Cumulative Mortality Curves Research Articles

Survival Benefit of Primary Tumor Treatment in Uveal Melanoma: A Re-Analysis of the Collaborative Ocular Melanoma Study (COMS) and Natural History Study (NHS) Cohorts.

To evaluate whether primary tumor treatment provides a survival benefit in uveal melanoma by comparing patients who declined treatment (Natural History Study, NHS) with those who received treatment in the Collaborative Ocular Melanoma Study (COMS) for medium-sized choroidal melanomas. Individual-level survival data were reverse-engineered from cumulative all-cause mortality curves in the original COMS and NHS publications. Censoring patterns were estimated from numbers at risk and descriptive statistics. A Bonferroni-corrected significance level of 0.017 was applied. Additionally, to ensure a conservative approach, NHS cohort data were iteratively adjusted by reducing the 8-year cumulative mortality by one percentage point if the Cox regression hazard ratio for all-cause mortality, the unadjusted risk ratio for death, and the 95% confidence intervals (CIs) of the Kaplan-Meier curves did not show a smaller survival difference than originally reported. Kaplan-Meier analysis revealed significantly higher cumulative mortality in the NHS cohort compared to the COMS cohort (log-rank p = 0.012). When restricting the analysis to the first 8 years to account for unclear censoring patterns beyond this period, the NHS cohort still demonstrated worse survival (p = 0.008). A sensitivity analysis, varying censoring times by ±25% over 1000 iterations, confirmed worse survival in the NHS cohort in 100% of cases. In this re-evaluation, patients who declined treatment for medium-sized choroidal melanomas had significantly worse survival, suggesting a potential survival benefit of primary tumor treatment.

Association between SpO2 and the risk of death in elderly T2DM patients with cerebral infarction: a retrospective cohort study.

This study aimed to evaluate the SpO2 (transcutaneous oxygen saturation) -mortality link in elderly T2DM (diabetes mellitus type 2) patients with cerebral infarction and identify their optimal SpO2 range. In this investigation, we employed a comprehensive approach. Initially, we screened the MIMIC-IV database, identifying elderly T2DM patients with cerebral infarction, utilizing specific ICD-9 and ICD-10 codes. We then harnessed the power of restricted cubic splines to craft a visual representation of the correlation between SpO2 and 1-year mortality. To enhance our analysis, we harnessed Cox multivariate regression, allowing us to compute adjusted hazard ratios (HR) accompanied by 95% confidence intervals (CIs). Additionally, we crafted Cumulative Mortality Curve analyses, augmenting our study by engaging in rigorous subgroup analyses, stratifying our observations based on pertinent covariates. In this study, 448 elderly T2DM patients with cerebral infarction were included. Within 1-year post-discharge, 161 patients (35.94%) succumbed. Employing Restricted Cubic Spline analysis, a statistically significant U-shaped non-linear relationship between admission ICU SpO2 levels and 1-year mortality was observed (P-value < 0.05). Further analysis indicated that both low and high SpO2 levels increased the mortality risk. Cox multivariate regression analysis, adjusting for potential confounding factors, confirmed the association of low (≤94.5%) and high SpO2 levels (96.5-98.5%) with elevated 1-year mortality risk, particularly notably high SpO2 levels (>98.5%) [HR = 2.06, 95% CI: 1.29-3.29, P-value = 0.002]. The cumulative mortality curves revealed the following SpO2 subgroups from high to low cumulative mortality at the 365th day: normal levels (94.5% < SpO2 ≤ 96.5%), low levels (SpO2 ≤ 94.5%), high levels (96.5% < SpO2 ≤ 98.5%), and notably high levels (>98.5%). Subgroup analysis demonstrated no significant interaction between SpO2 and grouping variables, including Sex, Age, Congestive heart failure, Temperature, and ICU length of stay (LOS-ICU; P-values for interaction were >0.05). Striking an optimal balance is paramount, as fixating solely on lower SpO2 limits or neglecting high SpO2 levels may contribute to increased mortality rates. To mitigate mortality risk in elderly T2DM patients with cerebral infarction, we recommend maintaining SpO2 levels within the range of 94.5-96.5%.

