Difference In 1-year Mortality Research Articles

Allograft discard risk index for lung transplantation

The demand for donor lungs continues to outpace the supply, yet nearly 75% of donor lungs intended for lung transplantation are discarded. We reviewed all donation after brain death organ donors listed within the UNOS Deceased Donor Database between 2005 and 2020. Univariable and multivariable analyses were run on the training set (n=69,355) with the primary outcome defined as lung discard, and the results were used to create a discard risk index (DSRI). Discard data were assessed at DSRI value deciles using the validation set (n=34,670), and differences in 1-year mortality were assessed using stratum-specific likelihood ratio (SSLR) analysis. Donor factors most associated with higher DSRI values included age > 65, PaO2 < 300, hepatitis C virus, and cigarette use. Factors associated with lower DSRI values included donor age < 40 and PaO2 > 400. The DSRI was a reliable predictor of donor discard, with a C-statistic of 0.867 in the training set and 0.871 in the validation set. The DSRI was not a reliable predictor of 30-day, 1-year, 3-year, and 5-year survival following transplantation (C-statistic 0.519-0.530). SSLR analysis resulted in three 1-year mortality strata (SSLR 0.88 in the 1st DSRI value decile, 1.03 in the 2nd-5th, & 1.19 in the 6th-10th). The factors leading to lung allograft discard are not the same as those leading to worse recipient outcomes. This suggests that with proper allocation, many of the grafts that are now commonly discarded could be used in the future donor pool with limited impact on mortality.

AML-266: Azacitidine or Decitabine Monotherapy for the Treatment of AML: A Comparative Systematic Review and Meta-Analysis

<h3>Context:</h3> Decitabine and azacitidine have been increasingly used to treat patients with acute myeloid leukemia (AML) who are elderly or not suitable for intensive chemotherapy. Despite their widespread use, there is no consensus on their efficacy, with considerable variability between studies. <h3>Objective:</h3> Our aim was to analyze and compare the efficacy of azacitidine and decitabine for the treatment of AML in elderly patients and/or patients not suitable for intensive chemotherapy. <h3>Design:</h3> A systematic review and meta-analysis was conducted. <h3>Patients or Other Participants:</h3> Trials were selected if performed on patients not eligible for intensive chemotherapy. The meta-analysis only includes data from the azacitidine or decitabine monotherapy arms; data from experimental arms were excluded from the analysis. <h3>Interventions:</h3> The results were summarized using a point estimate and 95% confidence interval (CI) for the means of the different outcomes between studies. <h3>Main Outcome Measures:</h3> Studies had to report at least one of the following outcomes: mortality, overall survival (OS), complete remission, complete remission with incomplete hematological recovery, or partial response. <h3>Results:</h3> The search strategy revealed 681 citations before duplicates were removed. Finally, 20 articles were included after analysis of abstracts and full text. A total of 3,000 patients from 23 cohorts were analyzed (12 cohorts of azacitidine and 11 of decitabine). A trend toward lower response rates was observed for azacitidine (31%, 95%CI: 24%–37%) compared to decitabine (40%, 95%CI: 31%–49%o, p=0.081). However, there was no significant difference in OS between azacitidine (9.99 months, 95%CI: 8.17–11.82) and decitabine (8.88 months, 95%CI: 7.67–10.08, p=0.550). Lower 1-year mortality with standard 7-day 75 mg/m² azacytidine treatment was observed compared to other azacitidine schedules (51%, 95%CI: 46%-57% <i>vs</i> 72%, 95%CI: 61%-82%, p=0.001). Moreover, OS was lower when administered for 5 days (6.28 months, 95%CI: 4.23-8.32) <i>versus</i> 7 days (10.90 months, 95%CI: 8.92–12.89, p=0.002). However, there was no significant difference in response rates, mortality, and OS when comparing the 5-day <i>vs</i> 10-day decitabine regimens. <h3>Conclusions:</h3> There were no significant differences in 1-year mortality or OS for azacitidine and decitabine (roughly 9 months). These results exploring single-HMA regimens could be useful for the design and use of new HMA-based combination schedules.

Outflow cannula position for left ventricular assist device: A propensity score-matched study.

