysis (P = 0.115 by Gray's test). In contrast, although cumulative incidences of SEMS dysfunction via the KM method were similar with and without chemotherapy (P = 0.647 by the log-rank test), cumulative incidence of SEMS dysfunction in the non-chemotherapy group was shown to be significantly lower (P = 0.031 by Gray's test) in a competing risk analysis. CONCLUSION Death as a competing risk event needs to be appropriately considered in estimating a cumulative incidence of SEMS dysfunction, otherwise analytical results may be biased.
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Affiliation(s)
- Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Ghaem Maralani H, Tai BC, Wong TY, Tai ES, Li J, Wang JJ, Mitchell P. The prognostic role of body mass index on mortality amongst the middle-aged and elderly: a competing risk analysis. Diabetes Res Clin Pract 2014; 103:42-50. [PMID: 24382466 DOI: 10.1016/j.diabres.2013.11.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 06/25/2013] [Accepted: 11/25/2013] [Indexed: 10/25/2022]
Abstract
AIMS To determine the relationship between body mass index (BMI) including its 5-year changes and mortality, and compare the results obtained using Cox and competing risks models. METHODS Our study subjects included 2216 persons aged ≥49 years who participated in the Blue Mountains Eye Study, Australia between 1992 and 1994, and returned for further follow-up examinations between 1997 and 1999. We examined the relationship between BMI and mortality using cubic spline. The Cox and competing risks models were used to assess the associations between baseline BMI and its 5-year changes with all-cause and cause-specific mortality. RESULTS Amongst subjects aged ≤70 years, the relationship between BMI and all-cause mortality was U-shaped. For those aged >70 years, an L-shaped relationship was seen with no elevation in risk amongst the overweight/obese. Based on the competing risks model, obesity at baseline was associated with increased risk of cardiovascular death and reduction in BMI at 5-year was linked to an increase risk of cancer death amongst those aged ≤70 years. The cause-specific Cox model showed that reduction in BMI at 5-year was associated with cancer-death regardless of age, and with cardiovascular deaths among subjects aged ≤70 years. Cox regression model showed larger magnitude of effect with wider confidence interval as compared with competing risks model. CONCLUSIONS Conditions associated with obesity are more likely to affect mortality among subjects aged ≤70 years, but not among those aged over 70 years. Cox model shows larger magnitude of effect in comparison with competing risks model.
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Affiliation(s)
- Haleh Ghaem Maralani
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore
| | - Bee Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore.
| | - Tien Y Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore; Duke-NUS Graduate Medical School, Singapore
| | - E Shyong Tai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Jialiang Li
- Department of Statistics and Applied Probability, National University of Singapore, Singapore
| | - Jie Jin Wang
- Centre for Vision Research, University of Sydney, Sydney, Australia; Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, Victoria, Australia
| | - Paul Mitchell
- Centre for Vision Research, University of Sydney, Sydney, Australia
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Koh GCH, Tai BC, Ang LW, Heng D, Yuan JM, Koh WP. All-cause and cause-specific mortality after hip fracture among Chinese women and men: the Singapore Chinese Health Study. Osteoporos Int 2013; 24:1981-9. [PMID: 23224227 PMCID: PMC9244854 DOI: 10.1007/s00198-012-2183-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Accepted: 09/28/2012] [Indexed: 10/27/2022]
Abstract
UNLABELLED All-cause mortality risk persisted for 5 years after hip fractures in both men and women. There may be gender-specific differences in effect and duration of excess risk for cause-specific mortality after hip fracture. INTRODUCTION To determine all-cause and cause-specific mortality risk in the first 5 years after hip fracture in an Asian Chinese population. METHODS The Singapore Chinese Health Study is a population-based cohort of 63,257 middle-aged and elderly Chinese men and women in Singapore recruited between 1993 and 1998. This cohort was followed up for hip fracture and death via linkage with nationwide hospital discharge database and death registry. As of 31 December 2008, we identified 1,166 hip fracture cases and matched five non-fracture cohort subjects by age and gender for each fracture case. Cox proportional hazards and competing risks regression models with hip fracture as a time-dependent covariate were used to determine all-cause and cause-specific mortality risk, respectively. RESULTS Increase in all-cause mortality risk persisted till 5 years after hip fracture (adjusted hazard ratio, aHR = 1.58 [95 % CI, 1.35-1.86] for females and aHR = 1.64 [95 % CI, 1.30-2.06] for males). Men had higher mortality risk after hip fracture than women for deaths from stroke and cancer up to 1 year post-fracture but women with hip fracture had higher coronary artery mortality risk than men for 5 years post-fracture. Men had higher risk of death from pneumonia while women had increased risk of death from urinary tract infections. There was no difference in mortality risk by types of hip fracture surgery. CONCLUSIONS All-cause mortality risk persisted for 5 years after hip fractures in men and women. There are gender-specific differences in effect size and duration of excess mortality risk from hip fractures between specific causes of death.
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Affiliation(s)
- G C-H Koh
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Block MD3, #03-20, 16 Medical Drive, 117597 Singapore, Singapore.