Troponin dependent 30-day mortality in patients with acute pulmonary embolism

Background: Troponin concentrations above upper reference are associated with increased mortality in patients with pulmonary embolism (PE). We aimed to assess whether risk of 30-day mortality increases in a dose-response relationship with concentration of troponin. Methods: Using Danish national registries, we identified patients ≥ 18 years of age hospitalized with first-time PE between 2013 and 2018 and available troponin measurements − 1/+1 day from admission. Patients were stratified into quintiles by increasing troponin concentration. Risk of 30-day mortality was assessed performing cumulative mortality curves and Cox regression model comparing the troponin quintiles. Results: We identified 5,639 PE patients of which 3,278 (58%) had a troponin concentration above upper reference. These patients were older (74 years), 50% male and with heavier comorbidity compared to patients with non-elevated troponin. We found increasing 30-day mortality with increasing troponin concentration (1% in 1st quintile (95% CI 0.5–1.5%), 2% in 2nd quintile (95% CI 1-2.5%), 8% in 3rd quintile (95% CI 5–9%), 11% in 4th quintile (95% CI 9–13%) and 15% in 5th quintile (95% CI 13–16%), confirmed in a Cox model comparing 1st quintile with 2nd quintile (HR 1.09; 95% CI 0.58–2.02), 3rd quintile (HR 3.68; 95% CI 2.20–6.15), 4th quintile (HR 5.51; 95% CI 3.34–9.10) and 5th quintile (HR 8.09; 95% CI 4.95–13.23). Conclusion: 30-day mortality was strongly associated with troponin concentration useful for improving risk stratification, treatment strategies and outcomes in PE patients.

Overdispersion Models for Clustered Toxicological Data in a Bioassay of Entomopathogenic Fungus

We consider discrete mortality data for groups of individuals observed over time. The fitting of cumulative mortality curves as a function of time involves the longitudinal modelling of the multinomial response. Typically such data exhibit overdispersion, that is greater variation than predicted by the multinomial distribution. To model the extra-multinomial variation (overdispersion) we consider a Dirichlet-multinomial model, a random intercept model and a random intercept and slope model. We construct asymptotic and robust covariance matrix estimators for the regression parameter standard errors. Applying this model to a specific insect bioassay of the fungus Beauveria bassiana, we note some simple relationships in the results and explore why these are simply a consequence of the data structure. Fitted models are used to make inferences on the effectiveness and consistency of different isolates of the fungus to provide recommendations for its use as a biological control in the field.

High cardiovascular disease mortality after penile squamous cell carcinomas diagnosis: Results from the United States SEER population, 2005-2016.

BackgroundCancer survivorship care is an emerging and necessary component of oncology management. To explore cardiovascular disease (CVD)-specific mortality and prognostic factors among patients with penile squamous cell carcinomas (PSCC). These results aid clinicians in furtherly understand this disease’s prognosis.MethodWe analyzed Surveillance, Epidemiology and End Results Program data for 2668 PSCC cases diagnosed between 2005 to 2016. We calculated standardized mortality ratios (SMRs) of CVD and all-cause mortality, comparing PSCC patients with general population men. A cumulative mortality curve and competitive risk regression model were utilized to evaluate the prognostic factors of CVD-specific death.ResultsDeath distribution is as follows: PSCC (42.4%), other causes (21.3%) CVD (19%), and other cancers (17.3%). PSCC patients are more like to die from CVD (SMR=3.2, 95%CI: 3.1-3.3) and all-cause death compared with the general population. Meanwhile, patients undergoing surgery show a relatively higher CVD-specific mortality than the general population (SMR=2.7, 95%CI: 2.4-3.2). In the competitive risk model, higher CVD mortality is associated with age, region, year of diagnosis, stage, and marital status (all P<0.05). Patients with the localized stage show a higher risk of CVD-specific death than those with regional or distant stage.ConclusionOur study mainly reveals that cardiovascular disease was the important cause of death and higher CVD-specific mortality among PSCC patients. Several associated factors related to CVD-specific death are also identified. In the future, more work in educating health care professionals on the components of survivorship care is needed to meet the long-term and late effects cancer patients experience.

Effects of radical cystectomy, radiotherapy, and chemotherapy on the risk of long-term heart-specific death in bladder cancer patients.

