All-cause Survival Research Articles

Survival benefit from corticosteroids in severe alcohol-associated hepatitis attributed to clinical and treatment differences in a large multicenter cohort

Background: Corticosteroids are recommended by multiple society guidelines for the treatment of severe alcohol-associated hepatitis (AH). However, their use remains controversial due to inconsistent studies regarding their survival benefit. Methods: This was a retrospective cohort study of first-time hospitalizations for severe AH (Maddrey’s Discriminant Function ≥32) admitted to the Veterans Health Administration between 1/3/2005-12/5/2020, 1) evaluating the effect of corticosteroid therapy on all-cause survival, 2) characterizing the clinical and psychosocial factors associated with corticosteroid use, and 3) determining the effect of duration of corticosteroid therapy on all-cause survival among treatment-responsive patients (Lille score <0.45). Results: During the study period, 2,618 patients were admitted with severe AH, of whom 1,083 (41.37%) received corticosteroids. Although corticosteroids were significantly associated with improved all-cause survival in the unadjusted model (p=0.022), no survival benefit was observed in the adjusted model after accounting for baseline and admission characteristics (adjusted hazard ratio [aHR]=1.01, p=0.818). Psychiatry consultation was the only factor evaluated that was protective against mortality (aHR=0.67, p<0.001). Among the 428 (49.7%) patients responsive to corticosteroids, duration of therapy was not associated with overall survival on unadjusted (p=0.696) or adjusted models (aHR=1.12, p=0.710 for a ≥28-day course compared to a ≤7-day reference). Conclusion: Despite being recommended by clinical guidelines for severe AH, corticosteroids have low utilization with no survival benefit after accounting for differences in patient characteristics and practice patterns. Among patients with treatment response per the Lille score, no difference was observed in overall survival between shorter and longer durations of corticosteroid therapy.

Deficits in Pre- and Post-transplant Functional, Motor, and Cognitive Deficits Associated With Graft Failure and Mortality in Pediatric Heart Transplant Recipients.

Pretransplant functional, motor, cognitive, and academic deficits are common in pediatric patients requiring heart transplantation (HT); some persist post-HT. We assessed the association between these quality of life (QoL) deficits and post-HT outcomes. Using SRTR data 2008-2023, we evaluated the functional, motor, cognitive, and academic status of pediatric HT recipients from listing to 15 years post-HT. We compared all-cause graft survival among patients with vs. without pre-HT deficits using Cox regressions. Among patients with a functioning graft at 1 year, we assessed the association between deficits at that time and subsequent graft failure. In 6153 HT recipients, 85.3% had pre-HT functional status ≤ 80%, 53.1% of patients could not tolerate a full academic load; this decreased to 15.2% and 15.0% postoperatively, and was sustained. Definite or probable cognitive deficits were seen in 17.4% of patients and motor delays in 18.6%; both remained stable post-HT at 18.0% and 16.4%, respectively. Graft survival was worse in those with either pre- or post-HT deficits in functional status. Worse pre-HT functional status was associated with risk of graft failure (adjusted hazard ratio [aHR] per 10% decrease = 1.03 1.06 1.08, p < 0.001); worse 1-year post-HT functional status was much more strongly associated with risk of graft failure (aHR = 1.13 1.18 1.23, p < 0.001). Pediatric HT recipients with decreased functional status are at higher risk for graft failure and mortality. These patients may benefit from early intervention aimed at improving functional status.

Inferior short-term survivorship and patient outcomes for cementless compared to hybrid fixation with a cemented femoral implant in a novel blade-anchored medial unicompartmental knee arthroplasty design: An analysis of 132 cases

PurposeFor younger, more active patients, a cementless unicompartmental knee arthroplasty (UKA) might be more advantageous than cemented fixation. Therefore, this study aimed to compare implant survivorship and patient-reported outcome measures (PROMs) between cementless and hybrid fixation (cemented femur and cementless tibial fixation) in a novel tibial blade-anchored, medial UKA design. MethodsTwo surgeon’s registries were reviewed for patients who underwent primary cementless or hybrid medial UKA for medial osteoarthritis between 2019 and 2022. Patients were included if implant survivorship and one-year postoperative PROMs (UCLA-activity score, Oxford Knee Score (OKS), Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR), pain (VAS) and satisfaction) were registered. Variables were compared using independent two-sample t-tests or the Chi-square test. Survival rates were determined using the Kaplan-Meier models and compared using the Log-rank test. ResultsA total of 132 knees were included (cementless 58.3%; cemented 41.7%; mean follow-up 3.1 ± 0.6 years). Three-year all-cause revision survival rate was significantly superior for the hybrid fixation (hybrid: 100%; cementless 88.5%[84.7%–92.3%], p = 0.026). However, the difference in three-year conversion rate to total knee arthroplasty (TKA) did not reach statistical significance. The one-year postoperative OKS (hybrid: 42.9 ± 4.8; cementless: 39.8 ± 6.4, p = 0.003) and KOOS-JR (hybrid:81.5 ± 13.7; cementless: 74.4 ± 12.1, p = 0.002) were significantly superior for the hybrid fixation. Three-year conversion rate to TKA and two-year postoperative PROMs did not significantly differ. ConclusionThe cementless medial UKA demonstrated a significantly inferior short-term all-cause survival rate and inferior postoperative one-year OKS and KOOS-JR compared to the hybrid medial UKA design with a cemented femoral component.