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Desai CS, Ning H, Kang J, Folsom AR, Polak JF, Sibley CT, Tracy R, Lloyd-Jones DM. Competing cardiovascular outcomes associated with subclinical atherosclerosis (from the Multi-Ethnic Study of Atherosclerosis). Am J Cardiol 2013; 111:1541-6. [PMID: 23499272 DOI: 10.1016/j.amjcard.2013.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 02/03/2013] [Accepted: 02/03/2013] [Indexed: 11/24/2022]
Abstract
Subclinical atherosclerosis measured by coronary artery calcium (CAC) is associated with increased risk for multiple cardiovascular disease (CVD) outcomes and non-CVD death simultaneously. The aim of this study was to determine the competing risks of specific CVD events and non-CVD death associated with varying burdens of subclinical atherosclerosis. A total of 3,095 men and 3,486 women from the Multi-Ethnic Study of Atherosclerosis (MESA), aged 45 to 84 years, from 4 ethnic groups were included. Participants were stratified by CAC score (0, 1 to 99, and ≥100). Competing Cox models were used to determine competing cumulative incidences and hazard ratios within a group (e.g., those with CAC scores ≥100) and hazard ratios for specific events between groups (e.g., CAC score ≥100 vs 0). Risks were compared for specific CVD events and also against non-CVD death. In women, during a mean follow-up period of 7.1 years, the hazard ratios for any CVD event compared with a non-CVD death occurring first for CAC score 0 and CAC score ≥100 were 1.40 (95% confidence interval 0.97 to 2.04) and 3.07 (95% confidence interval 2.02 to 4.67), respectively. Coronary heart disease was the most common first CVD event type at all levels of CAC, and coronary heart disease rates were 9.5% versus 1.6% (hazard ratio 6.24, 95% confidence interval 3.99 to 9.75) for women with CAC scores ≥100 compared with CAC scores of 0. Similar results were observed in men. In conclusion, at all levels of CAC, coronary heart disease was the most common first CVD event, and this analysis represents a novel approach to understanding the temporal sequence of cardiovascular events associated with atherosclerosis.
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Guerra C, Linde-Zwirble WT, Wunsch H. Risk factors for dementia after critical illness in elderly Medicare beneficiaries. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R233. [PMID: 23245397 PMCID: PMC3672622 DOI: 10.1186/cc11901] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 11/19/2012] [Indexed: 11/10/2022]
Abstract
Introduction Hospitalization increases the risk of a subsequent diagnosis of dementia. We aimed to identify diagnoses or events during a hospitalization requiring critical care that are associated with a subsequent dementia diagnosis in the elderly. Methods A cohort study of a random 5% sample of Medicare beneficiaries who received intensive care in 2005 and survived to hospital discharge, with three years of follow-up (through 2008) was conducted using Medicare claims files. We defined dementia using the International Classification of Diseases, 9th edition, clinical modification (ICD-9-CM) codes and excluded patients with any prior diagnosis of dementia or cognitive impairment in the year prior to admission. We used an extended Cox model to examine the association between diagnoses and events associated with the critical illness and a subsequent diagnosis of dementia, adjusting for known risk factors for dementia. Results Over the three years of follow-up, dementia was newly diagnosed in 4,519 (17.8%) of 25,368 patients who received intensive care and survived to hospital discharge. After accounting for known risk factors, having an infection (adjusted hazard ratio (AHR) = 1.25; 95% CI, 1.17 to 1.35), or a diagnosis of severe sepsis (AHR = 1.40; 95% CI, 1.28 to 1.53), acute neurologic dysfunction (AHR = 2.06; 95% CI, 1.72 to 2.46), and acute dialysis (AHR = 1.70; 95% CI, 1.30 to 2.23) were all independently associated with a subsequent diagnosis of dementia. No other measured ICU factors, such as need for mechanical ventilation, were independently associated. Conclusions Among ICU events, infection or severe sepsis, neurologic dysfunction, and acute dialysis were independently associated with a subsequent diagnosis of dementia. Patient prognostication, as well as future research into post-ICU cognitive decline, should focus on these higher-risk subgroups.
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Holgersson G, Hoye E, Bergqvist M, Ekman S, Nyman J, Helsing M, Friesland S, Holgersson M, Ekberg L, Blystad T, Ewers SB, Mörth C, Löden B, Henriksson R, Bergström S. Swedish Lung Cancer Radiation Study Group: predictive value of age at diagnosis for radiotherapy response in patients with non-small cell lung cancer. Acta Oncol 2012; 51:759-67. [PMID: 22793039 DOI: 10.3109/0284186x.2012.681064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION The aim of the present study was to investigate the impact of age at diagnosis on prognosis in patients treated with curatively intended radiotherapy for NSCLC. MATERIAL AND METHODS This is a joint effort among all the Swedish Oncology Departments that includes all identified patients with a diagnosed non-small cell lung cancer that have been subjected to curatively intended irradiation (≥50 Gy) treated during 1990 to 2000. Included patients had a histopathological/cytological diagnosis date as well as a death date or a last follow-up date. The following variables were studied in relation to overall and disease-specific survival: age, gender, histopathology, time period, smoking status, stage and treatment. RESULTS The median overall survival of all 1146 included patients was 14.7 months, while the five-year overall survival rate was 9.5%. Younger patients (<55 years), presented with a more advanced clinical stage but had yet a significantly better overall survival compared with patients in the age groups 55-64 years (p = 0.035) and 65-74 years (p = 0.0097) in a multivariate Cox regression analysis. The overall survival of patients aged ≥75 years was comparable to those aged <55 years. CONCLUSION In this large retrospective study we describe that patients younger than 55 years treated with curatively intended radiotherapy for NSCLC have a better overall survival than patients aged 55-64 and 65-74 years and that younger patients seem to benefit more from the addition of surgery and/or chemotherapy to radiotherapy. Due to the exploratory nature of the study, these results should be confirmed in future prospective trials.