BackgroundAt present, the low risk of bladder cancer (BCa)-specific death has allowed for investigation into treatment-related cardiotoxicity. To aid clinicians in selecting appropriate cardiovascular disease screening strategies and interventions, this study explored the heart-specific mortality and prognostic factors of patients with BCa after radical cystectomy (RC), radiotherapy (RT), or chemotherapy (CT), and compared their long-term heart-specific mortality with that of the general male population.MethodsWe identified three different treatments for BCa patients from the Surveillance, Epidemiology, and End Results (SEER) database: RC, RT, and CT. Patients were included from 2000 to 2012 and followed through 2015. A cumulative mortality curve and competitive risk regression model were applied to evaluate the prognostic factors of heart-specific mortality, and standardized mortality ratios (SMRs) were calculated.ResultsOf 39,500 men, 30.3%, 18.8%, and 50.9% received RC, RT, and CT, respectively. For patients with a survival period of less than 50 months, tumor-specific death exhibited a rapidly increasing trend, which subsequently flatlined. However, the rates heart-specific mortality and other causes exhibited a tendency to increase stably. The heart-specific and all-cause mortality rates of patients in any age group treated with the three abovementioned strategies were higher than those of the general population. The heart-specific mortality of patients with carcinoma in situ treated with RC and CT exceeded their all-cause mortality, while that of other tumor stages did not. The risks of heart-specific [sub-distribution hazard ratio (SHR) =1.38; 95% confidence interval (CI): 1.22–1.57] and tumor-specific (SHR =1.68; 95% CI: 1.60–1.77) deaths in patients who received RT were higher than those of patients who underwent CT.ConclusionsThe risks of heart-specific and tumor-specific deaths in patients who received RT were higher than those of the RC and CT groups, especially in patients over 65 years of age who received RT.

Prognostic impact of non-culprit chronic total occlusion over time in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention.

Previous studies indicated that a chronic total occlusion (CTO) in a non-infarct-related artery is linked to higher mortality mainly in the acute setting in patients with ST-elevation myocardial infarction (STEMI). Our aim was to assess the temporal distribution of mortality risk associated with non-culprit CTO over years after STEMI. The study included 8679 STEMI patients treated with primary percutaneous coronary intervention (PCI). Kaplan-Meier cumulative mortality curves for non-culprit CTO vs. no CTO were compared with log-rank test, with landmarks set at 30 days and 1 year. Adjusted Cox regression models were constructed to assess the impact of non-culprit CTO on mortality over different time intervals. Tests for interaction were pre-specified between non-culprit CTO and acute heart failure and left ventricular ejection fraction. The primary outcome variable was all-cause mortality, and the median follow-up was 5 years. Non-culprit CTO was present in 11.6% of patients (n = 1010). Presence of a CTO was associated with increased early [30-day adjusted hazard ratio (HR) 1.91, 95% confidence interval (CI) 1.54-2.36; P < 0.001] and late mortality (5-year adjusted HR 1.66, 95% CI 1.42-1.95; P < 0.001). Landmark analyses revealed an annual two-fold increase in mortality in patients with vs. without a CTO after the first year of follow-up. The observed pattern of mortality increase over time was independent of acute or chronic LV impairment. Non-culprit CTO is independently associated with mortality over 5 years after primary PCI for STEMI, with a constant annual two-fold increase in the risk of death beyond the first year of follow-up.

