All-cause Survival Research Articles

Early experience and technical aspects of physician-modified fenestration in thoracic endovascular aortic repair for aortic arch pathologies.

ObjectiveThis study was performed to describe the treatment of aortic arch pathologies with a physician-modified fenestration (PMF) technique in thoracic endovascular aortic repair (TEVAR).MethodsFrom August 2015 to August 2017, 32 patients with aortic arch pathologies underwent TEVAR with the PMF technique. All patients’ clinical data were analyzed with GraphPad Prism 7.0.ResultsThirty-four aortic stent-grafts were implanted in 32 patients. The mean proximal diameter of the stent-graft was 32.4 ± 3.4 cm, and the mean length was 170.0 ± 25.2 cm. Twenty-nine PMF procedures were performed to preserve the left subclavian artery (LSA) and three to preserve both the LSA and left common carotid artery. The mean distance between the pathology and LSA was 8.4 ± 4.0 mm. The mean procedure time (from first to last digital subtraction angiography) was 22.8 ± 20.8 min. The mean follow-up time was 8.3 ± 5.3 months. During follow-up, the all-cause survival rate was 83.3% and the patency rate of the branch artery after PMF was 96.0%.ConclusionThe PMF technique is a relatively safe, feasible, and time-saving method to preserve the branch artery in TEVAR for aortic arch pathologies. The short- to middle-term result of this technique is satisfactory.

Total hip arthroplasty following acetabular fracture: a clinical and radiographic outcome analysis of 67 patients.

Total hip arthroplasty (THA) is a challenging option for the treatment of posttraumatic arthritis due to acetabular fractures. The study aimed to determine the short- and mid-term clinical and radiographic results of THA following acetabular fracture. The fracture pattern, the extent of injury and the initial fracture treatment were considered to evaluate the influence of these factors on the clinical-radiographic outcome. 67 patients who received THA for the treatment of posttraumatic osteoarthritis after acetabular fracture between January 2007 and December 2012 were analyzed consecutively. The group consisted of 13 female (19%) and 54 male (81%) patients with a mean age of 59 (25-87) years at the time of THA. The time between acetabular injury and arthroplasty was 107 (1-504) months on average. The all-cause 8-year survival rate was 0.87% (0.76-0.93) and there were 8 revisions, half of them were due to aseptic loosening of the cup. The Harris Hip Score achieved was 75.7 ± 21.3 (26.9-100) points. Prior to THA, heterotopic ossifications were detected in 28% and after THA implantation in 42%. The decrease of the interval between injury and arthroplasty was associated with increasing patient age (p = 0.001) and surgical treatment of the acetabular fracture (p = 0.04). Complex fracture patterns were accompanied by acetabular bone defects more often than simple patterns (p = 0.03). Overall, arthroplasty due to posttraumatic osteoarthritis after acetabular fracture resulted in decreased overall survival rates and poorer clinical outcome as compared to primary arthroplasty.

Long-term freedom from aneurysm-related mortality remains favorable after endovascular abdominal aortic aneurysm repair in a 15-year multicenter registry

ObjectiveEndovascular aneurysm repair (EVAR) has become the preferred approach to abdominal aortic aneurysm (AAA) because of lower early morbidity and mortality than open repair. However, the ability of EVAR to prevent long-term aneurysm-related mortality (ARM) has been questioned in light of recent trial data. We have updated our long-term EVAR experience in a large multicenter registry to further examine this issue. MethodsBetween 2000 and 2010, 1736 patients with AAA underwent EVAR in a large integrated regional healthcare system. We extended follow-up in this previously reported cohort through 2015 and identified predictors associated with ARM and need for major reintervention. The primary outcome was ARM. Secondary outcomes were all-cause mortality, delayed aneurysm rupture, major adverse event, major reintervention, sac growth of more than 5 mm, and type I or III endoleak. End points were analyzed for the whole cohort and compared for patients who underwent EVAR during the earlier (2000-2005) and latter (2006-2010) halves of the enrollment period to assess for changes in outcomes over time of repair. ResultsThe overall follow-up rate was 96.3%, and median follow-up was 5.5 years (interquartile range, 2.8-7.7 years). During the study period, 958 patients died, of whom 63 experienced ARM (6.6%). Overall crude rate of freedom from ARM was 96.4%. Delayed aneurysm rupture was seen in 1.3% (n = 23), with a median time to event of 4.1 years (interquartile range, 1.7-7.2 years). Major adverse events occurred in 12.4% of patients, and major reintervention was performed in 10.3%. Overall freedom from major adverse event or major reintervention was seen in 84.0%. Significant predictors of ARM included female sex, age 80 to 89 years, urgent EVAR, and any major reintervention. The unadjusted cumulative probability of all-cause survival was significantly higher in the late group than the early group at 5 years (66.8% vs 59.8%; P = .01, log-rank test); however, freedom from ARM at 5 years was not significantly different (96.5% and 97.1%, respectively; P = .67, log-rank test). ConclusionsOur results demonstrate favorable long-term freedom from major adverse event or major reintervention after EVAR and extremely low rates of ARM and delayed rupture. Our findings support EVAR as a safe, long-term solution for managing patients with AAA and provide insight into clinical parameters that can be used to stratify patients' post-EVAR surveillance and need for reintervention.