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Beuscart JB, Pagniez D, Boulanger E, Lessore de Sainte Foy C, Salleron J, Frimat L, Duhamel A. Overestimation of the probability of death on peritoneal dialysis by the Kaplan-Meier method: advantages of a competing risks approach. BMC Nephrol 2012; 13:31. [PMID: 22646159 PMCID: PMC3500245 DOI: 10.1186/1471-2369-13-31] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 05/14/2012] [Indexed: 11/10/2022] Open
Abstract
Background In survival analysis, patients on peritoneal dialysis are confronted with three different outcomes: transfer to hemodialysis, renal transplantation, or death. The Kaplan-Meier method takes into account one event only, so whether it adequately considers these different risks is questionable. The more recent competing risks method has been shown to be more appropriate in analyzing such situations. Methods We compared the estimations obtained by the Kaplan-Meier method and the competing risks method (namely the Kalbfleisch and Prentice approach), in 383 consecutive incident peritoneal dialysis patients. By means of simulations, we then compared the Kaplan-Meier estimations obtained in two virtual centers where patients had exactly the same probability of death. The only difference between these two virtual centers was whether renal transplantation was available or not. Results At five years, 107 (27.9%) patients had died, 109 (28.4%) had been transferred to hemodialysis, 91 (23.8%) had been transplanted, and 37 (9.7%) were still alive on peritoneal dialysis; before five years, 39 (10.2%) patients were censored alive on peritoneal dialysis. The five-year probabilities estimated by the Kaplan-Meier and the competing risks methods were respectively: death: 50% versus 30%; transfer to hemodialysis: 59% versus 32%; renal transplantation: 39% versus 26%; event-free survival: 12% versus 12%. The sum of the Kaplan-Meier estimations exceeded 100%, implying that patients could experience more than one event, death and transplantation for example, which is impossible. In the simulations, the probability of death estimated by the Kaplan-Meier method increased as the probability of renal transplantation increased, although the probability of death actually remained constant. Conclusion The competing risks method appears more appropriate than the Kaplan-Meier method for estimating the probability of events in peritoneal dialysis in the context of univariable survival analysis.
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Biau DJ, Ferguson PC, Chung P, Griffin AM, Catton CN, O'Sullivan B, Wunder JS. Local recurrence of localized soft tissue sarcoma: a new look at old predictors. Cancer 2012; 118:5867-77. [PMID: 22648518 DOI: 10.1002/cncr.27639] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 04/03/2012] [Accepted: 04/03/2012] [Indexed: 11/12/2022]
Abstract
BACKGROUND The objective of this study was to examine the effect of known predictors of local recurrence of soft tissue sarcoma in a competing risk setting. METHODS The outcome of interest was the cumulative probability of local recurrence per category of relevant predictors, with death as a competing event. In total, 1668 patients with a localized soft tissue sarcoma of the extremity or trunk were included. RESULTS Tumor size (hazard ratio, 3.3), depth (hazard ratio, 3.2), and histologic grade (hazard ratio, 4.5) were the variables that had the most effect on the risk of metastasis and, accordingly, were the most likely to induce competition. Surgical margins (hazard ratio, 3.3), histologic grade (hazard ratio, 2.1), presentation status (hazard ratio, 2.4), and tumor depth (hazard ratio, 1.5) were the variables that had the most effect on the risk of local recurrence. The 10-year cumulative probabilities of local recurrence were markedly different within categories for presentation status (P < .001) and surgical margin status (P < .001). However, because of the competing effect of death, there was little difference in the 10-year cumulative probabilities of local recurrence with regard to tumor depth (12% and 11.4% for deep and superficial tumors, respectively; P = .2), tumor size (10.6% and 13.3% for large and small tumors, respectively; P = .99), or histologic tumor grade (12.6%, 10.7%, and 11.1% for high, intermediate, and low-grade tumors, respectively; P = .17). CONCLUSIONS Because of the competition between local recurrence and death, histologic tumor grade, tumor size, and tumor depth had little influence on the cumulative probability of local recurrence. The authors concluded that local management should be based on presentation status and surgical margins rather than other, previously acknowledged factors.