Abstract 8: Retinopathy is Associated With Stroke, Dementia, and Mortality

Introduction: Retinal microvascular abnormalities have been associated with stroke, but their association with dementia and death is less well described. We tested the hypothesis that retinopathy is associated with stroke, dementia, and age-adjusted mortality. Methods: Data were obtained from the US National Health and Nutrition Examination Surveys from 2005 to 2008, with linked mortality through 2015. Severity of retinopathy was defined as no retinopathy, mild nonproliferative retinopathy (NPR), moderate-severe NPR, and proliferative retinopathy. Logistic regression models were performed to evaluate the relationships between retinopathy, stroke, and dementia, respectively. Independent relationships between retinopathy and all-cause mortality were assessed using Cox regression models, before and after adjusting for covariates. All analyses were adjusted for the complex survey design. Results: Of 5,543 participants aged ≥18 years with gradable retinal imaging, 696 had retinopathy, 289 had stroke, and 597 had dementia. Mean age of subjects was 56.3 ± 11.7 years. Retinopathy was associated with higher risk of stroke (adj OR 2.39, P &lt;0.001) and dementia (adj OR 1.68, P =0.005). Over a median duration of 118 months (IQR 111-125), there was a dose-dependent relationship between severity of retinopathy and all-cause mortality (adjusted hazard ratios were 1.0, 1.5, 2.4, 3.4 across retinopathy severity; P =0.021). The Figure shows the age-adjusted cumulative mortality curves by retinopathy severity. Conclusions: Participants with retinopathy have a greater than 2-fold increase in stroke risk and a 1.7-fold increase in dementia risk. Having more severe retinopathy confers a higher risk of death after adjusting for age and vascular risk factors. The retina may serve as a tissue biomarker in intervention trials for cerebrovascular and neurodegenerative diseases.

Long-term safety of drug-coated devices for peripheral revascularisation.

Meta-analyses of randomised trials of paclitaxel-coated peripheral devices found an association with worse long-term survival. We aimed to assess long-term mortality in patients treated with drug-coated versus non-drug-coated devices who are insured by Medicare Advantage (MA), an alternative to traditional Medicare that represents >30% of the Medicare eligible population. We analysed data from an MA administrative claims data source that includes both inpatient and outpatient femoropopliteal artery revascularisation procedures. Patients treated with or without drug-coated devices for femoropopliteal artery revascularisation from 4/2015-12/2017 were studied using Optum's De-identified Clinformatics Datamart Database. Mortality was assessed up to December 2019 using Kaplan-Meier cumulative mortality curves and Cox proportional hazard models. Inverse probability of treatment weighting was used to adjust for differences between groups. Of 16,796 patients revascularised, 4,427 (26.4%) were treated with drug-coated devices: 3,600 (81.3%) balloons and 827 (18.7%) stents. The median follow-up was 2.66 years (IQR 2.02-3.52). Treatment with drug-coated devices was associated with similar long-term mortality to non-drug-coated devices (adjusted HR 1.03, 95% CI: 0.96-1.10; p=0.39). Results were comparable for patients treated with balloons alone (adjusted HR 1.00, 95% CI: 0.92-1.08; p=0.96) or stents (adjusted HR 1.02, 95% CI: 0.88-1.18; p=0.78). These findings did not differ based on treatment setting, disease severity, age, sex or comorbidity burden (interaction p>0.05 for all). In this large cohort, there was no evidence of increased long-term mortality following treatment with drug-coated devices.

Effects of Radiotherapy or Radical Prostatectomy on the Risk of Long-Term Heart-Specific Death in Patients With Prostate Cancer.

Objective: The prognosis of patients with prostate cancer (PCa) has improved in recent years, but treatment-related cardiotoxicity remains unclear. This study investigated the heart-specific mortality and prognostic factors of patients with PCa after radiotherapy (RT) or radical prostatectomy (RP), and compared their long-term heart-specific mortality with that of the general male population.Materials and Methods: Data were taken from the Surveillance, Epidemiology, and End Result (SEER) database. Patients with PCa were included who underwent RT or RP from 2000 to 2012, and were followed through 2015. A cumulative mortality curve and a competitive risk regression model were applied to assess the prognostic factors of heart-specific mortality. Standardized mortality rates (SMRs) were calculated.Results: Of 389,962 men, 49.7% and 50.3% received RP and RT, respectively. The median follow-up was 8.3 years. For patients given RT, in about 9 years postdiagnosis, the cumulative mortality due to heart-specific disease exceeded that due to PCa. In patients who underwent RP, cumulative mortality from heart-specific disease or PCa was comparable. Relative to the general male population, overall, the heart-specific mortality of patients with PCa receiving RT or RP was not higher, but in patients aged 70 to 79 years, those given RT experienced slightly higher heart-specific mortality than the age-matched general population.Conclusions: Patients with PCa treated with RT or RP overall do not incur risk of heart-specific mortality higher than that of the general male population, except for patients aged 70–74 years receiving RT.