The clinical consequences of alternative outflow cannula positioning in patients undergoing left ventricular assist device implantation are unknown. We evaluated clinical outcomes in patients who underwent implantation with the outflow cannula implanted from the right side into the ascending aorta versus the left side of the pericardium. Fifty consecutive patients with terminal left heart failure underwent implantation using the Medtronic Heartware Ventricular Assist Device at Toronto General Hospital. Patients were divided between left and right outflow cannula positioning during implantation where anastomosis occurred in the ascending aorta. Propensity score matching using exact matching on the following pre-specified covariates: Interagency Registry for Mechanically Assisted Circulatory Support score, previous cardiac surgery, and preoperative inotrope use. Fifty consecutive patients (25 left implantation and 25 right implantation) were included in the unmatched cohort and 45 patients (25 left implantation and 20 right implantation) were included in the matched cohort. No significant differences in baseline demographics. Pump thrombosis occurred in 10% (n = 2) receiving right-sided implantation and 8% (n = 2) with left implantation (p = 1.00). Postoperative stroke occurred in 10% (2/20) with right implantation and 16% (4/25) with left implantation (p = .88). No difference in 1-year mortality between right 20% (5/25) and left 25% (5/20) implantation (p = .97). No observed difference in mortality when adjusting for competing risk of heart transplantation. There was also no difference in stroke, pump thrombosis, driveline infection. Larger studies are required to confirm these findings. These preliminary data support the use of left-sided anastomoses to facilitate subsequent re-entry during heart transplantation.

Liver transplantation from discarded liver grafts: Expanding the donor liver pool in Mexico

Extended criteria donors (ECD) in liver transplantation has become a common policy because the shortage of optimal organs. Most of liver transplantation groups agree that prolonged cold ischemia, obesity, steatosis, age, hipernatremia, inotropic support, non heart beating donors (NHBD), split livers are related to primary non-function (PNF) of the liver graft with high morbidity and mortality. Discarded liver grafts by contrast accounts every year for more than two-fold the liver transplants done in Mexico. Poor donor characteristics such as steatosis > 40%, severe hyponatremia, alcohol abuse and obesity are frequently cause of declination by most transplant teams. A five year period was observed from January 2015 to January 2020. Donor variables such as severe hipernatremia (> 165 Meq/l), moderate steatosis (> 40%), BMI (> 30 kg/m2), alcohol abuse and cold ischemia time (CIT) more than 8 hr were recorded and considered risk factors for PNF. Delayed graft function (DGF), PNF and complications were evaluated. All liver donors were discarded by at least three main liver transplant centers in Mexico City. 155 LT were done. Marginal donors 60 (38.7%). Discarded livers 40 (66.6%). Severe hypernatremia (165-188 Meq/l), 19 (47.5%), obesity (30-45 kg/m2), 30 (75%) and moderate to severe steatosis (40-76%), 21 (52.5%), alcohol abuse 2 (5%). There were no differences in PNF rate, when three factors coexists DGF rate were slightly higher than control group. No differences in 1-year mortality. Discarded livers are an acceptable choice to expand liver pool donors. Moderate steatosis, severe hypernatremia and obesity seems to be good candidates for LT.

Clinical outcomes of older adults listed for heart transplantation in the United States

To examine if older age (>70 years) should be a relative contraindication for heart transplantation, we evaluated the characteristics and outcomes of patients with age ≥70 years listed for heart transplantation; and whether post-transplantation survival was inferior to younger counterparts. Retrospective cohort analysis. The scientific registry of transplant recipients (SRTR). Adults (≥18 years) listed for heart transplantation in the SRTR between 2000 and 2018. Heart transplantation. Characteristics and outcomes were compared for adults ≥70 years and <70 years. We evaluated waitlist mortality and post-transplant 1-year and 5-year survivals. The study included 57,285 patients (age range 18-79 years) listed for heart transplantation; 1203 (2.1%) age ≥70 years. Of these, 37,135 patients underwent heart transplantation; 806 (2.2%) were age ≥70 years. Yearly listing of those age ≥70 years has consistently increased from 2.5% (n= 30) in 2000 to 11% (n= 132) in 2017 (p< 0.01). As compared with the age <70 years group, those ≥70 years had a similar risk of death while waiting (sub-hazard ratio [SHR] 0.86, 95% confidence interval [HR] 0.68-1.08; p= 0.19) but were more likely to be transplanted (SHR 1.36, 95% CI 1.26-1.48; p< 0.01). Among the older patients, the overall post-transplant 1- and 5-year mortality rate was 10.4% and 19.2%, respectively. Older recipients had lower unadjusted survival compared with younger recipients (log-rank p= 0.03). However, after adjustment for relevant covariates, there was no significant difference in 5-year mortality between both groups (HR 1.06, 95% CI 0.91-1.254; p= 0.43). Post-transplant survival up to 5 years among patients of age ≥70 years was similar to that of younger recipients. Older patients who received heart transplantation appear to have lower risk features but receive hearts from higher risk donors. Chronologic age alone should not constitute a contraindication for heart transplantation, although careful patient selection criteria should be applied.