A Multistate Model Incorporating Relative Survival Extrapolation and Mixed Time Scales for Health Technology Assessment.

Multistate models have been widely applied in health technology assessment. However, extrapolating survival in a multistate model setting presents challenges in terms of precision and bias. In this article, we develop an individual-level continuous-time multistate model that integrates relative survival extrapolation and mixed time scales. We illustrate our proposed model using an illness-death model. We model the transition rates using flexible parametric models. We update the hesim package and the microsimulation package in R to simulate event times from models with mixed time scales. This feature allows us to incorporate relative survival extrapolation in a multistate setting. We compare several multistate settings with different parametric models (standard vs. flexible parametric models), and survival frameworks (all-cause vs. relative survival framework) using a previous clinical trial as an illustrative example. Our proposed approach allows relative survival extrapolation to be carried out in a multistate model. In the example case study, the results agreed better with the observed data than did the commonly applied approach using standard parametric models within an all-cause survival framework. We introduce a multistate model that uses flexible parametric models and integrates relative survival extrapolation with mixed time scales. It provides an alternative to combine short-term trial data with long-term external data within a multistate model context in health technology assessment.

Bioprosthetic versus mechanical prostheses in patients aged 50 to 70 years undergoing aortic valve replacement surgery: outcomes analysis from propensity score matching

Abstract Introduction Despite increasing use of bioprosthetic surgical aortic valve replacement (bAVR) in patients ≤70 years [1, 2], the relative benefits compared to mechanical valve replacement (mAVR) remain uncertain [3, 4]. Purpose The current study aims to compare mortality and other important clinical endpoints by prosthesis type for patients aged 50-70 years who received an AVR in a well-characterised Australian cohort. Methods A retrospective cohort study was designed utilising the WAVES Patient Registry and incorporating linked administrative outcome data including all patients who had an AVR in Western Australian public hospitals between 2010-2020. The primary endpoint was all-cause mortality. Secondary endpoints included cardiovascular (CV) mortality, separately and combined with non-fatal myocardial infarction and non-fatal stroke (MACE), major bleeding, and days alive and out of hospital (DAOH). Outcomes were compared based on a propensity-matched analysis (including demographics, biometrics, and clinical characteristics). Results Within the initial cohort of 727 patients undergoing surgical AVR (mean age = 63 ± SD 6), a propensity-matched cohort identified 151 patients each with bAVR (mean age = 61 ± 4) and mAVR (mean age = 60 ± 5). Patients who received mAVR versus bAVR had improved all-cause survival (Hazard Ratio [HR] 0.50; 95% CI 0.25-0.99) but increased risk of major bleeding (HR 4.85; 95% CI 1.57-14.98). There were no significant differences in CV mortality (HR 0.58; 95% CI 0.19-1.74), MACE (HR 0.59; 95 % CI 0.32-1.07), or DAOH by prosthesis type (P = 0.452). Conclusions Patients aged 50-70 years who underwent mAVR had lower risk of all-cause mortality compared with bAVR, despite higher bleeding risk. Although risks of CV mortality and MACE were lower in mAVR, statistical significance was not reached, likely due to the small sample size. Larger studies are necessary to confirm these findings, which have important clinical implications.

Clinical relevance of protein-truncating variants of germline DNA repair genes in prostate cancer