Impact of Initial Therapy on Survival In Splenic Marginal Zone Lymphoma

A variety of treatment options exist for splenic marginal zone lymphoma (SMLZ). Although no prospective, randomized data have directly compared these modalities, small, single institution studies have shown superior outcomes with splenectomy compared to chemotherapy. Many patients can be managed with observation. Here we aimed to compare splenectomy, chemotherapy, or observation on overall (OS) and disease specific survival (DSS) in a large population-based cohort. SEER 18 database was used to identify patients diagnosed with SMZL from 1993 to 2014 using ICD-O-3 code 9689/3. Patients with treatment, overall survival, and cause specific survival data were included for analysis. Treatment modalities were grouped into observation, surgery, chemotherapy, surgery and chemotherapy, or radiotherapy. OS and DSS were calculated utilizing the Kaplan Meier method. Univariate survival analysis was performed with variables to assess their impact on survival using log-rank test. Multivariate analysis (MVA) was performed using cox proportional hazards models to adjust the effect of age, sex, race, Ann Arbor staging, history of prior cancer, and treatment modality for the other variables. 2062 patients with SMZL met eligibility criteria. Median age was 67.9 (range 25 – 96) with 52.6% (n=1084) women, 90.3% (n=1841) white, 65.0% (n=1340) Ann Arbor Stage IV disease, and 18.0% (n=370) with a previous cancer diagnosis. After SMZL diagnosis, 31.9% (n=657) were observed, 42.7% (n=881) received surgery, 33.1% (n=682) received chemotherapy, 8% (n=165) received a surgery and chemotherapy, and 0.9% (n=19) received radiotherapy. 5-year DSS and OS was 73% and 41%. Median survival of those who received surgery vs. those who did not was 134 vs. 105 months (p=0.007). Median survival of those who received chemotherapy vs. those who did not was 33.1 vs. 66.9 months (p=0.11). Median survival of those who were observed vs. those who received treatment of any kind was 111 vs. 123 months (p=0.25). On univariate analysis, age >70 (p=0.002) and having >1 cancer (p<0.001) were associated with an increased risk of all-cause mortality. Treatment with surgery (p=0.007) was associated with a decreased risk of all-cause mortality. On MVA, age >70 (p=0.002) was associated with an increased risk of all-cause mortality. Chemotherapy use was associated with an increased risk of all-cause (p=0.003) and disease-specific (p<0.001) mortality. Treatment with surgery or observation was not associated with all-cause or disease-specific mortality on MVA. In patients with SMZL, chemotherapy use was associated with an increased risk of both all-cause and disease-specific survival, possibly attributable to selection biases, with comparisons limited by absence of data on performance status, comorbidities and salvage therapy as well as under-reporting of chemotherapy in the SEER registries. Surgery or observation remains reasonable options for SMZL.

Endovascular Repair of Ruptured Abdominal Aortic Aneurysm Is Superior to Open Repair: Propensity-Matched Analysis in the Vascular Quality Initiative