Using randomized trial data to estimate effects of complex treatment regimens in real-world patients.

e18706 Background: Real-world patients often differ from trial participants in prognostic factors such as age, sex, and cancer substage. New methods combine covariate data from real-world patients (the “target population”) with outcome and covariate data from a trial to estimate treatment effects in the target population that take these differences into account. With some assumptions, these methods can also estimate outcomes under treatment regimens not studied in the trial such as “what if we only gave six cycles of chemotherapy?” or “what if patients all perfectly followed a protocol?” Methods: Data from the MOSAIC trial of 5-fluorouracil (5FU) vs oxaliplatin + 5FU (FOLFOX) were combined with covariate data from a target population of stage III colon cancer patients in the US Oncology Network meeting trial eligibility criteria. We used weighting and G-computation to estimate five-year mortality and treatment-related paresthesia risk in the target population for four regimens: treatment with up to 12 cycles of 5FU, if providers used their discretion on dose reductions and delays (5FU-MD); up to 12 cycles of FOLFOX with similar physician discretion (FOLFOX-MD); up to 6 cycles of FOLFOX, with providers perfectly following a strict and specific protocol of dose reductions and delays (6-cycle FOLFOX-P, “P” for “per protocol”); and up to 12 cycles of FOLFOX, following the same strict protocol (12-cycle FOLFOX-P). Results: Tablepresents five-year all-cause mortality and paresthesia risk under each regimen in the stage III target population estimated from the models built in trial participants. Paresthesia risk increased with cumulative oxaliplatin dose. Estimated 5-year mortality was lowest with 12-cycle FOLFOX-P. Conclusions: In a target population of US Oncology Network patients with stage III colon cancer, strict protocols of 12 cycles of FOLFOX were predicted to improve survival compared to strict 6-cycle FOLFOX regimens or less strict 12-cycle FOLFOX and 5FU regimens at the cost of substantial increases in side effects. While estimates of risk differences in 5-year mortality were imprecise, combining trial and real-world data and then using weights and G-computation allowed estimation of benefits and harms of multiple regimens in a clinically relevant patient population.[Table: see text]

Early reperfusion strategy selection and prognosis analysis in patients with acute ST segment elevation myocardial infarction: based on the data of 49 hospitals in Hebei Province

To explore the selection of strategies for early reperfusion therapy and its impact on prognosis in patients with acute ST segment elevation myocardial infarction (STEMI). The treatment data and 3-year follow-up results of acute myocardial infarction (AMI) patients in 49 hospitals in Hebei Province from January to December 2016 were collected. Patients with STEMI who received either intravenous thrombolytic therapy (ITT) or primary percutaneous coronary intervention (PPCI) within 12 hours of onset were enrolled. Baseline data, the time from the first diagnosis to the start of reperfusion (FMC2N for ITT patients and FMC2B for PPCI patients), vascular recanalization rate, in-hospital mortality, 1-year mortality, and 3-year mortality were compared between ITT and PPCI groups. The efficacy and prognosis of ITT and PPCI at different starting time of reperfusion (FMC2N ≤ 30 minutes, FMC2N > 30 minutes, FMC2B ≤ 120 minutes, FMC2B > 120 minutes) were analyzed. A total of 1 371 STEMI patients treated with ITT or PPCI were selected, including 300 patients in the ITT group and 1 071 patients in the PPCI group. 1 055 patients were actually followed up (205 patients in the ITT group and 850 patients in the PPCI group), with a rate of 79.4%. There were no significant differences in age, gender, and previous history between the two groups. The time from the first diagnosis to the start of reperfusion in the ITT group was shorter than that in the PPCI group [minutes: 63 (38, 95) vs. 95 (60, 150), U = -9.286, P = 0.000], but was significantly longer than the guideline standard. Compared with the ITT group, the vascular recanalization rate in the PPCI group was higher [95.5% (1 023/1 071) vs. 88.3% (265/300), P < 0.01], and in-hospital mortality was lower [2.1% (22/1 071) vs. 6.7% (20/300), P < 0.01], but there were no significant differences in the 1-year mortality and 3-year mortality [5.3% (45/850) vs. 4.4% (9/205), 9.5% (81/850) vs. 9.3% (19/205), both P > 0.05]. Between ITT group and PPCI group with different reperfusion starting time, the FMC2N > 30 minutes group had the lowest vascular recanalization rate and the highest in-hospital mortality. Pairwise comparison showed that the vascular recanalization rate of the FMC2B ≤ 120 minutes group and the FMC2B > 120 minutes group were significantly higher than those of the FMC2N > 30 minutes group [95.5% (654/685), 95.6% (369/386) vs. 88.0% (220/250), both P < 0.008], the in-hospital mortality was significantly lower than that of the FMC2N > 30 minutes group [2.0% (14/685), 2.1% (8/386) vs. 7.6% (19/250), both P < 0.008]. There was no significant difference in 1-year mortality (χ2 = 2.507, P = 0.443) and 3-year mortality (χ2 = 2.204, P = 0.522) among the four groups. For STEMI patients within 12 hours of onset, reperfusion therapy should be performed as soon as possible. PPCI showed higher infarct related artery opening rate and lower in-hospital mortality compared with ITT, and had no effect on 1-year and 3-year mortality.