BackgroundInterpreting genetic variants remains a challenge in prostate cancer (PCa). Although many annotation tools are available for prioritizing causal variants, the clinical relevance of these variants is rarely studied.MethodsWe collected a cohort study that included 274 PCa patients from June 2017 to December 2020 and sequenced 19 DNA damage repair (DDR) genes in these patients and explored the clinical consequence of these different approaches. We also examined all-cause and PCa-specific survival in DDR gene mutation carriers compared to non-carriers after androgen receptor (AR)-directed therapy.ResultsWe identified 13 variants from 19 DDR genes in a total of 14 (5.1%) patients who had at least one presumed pathogenic mutation using different annotation methods. Four variants were annotated as pathogenic, 11 variants were predicted as protein-truncating variants (PTVs), four variants received proxy-deleterious (Combined Annotation-Dependent Depletion scores of > 30), and only one variant was identified as a pathogenic variant or as having a functional effect by all three methods. PCa patients with PTVs were significantly associated with early onset, high cancer stage, and a worse response to AR-directed treatment. However, patients carrying a proxy-deleterious variant were only associated with a higher T (tumor) stage and N (node) stage than those without such a variant, but not associated with other clinical characteristics. In patients treated with AR-directed therapy, patients with a PTV showed an increased risk of all-cause death (adjusted hazard ratio (aHR) = 3.51, 95% confidence interval (CI): 1.06 ~ 11.56) and PCa-specific death (aHR = 4.49, 95% CI: 1.87 ~ 10.77) compared to non-PTV carriers after adjustment. We were unable to examine gene-specific risks due to the small number of patients.ConclusionsPTVs may assist in guiding treatment and early screening in PCa, while population-specific data for pathogenic variants are still being amassed.

Precision phenotyping from routine laboratory parameters for out of hospital survival prediction in an all comers prospective PCI registry

Out-of-hospital mortality in coronary artery disease (CAD) is particularly high and established adverse event prediction tools are yet to be available. Our study aimed to investigate whether precision phenotyping can be performed using routine laboratory parameters for the prediction of out-of-hospital survival in a CAD population treated by percutaneous coronary intervention (PCI). All patients treated by PCI and discharged alive in a tertiary center between January 2016 – December 2022 that have been included prospectively in the local registry were analyzed. 115 parameters from the PCI registry and 266 parameters derived from routine laboratory testing were used. An extreme gradient-boosted decision tree machine learning (ML) algorithm was trained and used to predict all-cause and cardiovascular-cause survival. A total of 4027 patients with 4981 PCI hospitalizations were randomly included in the 70% training dataset and 1729 patients with 2160 PCI hospitalizations were randomly included in the 30% validation dataset. All-cause and cardiovascular cause mortality was 17.5% and 12.2%. The integrated area under the receiver operator characteristic curve for prediction of all-cause and cardiovascular cause mortality by the ML on the validation dataset was 0.844 and 0.837, respectively (all p < 0.001). Parameters reflecting renal function (first and maximum serum creatinine), hematologic function (mean corpuscular hemoglobin concentration, platelet distribution width), and inflammatory status (lymphocyte per monocyte ratio) were among the most important predictors. Accurate out-of-hospital survival prediction in CAD can be achieved using routine laboratory parameters. ML outperformed clinical risk scores in predicting out-of-hospital mortality in a prospective all-comers PCI population and has the potential to precisely phenotype patients.

The role of multiple mediation with contextual neighborhood measures in ovarian cancer survival

BackgroundMediation by multiple agents can affect the relation between neighborhood deprivation and segregation indices and ovarian cancer survival. In this paper, we examine a variety of potential clinical mediators in the association between deprivation indices (DIs) and segregation indices (SIs) with all-cause survival among women with ovarian cancer in the African American Cancer Epidemiology Study (AACES). MethodsWe use novel Bayesian multiple mediation structural models to assess the joint role of mediators (stage at diagnosis, histology, diagnostic delay) combined with the DIs and SIs (Yost, ADI, Kolak’s URB, ICE-income) and a set of confounders with survival. The confounder set is selected in a preliminary step, and each DI or SI is included in separate model fits. ResultsWhen multiple mediators are included, the total impact of DIs and SIs on survival is much reduced. Unlike the single mediator examples previously reported, the Yost, ADI and ICE-income indices do not display significant direct effects. This suggests that when important clinical mediators are included, the impact of neighborhood SES indices is significantly attenuated. It is also clear that certain behavioral and demographic measures such as physical activity, smoking, or adjusted family income do not have a significant role in survival when mediated by clinical factors. ConclusionMultiple mediation via clinical and diagnostic-related measures reduces the contextual effects of neighborhood measures on ovarian cancer survival. The robust association of the Kolak URB index on survival may be due to its relevance to access to care, unlike SES-based indices whose impact was significantly reduced when important clinical mediators were included.

Association Between Medicaid Coverage Continuity and Survival in Patients With Newly Diagnosed Pediatric and Adolescent Cancers.