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Affiliation(s)
- David J Biau
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
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Better stent function with chemotherapy: effects of chemotherapy or just a better prognosis? Gastrointest Endosc 2012; 75:1120-1; author reply 1121-2. [PMID: 22520884 DOI: 10.1016/j.gie.2011.11.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 11/22/2011] [Indexed: 12/11/2022]
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Corbacioglu S, Cesaro S, Faraci M, Valteau-Couanet D, Gruhn B, Rovelli A, Boelens JJ, Hewitt A, Schrum J, Schulz AS, Müller I, Stein J, Wynn R, Greil J, Sykora KW, Matthes-Martin S, Führer M, O'Meara A, Toporski J, Sedlacek P, Schlegel PG, Ehlert K, Fasth A, Winiarski J, Arvidson J, Mauz-Körholz C, Ozsahin H, Schrauder A, Bader P, Massaro J, D'Agostino R, Hoyle M, Iacobelli M, Debatin KM, Peters C, Dini G. Defibrotide for prophylaxis of hepatic veno-occlusive disease in paediatric haemopoietic stem-cell transplantation: an open-label, phase 3, randomised controlled trial. Lancet 2012; 379:1301-9. [PMID: 22364685 DOI: 10.1016/s0140-6736(11)61938-7] [Citation(s) in RCA: 242] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Hepatic veno-occlusive disease is a leading cause of morbidity and mortality after haemopoietic stem-cell transplantation (HSCT). We aimed to assess whether defibrotide can reduce the incidence of veno-occlusive disease in this setting. METHODS In our phase 3 open-label, randomised controlled trial, we enrolled patients at 28 European university hospitals or academic medical centres. Eligible patients were younger than 18 years, had undergone myeloablative conditioning before allogeneic or autologous HSCT, and had one or more risk factor for veno-occlusive disease based on modified Seattle criteria. We centrally assigned eligible participants on the basis of a computer-generated randomisation sequence (1:1), stratified by centre and presence of osteopetrosis, to receive intravenous defibrotide prophylaxis (treatment group) or not (control group). The primary endpoint was incidence of veno-occlusive disease by 30 days after HSCT, adjudicated by a masked, independent review committee, in eligible patients who consented to randomisation (intention-to-treat population), and was assessed with a competing risk approach. Patients in either group who developed veno-occlusive disease received defibrotide for treatment. We assessed adverse events to 180 days after HSCT in all patients who received allocated prophylaxis. This trial is registered with ClinicalTrials.gov, number NCT00272948. FINDINGS Between Jan 25, 2006, and Jan 29, 2009, we enrolled 356 eligible patients to the intention-to-treat population. 22 (12%) of 180 patients randomly allocated to the defibrotide group had veno-occlusive disease by 30 days after HSCT compared with 35 (20%) of 176 controls (risk difference -7·7%, 95% CI -15·3 to -0·1; Z test for competing risk analysis p=0·0488; log-rank test p=0·0507). 154 (87%) of 177 patients in the defibrotide group had adverse events by day 180 compared with 155 (88%) of 176 controls. INTERPRETATION Defibrotide prophylaxis seems to reduce incidence of veno-occlusive disease and is well tolerated. Thus, such prophylaxis could present a useful clinical option for this serious complication of HSCT. FUNDING Gentium SpA, European Group for Blood and Marrow Transplantation.
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Pahl E, Sleeper LA, Canter CE, Hsu DT, Lu M, Webber SA, Colan SD, Kantor PF, Everitt MD, Towbin JA, Jefferies JL, Kaufman BD, Wilkinson JD, Lipshultz SE. Incidence of and risk factors for sudden cardiac death in children with dilated cardiomyopathy: a report from the Pediatric Cardiomyopathy Registry. J Am Coll Cardiol 2012; 59:607-15. [PMID: 22300696 DOI: 10.1016/j.jacc.2011.10.878] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 10/11/2011] [Accepted: 10/31/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The purpose of this study was to establish the incidence of and risk factors for sudden cardiac death (SCD) in pediatric dilated cardiomyopathy (DCM). BACKGROUND The incidence of SCD in children with DCM is unknown. The ability to predict patients at high risk of SCD will help to define who may benefit most from implantable cardioverter-defibrillators. METHODS The cohort was 1,803 children in the PCMR (Pediatric Cardiomyopathy Registry) with a diagnosis of DCM from 1990 to 2009. Cumulative incidence competing-risks event rates were estimated. We achieved risk stratification using Classification and Regression Tree methodology. RESULTS The 5-year incidence rates were 29% for heart transplantation, 12.1% non-SCD, 4.0% death from unknown cause, and 2.4% for SCD. Of 280 deaths, 35 were SCD, and the cause was unknown for 56. The 5-year incidence rate for SCD incorporating a subset of the unknown deaths is 3%. Patients receiving antiarrhythmic medication were at higher risk of SCD (hazard ratio: 3.0, 95% confidence interval: 1.1 to 8.3, p = 0.025). A risk stratification model based on most recent echocardiographic values had 86% sensitivity and 57% specificity. Thirty of 35 SCDs occurred in patients who met all these criteria: left ventricular (LV) end-systolic dimension z-score >2.6, age at diagnosis younger than 14.3 years, and the LV posterior wall thickness to end-diastolic dimension ratio <0.14. Sex, ethnicity, cause of DCM, and family history were not associated with SCD. CONCLUSIONS The 5-year incidence rate of SCD in children with DCM is 3%. A risk stratification rule (86% sensitivity) included age at diagnosis younger than 14.3 years, LV dilation, and LV posterior wall thinning. Patients who consistently meet these criteria should be considered for implantable cardioverter-defibrillator placement.
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Affiliation(s)
- Elfriede Pahl
- Children's Memorial Hospital, Northwestern University, Chicago, IL 60614, USA.