Prognosis of patients with left circumflex artery acute myocardial infarction in relation to ST-segment on admission electrocardiogram

Abstract Funding Acknowledgements Type of funding sources: None. Background. Total thrombotic occlusion of the LCX may present without ST-segment elevations. Objective. To examine the difference in clinical outcomes between patients with acute MI due to LCX occlusion or stenosis with and without ST-segment elevation. Methods. The present study is a dual center, observational, retrospective cohort study comprising all patients admitted to between 2009 and 2019 with LCX-related. Results. A total of 897 patients with LCX-related MI were included. Most (56.6%) presented with NSTEMI, which was associated with higher rates of 1-year hospitalization for ACS (15.8% vs 11.1%; P=.05) and PCI (20.9% vs 14.4%; P=.05). STEMI was associated with higher 30-day mortality compared with NSTEMI (3.9% vs 1.7%, P=.05), with no difference in 1-year mortality (6.7% vs 5.6%, P=.55). Multivariate analysis found left dominant circulation (odds ratio [OR], 2.62; 95% confidence interval [CI], 1.4-4.7) and diabetes mellitus (OR, 2.13; 95% CI, 1.2-3.6) to be independent predictors of 1-year mortality. Conclusion. Patients suffering from NSTEMI and STEMI related to LCX occlusion or stenosis have similar 1-year mortality. Left dominance was associated with higher short- and long-term mortality. These results suggest that a substantial population of patients who present as NSTEMI should be treated promptly and aggressively as STEMI patients.

Higher 1-year mortality in women admitted to intensive care units after cardiac arrest: A nationwide overview from the Netherlands between 2010 and 2018.

We study sex differences in 1-year mortality of out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) patients admitted to the intensive care unit (ICU). A retrospective cohort analysis of OHCA and IHCA patients registered in the NICE registry in the Netherlands. The primary and secondary outcomes were 1-year and hospital mortality, respectively. We included 19,440 OHCA patients (5977 women, 30.7%) and 13,461 IHCA patients (4889 women, 36.3%). For OHCA, 1-year mortality was 63.9% in women and 52.6% in men (Hazard Ratio [HR] 1.28, 95% Confidence Interval [95% CI] 1.23-1.34). For IHCA, 1-year mortality was 60.0% in women and 57.0% in men (HR 1.09, 95% CI 1.04-1.14). In OHCA, hospital mortality was 57.4% in women and 46.5% in men (Odds Ratio [OR] 1.42, 95% CI 1.33-1.52). In IHCA, hospital mortality was 52.0% in women and 48.2% in men (OR 1.11, 95% CI 1.03-1.20). Women admitted to the ICU after cardiac arrest have a higher mortality rate than men. After left-truncation, we found that this sex difference persisted for OHCA. For IHCA we found that the effect of sex was mainly present in the initial phase after the cardiac arrest.

Factors associated with mortality in older patients sustaining pelvic or acetabular fractures

IntroductionThis study aimed to investigate potential factors, including delay to surgical stabilisation, affecting mortality in older patients sustaining pelvic or acetabular (PA) fractures.Materials and methodsA retrospective review of the Trauma Audit and Research Network (TARN) database was performed to identify older patients (aged 65 and over) sustaining PA fractures treated surgically in a UK Major Trauma Centre (MTC) between 2015 and 2019. Chi-squared and Fisher tests were used to compare 1-year mortality rates following operative intervention between patients treated within 72 h and after 72 h. Kaplan–Meier curves were used to visualise survival probability; significant predictors of survival were found using Cox proportional hazard models.ResultsOf 564 older patients with PA fractures, 70 met the inclusion criteria. The mean age was 76.1 years. The overall 1-year mortality rate was 20%. When patients were grouped by time to surgery (fracture fixation within or greater than 72 h), there was no statistically significant difference in 1-year mortality. Patients whose surgery was delayed more than 72 h were more likely to have longer hospital stays (p = 0.002) or to have suffered from polytrauma (p = 0.025). Age, Charlson Co-morbidities Index (CCI) and pre-op mobility status were associated with statistically significant differences in overall mortality. The same factors were associated with a significantly increased hazard of death in the multivariate Cox proportional hazards model. Patient gender, mechanism of injury, Injury Severity Score (ISS) > 15 and head injury were not significant predictors of mortality.ConclusionSurgical intervention within 72 h of injury did not result in decreased mortality in older patients with PA fractures. The 1-year mortality rate between older PA fractures and hip fractures was comparable. Consideration should be given to a combined multidisciplinary approach between orthogeriatric and expert PA surgeons for these patients.