The three randomized trials comparing endovascular aneurysm repair (rEVAR) with open surgical repair (rOSR) of ruptured abdominal aortic aneurysm (rAAA) were poorly designed and heavily criticized. The short- and long-term survival advantages of rEVAR remain unclear. We sought to compare the two treatment modalities using a propensity-matched analysis in a real-world setting. All rOSR and rEVAR procedures in the Vascular Quality Initiative were analyzed (2003-2018). Raw and propensity-matched rEVAR and rOSR cohorts were compared. Primary outcomes included postoperative major adverse events (MAEs; cardiovascular, pulmonary, renal, bowel/limb ischemia, reoperation) and 30-day and 1-year mortality. Univariate, multivariate, and Kaplan-Meier analyses were performed. There were 4929 rAAA repairs performed, 2749 rEVAR and 2180 rOSR. Compared with rEVAR, rOSR had higher myocardial ischemia events (15% vs 10%; P < .001), MAEs (67% vs 37%; P < .001), and 30-day death (34% vs 21%; P < .001; Table I). On adjusted analysis, rOSR was predictive of 30-day mortality (odds ratio, 1.9; 95% confidence interval, 1.6-2.2). After 1:1 matching, the study cohort consisted of 724 pairs of rOSR and rEVAR patients. The rOSR patients had twice the length of stay (median, 10 days [interquartile range, 5-19 days] vs 5 days [interquartile range, 3-10 days]; P < .001). Univariate analysis demonstrated persistent increased 30-day mortality after rOSR (32% vs 18%; P < .001) and higher rates of myocardial infarction (rOSR 14% vs rEVAR 8%; P = .002), respiratory complications (38% vs 20%; P < .001), and acute kidney injury (42% vs 26%; P < .001). Overall MAE rate was higher after rOSR (68% vs 35%; P < .001). Multivariable regression analysis of the propensity-matched pairs demonstrated that rOSR was associated with double the 30-day mortality compared with rEVAR (odds ratio, 2.1; 95% confidence interval, 1.7-2.8; Table II). All-cause 1-year survival was 73% and 59% after rEVAR and rOSR in the propensity-matched cohort, respectively (P < .001). This is the largest study of rAAA demonstrating clear short- and long-term survival benefit of rEVAR over rOSR that persisted after matching on all major demographic, comorbid, and anatomic variables. Furthermore, patients undergoing rOSR had twice the length of stay with increased rates of complications compared with rEVAR. These data suggest a more aggressive endovascular approach for rAAA in patients with suitable anatomy.Table IDemographics of matched and nonmatched patients undergoing endovascular aneurysm repair (rEVAR) or open surgical repair (rOSR) of ruptured abdominal aortic aneurysm (rAAA)NonmatchedMatchedrEVAR (n = 2749)rOSR (n = 2180)P valuerEVARa (n = 724)rOSRa (n = 724)P valueDemographics Age, years73 (66-81)72 (66-79)<.00172 (66-80)72 (66-79).79 Sex, female586 (21)475 (22).68127 (19)162 (22).10 White race2392 (87)1984 (91)<.001653 (90)660 (91).53Comorbidities Smoking history2083 (77)1761 (84)<.001590 (82)579 (80).46 CHF337 (13)196 (9)<.00159 (8)67 (9).46 COPD780 (29)705 (33).002217 (30)224 (31).69 ESRD45 (2)16 (1).011 (0.1)1 (0.1)1Anatomic Prior AAA repair73 (3)217 (10)<.00117 (2)19 (3).74 Maximum AAA diameter, mm71 (60-85)77 (64-90)<.00175 (63-89)75 (63-89)1 Iliac aneurysmal disease615 (24)476 (23).23179 (26)159 (22).12AAA, Abdominal aortic aneurysm; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; ESRD, end-stage renal disease.Categorical variables are presented as number (%). Continuous variables are presented as median (interquartile range).aMatched on type of operative repair, age, race, smoking history, congestive heart failure, chronic obstructive pulmonary disease, end-stage renal disease, prior AAA repair, maximal aortic sac diameter, preoperative medications. Open table in a new tab Table IIPredictors of 30-day mortality after ruptured abdominal aortic aneurysm (rAAA) repair in both unmatched (model 1) and matched (model 2) cohortsOR (95% CI)P valueModel 1: Unmatched cohorta Open operative repair1.86 (1.56-2.23)<.001 Age ≥60 years2.06 (1.33-3.20).001 Female sex1.53 (1.24-1.90)<.001 Obese1.32 (1.09-1.58).004 Congestive heart failure1.38 (1.04-1.83).03 Maximal AAA diameter ≥71 mm1.38 (1.06-1.81).02Model 2: Propensity-matched cohortb Open operative repair2.14 (1.66-2.77)<.001 Age ≥60 years2.59 (1.34-5.00).01 Female sex1.46 (1.07-1.98).02 Obese1.48 (1.14-1.93).004 Hypertension0.55 (0.41-0.74)<.001AAA, Abdominal aortic aneurysm; CI, confidence interval; OR, odds ratio.aAdjusts for type of repair, age, sex, race, obesity, smoking history, coronary artery disease, congestive heart failure, maximal aortic diameter, iliac aneurysmal disease.bAdjusts for type of repair, age, sex, obesity, smoking history, hypertension, preoperative medications, congestive heart failure, maximal aortic diameter, iliac aneurysmal disease. Open table in a new tab

Comparison among Different Scoring Systems in Predicting Procedural Success and Long-Term Outcomes after Percutaneous Coronary Intervention in Patients with Chronic Total Coronary Artery Occlusions.