Many patients with cancer do not gain Medicaid coverage until a cancer diagnosis, which can reduce access to early cancer detection and timely treatment, potentially driving inferior survival. Little is known about whether continuous Medicaid coverage prediagnosis through postdiagnosis (v gaining Medicaid at/after diagnosis) provides survival benefits for pediatric/adolescent oncology patients. We identified patients newly diagnosed with cancer at age 21 years or younger in a large pediatric health system between 2007 and 2016. Electronic medical records (EMRs) were linked to Medicaid administrative data to differentiate insurance continuity patterns during the 6 months preceding through the 6 months after cancer diagnosis (assessment window): continuous Medicaid, newly gained Medicaid (at or after diagnosis), and other Medicaid enrollment patterns. For patients not linked to Medicaid data, we used EMR-reported insurance types at diagnosis. We followed patients from 6 months postdiagnosis up to 5 years, death, or December 2020, whichever came first. Multivariable regressions estimated all-cause and cancer-specific survival, controlling for sociodemographic and cancer-related factors. Among 1,800 patients included in the analysis, 1,293 (71.8%) had some Medicaid enrollment during the assessment window; among them, 47.6% had continuous Medicaid and 36.3% had newly gained Medicaid. Patients not linked with Medicaid data had private (26.9%) or other/no insurance (1.2%) at diagnosis. Compared with patients with continuous Medicaid, those with newly gained Medicaid had higher risks of all-cause death (hazard ratio [HR], 1.41 [95% CI, 1.10 to 1.81]; P = .008) and cancer-specific death (HR, 1.46 [95% CI, 1.12 to 1.90]; P = .005). Continuous Medicaid coverage throughout cancer diagnosis is associated with survival benefits for pediatric/adolescent patients. This finding has critical implications as millions of American individuals have been losing coverage since the unwinding of the Medicaid Continuous Enrollment Provision.

Association between surgeon training grade and the risk of revision following unicompartmental knee replacement: An analysis of National Joint Registry data.

Unicompartmental knee replacements (UKRs) are performed by surgeons at various stages in training with varying levels of supervision, but we do not know if this is a safe practice with comparable outcomes to consultant-performed UKR. The aim of this study was to use registry data for England and Wales to investigate the association between surgeon grade (consultant, or trainee), the senior supervision of trainees (supervised by a scrubbed consultant, or not), and the risk of revision surgery following UKR. We conducted an observational study using prospectively collected data from the National Joint Registry for England and Wales (NJR). We included adult patients who underwent primary UKR for osteoarthritis (n = 106,206), recorded in the NJR between 2003 and 2019. Exposures were the grade of the operating surgeon (consultant, or trainee) and whether or not trainees were directly supervised by a consultant during the procedure (referred to as "supervised by a scrubbed consultant"). The primary outcome was all-cause revision surgery. The secondary outcome was the number of procedures revised for the following specific indications: aseptic loosening/lysis, infection, progression of osteoarthritis, unexplained pain, and instability. Flexible parametric survival models were adjusted for patient, operation, and healthcare setting factors. We included 106,206 UKRs in 91,626 patients, of which 4,382 (4.1%) procedures were performed by a trainee. The unadjusted cumulative probability of failure at 15 years was 17.13% (95% CI [16.44, 17.85]) for consultants, 16.42% (95% CI [14.09, 19.08]) for trainees overall, 15.98% (95% CI [13.36, 19.07]) for trainees supervised by a scrubbed consultant, and 17.32% (95% CI [13.24, 22.50]) for trainees not supervised by a scrubbed consultant. There was no association between surgeon grade and all-cause revision in either crude or adjusted models (adjusted HR = 1.01, 95% CI [0.90, 1.13]; p = 0.88). Trainees achieved comparable all-cause survival to consultants, regardless of the level of scrubbed consultant supervision (supervised: adjusted HR = 0.99, 95% CI [0.87, 1.14]; p = 0.94; unsupervised: adjusted HR = 1.03, 95% CI [0.87, 1.22]; p = 0.74). Limitations of this study relate to its observational design and include: the potential for nonrandom allocation of cases by consultants to trainees; residual confounding; and the use of the binary variable "surgeon grade," which does not capture variations in the level of experience between trainees. This nationwide study of UKRs with over 16 years' follow up demonstrates that trainees within the current training system in England and Wales achieve comparable all-cause implant survival to consultants. These findings support the current methods by which surgeons in England and Wales are trained to perform UKR.