Assessing Race and Socioeconomic Status Based Differences in Survival after Pulmonary Thromboendarterectomy for Chronic Thromboembolic Pulmonary Hypertension

<h3>Purpose</h3> Pulmonary thromboendarterectomy (PTE) is a definitive treatment for chronic thromboembolic pulmonary hypertension (CTEPH). Race and socioeconomic based disparities in PTE outcomes have not been well studied. <h3>Methods</h3> We retrospectively reviewed all patients who underwent PTE for CTEPH at our institution from June 2009 to July 2019, tracking patient demographic information including self-identified race, preoperative variables, and 5-year mortality. SES was assessed using the zip code-linked Distressed Communities Index, a validated holistic measure of community well-being. Survival was estimated with Kaplan-Meier and compared using the log-rank test. Factors associated with mortality were estimated using Cox proportional hazards analysis. <h3>Results</h3> Of the 235 patients that underwent PTE during the study period, 100 (42.5%) were white and 88 (37.4%) were black. Out of our 47 (20.1%) patients who were not white or black, we had too few patients of other races to analyze. White patients had a higher median age at surgery than black patients (57 vs 52 years, p = 0.043). There was no difference in 5-year mortality after PTE between black and white patients (p = 0.54, Figure 1). SES (HR 0.97, 95% CI [0.94,0.996], p=0.02) was significantly associated with mortality, while race (HR 0.78, 95% CI [.213, 2.891], p=0.78) was not. <h3>Conclusion</h3> SES but not race was not associated with mortality following PTE at our center. However, additional studies with larger sample sizes are warranted.

Changes in survival and causes of death among people living with HIV: Three decades of surveys from Tokyo, one of the Asian metropolitan cities

IntroductionSurvival among people living with HIV (PLWH) has dramatically improved in the antiretroviral therapy (ART) era. This is the first study in Asia to describe three decades of surveys on survival and causes of death among PLWH. MethodsWe included 1121 HIV-infected patients, categorized into three period groups according to date of first visit: 1986–1996 (Pre-ART); 1997–2007 (Early-ART); and 2008–2018 (Late-ART). ResultsTen-year all-cause mortality has reduced from Pre-ART (49.6/1000 person-years) to Late-ART (6.3/1000 person-years). Mortality for AIDS-defining illnesses (ADIs) has also reduced from Pre-ART (34.4/1000 person-years) to Late-ART (2.9/1000 person-years), and mortality for non-ADIs has reduced from Pre-ART (11.7/1000 person-years) to Late-ART (2.9/1000 person-years). In the ART-era, deaths from non-AIDS-defining malignancies and unnatural events including suicide represented the majority of non-ADI-related deaths and mortality rates of non-AIDS defining malignancies and unnatural cause event were not different between each group (3.4, 1.9 and 2.5/1000 person-years). Crude cumulative survival improved over the study period, and 10-year survival ratios of HIV-infected patients to the general Japanese population approached 1.00, from Pre-ART (0.66) to Late-ART (0.99). Even in the Late-ART period, survival remained lower in patients with a history of ADIs than in those without, but the difference in 5-year mortality between these groups has shrunk in the Late-ART compared to the Pre-ART. ConclusionsMortality for ADIs and non-ADIs in PLWH has reduced in the Early-ART and Late-ART. To improve survival for PLWH further, early HIV detection and treatment and good management of non-AIDS-defining malignancies and mental disorders are needed. (248/250).

Long-term safety and efficacy of angioplasty of femoropopliteal artery disease with drug-coated balloons from the AcoArt I trial

ObjectiveWe evaluated the long-term safety and efficacy of treatment using drug-coated balloons (DCBs) in Chinese patients with severe femoropopliteal artery (FPA) disease (FPAD). MethodsIn this prospective, multicenter, randomized controlled trial, 200 Chinese patients with FPAD were prospectively randomized to undergo percutaneous transluminal angioplasty with a DCB or an uncoated balloon (UCB). The clinical endpoints were all-cause mortality, clinically driven target lesion revascularization, and major amputation of the treated leg within 5 years after treatment. ResultsDuring the 5-year follow-up period, freedom from all-cause mortality was 82.7% in the DCB group compared with 73.2% in the UCB group (log-rank P = .262). Freedom from clinically driven target lesion revascularization was 77.5% in the DCB group vs 59.1% in the UCB group (log-rank P < .001). No device- or procedure-related deaths occurred in either group. Cox regression analysis revealed that coronary heart disease and provisional FPA lesion stenting were associated with an increased mortality risk and the nominal paclitaxel dose was not associated with mortality during the 5-year follow-up period. ConclusionsWe found no significant differences in 5-year mortality between patients with FPAD treated with DCBs vs UCBs. The clinical benefit of DCBs vs UCBs in terms of clinically driven target lesion revascularization persisted for the 5-year period.