Impact of a CTO in a non-infarct-related artery on long-term mortality in patients undergoing primary PCI

Abstract Background Previous studies showed increased mortality rates in patients with ST-elevation myocardial infarction (STEMI) and a chronic total occlusion (CTO) in a non-infarct-related artery, but long-term data are scarce. Purpose Our aim was to assess all-cause mortality during 5 years follow-up in patients with a remaining nonculprit CTO after being treated with primary PCI. Methods The study included 9504 patients admitted for primary PCI during 2009–2019, with available baseline angiography, from an electronic, prospective registry of a high-volume catheterization laboratory. Kaplan Meier cumulative mortality curves for non-culprit CTO vs. no CTO were compared with the log-rank test, with landmarks set at 30 days and then annually up to 5 years follow-up. Adjusted Cox regression models were constructed to assess 30-day and 5-year mortality risk of a non-culprit CTO. Median follow-up was 1507 days. Results Nonculprit CTO was present in 13.2% of patients (n=1253). Presence of a nonculprit CTO was associated with older age (64 vs. 61, p&amp;lt;0.001), more frequent history of cardiovascular disease including prior MI (33% vs. 14%, p&amp;lt;0.001), stroke (10.3% vs. 5.9%, p&amp;lt;0.001) and CABG (10.5% vs. 1.5%, p&amp;lt;0.001), higher rates of renal failure (10.7% vs. 4.8%, p&amp;lt;0.001), as well as more often Killip class 2–4 on admission (29% vs. 16%, p&amp;lt;0.001) and a lower ejection fraction (40% vs. 47%, p&amp;lt;0.001). Crude mortality rates were significantly increased in patients with a nonculprit CTO vs. no CTO, at both 30 days (15.7% vs. 5.6%, p&amp;lt;0.001) and 5 years (54.6% vs. 27.9%, p&amp;lt;0.001). After adjusting for the observed baseline differences, nonculprit CTO was still associated with an elevated mortality risk at both 30-days (HR 1.5, CI95% 1.1–1.9, p=0.007) and 5 years (HR 1.6, CI95% 1.4–1.9, p&amp;lt;0.001). Landmark analyses showed continuously increasing risk of mortality in the presence of a nonculprit CTO, as compared with primary PCI-treated patients with no CTO (30 days to 1 year 11.4% vs. 4.9%, p&amp;lt;0.001; 1st to 2nd year of follow-up 6.3% vs. 3.4%, p&amp;lt;0.001; 2nd to 3rd year 6.2% vs. 2.8%, p&amp;lt;0.001; 3rd to 4th year 7.4% vs. 3.0%, p&amp;lt;0.001; and 4th to 5th year 5.2% vs. 3.6%, p=0.1). Conclusions Presence of a nonculprit CTO is independently associated with 5-year mortality after primary PCI. Importantly, the mortality risk increases continuously with an average annual absolute difference of 3%, in patients with a nonculprit CTO vs. those with no CTO. Nonculprit CTO vs. no CTO Funding Acknowledgement Type of funding source: None

Novel microsimulation model of tobacco use behaviours and outcomes: calibration and validation in a US population

Background and objectiveSimulation models can project effects of tobacco use and cessation and inform tobacco control policies. Most existing tobacco models do not explicitly include relapse, a key component of...

Trends in Late Mortality Among Adolescent and Young Adult Cancer Survivors.

Over the past several decades, treatment of cancer in adolescents and young adults (AYAs) has evolved substantially, leading to steady improvements in estimated 5-year survival at diagnosis. However, the impact on late mortality in this population is largely unexamined. We investigated temporal trends in mortality among 5-year AYA cancer survivors. The Surveillance, Epidemiology, and End Results database was used to identify AYAs (age 15-39 years) diagnosed with cancer during 1975-2011 who survived at least 5 years beyond diagnosis. Survival months were accrued from 5 years postdiagnosis until death or the end of 2016. Cumulative mortality from all causes, the primary cancer, other cancers, and noncancer or nonexternal causes (ie, excluding accidents, suicide, homicide) were estimated according to diagnosis era. Among 282 969 five-year AYA cancer survivors, 5-year mortality (ie, from 5 through 10 years postdiagnosis) from all-causes decreased from 8.3% (95% confidence interval = 8.0% to 8.6%) among those diagnosed in 1975-1984 to 5.4% (95% confidence interval = 5.3% to 5.6%) among those diagnosed in 2005-2011. This was largely explained by decreases in mortality from the primary cancer (6.8% to 4.2%) between these periods. However, for specific cancer types, including colorectal, bone, sarcomas, cervical/uterine, and bladder, cumulative mortality curves demonstrated little improvement in primary cancer mortality over time. Some reduction in late mortality from noncancer or nonexternal causes was apparent for Hodgkin lymphoma, leukemia, kidney cancer, head and neck cancers, and trachea, lung, and bronchus cancers. Over the past four decades, all-cause and cancer-specific mortality have decreased among 5-year AYA cancer survivors overall, but several cancer types have not shared in these improvements.