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Lim SH, Tai BC, Yuan JM, Yu MC, Koh WP. Smoking cessation and mortality among middle-aged and elderly Chinese in Singapore: the Singapore Chinese Health Study. Tob Control 2011; 22:235-40. [DOI: 10.1136/tobaccocontrol-2011-050106] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Desai CS, Ning H, Lloyd-Jones DM. Competing cardiovascular outcomes associated with electrocardiographic left ventricular hypertrophy: the Atherosclerosis Risk in Communities Study. Heart 2011; 98:330-4. [PMID: 22139711 DOI: 10.1136/heartjnl-2011-300819] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Individuals with electrocardiographically determined left ventricular hypertrophy (ECG LVH) are at risk of multiple cardiovascular disease (CVD) outcomes simultaneously. The study sought to characterise the competing incidences for subtypes of first CVD events or non-CVD death in those with and without ECG LVH. METHODS Participants in the Atherosclerosis Risk in Communities (ARIC) Study were included. ECG LVH was defined according to Sokolow-Lyon criteria. Competing Cox models were used to compare hazards for diverse outcomes within groups (e.g., among those with ECG LVH) and for a given event between groups (ECG LVH vs. no ECG LVH). RESULTS After 15 years, men with ECG LVH at baseline (N=383) had a cumulative incidence of first CVD events and non-CVD deaths of 29.2% and 6.1%, respectively (HR 4.86; 95% CI 3.04 to 7.77). In men without ECG LVH (N=6576) the incidence of any first CVD event and non-CVD death was 18.9% and 6.9%, respectively (HR 2.67; 2.39 to 2.98). Similar associations were observed in women (N=381 with and N=8187 without ECG LVH). Coronary heart disease (CHD) was the most common first event in men with ECG LVH (15.0%) and heart failure was the most common first event in women with ECG LVH (10.5%). After adjustment for risk factors including systolic blood pressure, any CVD event remained the most likely first event. CONCLUSIONS Among middle-aged individuals with ECG LVH, the most likely first events are CHD in men and heart failure in women; these results may have implications for preventive approaches.
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Affiliation(s)
- Chintan S Desai
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1402, Chicago, IL 60611, USA
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40
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Alvarez JA, Orav EJ, Wilkinson JD, Fleming LE, Lee DJ, Sleeper LA, Rusconi PG, Colan SD, Hsu DT, Canter CE, Webber SA, Cox GF, Jefferies JL, Towbin JA, Lipshultz SE. Competing risks for death and cardiac transplantation in children with dilated cardiomyopathy: results from the pediatric cardiomyopathy registry. Circulation 2011; 124:814-23. [PMID: 21788591 DOI: 10.1161/circulationaha.110.973826] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pediatric dilated cardiomyopathy (DCM) is the leading indication for heart transplantation after 1 year of age. Risk factors by etiology at clinical presentation have not been determined separately for death and transplantation in population-based studies. Competing risks analysis may inform patient prioritization for transplantation listing. METHODS AND RESULTS The Pediatric Cardiomyopathy Registry enrolled 1731 children diagnosed with DCM from 1990 to 2007. Etiologic, demographic, and echocardiographic data collected at diagnosis were analyzed with competing risks methods stratified by DCM etiology to identify predictors of death and transplantation. For idiopathic DCM (n=1192), diagnosis after 6 years of age, congestive heart failure, and lower left ventricular (LV) fractional shortening z score were independently associated with both death and transplantation equally. In contrast, increased LV end-diastolic dimension z score was associated only with transplantation, whereas lower height-for-age z score was associated only with death. For neuromuscular disease (n=139), lower LV fractional shortening was associated equally with both end points, but increased LV end-diastolic dimension was associated only with transplantation. The risks of death and transplantation were increased equally for older age at diagnosis, congestive heart failure, and increased LV end-diastolic dimension among those with myocarditis (n=272) and for congestive heart failure and decreased LV fractional shortening among those with familial DCM (n=79). CONCLUSIONS Risk factors for death and transplantation in children varied by DCM etiology. For idiopathic DCM, increased LV end-diastolic dimension was associated with increased transplantation risk but not mortality. Conversely, short stature was significantly related to death but not transplantation. These findings may present an opportunity to improve the transplantation selection algorithm.
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Affiliation(s)
- Jorge A Alvarez
- Department of Pediatrics (D820), Miller School of Medicine, University of Miami, P.O. Box 016820, Miami, FL 33101, USA
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Belot A, Remontet L, Launoy G, Jooste V, Giorgi R. Competing risk models to estimate the excess mortality and the first recurrent-event hazards. BMC Med Res Methodol 2011; 11:78. [PMID: 21612632 PMCID: PMC3123657 DOI: 10.1186/1471-2288-11-78] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 05/25/2011] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND In medical research, one common competing risks situation is the study of different types of events, such as disease recurrence and death. We focused on that situation but considered death under two aspects: "expected death" and "excess death", the latter could be directly or indirectly associated with the disease. METHODS The excess hazard method allows estimating an excess mortality hazard using the population (expected) mortality hazard. We propose models combining the competing risks approach and the excess hazard method. These models are based on a joint modelling of each event-specific hazard, including the event-free excess death hazard. The proposed models are parsimonious, allow time-dependent hazard ratios, and facilitate comparisons between event-specific hazards and between covariate effects on different events. In a simulation study, we assessed the performance of the estimators and showed their good properties with different drop-out censoring rates and different sample sizes. RESULTS We analyzed a population-based dataset on French colon cancer patients who have undergone curative surgery. Considering three competing events (local recurrence, distant metastasis, and death), we showed that the recurrence-free excess mortality hazard reached zero six months after treatment. Covariates sex, age, and cancer stage had the same effects on local recurrence and distant metastasis but a different effect on excess mortality. CONCLUSIONS The proposed models consider the excess mortality within the framework of competing risks. Moreover, the joint estimation of the parameters allow (i) direct comparisons between covariate effects, and (ii) fitting models with common parameters to obtain more parsimonious models and more efficient parameter estimators.