The effect of combination therapy with erythropoietin and methylprednisolone in patients with traumatic cervical spinal cord injury: a pilot randomized controlled trial.

Pilot double-blinded randomized controlled trial. To investigate the additive effect of recombinant human erythropoietin (rhEPO) on functional outcome and disability in patients with traumatic cervical spinal cord injury (TCSCI). University-affiliated hospital in Mashhad, Iran. Patients with acute TCSCI admitted within 8 h after injury were randomly assigned to receive only methylprednisolone (M group) or rhEPO 500 IU/mL plus methylprednisolone (M + E group). All the patients underwent surgery within the next several days. Neurological function was assessed on admission, and at 6th and 12th months after the injury according to the sphincter function and American spinal cord injury association (ASIA) scale. Overall, 54 patients (mean age: 39.7 ± 13.3 years) including 46 (85%) males were studied in two groups of 27. The likelihood of developing adverse neurological outcomes (ASIA impairment score of A compared to D or E) was not significantly different between the groups after 6 (OR = 0.39, 95% CI = 0.03-4.80, P = 0.46) and 12 months (OR = 0.83, 95% CI = 0.11-6.11, P = 0.86). The groups also showed no significant difference in 1-year mortality (OR = 0.83, 95% CI = 0.25-2.74, P = 0.76). It is not clear whether combination therapy with erythropoietin compared to methylprednisolone alone improves neurological functions of patients with TCSCI. Our study provides interim data to guide future larger definitive trials.

Effect of oral administration of branched-chain amino acids supplementation on the mortality of patients with hepatocellular carcinoma: a meta-analysis

Objective: To investigate the effect of oral administration of branched-chain amino acids (BCAA) supplementation on the mortality of patients with hepatocellular carcinoma (HCC) after treatment. Methods: Computer searching of PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, and Chinese Biomedical Literature Database was conducted to search for clinical controlled trials and randomized controlled trials (RCTs) on the effect of oral administration of BCAA on the mortality of patients with HCC. The retrieval time limit was from the time of the establishment of each database to December 30, 2019. Two researchers independently screened the literature and extracted the data. Another researcher assessed the risk of bias in the included studies and then used RevMan 5.3 software for meta-analysis. Results: A total of 14 studies were included with 1 179 patients. The overall results showed that oral administration of BCAA had no significant effect on the mortality of HCC patients at 1 year after treatment (RR=0.85, 95%CI:0.68-1.06, P=0.16), while the mortalities of patients at 3 years (RR=0.73, 95%CI: 0.61-0.88, P=0.000 7) and 5 years (RR=0.57, 95%CI:0.34-0.96, P=0.03) after treatment were significantly lower than those of the control group. The subgroup analysis showed that for radiofrequency ablation (RFA) patients, there was no significant difference in 1-year mortality between the BCAA group and the control group (RR=0.96, 95%CI:0.14-6.5, P=0.97), while 3-year mortality was significantly reduced (RR=0.59, 95%CI:0.43-0.81, P=0.001); for hepatectomy patients, there was no significant differences in 1 -and 3-year mortality between the two groups (RR=0.90, 95%CI:0.44-1.88, P=0.79; RR=0.97, 95%CI:0.71-1.33, P=0.85, respectively). In addition, as for albumin levels, BCAA supplementation significantly increased albumin levels without considering the treatment of HCC (SD=0.45, 95%CI: 0.29-0.90; P=0.000 1), but had no significant effect on hepatectomy patients (SD=0, 95%CI: -0.41-0.41, P=0.99). Conclusion: BCAA supplementation might improve liver reserve function and long-term prognosis of HCC patients, which was related to the surgical method. Supplementing BCAA reduced the long-term mortality of RFA patients, but had no significant effect on hepatectomy patients.

Relative impact of red blood cell transfusion and anaemia on 5-year mortality in cardiac surgery.