Background and objectives: Different scoring systems are used to stratify patients with chronic total coronary artery occlusions (CTO) according to disease complexity to predict the success of the percutaneous coronary intervention (PCI). Comparison among different CTO scoring systems and long-term outcome for patients with CTO after PCI has not been well established. The objectives of the study were to assess the ability of different disease severity scoring systems to predict, first, procedural success and, second, overall survival in patients with a successful procedure. Materials and Methods: A total of 551 patients who underwent elective CTO PCI in Riga East University hospital from January 2007 to December 2016 were included in the study. Four scoring systems (J CTO, PROGRESS CTO, CL, and CASTLE) were calculated. ROC curves were used to assess the association between scores and procedural success, and the Kaplan–Meier method and Cox regression were used to estimate the association with death from any cause after a successful procedure, Results: 454 of 551 cases were successful. With increasing disease complexity, the procedural success rate was significantly reduced in all scoring systems (p < 0.001): Area under the curve was 0.714 for J CTO score, 0.605 for PROGRESS CTO, 0.624 for CL and 0.641 for CASTLE scores. During the median 6.8 years of follow-up time, survival was better in the successful procedure group (p = 0.041). Among patients with procedural success, only PROGRESS and CASTLE scores showed an association with all-cause risk of death. After adjustment for baseline characteristics, patients having high PROGRESS score had almost twice higher risk of death (HR 1.81(95% CI 1.19–2.75)), and those with high and intermediate CASTLE score experienced almost four (HR 3.68(95% CI 1.50–9.05)) and two (HR 2.15, (95% CI 1.42–3.23)) times higher risk of death than the low score patients, respectively. Conclusions: All four CTO scoring systems had moderate ability to predict procedural success. More complex CTO PCI patients, assessed by PROGRESS and CASTLE scores, has worse all-cause survival in six to seven years after a successful procedure; whereas J CTO and CL scores had no association with survival.

Endovascular Aneurysm Repair May Provide a Survival Advantage in Patients Deemed Physiologically Ineligible for Open Abdominal Aortic Aneurysm Repair

Cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capacity and fitness. It can be used to guide decision making prior to major vascular surgery. The EVAR-2 trial suggested that endovascular aneurysm repair (EVAR) in patients unfit for open repair failed to provide a significant survival advantage over nonsurgical management. The aim of this study is to assess contemporary survival differences between patients with poor CPET measures who underwent EVAR or were not offered surgical intervention. A prospectively maintained database of CPET results of patients considered for elective infrarenal aortic aneurysm repair were interrogated. Anaerobic threshold (AT) of <11mL/min/kg was used to indicate poor physical fitness. Hospital electronic records were then reviewed for perioperative, reintervention, and long-term outcomes. Between November 2007 and October 2017, 532 aortic aneurysm repairs were undertaken, of which 376 underwent preoperative CPET. Seventy patients were identified as having an AT <11mL/min/kg. Thirty-seven patients underwent EVAR and 33 were managed nonsurgically. All-cause survival at 1, 3, and 5years for those patients who underwent EVAR was 97%, 92%, and 81%, respectively. For those not offered surgical intervention survival at the same points was 72%, 48%, and 24% [hazard ratio, HR=5.13 (1.67-15.82), P=0.004]. Aneurysm-specific survival at 1, 3, and 5years for those patients who underwent EVAR was 97%, 94%, and 94%, respectively. Survival at the same time points for those not offered surgical intervention was 90%, 69%, and 39%, respectively [HR=7.48 (1.37-40.82), P=0.02]. In this small, retrospective, single-center, nonrandomized cohort, EVAR may provide a survival advantage in patients with poor physical fitness identified via CPET. Randomized studies with current generation EVAR are required to validate the results shown here.

Clinical Characteristics and Long-Term Mortality Rate in Female Patients with Takotsubo Syndrome Compared with Female Patients with ST-Elevation Acute Myocardial Infarction: A Retrospective Study from a Single Center

Background Takotsubo syndrome (TTS) is characterized by acute transient, stress-induced, left ventricular systolic dysfunction, generally presenting with apical ballooning. It can mimic an acute coronary syndrome, but with a milder increase in cardiac enzymes and without culprit coronary artery disease on angiography. Data on long-term follow-up and survival in patients with TTS, compared with patients with ST-elevation myocardial infarction (STEMI), are scarce. Purpose To assess all-cause mortality rate and survival in a consecutive series of female patients with TTS compared with age- and sex-matched STEMI patients on long-term follow-up. Methods and Results We collected data of 65 TTS female patients (TTS group) with a mean age of 73.42 ± 11.35 years from 2001 to 2013. Collection of follow-up information was concluded for all patients in 2016. To compare the mortality and survival of TTS patients with those of the STEMI population, we used data from our STEMI Registry, a prospective registry of 7446 STEMI patients admitted from 2001 to 2013 to our cath-lab for primary percutaneous coronary intervention (p-PCI). From the registry, we selected 104 STEMI patients (STEMI group) comparable to our TTS group in terms of age (mean age of 72.33 ± 11.92 years) and sex. On follow-up examination after a median of 1000 days, the TTS group had a lower all-cause mortality rate than the STEMI group (7.69% versus 23.08%). This difference was statistically different between the two groups (log-rank test, p value = 0.03). Conclusions In our study, TTS and STEMI patients displayed a statistically significant difference in long-term survival. Specifically, the TTS group had a lower mortality rate than the STEMI group. This seems to suggest that TTS and STEMI are two different clinical entities with two different clinical outcomes.