Long-term impact of immigration status on outcomes in pediatric kidney transplant recipients

This study aimed to investigate the effects of documentation status on pediatric kidney transplant outcomes in a single-center setting, emphasizing the significance of state insurance access for undocumented patients and federal policies like Deferred Action for Childhood Arrivals (DACA) on patient outcomes. A cohort of 283 patients, including 48 undocumented individuals, who received their first kidney transplant as children between 1998 and 2011 was analyzed. There was no significant difference in unadjusted all-cause (P = .91) and death-censored (P = .38) graft survival between undocumented patients and patients with permanent legal status, subsequently referred to as US residents. Additionally, in the Cox proportional hazards model, immigration status was not significantly associated with all-cause graft survival (hazard ratio 0.87, 95% CI 0.51-1.46, P = .6). Telephone interviews were conducted with the undocumented cohort. Forty-one of 48 of the undocumented recipients were contacted. Ninety-five percent had access to insurance with 68.3% on Medicaid or Medicare. DACA recipients exhibited higher employment rates (88% vs 67%, P = .11) and were more likely to complete a degree beyond high school (47.1% vs 12.5%, P = .01). Immigration status did not impact long-term graft survival, suggesting eligibility expansions for state-funded insurance and DACA may improve access to transplant care for undocumented patients. Moreover, DACA recipients showed trends toward increased employment and education compared to non-DACA recipients.

Association of housing status and cancer diagnosis, care coordination and outcomes in a public hospital: a retrospective cohort study

ObjectivesCancer is a leading cause of death in unhoused adults. We sought to examine the association between housing status, stage at diagnosis and all-cause survival following cancer diagnosis at a...

Sex differences in all-cause mortality and life span between women with premature menopause and men: propensity score matching analysis.

This study investigated sex differences in all-cause mortality and life span between women undergoing premature menopause and men using propensity score matching analysis. Data were from the National Health and Nutrition Examination Survey (1999-2018) and the National Health and Nutrition Examination Survey III (1988-1994). We included 3,214 women experiencing premature menopause and 23,067 men. The participants were all older than 40 years. Propensity score matching analysis created matched cohorts of women and men using a 1:1 ratio. We employed Cox proportional hazard models to estimate unadjusted and adjusted hazard ratios (HR) (95% confidence interval [CI]) for the association between sex and both all-cause mortality and survival up to the 75th percentile of life span. A subgroup analysis examined the effects of hormone therapy on mortality and life span. Compared with men in the matched cohorts, the adjusted HR values (95% CI) for all-cause mortality in women with age at menopause at <35, 35 to 39, and <40 years were 0.65 (0.54-0.78), 0.72 (0.59-0.87), and 0.67 (0.60-0.76), respectively. However, the adjusted HR values (95% CI) for women and men to survive to the 75th percentile of life span were not statistically significant. Besides, there was no significant difference in the mean life span between deceased women and men in the matched cohorts. In the subgroup analysis, the mean life span did not differ significantly between deceased women taking hormone therapy and men. However, the average life span of women never using hormone therapy was significantly longer than that of men (78.3 ± 11.6 vs 76.6 ± 11.9 years, P = 0.0154). Women experiencing premature menopause had lower risks of all-cause mortality than men, but the advantage that women had in terms of life span was insignificant.

Obesity and 1-year all-cause survival of adult intensive care patients with heart failure: data from the MIMIC-IV.

BackgroundHeart failure is a disease that threatens global public safety. In recent years, the obesity paradox has been studied in cardiovascular disease and other fields. With the progress of aging, metabolic changes and regulation of fat function, it also provides many bridges for the dialogue between disease and molecular metabolism. The purpose of this study is to investigate the effect of obesity on the outcome of adult intensive care patients with heart failure combined with age factors.MethodData were derived from the fourth-generation Medical Information Marketplace for Intensive Care (MIMIC-IV version2.1) using structured query language on the Navicat (12.0.11) platform. People were divided into two groups based on the body mass index (BMI), one group with BMI ≥ 30 kg/m² and another group with BMI < 30 kg/m². Afterwards, the patients were divided into two subgroups based on their ages. One group included patients aged<60, and the other included patients aged ≥ 60. The extracted information includes demographic characteristics, laboratory findings, comorbidities, scores. Main results included in-hospital mortality, ICU mortality, and 1-year mortality. Secondary outcomes included hospital interval and ICU interval, use of renal replacement therapy, and rates of noninvasive and invasive ventilation support.ResultIn this cohort study, 3390 people were in the BMI<30 group, 2301 people were in the BMI ≥ 30 group, 960 people were in the age<60 group, and 4731 people were in the age ≥ 60 group, including 3557 patients after propensity score matching in high age group. Among patients aged ≥ 60, BMI ≥ 30 group vs. BMI<30 group showed significantly lower in-hospital mortality (13% vs. 16%) and one-year mortality (41% vs. 55%), respectively. Neither primary nor secondary outcomes were significantly described in the competition among patients aged under 60. Restricted cubic spline reveals a J-shaped nonlinear association between BMI and clinical endpoints within the entire cohort. Kaplan-Meier curves revealed a survival advantage in BMI ≥ 30 group (p < 0.001). Following age stratification, a beneficial effect of BMI categories on one-year mortality risk was observed in heart failure patients aged ≥ 60 (Univariable HR, 0.71, 95% CI, 0.65–0.78, p < 0.001; Multivariable HR, 0.74, 95% CI, 0.67–0.81, p < 0.001), but not in those under 60 years old.OutcomeIn ICU patients with heart failure, obesity offers a survival benefit to those aged ≥ 60. No obesity paradox was observed in patients younger than 60 years old. The obesity paradox applies to patients aged ≥ 60 with heart failure.