Reclassifying severity after 48 hours could better predict mortality in acute respiratory distress syndrome.

Background:Disease severity may change in the first week after acute respiratory distress syndrome (ARDS) onset. The aim of this study was to evaluate whether the reclassification of disease severity after 48 h (i.e. day 3) of ARDS onset could help in predicting mortality and determine factors associated with ARDS persistence and mortality.Methods:We performed a secondary analysis of a 3-year prospective, observational cohort study of ARDS in a tertiary care referral center. Disease severity was reclassified after 48 h of enrollment, and cases that still fulfilled the Berlin criteria were regarded as nonresolving ARDS.Results:A total of 1034 ARDS patients were analyzed. Overall hospital mortality was 57.7% (56.7%, 57.5%, and 58.6% for patients with initial mild, moderate, and severe ARDS, respectively, p = 0.189). On day 3 reclassification, the hospital mortality rates were as follows: resolved (42.1%), mild (47.9%), moderate (62.4%), and severe ARDS (76.1%) (p < 0.001). Patients with improving severity on day 3 had lower mortality (48.8%), whereas patients with the same or worsening severity on day 3 had higher mortality (62.7% and 76.3%, respectively). Patients who were older, had lower PaO2/FiO2, or higher positive end-expiratory pressure on day 1 were significantly associated with nonresolving ARDS on day 3. A Cox regression model with ARDS severity as a time-dependent covariate and competing risk analysis demonstrated that ARDS severity was independently associated with hospital mortality, and nonresolving ARDS had significantly increased hazard of death than resolved ARDS (p < 0.0001). Cumulative mortality curve for ARDS severity comparisons demonstrated significantly different (overall comparison, p < 0.001).Conclusions:Reclassification of disease severity after 48 h of ARDS onset could help to divide patients into subgroups with greater separation in terms of mortality. The reviews of this paper are available via the supplemental material section.

P3650Prognostic impact of post procedural aortic valve insufficiency on long-term risk for surgical aortic valve repair in patients undergoing balloon valvuloplasty for congenital aortic valve stenosis

Abstract Background Limited evidence is available regarding the prognostic impact of post procedural aortic valve insufficiency (AVI) on long-term outcome in patients with congenital aortic valve stenosis treated with balloon aortic valvuloplasty (BAV). Purpose To assess the prognostic impact of immediate post procedural AVI on long-term outcome in patients undergoing BAV for congenital aortic valve stenosis. Methods We analyzed 89 patients (median age 4 years, range 6 days to 25 years), undergoing BAV during 2004–2017, from a prospective registry of a tertiary university center, with a median follow-up period of 4 years. Patients were classified into two groups based on presence of immediate post procedural AVI grade more than “+1/4” as assessed by echocardiography. Kaplan Meier cumulative mortality curves for groups above vs. bellow post procedural AVI grade “+1/4” were compared with log-rank test. Cox regression model was used to assess the risk for surgical aortic valve repair (SAVR) in long-term follow up with patients without worsening of AVI after BAV serving as the reference group. Results During follow up, SAVR was performed in 20% (n=18) of patients. Patients with immediate post procedural AVI grade more than “+1/4” after BAV had significantly higher long-term risk for SAVR compared to those without AVI worsening (72% vs. 18%, log-rank p&lt;0.001). When adjusted for other significant aortic valve repair predictors, such as bicuspid aortic valve, neonatal age, residual aortic valve peak gradient &gt;35 mm Hg, the presence of AVI grade more than “+1/4” immediately after BAV was independently associated with 6-fold (HR=5.60, 95% CI 2.03–15.42, p=0.001) increased risk for SAVR. Kaplan-Meier freedom from SAVR curves Conclusion The presence of post procedural AVI grade more than “+1/4” in patients undergoing BAV for congenital aortic valve stenosis is independently associated with the increased risk for SAVR in long-term follow up.