The aim was to compare the relative effects of red blood cell (RBC) transfusion and preoperative anaemia on 5-year mortality following open-heart cardiac surgery using structural equation modelling. We hypothesized that patient risk factors associated with RBC transfusion are of larger importance than transfusion itself. This prospective cohort study, part of the Cardiac Surgery Outcome Study at St. Olavs University Hospital, Trondheim, Norway, included open-heart on-pump cardiac surgery patients operated on from 2000 through 2017 (n = 9315). Structural equation modelling, which allows for intervariable correlations, was used to analyse pathway diagrams between known risk factors and observed mortality between 30 days and 5 years postoperatively. Observation times between 30 days and 1 year, and 1-5 years postoperatively were also compared with the main analysis. In a simplified model, preoperative anaemia had a larger effect on 5-year mortality than RBC transfusion (standardized coefficients: 0.17 vs 0.09). The complete model including multiple risk factors showed that patient risk factors such as age (0.15), anaemia (0.10), pulmonary disease (0.11) and higher creatinine level (0.12) had larger effects than transfusion (0.03). Results from several sensitivity analyses supported the main findings. The models showed good fit. Preoperative anaemia had a larger impact on 5-year mortality than RBC transfusion. Differences in 5-year mortality were mainly associated with patient risk factors.

Treatment profile and long-term outcome of intensive care unit-admitted patients with liver cirrhosis or other liver disease in relation to alcohol consumption

Objective To examine the impact of alcohol consumption on the treatment profile, mortality and causes of death in intensive care unit (ICU)-admitted patients with liver cirrhosis and other liver disease. Methods Data on liver disease and ICU treatment of patients with previously diagnosed liver disease between 2015 and 2017 were retrospectively collected from medical records at Oulu University Hospital, Finland. The median follow-up was 367 days. The causes of death were obtained from Statistics Finland. Results From 250 patients, high-risk alcohol consumption was present in 74.7% (71 of 95) cirrhotic patients and 43.2% (67 of 155) patients in the other liver disease group. Gastrointestinal causes were the most common admission causes. Despite the higher SOFA scores in the alcoholic liver cirrhosis patients compared with the non-alcoholic cirrhosis, there were no differences in the need for organ support, length of ICU stay or outcome between the groups or the subgroups. There were no differences in 1-year mortality between the cirrhosis groups (alcoholic cirrhosis 43.7% versus non-alcoholic cirrhosis 45.8%, p = 1.0) or between the other liver disease groups (patients with alcohol consumption 37.3% versus patients without alcohol consumption 36.4%, p = 1.0). The patients with high-risk alcohol consumption died more often due to liver disease, whereas the patients without high-risk alcohol consumption died often due to malignancies. Conclusions We report no significant impact of alcohol consumption on the ICU treatment profile or mortality of patients with cirrhosis or other liver disease. The high mortality underlines the importance of preventive measures after ICU admission.

The Effect of Blood Transfusion in Lung Donors on Recipient Survival

Blood transfusion can have detrimental effects on the pulmonary system, leading to lung injury and respiratory decompensation with subsequent increased morbidity and mortality in surgical and critically ill patients. How much of this effect is carried from a lung donor to transplant recipient is not fully understood, raising questions regarding transplant suitability of lungs from transfused donors. United Network for Organ Sharing data were reviewed. Lung transplants from adult donors and known donor transfusion status were included; multiorgan transplants and retransplants were excluded. Recipient mortality was evaluated based on donor and recipient characteristics using a Kaplan-Meier survival estimate, Cox proportional hazards, and logistic regression models. We further assessed whether recipient mortality risk modified the donor transfusion effect. From March 1996 to June 2017, 20,294 transplants were identified. Outcome analysis based on transfusion status showed nonsignificant difference in 1-year mortality (P= .214). Ninety-day recipient mortality was significantly higher with transfusion of >10 units (U) vs 1-10 U or no transfusion (8.5%, 6.1%, and 6.0%, respectively, P= .005). Multivariable analysis showed increased 90-day mortality with transfusion of >10 U compared to no transfusion (odds ratio 1.62, P < .001), whereas 1-10 U showed no difference (odds ratio 1.07, P= .390). When stratified by recipient transplant risk, transfusion of >10 U was associated with increased mortality even with the lowest-risk recipients, while transfusion of 1-10 U showed no mortality increase even in the highest-risk recipients. Donor transfusion of >10 U of blood was associated with increased 90-day recipient mortality even in low-risk transplants. This risk should be considered when evaluating donor lungs.