Inequalities for women diagnosed with distal arch and descending thoracic aortic aneurysms: results from the Effective Treatments for Thoracic Aortic Aneurysms (ETTAA) cohort study.

Women with thoracic aortic aneurysms within the arch or descending thoracic aorta have poorer survival than men. Sex differences in relative thoracic aortic aneurysm size may account for some of the discrepancy. The aim of this study was to explore whether basing clinical management on aneurysm size index (maximum aneurysm diameter/body surface area) rather than aneurysm size can restore equality of survival by sex. The Effective Treatments for Thoracic Aortic Aneurysms (ETTAA; ISRCTN04044627) study was a prospective, observational cohort study. Adults referred to National Health Service hospitals in England with new/existing arch or descending thoracic aorta aneurysms greater than or equal to 4 cm in diameter were followed from March 2014 to March 2022. Baseline characteristics and survival to intervention and overall were compared for men and women. Survival models were used to assess the association between all-cause survival and sex, with and without adjustment for aneurysm diameter or aneurysm size index. A total of 886 thoracic aortic aneurysm patients were recruited: 321 (36.2%) women and 565 (63.8%) men. The mean(s.d.) aneurysm diameter was the same for women and men (5.7(1.1) versus 5.7(1.2) cm respectively; P = 0.751), but the mean(s.d.) aneurysm size index was greater for women than for men (3.32(0.80) versus 2.83(0.63) respectively; P < 0.001). Women had significantly worse survival without intervention: 110 (34.3%) women and 135 (23.9%) men (log rank test, P < 0.001). All-cause mortality remained greater for women after adjustment for diameter (HR 1.65 (95% c.i. 1.35 to 2.02); P < 0.001), but was attenuated after adjustment for aneurysm size index (HR 1.11 (95% c.i. 0.89 to 1.38); P = 0.359). Similar results were found for all follow-up, with or without intervention, and findings were consistent for descending thoracic aorta aneurysms alone. Guidelines for referral to specialist services should consider including aneurysm size index rather than diameter to reduce inequity due to patient sex.

PRAME Expression in Merkel Cell Carcinoma.

Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine tumor of the skin. Risk factors include extensive sun damage, infection with Merkel cell polyomavirus, and an immunocompromised state. PRAME, also known as preferentially expressed antigen in melanoma, is a cancer-testis antigen recently found to be a useful diagnostic tool in the workup of melanocytic neoplasms. However, the expression pattern of PRAME in Merkel cell carcinoma is unknown. In this study, we examine PRAME expression in Merkel cell carcinoma and explore its prognostic implications. The institutional archives at the University of Virginia were used to search for tumors classified as Merkel cell carcinoma from 2004 to 2022. All potential cases were reviewed to confirm the diagnosis, and electronic medical records were searched for clinical and demographic data. Tumors were subsequently immunostained for PRAME and Merkel cell polyomavirus. Cox proportional hazards regression models were used to estimate relative (all-cause) survival of PRAME positivity and MCPyV positivity in our study as well as MCC-specific survival of PRAME positivity. Univariate and multivariable models were created for each outcome related to all-cause survival. A total of 39 cases were included in the study. Twenty-eight percent (11 cases) demonstrated strong PRAME expression, and 27% of cases were positive for Merkel cell polyomavirus. There was no statistically significant correlation between PRAME expression and virus positivity. With respect to PRAME, the adjusted all-cause mortality hazard ratio was 11.4 (95% CI: 1.8, 70.8). The unadjusted MCC-specific hazard ratio was 4.6 (95% CI: 0.8, 27.5). The adjusted hazard ratio pertaining to Merkel cell polyomavirus infection was 0.25 (95% CI: 0.02, 2.96). In this limited cohort, PRAME expression appears to correlate with worse outcomes in Merkel cell carcinoma.