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Affiliation(s)
- Aurélien Belot
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France.
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42
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Tai BC, Wee J, Machin D. Analysis and design of randomised clinical trials involving competing risks endpoints. Trials 2011; 12:127. [PMID: 21595883 PMCID: PMC3130669 DOI: 10.1186/1745-6215-12-127] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 05/19/2011] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND In randomised clinical trials involving time-to-event outcomes, the failures concerned may be events of an entirely different nature and as such define a classical competing risks framework. In designing and analysing clinical trials involving such endpoints, it is important to account for the competing events, and evaluate how each contributes to the overall failure. An appropriate choice of statistical model is important for adequate determination of sample size. METHODS We describe how competing events may be summarised in such trials using cumulative incidence functions and Gray's test. The statistical modelling of competing events using proportional cause-specific and subdistribution hazard functions, and the corresponding procedures for sample size estimation are outlined. These are illustrated using data from a randomised clinical trial (SQNP01) of patients with advanced (non-metastatic) nasopharyngeal cancer. RESULTS In this trial, treatment has no effect on the competing event of loco-regional recurrence. Thus the effects of treatment on the hazard of distant metastasis were similar via both the cause-specific (unadjusted csHR = 0.43, 95% CI 0.25 - 0.72) and subdistribution (unadjusted subHR 0.43; 95% CI 0.25 - 0.76) hazard analyses, in favour of concurrent chemo-radiotherapy followed by adjuvant chemotherapy. Adjusting for nodal status and tumour size did not alter the results. The results of the logrank test (p = 0.002) comparing the cause-specific hazards and the Gray's test (p = 0.003) comparing the cumulative incidences also led to the same conclusion. However, the subdistribution hazard analysis requires many more subjects than the cause-specific hazard analysis to detect the same magnitude of effect. CONCLUSIONS The cause-specific hazard analysis is appropriate for analysing competing risks outcomes when treatment has no effect on the cause-specific hazard of the competing event. It requires fewer subjects than the subdistribution hazard analysis for a similar effect size. However, if the main and competing events are influenced in opposing directions by an intervention, a subdistribution hazard analysis may be warranted.
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Affiliation(s)
- Bee-Choo Tai
- Department of Epidemiology and Public Health, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Joseph Wee
- Department of Radiation Oncology, National Cancer Centre, Singapore
| | - David Machin
- Children's Cancer and Leukaemia Group, University of Leicester, UK
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van Dalen EC, van As JW, de Camargo B. Methotrexate for high-grade osteosarcoma in children and young adults. Cochrane Database Syst Rev 2011; 2011:CD006325. [PMID: 21563152 PMCID: PMC6466691 DOI: 10.1002/14651858.cd006325.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The majority of the currently used treatment protocols for osteosarcoma are based on a combination of doxorubicin, cisplatin, methotrexate (MTX) and/or ifosfamide, of which MTX seems to be one of the most active drugs. However, in the literature, this has not been unambiguously proven. OBJECTIVES To compare the effectiveness of treatment including MTX with treatment without MTX for children and young adults (up to 21 years) with primary high-grade osteosarcoma. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, issue 4, 2010), MEDLINE (1966 to January 2011) and EMBASE (1980 to January 2011). In addition, we searched reference lists of relevant articles, conference proceedings and ongoing trials databases. SELECTION CRITERIA Randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing the effectiveness of treatment including MTX with treatment without MTX in the treatment of paediatric high-grade osteosarcoma. DATA COLLECTION AND ANALYSIS Two reviewers independently performed the study selection. One reviewer performed the data extraction and quality assessment, which was checked by another reviewer. MAIN RESULTS We could not identify any studies in which the only difference between the treatment groups was the use of MTX.We did identify a RCT comparing MTX with cisplatin (n=30 children). The risk of bias in this study was difficult to assess due to a lack of reporting. Survival could not be evaluated, but no evidence of a significant difference in response rate between the treatment groups was identified (RR=0.44; 95% CI 0.17 to 1.13; P=0.09). A significant difference in the occurrence of toxicities in favour of MTX was identified, but with regard to quality of life treatment with cisplatin seemed to give better results.For other combinations of treatment including and not including MTX no studies were identified. AUTHORS' CONCLUSIONS Since no RCTs or CCTs in which only the use of MTX differed between the treatment groups were identified, no definitive conclusions can be made about the effects on antitumour efficacy, toxicities and quality of life of the addition of MTX to treatment of children and young adults with primary high-grade osteosarcoma. The same is true for combinations of treatment including and not including MTX other than treatment with MTX versus treatment with cisplatin. Only 1 RCT comparing MTX with cisplatin treatment was available and therefore, no definitive conclusions can be made about the effectiveness of these agents in children and young adults with primary high-grade osteosarcoma. Furthermore, this study was performed in a different treatment era. Nowadays single agent treatment of osteosarcoma is considered inadequate. Based on the currently available evidence, we are not able to give recommendations for the use of MTX in clinical practice. More high quality research is needed.