Comparing Whole Brain Radiation, 1, 3, And 5 Fraction Stereotactic Radiation In Patients With Brain Metastases

Patients with brain metastases are commonly treated with Radiation therapy (RT). Commonly used RT options include whole brain radiation (WBRT), Stereotactic radiosurgery (1 fraction, fx) or stereotactic radiation therapy (SRT, 2-5 fractions) depending on the number of lesions, primary cancer, KPS and other patient and tumor characteristics. The purpose of this study was to compare 1-year survival outcomes between WBRT, 1 fx SRS, 3 fx SRT and 5fx SRT. A retrospective analysis of 910 treatments with radiation therapy (RT) for 700 patients with brain metastases was performed (2012-2018). Treatment variables were extracted using Oncora software platform. Data for the four treatment groups (1fx, 3fx, 5fx and WBRT) was collected. Baseline characteristics between the treatment groups were compared using Chi-square test, Analysis of Variance, and the Kruskal-Wallis test. Mortality at 1 year was compared between the four treatment groups using a logistic regression model, adjusting for age, gender and KPS. Hosmer-Lemeshow test was used to determine whether the model provided a good fit. Tukey’s method was used to adjust for the multiple comparisons between the 4 treatment groups. P<0.05 was considered statistically significant. SAS 9.4 was used for the statistical analysis. Mean age (SD) was 63.3(12.3) years. Gender distribution was 397 (56.7%) females and 303 (43.3%) males. Treatment modalities were 244(34.9%) 1fx, 65(9.3%) 3fx, 14(2.0%) 5fx and 377(53.9%) whole brain (WBRT). Median 1fx dose was 20Gy, 3fx dose 24Gy and 5fx dose 30Gy and WBRT dose of 30Gy. Treatment groups were similar in term of age (p = 0.44). There were significant differences in the terms of the KPS distributions between treatments (p<0.0001), with median of 80, 80, 80 and 70 for treatments 1fx, 3fx, 5fx and WBRT, respectively although no significant gender differences were observed among the treatment groups (p = 0.44). The overall mortality rate at 1 year was 69.3%, with 136(55.7%), 42(64.6%), 8(57.1%) and 299(79.3%) for 1fx, 3fx, 5fx and WBRT, respectively. In the 6 pairwise comparisons (table1), 1fx had 62% lower odds of death compared to WBRT (OR = 0.38, 95% CI 0.23 to 0.63, p<0.0001). Age was significantly associated with mortality (OR = 1.03, 95% CI 1.02 to 1.05, p<0.0001), with 3% higher odds of 1-year mortality, for every 1-year increase in age. In women, 10 units increase of KPS had 31% lower odds of 1-year mortality (OR = 0.69, 95% CI 0.56 to 0.85, p = 0.001), while not significant in men (OR = 0.93, 95% CI 0.74 to 1.17, p = 0.56). We found that “Non-WBRT” group had 59% lower odds of 1-year mortality (OR = 0.41, 95% CI 0.28 to 0.59, p<0.0001) compared to the WB group. There was no difference in 1-year mortality in the three stereotactic protocols. Single fraction SRS had improved survival compared to WBRT at 1 year. Prospective studies are needed are needed to confirm survival and toxicity in the treatment groups.

Symptom Burden Is Associated with Psychological Wellbeing and Mortality in Older Adults.

Over half of outpatient visits are due to physical symptoms; yet, the significance of symptoms in relation to older people's wellbeing and prognosis has gained very little research attention. This study aims to analyze the prognostic value of symptom burden, derived from symptom count and frequency, in an older cohort aged 75 to 95. We also explore the association between symptom burden and psychological wellbeing. Randomly assigned cohorts of community-dwelling people aged 75-95 filled in the postal questionnaire of the Helsinki Aging Study in 2009. Community-based, postal questionnaires (survey response rate 74%). 1583 community-dwelling people aged 75-95 in the urban Helsinki area. Main outcomes and measures: The inquired symptoms were dizziness, back pain, joint pain, chest pain or discomfort, shortness of breath, leg pain when walking, loss of appetite, and urinary incontinence. Symptom burden was calculated according to the number of symptoms and their frequency (score range: 0-8). The participants were subdivided into four groups according to their symptom burden. Mortality data was extracted from the Finnish Population Register in 2014. Psychological wellbeing (PWB) was measured using the validated PWB score. Of 1583 participants, 18% reported no symptoms over the past 2 weeks (Group 0), 31% scored 0.5-1 in the symptom burden score (Group 1), 23% scored 1.5-2 (Group 2), and 28% scored 2.5-8 (Group 3). There was a linear relationship between symptom burden and comorbidities, functional status, falls, and PWB. The groups showed a significant difference in 5-year mortality, even adjusted for age, sex, and comorbidities: Group 1 1.18, 95% CI 0.84-1.66; Group 2 1.63, 95% CI 1.15-2.31, and Group 3 2.08, 95% CI 1.49-2.91 compared to Group 0 (p for linearity <0.001). Conclusion and relevance: Symptom burden is associated with higher mortality and lower PWB independent of comorbidities in community-dwelling people aged 75-95. We conclude that somatic symptoms need to be assessed when examining the general health status of an aging patient. Self-reported symptoms seem to convey information about health that cannot be derived from medical diagnoses only.