Fractional Excretion of Phosphate (FeP) Is Associated with End-Stage Renal Disease Patients with CKD 3b and 5.

Background: The perturbation of phosphate homeostasis portends unfavorable outcomes in chronic kidney disease (CKD). However, the absence of randomized clinical trials (RCT) fuels the discussion of whether phosphate or some other phosphorous-related factor(s) such as fibroblast growth factor 23 (FGF-23) mediates the cardiovascular and systemic toxicity. We herein test whether the fractional excretion of phosphate (FeP) as a marker of renal stress to excrete phosphorous predicts unfavorable outcomes in CKD patients. Methods: Retrospective, cross-sectional observational study. For current analysis, an historical cohort of 407 records of CKD stage 3b-5 patients attending between January 2010 and October 2015 at the Nephrology Unit of Solofra (AV), Italy were utilized. Demographic, clinical, laboratory, and outcome data were identified through the subjects’ medical records. We tested whether quartiles of FeP are associated with the risk of CKD progression or all causes of death. Parametric as well as non-parametric tests, linear and logistic regression, as well as survival analysis were utilized. Results: Overall, we investigated middle-age (mean 66.0, standard deviation 12.3 years) men and women (male 43%) with CKD stage 3b to 5 (creatinine clearance 32.0 (13.3) mL/min). Older age, lower diastolic blood pressure, poor renal function, as well as higher serum phosphate were associated with FeP. Patients with higher FeP were at an increased risk of starting dialysis or dying (hazard ratio 2.40; 95% confidence interval (1.44, 3.99)). Notably, when the two endpoints were analyzed separately, FeP was associated with renal but not all-cause survival. Conclusion: FeP is associated with ESRD, but not all-cause mortality risk in a large cohort of moderate to advanced CKD patients. Future efforts are required to validate FeP as a marker of nephron stress and risk factor for CKD progression in this high-risk population.

Illustration of different modelling assumptions for estimation of loss in expectation of life due to cancer

BackgroundThe life expectancy of cancer patients, and the loss in expectation of life as compared to the life expectancy without cancer, is a useful measure of cancer patient survival and complement the more commonly reported 5-year survival. The estimation of life expectancy and loss in expectation of life generally requires extrapolation of the survival function, since the follow-up is not long enough for the survival function to reach 0. We have previously shown that the survival of the cancer patients can be extrapolated by breaking down the all-cause survival into two component parts, the expected survival and the relative survival, and make assumptions for extrapolation of these functions independently. When extrapolating survival from a model including covariates such as calendar year, age at diagnosis and deprivation status, care has to be taken regarding the assumptions underlying the extrapolation. There are often different alternative ways for modelling covariate effects or for assumptions regarding the extrapolation.MethodsIn this paper we describe and discuss different alternative approaches for extrapolation of survival when estimating life expectancy and loss in expectation of life for cancer patients. Flexible parametric models within a relative survival setting are used, and examples are presented using data on colon cancer in England.ResultsGenerally, the different modelling assumptions and approaches give small differences in the estimates of loss in expectation of life, however, the results can differ for younger ages and for conditional estimates.ConclusionSensitivity analyses should be performed to evaluate the effect of the assumptions made when modelling and extrapolating survival to estimate the loss in expectation of life.

Ongoing improvements in postoperative survival of glioblastoma in the temozolomide era: a population-based data linkage study.

Translating outcomes achieved by clinical trials into routine care is crucial to improving outcomes of glioblastoma (GBM). This study examines the extent to which an advance in treatment for GBM has translated into meaningful, population-level survival benefits in New South Wales (NSW), Australia. This retrospective cohort study used linked population-based cancer registry, admitted patient, and mortality datasets. The cohort (n = 2604) included NSW residents aged ≥18 years with a histologically confirmed GBM and a surgical resection between July 2001 and December 2012. The study outcome was all-cause survival, examined using multivariable proportional hazard models. The main study factor was period of surgery, categorized into 4 periods corresponding to different eras in temozolomide (TMZ) use. Survival was examined over time by age (≤70 and >70 years) and for a subcohort selected to approximate the seminal European Organisation for Research and Treatment of Cancer (Stupp) protocol trial cohort. TMZ use was estimated using aggregate prescription claims data. Median survival in 2001-2003, 2004-2006, 2007-2009, and 2010-2012 was 7.4, 9.0, 9.8, and 10.6 months, and risk-adjusted 2-year survival was 8.2%, 13.8%, 15.5%, and 18.3%, respectively. Survival improved for those aged ≤70 years and those aged >70 years. In the proxy trial subcohort, median and 2-year survival were 14.3 months and 27.3%, respectively. The volume of TMZ prescribed annually increased rapidly from 2005. Introduction of TMZ into standard care in 2005 coincided with improvements in survival and a rapid increase in TMZ prescribing. Optimization of care has continued to improve survival of people with GBM in subsequent years.