Mortality and acute complications in children and young adults diagnosed with Type 1 diabetes in Yorkshire, UK: acohort study.

To examine all-cause and cause-specific mortality in a population-based cohort of people with early and late onset of Type 1 diabetes. The Yorkshire Register of Diabetes in Children and Young People includes individuals with early (0-14years) and late (15-29years) Type 1 diabetes onset, diagnosed between 1978 and 2013. This register was linked to death certification data from the Office for National Statistics to calculate standardized mortality ratios, cumulative mortality curves using Kaplan-Meier survival estimates, and Cox regression modelling. Ethnicity was derived using Onomap. Deprivation status was classified using the Townsend index. The underlying cause of death in each case was clinically verified. There were 229 deaths in 5498 individuals with 100 959 person-years of follow-up. The overall standardized mortality ratio was 4.3 (95% CI 3.8 to 4.9). There were no significant differences in standardized mortality ratios according to age of onset, sex or deprivation status. The standardized mortality ratios were significantly higher for people of white ethnic origin [8.1 (95% CI 6.9 to 9.4)] than for those of South-Asian ethnic origin [3.4 (95% CI 1.7 to 6.4)]. The mortality risk was lower in those diagnosed in later years (2002 to 2013 for the early-onset and 2006 to 2013 for the late-onset group) compared with earlier years (1991 to 1997 for the early-onset and 1991 to 1997 for the late-onset group) for both onset groups [hazard ratio 0.13 (95% CI 0.05 to 0.33) vs 0.24 (95% CI 0.07 to 0.81)]. Mortality risk improved over time for chronic complications in the early-onset group only, but there was no improvement in either onset group with regard to acute complications. An excess of deaths in the population with Type 1 diabetes remains. Although the all-cause mortality risk has fallen over time, no improvement has been found in the mortality risk associated with acute complications.

Effects of Antiretroviral Therapy and Depressive Symptoms on All-Cause Mortality Among HIV-Infected Women.

Depression affects up to 30% of human immunodeficiency virus (HIV)-infected individuals. We estimated joint effects of antiretroviral therapy (ART) initiation and depressive symptoms on time to death using a joint marginal structural model and data from a cohort of HIV-infected women from the Women's Interagency HIV Study (conducted in the United States) from 1998-2011. Among 848 women contributing 6,721 years of follow-up, 194 participants died during follow-up, resulting in a crude mortality rate of 2.9 per 100 women-years. Cumulative mortality curves indicated greatest mortality for women who reported depressive symptoms and had not initiated ART. The hazard ratio for depressive symptoms was 3.38 (95% confidence interval (CI): 2.15, 5.33) and for ART was 0.47 (95% CI: 0.31, 0.70). Using a reference category of women without depressive symptoms who had initiated ART, the hazard ratio for women with depressive symptoms who had initiated ART was 3.60 (95% CI: 2.02, 6.43). For women without depressive symptoms who had not started ART, the hazard ratio was 2.36 (95% CI: 1.16, 4.81). Among women reporting depressive symptoms who had not started ART, the hazard ratio was 7.47 (95% CI: 3.91, 14.3). We found a protective effect of ART initiation on mortality, as well as a harmful effect of depressive symptoms, in a cohort of HIV-infected women.

Risk factors for mortality in geriatric hip fractures: a compressional study of different surgical procedures in 785 consecutive patients.