Incidence and survival of pediatric and adult hepatocellular carcinoma, United States, 2001–2020

BackgroundHepatocellular carcinoma accounts for approximately 80 % of liver neoplasms. Globally, hepatocellular carcinoma ranks as the third most lethal cancer, with the number of deaths expected to further increase by 2040. In adults, disparities in incidence and survival are well described while pediatric epidemiology is not well characterized. We describe incidence and survival for pediatric (ages 0–19 years) hepatocellular carcinoma cases and compare these measures to adults (ages ≥ 20 years) diagnosed with hepatocellular carcinoma. MethodsWe assessed incidence data from the US Cancer Statistics database during 2003–2020 and 5-year survival from the National Program of Cancer Registries during 2001–2019. Incidence trends were determined by annual percent change (APC) and average APC (AAPC) using joinpoint regression. Five-year survival was evaluated by relative survival, and all-cause survival was estimated using multivariate Cox modeling. Corresponding 95 % confidence intervals (CI) were calculated for all analyses. ResultsIncidence rate per 100,000 persons was 0.056 (95 %CI:0.052–0.060) for pediatric cases and 7.793 (7.767–7.819) for adults. Incidence was stable in the pediatric population (0.3 AAPC, − 1.1 to 1.7). In contrast, after periods of increase, incidence declined in adults after 2015 (-1.5 APC). Relative survival increased over time for both pediatric and adult ages and was higher for children and adolescents (46.4 %, 95 %CI:42.4–50.3) than adults (20.7 %, 95 %CI:20.5–20.9). Regression modeling showed that non-Hispanic Black race and ethnicity was associated with higher risk of death in children and adolescents (1.48, 95 %CI:1.07–2.05) and adults (1.11, 95 %CI:1.09–1.12) compared to non-Hispanic white race and ethnicity. ConclusionsBetween 2003 and 2020 in the United States, pediatric incidence was stable while incidence in adults began to decline after 2015. Survival was higher across all stages for children and adolescents compared to adults. Non-Hispanic Black race and ethnicity showed a higher risk of death for both age groups. Further studies could explore the factors that influence these outcome disparities.

No difference in midterm outcomes and complication rate between retroperitoneal and transperitoneal open aortic aneurysm repair in females.

Abdominal Aortic Aneurysms (AAA) in females are less prevalent, have higher expansion rates and experience rupture at smaller diameters than in males. Studies have compared outcomes of the retroperitoneal (RP) and transperitoneal (TP) approach in open aortic aneurysm repair (OAR) with conflicting results. No study to date has compared the two approaches solely in females. In this study we compare midterm outcomes of the RP and TP approach in females undergoing OAR. Single-center, retrospective review of all females undergoing OAR from 2010 to 2021. Patients undergoing elective, symptomatic and ruptured OAR were included. The cohort was stratified by surgical approach RP versus TP and midterm outcomes were compared amongst the groups. Outcomes included mortality, graft related, and non-graft related complications. A total of 244 patients (RP n = 133; TP n = 111) were identified. Follow-up period was 28 ± 30.7months. Baseline perioperative characteristics were similar except that more people in the RP group had ejection fraction ((EF) > 50% (82% vs 68%), p = .037). Patients who underwent RP repair had longer visceral/renal ischemia time (p = .01), larger graft diameter (18 vs 16mm; p = <0.001), were more likely to have a suprarenal clamp placed(70.5 vs 48.2; p < .001), and had decreased autotransfusion volume (611 vs 861mL; p < .01) compared to those who underwent TP repair. Number of deaths was higher in the TP group during study follow-up period (36.4 vs 23.8; p = .035), but the difference of the time to event analysis was not significant. There was no difference in all-cause survival at 36 months between RP and TP (77.8 vs 76.8; p = .045). Overall midterm complications were 9.5% in both groups. Any graft related complication was 1.8% in TP versus 3% RP (p = .69). In a multivariable model, after adjusting for age, urgency, smoking, prior aneurysm repair, and ASA level, the hazard ratio decreases with the RP approach, however this did not reach significance (p = .052). In a 12-year period of OAR in females, TP and RP results were comparable at midterm analysis. The RP approach appeared to be used more often for OAR requiring suprarenal clamping. Although the TP group had increased mortality, the difference of the time to event analysis was not significant. Midterm postoperative complications in both groups were low. This suggests that both approaches are safe in the female population and decision should be driven by anatomy and surgeon's preference.

Access to Prostate-Specific Antigen Testing and Mortality Among Men With Prostate Cancer