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Affiliation(s)
- Elvira C van Dalen
- Princess Máxima Center for Pediatric OncologyHeidelberglaan 25UtrechtNetherlands3584 CS
| | - Jorrit W van As
- Princess Máxima Center for Pediatric Oncologyc/o Cochrane Childhood CancerHeidelberglaan 25UtrechtNetherlands3584 CS
| | - Beatriz de Camargo
- Centro de Pesquisa, Instituto Nacional do CancerPediatric Hematology‐Oncology ProgramRio de JaneiroRJBrazil
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Tai BC, Grundy R, Machin D. On the Importance of Accounting for Competing Risks in Pediatric Brain Cancer: II. Regression Modeling and Sample Size. Int J Radiat Oncol Biol Phys 2011; 79:1139-46. [DOI: 10.1016/j.ijrobp.2009.12.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Revised: 11/16/2009] [Accepted: 12/14/2009] [Indexed: 11/12/2022]
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Belot A, Abrahamowicz M, Remontet L, Giorgi R. Flexible modeling of competing risks in survival analysis. Stat Med 2011; 29:2453-68. [PMID: 20645282 DOI: 10.1002/sim.4005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Prognostic studies often involve modeling competing risks, where an individual can experience only one of alternative events, and the goal is to estimate hazard functions and covariate effects associated with each event type. Lunn and McNeil proposed data manipulation that permits extending the Cox's proportional hazards model to estimate covariate effects on the hazard of each competing events. However, the hazard functions for competing events are assumed to remain proportional over the entire follow-up period, implying the same shape of all event-specific hazards, and covariate effects are restricted to also remain constant over time, even if such assumptions are often questionable. To avoid such limitations, we propose a flexible model to (i) obtain distinct estimates of the baseline hazard functions for each event type, and (ii) allow estimating time-dependent covariate effects in a parsimonious model. Our flexible competing risks regression model uses smooth cubic regression splines to model the time-dependent changes in (i) the ratio of event-specific baseline hazards, and (ii) the covariate effects. In simulations, we evaluate the performance of the proposed estimators and likelihood ratio tests, under different assumptions. We apply the proposed flexible model in a prognostic study of colorectal cancer mortality, with two competing events: 'death from colorectal cancer' and 'death from other causes'.
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Affiliation(s)
- Aurélien Belot
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, F-69424, France.
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46
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Franklin J, Eichenauer D, Monsef I, Engert A. Optimisation of chemotherapy and radiotherapy for untreated Hodgkin lymphoma patients with respect to second malignant neoplasms, overall and progression-free survival. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008814] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Verduijn M, Grootendorst DC, Dekker FW, Jager KJ, le Cessie S. The analysis of competing events like cause-specific mortality--beware of the Kaplan-Meier method. Nephrol Dial Transplant 2010; 26:56-61. [DOI: 10.1093/ndt/gfq661] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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48
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Foerster SR, Canter CE, Cinar A, Sleeper LA, Webber SA, Pahl E, Kantor PF, Alvarez JA, Colan SD, Jefferies JL, Lamour JM, Margossian R, Messere JE, Rusconi PG, Shaddy RE, Towbin JA, Wilkinson JD, Lipshultz SE. Ventricular Remodeling and Survival Are More Favorable for Myocarditis Than For Idiopathic Dilated Cardiomyopathy in Childhood. Circ Heart Fail 2010; 3:689-97. [DOI: 10.1161/circheartfailure.109.902833] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Myocarditis is a cause of a new-onset dilated cardiomyopathy phenotype in children, with small studies reporting high rates of recovery of left ventricular (LV) function.
Methods and Results—
The presenting characteristics and outcomes of children with myocarditis diagnosed clinically and with biopsy confirmation (n=119) or with probable myocarditis diagnosed clinically or by biopsy alone (n=253) were compared with children with idiopathic dilated cardiomyopathy (n=1123). Characteristics at presentation were assessed as possible predictors of outcomes. The distributions of time to death, transplantation, and echocardiographic normalization in the biopsy-confirmed myocarditis and probable myocarditis groups did not differ (
P
≥0.5), but both groups differed significantly from the idiopathic dilated cardiomyopathy group (all
P
≤0.003). In children with myocarditis, lower LV fractional shortening
z
-score at presentation predicted greater mortality (hazard ratio, 0.85; 95% confidence interval, 0.73 to 0.98;
P
=0.03) and greater LV posterior wall thickness predicted transplantation (hazard ratio, 1.17; 95% confidence interval, 1.02 to 1.35;
P
=0.03). In those with decreased LV fractional shortening at presentation, independent predictors of echocardiographic normalization were presentation with an LV end-diastolic dimension
z
-score >2 (hazard ratio, 0.36; 95% confidence interval, 0.22 to 0.58;
P
<0.001) and greater septal wall thickness (hazard ratio, 1.16; 95% confidence interval, 1.01 to 1.34;
P
=0.04).