Only a little is known about whether type of surgical intervention has an effect on mortality of these patients. Our primary objective was to assess whether different type of surgical procedures has an effect on mortality among elderly patients with hip fracture. A secondary objective was to examine factors that are related to mortality in our patient population. Our hypothesis is that type of surgical procedure, especially external fixation, should have an influence on mortality outcomes. We included 785 patients age 65years or older, with hip fractures. Operative treatment consisted of external fixation, internal fixation, total hip arthroplasty and hip hemiarthroplasty. Age, gender, type of fracture, type of surgery performed, American Society of Anesthesiology (ASA) grade, clinical comorbidities, anesthesia type, blood transfusion requirement, time to surgery, intensive care unit requirement, operation length and length of hospital stay and number of comorbidities were documented. During the study period, 785 patients (262 male, 523 female) were included to study, Overall mortality rate was 37.2% (292/785). Their age ranged between 65 and 100years (mean 81). Surgery type Kaplan-Meier cumulative mortality curves suggested no significant difference between four different types of surgery groups (p=0.064). Transfusion requirement was significantly lower in external fixation group comparing to other groups (p=0.014). Cox regression analysis showed the number of comorbidities 2 and≥3 (p=0.0027, p=0.015), transfusion requirement (p=0.0001), ASA 4 (p=0.016) to be significant predictors of mortality. Transfusion requirement, ASA grade 4 and having more than two comorbidities are risk factors for mortality in geriatric hip fractures. Type of surgical intervention and fracture type had similar mortality rates in our patient population.

Relationship of the Number of Removed Lymph Nodes to Bladder Cancer and Competing Mortality After Radical Cystectomy

The extent of lymph node dissection in radical cystectomy is a subject of controversy. A more extended dissection has been reported to be associated with superior survival. We analyzed the relationship between the lymph node count and different causes of death in a sample of 735 patients who underwent radical cystectomy for recurrent or muscle-invasive urothelial or undifferentiated carcinoma of the bladder. The median follow-up was 7.8 yr. The median lymph node count was 17, and the median age was 67 yr. Although there was a clear association between lymph node count and overall survival (≥21 vs <10 lymph nodes: 10-yr rates: 59% vs 32%, respectively; hazard ratio: 0.63; 95% confidence interval, 0.46–0.87; log-rank test: p=0.0056), there was no detectable relationship between bladder cancer mortality and lymph node count (narrowly congruent cumulative mortality curves, Pepe-Mori test, p values ranging between 0.40 and 0.93). The differences were virtually entirely attributable to differences in competing mortality. These observations indicate that serious bias may occur when the lymph node count is used to stratify patients undergoing radical cystectomy. The results of the ongoing randomized trials should be awaited to reliably answer the question of the degree to which more extensive dissection may improve outcome. Patient summarySurvival differences in patients stratified by lymph node count may be attributed to competing mortality. The results of ongoing randomized trials should be awaited to answer the question of the degree to which more extensive lymph node dissection may improve outcome.

Increasing rates of surgical treatment and preventing comorbidities may increase breast cancer survival for Aboriginal women.

BackgroundLower breast cancer survival has been reported for Australian Aboriginal women compared to non-Aboriginal women, however the reasons for this disparity have not been fully explored. We compared the surgical treatment and survival of Aboriginal and non-Aboriginal women diagnosed with breast cancer in New South Wales (NSW), Australia.MethodsWe analysed NSW cancer registry records of breast cancers diagnosed in 2001–2007, linked to hospital inpatient episodes and deaths. We used unconditional logistic regression to compare the odds of Aboriginal and non-Aboriginal women receiving surgical treatment. Breast cancer-specific survival was examined using cumulative mortality curves and Cox proportional hazards regression models.ResultsOf the 27 850 eligible women, 288 (1.03%) identified as Aboriginal. The Aboriginal women were younger and more likely to have advanced spread of disease when diagnosed than non-Aboriginal women. Aboriginal women were less likely than non-Aboriginal women to receive surgical treatment (odds ratio 0.59, 95% confidence interval (CI) 0.42-0.86). The five-year crude breast cancer-specific mortality was 6.1% higher for Aboriginal women (17.7%, 95% CI 12.9-23.2) compared with non-Aboriginal women (11.6%, 95% CI 11.2-12.0). After accounting for differences in age at diagnosis, year of diagnosis, spread of disease and surgical treatment received the risk of death from breast cancer was 39% higher in Aboriginal women (HR 1.39, 95% CI 1.01-1.86). Finally after also accounting for differences in comorbidities, socioeconomic disadvantage and place of residence the hazard ratio was reduced to 1.30 (95% CI 0.94-1.75).ConclusionPreventing comorbidities and increasing rates of surgical treatment may increase breast cancer survival for NSW Aboriginal women.