Fifteen-year survival of the Cedior™ total knee prosthesis.

Total knee arthroplasty (TKA) is an effective treatment for advanced osteoarthritis of the knee. No large and long-term follow-up study has been done about Cedior® prosthesis. The study hypothesis was that 15-year survival for the Cedior™ prosthesis is at least as good as rates reported for other models. A continuous retrospective single-center study included patients managed by Cedior™ TKA with at least 15-year follow-up. The main endpoint was prosthesis survival; secondary objectives were to identify factors for implant revision and to assess functional scores at 15years. In the present series, 15-year all-cause survival for the Cedior® knee prosthesis was 93.03%; comparable to rates in the literature, posterior-stabilized implants showed higher revision rates. No other factors for revision emerged. These findings are comparable with those of the literature.

Association between cancer concealment and the survival of the patients with non-small cell lung carcinoma.

To explore the relationship between cancer awareness and the survival of the patients with non-small cell lung carcinoma (NSCLC). Methods: A total of 865 NSCLC patients were screened for the risk factors, including age, gender, address, tumor/lymph nodes/metastasis (TNM) stage, and cancer awareness. Survival of the patients was calculated by Kaplan-Meier method and Cox regression analysis. Results: After an average observation time of 304 d (ranging from 0 to 4 718 d), 62 of the 394 patients in the cancer awareness group survived, whereas 26 of the 471 patients in the cancer concealment group survived. Cancer-specific and all-cause survival was poorer in the cancer concealment group (P<0.001 for each, log-rank test). Cox multivariate regression analysis showed that cancer concealment displayed significantly lower cancer-specific survival [hazard ratio (HR)=1.534, 95% confidence interval (CI) 1.320 to 1.784, P<0.001] and all-cause survival (HR=1.558, 95% CI 1.346 to 1.803, P<0.001). Conclusion: Cancer concealment is associated with a poor survival of NSCLC patients, which may prohibit the patients from obtaining the real "right to survival".

Differences in presentation and survival of Asians compared to Caucasians with ovarian cancer: An NRG Oncology/GOG Ancillary study of 7914 patients

PurposeTo compare patient/tumor characteristics and outcomes of Asians to Caucasian patients with epithelial ovarian cancer. MethodsAncillary data were pooled and analyzed from ten prospective randomized front-line Gynecologic Oncology Group clinical trials from 1996 to 2011. Demographic, clinicopathologic features, disease-specific and all-cause survival were analyzed. ResultsOf 7914 patients, 7641 were Caucasian and 273 Asian. When compared to Caucasians, Asians were younger at trial enrollment, had a better performance status, earlier-stage cancers (17.2% vs. 8.1% with stage I; p < 0.001), and were more likely to be of clear cell (15.8% vs. 6.2%, p < 0.001) and mucinous (3.3% vs. 1.9%, p < 0.001) histology. Asians had an improved 5-year disease-specific survival of 54.1% compared to 46.1% for Caucasians, p = 0.001. In multivariate analysis, the Asian race remained a significant prognostic factor for all-cause survival (HR: 0.84; 95% CI: 0.72–0.99; p = 0.04). Other factors predictive of improved survival included younger age, better performance status, optimal cytoreduction, earlier stage, non-clear cell histology, and lower grade tumors. ConclusionAsians enrolled into phase III ovarian cancer clinical trials were younger, with better performance status, earlier-stage of disease, and have a greater number of clear cell and mucinous tumors. After adjusting for these prognostic factors, Asians have a better survival compared to Caucasians.

Head and neck squamous cell carcinoma and metachronous second primaries

ObjectivesTo assess the rate of second (or more) primaries after treatment for head and neck squamous cell carcinoma (HNSCC), and survival compared to patients with a single head and neck cancer. Material and methodA single-center retrospective study was performed in a University Hospital Center in 541 patients between 2002 and 2010. ResultsOne hundred and forty-one patients (26.06%) presented 172 metachronous cancers. Overall 5-year survival was 20.3% with and 38.1% without metachronous cancer. Median and mean survival were respectively 21.9 and 51 months in patients with a single cancer, versus 13.9 and 26.5 months in case of metachronous cancer. Specific survival was comparable to overall survival. All-cause and specific survival were significantly poorer in metachronous cancer (P=0.001; log-rank α=0.05). ConclusionAt least a quarter of HNSCC patients go on to develop a metachronous second primary. These are of poor prognosis, whatever their location.