Conclusions—
Children with biopsy-confirmed or probable myocarditis had similar proportions of death, transplantation, and echocardiographic normalization 3 years after presentation and better outcomes than those of children with idiopathic dilated cardiomyopathy. In children with myocarditis who had impaired LV ejection at presentation, rates of echocardiographic normalization were greater in those without LV dilation and in those with greater septal wall thickness at presentation.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00005391.
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Affiliation(s)
- Susan R. Foerster
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Charles E. Canter
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Amy Cinar
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Lynn A. Sleeper
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Steven A. Webber
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Elfriede Pahl
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Paul F. Kantor
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Jorge A. Alvarez
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Steven D. Colan
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - John L. Jefferies
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Jacqueline M. Lamour
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Renee Margossian
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Jane E. Messere
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Paolo G. Rusconi
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Robert E. Shaddy
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Jeffrey A. Towbin
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - James D. Wilkinson
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
| | - Steven E. Lipshultz
- From Washington University at St Louis (S.R.F., C.E.C.), Saint Louis, Mo; New England Research Institutes, Inc (A.C., L.A.S.), Watertown, Mass; the University of Pittsburgh (S.A.W.), Pittsburgh, Pa; Northwestern University (E.P.), Chicago, Ill; Hospital for Sick Children (P.F.K.), Toronto, Ontario, Canada; University of Miami (J.A.A., P.G.R., J.D.W., S.E.L.), Miami, Fla; Children's Hospital Boston (S.D.C., R.M., J.E.M.), Boston, Mass; Baylor College of Medicine (J.L.J.), Houston, Tex; Albert
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49
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Lim HJ, Zhang X, Dyck R, Osgood N. Methods of competing risks analysis of end-stage renal disease and mortality among people with diabetes. BMC Med Res Methodol 2010; 10:97. [PMID: 20964855 PMCID: PMC2988010 DOI: 10.1186/1471-2288-10-97] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Accepted: 10/21/2010] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND When a patient experiences an event other than the one of interest in the study, usually the probability of experiencing the event of interest is altered. By contrast, disease-free survival time analysis by standard methods, such as the Kaplan-Meier method and the standard Cox model, does not distinguish different causes in the presence of competing risks. Alternative approaches use the cumulative incidence estimator by the Cox models on cause-specific and on subdistribution hazards models. We applied cause-specific and subdistribution hazards models to a diabetes dataset with two competing risks (end-stage renal disease (ESRD) or death without ESRD) to measure the relative effects of covariates and cumulative incidence functions. RESULTS In this study, the cumulative incidence curve of the risk of ESRD by the cause-specific hazards model was revealed to be higher than the curves generated by the subdistribution hazards model. However, the cumulative incidence curves of risk of death without ESRD based on those three models were very similar. CONCLUSIONS In analysis of competing risk data, it is important to present both the results of the event of interest and the results of competing risks. We recommend using either the cause-specific hazards model or the subdistribution hazards model for a dominant risk. However, for a minor risk, we do not recommend the subdistribution hazards model and a cause-specific hazards model is more appropriate. Focusing the interpretation on one or a few causes and ignoring the other causes is always associated with a risk of overlooking important features which may influence our interpretation.
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Affiliation(s)
- Hyun J Lim
- Department of Community Health & Epidemiology College of Medicine, University of Saskatchewan 107 Wiggins Road Saskatoon, SK S7N 5E5, Canada
| | - Xu Zhang
- Department of Mathematics &Statistics Georgia State University 750 COE, 7th floor, 30 Pryor Street Atlanta, Georgia 30303, USA
| | - Roland Dyck
- Department of Medicine, University of Saskatchewan 103 Hospital Drive Saskatoon, SK S7J 5B6, Canada
| | - Nathaniel Osgood
- Department of Computer Science University of Saskatchewan 110 Science Place Saskatoon, SK S7N 5C9, Canada
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50
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Filleron T, Laplanche A, Boher JM, Kramar A. An R function to non-parametric and piecewise analysis of competing risks survival data. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2010; 100:24-38. [PMID: 20338662 DOI: 10.1016/j.cmpb.2010.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 02/13/2010] [Accepted: 02/21/2010] [Indexed: 05/29/2023]
Abstract
Competing risks are frequently encountered in the analysis of survival data. Different methods of analysis can be used in estimated and comparing cumulative incidence functions provided enough information is available as to the times and causes of failure. Algorithms written in R have been developed to handle this type of data. In this paper we propose an R add-on function to the cmprsk package. This function is specifically oriented towards the non-parametric analysis of competing risk data and which provides analyses of three commonly used methods all in one program. We illustrate the use of this function with two examples in oncology and compare the estimates with those provided on the cmprsk and survival package.
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Affiliation(s)
- Thomas Filleron
- Institut Claudius Regaud, 20-24 rue du Pont Saint Pierre, 31052 Toulouse, France.
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