Prostate-specific antigen (PSA) screening for prostate cancer is controversial but may be associated with benefit for certain high-risk groups. To evaluate associations of county-level PSA screening prevalence with prostate cancer outcomes, as well as variation by sociodemographic and clinical factors. This cohort study used data from cancer registries based in 8 US states on Hispanic, non-Hispanic Black, and non-Hispanic White men aged 40 to 99 years who received a diagnosis of prostate cancer between January 1, 2000, and December 31, 2015. Participants were followed up until death or censored after 10 years or December 31, 2018, whichever end point came first. Data were analyzed between September 2023 and January 2024. County-level PSA screening prevalence was estimated using the Behavior Risk Factor Surveillance System survey data from 2004, 2006, 2008, 2010, and 2012 and weighted by population characteristics. Multivariable logistic, Cox proportional hazards regression, and competing risks models were fit to estimate adjusted odds ratios (AOR) and adjusted hazard ratios (AHR) for associations of county-level PSA screening prevalence at diagnosis with advanced stage (regional or distant), as well as all-cause and prostate cancer-specific survival. Of 814 987 men with prostate cancer, the mean (SD) age was 67.3 (9.8) years, 7.8% were Hispanic, 12.2% were non-Hispanic Black, and 80.0% were non-Hispanic White; 17.0% had advanced disease. There were 247 570 deaths over 5 716 703 person-years of follow-up. Men in the highest compared with lowest quintile of county-level PSA screening prevalence at diagnosis had lower odds of advanced vs localized stage (AOR, 0.86; 95% CI, 0.85-0.88), lower all-cause mortality (AHR, 0.86; 95% CI, 0.85-0.87), and lower prostate cancer-specific mortality (AHR, 0.83; 95% CI, 0.81-0.85). Inverse associations between PSA screening prevalence and advanced cancer were strongest among men of Hispanic ethnicity vs other ethnicities (AOR, 0.82; 95% CI, 0.78-0.87), older vs younger men (aged ≥70 years: AOR, 0.77; 95% CI, 0.75-0.79), and those in the Northeast vs other US Census regions (AOR, 0.81; 95% CI, 0.79-0.84). Inverse associations with all-cause mortality were strongest among men of Hispanic ethnicity vs other ethnicities (AHR, 0.82; 95% CI, 0.78-0.85), younger vs older men (AHR, 0.81; 95% CI, 0.77-0.85), those with advanced vs localized disease (AHR, 0.80; 95% CI, 0.78-0.82), and those in the West vs other US Census regions (AHR, 0.89; 95% CI, 0.87-0.90). This population-based cohort study of men with prostate cancer suggests that higher county-level prevalence of PSA screening was associated with lower odds of advanced disease, all-cause mortality, and prostate cancer-specific mortality. Associations varied by age, race and ethnicity, and US Census region.

Comparison of the Value of Four Objective Nutritional Indices in Assessing the Long-Term Prognosis of Elderly Patients with Heart Failure with Preserved Ejection Fraction.

The long-term prognosis of heart failure with preserved ejection fraction (HFpEF) is influenced by malnutrition. Currently, there's a deficit in objective and comprehensive nutritional assessment methods to evaluate the nutritional status and predicting the long-term outcomes of HFpEF patients. Our retrospective study included two hundred and eighteen elderly HFpEF patients admitted to the cardiovascular ward at the Air Force Medical Centre from January 2016 to December 2021. Based on follow-up outcomes, patients were categorized into all-cause death (99 cases) and Survival (119 cases) groups. We compared general data, laboratory results, and nutritional indexes between groups. Differences in subgroups based on Triglyceride-Total Cholesterol-Body Weight Index (TCBI), Geriatric Nutritional Risk Index (GNRI), Prognostic Nutritional Index (PNI), and Controlled Nutrition Score (CONUT) were analyzed using Kaplan-Meier survival curves and log-rank test. COX regression was used to identify all-cause mortality risk factors, and the predictive accuracy of the four nutritional indices was assessed using receiver operating characteristic (ROC) curves and Delong test analysis. A total of 101 (45.41%) HFpEF patients experienced all-cause mortality during 59.02 1.79 months of follow-up. The all-cause mortality group exhibited lower GNRI and PNI levels, and higher CONUT levels than the Survival group (p 0.05). Kaplan-Meier analysis revealed lower cumulative survival in the low GNRI ( 96.50) and low PNI ( 43.75) groups, but higher in the low CONUT ( 2) group, compared to their respective medium and high-value groups. Multifactorial COX regression identified low PNI ( 43.75) as an independent all-cause mortality risk factor in elderly HFpEF patients. ROC and Delong's test indicated PNI (area under the curve [AUC] = 0.698, 95% confidence interval [CI] 0.629-0.768) as a more effective predictor of all-cause mortality than TCBI (AUC = 0.533, 95% CI 0.456-0.610) and CONUT (AUC = 0.621, 95% CI 0.547-0.695; p 0.05). However, there was no significant difference compared to GNRI (AUC = 0.663, 95% CI 0.590-0.735; p 0.05). In elderly HFpEF patients a PNI 43.75 was identified as an independent risk factor for all-cause mortality. Moreover, PNI demonstrates superior prognostic performance in predicting all-cause mortality in elderly patients with HFpEF when compared to TCBI, GNRI, and COUNT.