Long-term comparative study of large-diameter metal-on-metal bearings: Resurfacing versus total arthroplasty with large-diameter Durom™ bearing

IntroductionShort-term results in total hip arthroplasty (THA) with large-diameter metal-on-metal (MoM) bearings were encouraging, but high failure rates have been reported in the long term, notably implicating corrosion due to modularity. Several studies compared resurfacing (to which modularity does not apply) versus large-diameter MoM THA; but, to our knowledge, none compared the same bearing in the two situations with more than 10 years’ follow-up. We therefore conducted a retrospective case-control study, using a single cup model (Durom™, Zimmer, Warsaw, USA) for both resurfacing (R) and large-diameter THA, to determine the role of modularity in failure of large-diameter MoM bearings. The study compared (1) metallic ion levels, and (2) survival, functional scores and complications rates between R and THA. HypothesisLarge-diameter MoM bearing failure implicates not bearing wear but head-neck junction modularity in larger-diameter MoM THA. Material and methodEighty-three THAs and 90 Rs were included between February 2004 and March 2006. All patients had clinical and radiologic follow-up with chromium (Cr) and cobalt (Co) ion blood assay. ResultsIn the THA group, 24 of the 83 patients (28.9%) underwent revision for adverse reaction to metal debris (ARMD), versus none in the R group. Ten-year all-cause survival was significantly better in R (97.7%; 95% CI, 96.2–99.2) than THA (67.1%; 95% CI, 60.9–73.3). Median blood ion level was higher in THA (with a difference between Co and Cr: 5.75μg/L (range, 3.82–19.2) versus 1.75μg/L (range, 1.34–2.94) respectively) than in R (no difference: 0.89μg/L (range, 0.67–2.89) and 1.07μg/L (range, 0.67–1.65) respectively). In the THA group, there were positive correlations between Co and Cr elevation and implant revision (both p<0.0001). Co/Cr ratio was significantly higher in THA (2.57) than R (0.88) (p<0.0001), and higher again in the 24 cases of THA revision (4.67). There was no significant difference in mean PMA score (THA: 17.08±1.82 (range, 7–18); R: 17.50±0.74 (range, 15–18)), whereas mean Oxford score was better in R (14.32±2.5 (range, 12–24)) than THA (18.17±8.05 (range, 12–42)) (p=0.02). DiscussionThe present study confirmed the incontrovertible implication of modularity in failure of large-diameter MoM THA, by analyzing the same bearing in THA and in resurfacing. Trunnionosis was observed in the 24 cases of revision, with the THA adaptation ring inducing serious metallic ion release (with dissociated Co/Cr ratio), accounting for the high rate of revision. Level of evidenceIII, case-control study.

Cardiorenal syndrome in incident peritoneal dialysis patients: What is its effect on patients' outcomes?

BackgroundPeritoneal dialysis (PD) is increasingly used for long-term management of Cardiorenal Syndrome (CRS). We compared outcomes in incident PD patients according to their baseline heart failure status.MethodsThis retrospective cohort study evaluated all-cause and cardiovascular mortality in incident PD patients with different heart failure status (non-CRS, acute heart failure [AHF], type II CRS, type IV CRS) who started PD between 2006 and 2016 in the Peking University Third Hospital.ResultsOf 748 patients included in the study, there were 466 (62.3%), 214 (28.6%), 27 (3.6%), and 41 (5.5%) patients in the non-CRS, AHF, type II CRS and type IV CRS groups, respectively. Patients with CRS were older (p<0.001), with more diabetes mellitus (p<0.001), coronary heart history (p<0.001), higher estimated glomerular filtration rate (eGFR) (p<0.001), lower serum creatinine (p<0.001) and phosphorus levels (p = 0.003) compared to non-CRS patients. Respective all-cause survival rates for patients with non-CRS, AHF, type II CRS and type IV CRS were 90.6%, 87.1%, 85.2% and 84.8% at 1 year, and 63.1%, 47.7%, 27.3% and 35.1% at 5 years (p<0.001). The corresponding figures for cardiovascular survival were 93%, 92%, 84% and 81% at 1 year, and 67%, 59%, 55% and 54% at 5 years (p<0.001). However, after adjusting for confounding factors, the presence of CRS was not independently associated with all-cause mortality whereas type IV CRS (HR 2.10, 95% CI 1.03–4.28, p = 0.04) was associated with higher cardiovascular mortality as compared to without CRS.ConclusionIncident PD patients with different types of CRS had higher rates of both all-cause and cardiovascular mortality compared with patients without CRS. However, these observed adverse outcomes may be related to associated older age and higher prevalence of comorbidities, rather than CRS per se, except for type IV CRS, treatment strategies to reduce high cardiovascular CVD mortality may needed.

Treatment and survival of Asian women diagnosed with breast cancer in New Zealand.

This study aims to examine the differences in characteristics, treatment and survival between Asian and European women diagnosed with stage I-III breast cancer in New Zealand. The studied population included European women and Asian women diagnosed with stage I-III breast cancer between June 2000 and May 2013 identified from the combined Waikato and Auckland Breast Cancer Registers. Characteristics and treatment were compared between Asian and European women. Kaplan-Meier method was used to examine the survival difference. Cox proportional hazards model was used to estimate the hazard ratio (HR) of mortality. The studied cohort included 8608 European and 949 Asian women. Asian women were younger, had less comorbidities and were less likely to be obese than European women. Asian women were more likely to have grade 3, larger and HER2+ breast cancers. Asian women were more likely to receive mastectomy, less likely to have reconstruction after mastectomy, less likely to have chemotherapy, less likely to be treated with trastuzumab if HER2+, and had better adherence to endocrine therapy (adjusted odds ratio: 1.54; 95% CI 1.22-1.93). Asian women had better cancer-specific survival and all-cause survival than European women. The adjusted HR of cancer-specific mortality and all-cause mortality were 0.64 (95% CI 0.49-0.82) and 0.68 (95% CI 0.55-0.84), respectively. Asian women are more likely to have high grade, larger and HER2+ breast cancers than European women. In spite of this, they had better breast cancer outcomes. Possible explanations include the differences in adherence to endocrine therapy, age, BMI and comorbidities.

Survival and functional outcome of revision total knee arthroplasty with a total stabilizer knee system: minimum 5years of follow-up.

Revision knee arthroplasty surgery can range from patella resurfacing or polyethylene exchange, to staged revision and revision to a more constrained implant. Subsequently, the ability to elicit outcomes becomes difficult to obtain and hence information on functional outcome and survivorship for all modes of failure with a single revision system is valuable. We retrospectively assessed 100 consecutive revision knee replacements that were converted from a primary knee replacement to a Triathlon total stabilizer (TS) knee system (Stryker Orthopaedics, Mahwah, NJ). Inclusion criteria included failure of a primary knee replacement of any cause converted to a Stryker TS knee system. Midterm outcome of at least 5years was required. Implants survivorship, Oxford Knee Score (OKS), Forgotten Joint Score (FJS-12), Short Form (SF-) 12, reported patient satisfaction and radiographic analysis were recorded. The all-cause survival rate at 5years was 89.0% [95% confidence interval (CI) 87.3 to 90.7]. The all-cause survival rate was generally static after the first 4years. The mean OKS was 27 (SD 11.9, range 0 to 46), FJS was 32.3 (SD 30.4, range 0 to 100), SF-12 physical component summary was 40.6 (SD 17.6, range 23.9 to 67.1), and mental component summary was 48.3 (SD 15.5, range 23.9 to 69.1). Reported patient satisfaction in patients who were not re-revised was 82%. The midterm survivorship of cemented Stryker Triathlon TS knee revision for all-cause mode of failure is good to excellent; however, future follow-up is required to ensure this survivorship is observed into the long term. Despite limited functional outcome, overall patient satisfaction rates are high.

Irish wolfhounds with subclinical atrial fibrillation: progression of disease and causes of death

IntroductionTo evaluate the frequency of dilated cardiomyopathy (DCM) and cardiac death (CD) in Irish wolfhounds (IW) with subclinical atrial fibrillation (AF) and to compare cardiac and all-cause mortality to those of a contemporaneous control group of apparently healthy IW with sinus rhythm. AnimalsFifty-two IW with AF, but without echocardiographic evidence of DCM or other cardiac disease, and an age- and gender-matched control cohort of 52 apparently healthy IW. MethodsData from 1552 IW were retrospectively evaluated. Fifty-two dogs with subclinical AF were compared with 52 IW controls. Time from initial diagnosis to development of DCM was recorded, and survival data were analyzed using cumulative incidence functions. Results26/52 AF dogs developed DCM. At study end, in the AF and control group each, 49/52 AF dogs had died, three remained alive. Death in the AF cohort was attributed to CD in 22/49 dogs (12 congestive heart failure [CHF], 10 sudden cardiac deaths [SCD]), while 27 dogs died from non-CD. In the control group, significantly fewer dogs developed DCM (11/52 dogs, p=0.004), even fewer died from CD (5/49; three CHF, two SCD; p=0.001). The odd ratios (95% confidence interval) for dogs with AF vs. controls to develop DCM was 3.7 (1.6–8.8) and to die from CD was 7.2 (2.4–21.2). Median all-cause survival for AF IWs (CD, 36.3 months; non-CD, 33.2 months) did not differ significantly from the control group (CD, 28.6 months, p=0.377; non-CD, 45.3 months, p=0.631). ConclusionIW with subclinical AF commonly develop DCM and die from cardiac death.