Hazard Of Death Research Articles

DISP-18. RACIAL DISPARITY IN THE UTILIZATION OF MOLECULAR DIAGNOSTIC AS A PROXY FOR SUB-OPTIMAL CLINICAL CARE IN GLIOBLASTOMA PATIENTS

Abstract BACKGROUND Molecular characterization of IDH mutation and MGMT-promoter methylation (MGMTm) are standard-of-care (SOC) diagnostics and essential to diagnosis, treatment, and prognosis of glioblastomas. Here, we determined the extent to which racial disparity occurs in this dimension of oncologic care. METHODS 31,439 glioblastoma patients were derived from the National Cancer Database (NCDB,2018-2021), with 20,736 IDH-wildtype patients with defined MGMT-status. Accessibility to SOC diagnostics was defined as whether patients got IDH/MGMT testing or not. Race/Ethnicity was grouped into Non-Hispanic White (NHW), Non-Hispanic Black, Asian/Pacific Islander, Hispanic, and Others. Receipt of SOC diagnostics and treatments, post-operative outcomes, and overall survival (OS) were explored using multivariable logistic regression, Kaplan-Meier method, and Cox proportional hazards models. RESULTS Relative to NHWs, all racial minority groups were less likely to have undergone IDH or MGMT-testing. These effects remain robust after adjusting for economic status, insurance, and facility type. Patients who received neither IDH nor MGMT-testing were 38% less likely to undergo SOC concurrent chemo-/radiation therapy (cCRT) relative to those having both testing. Further, patients having neither IDH nor MGMT-testing showed significantly higher risk of 30-day mortality (aOR:2.20), 90-day mortality (aOR:1.60), and hazard of death (median OS:8.9-mon,aHR:1.09,p=0.002) than those having both testing (median OS:12.9-mon). Of those tested for both IDH/MGMT, the odds of bearing a methylated MGMT-promoter remained relatively constant across five racial groups. Non-NHW glioblastomas patients were significantly less likely to receive SOC-modality. Of the patients who underwent IDH/MGMT-testing and cCRT, median OSs were 23.7 and 14.4-mon for MGMT-methylated and unmethylated glioblastoma, respectively. No significant difference in hazards of death for racial/ethnic minorities compared to NHWs was detected, regardless of MGMT-methylation status. CONCLUSIONS Our findings suggest that non-NHW glioblastoma patients are less likely to undergo SOC diagnostic (IDH/MGMT) testing, which serves as a proxy for receipt of sub-optimal clinical care. For glioblastoma patients who underwent SOC molecular testing and treatment, survival is similar across racial groups.

Better health-related quality of life is associated with prolonged survival and reduced hospitalization risk among dialysis-dependent chronic kidney disease patients: a historical cohort study

Rationale & objectiveEnd-stage kidney disease (ESKD) negatively affects patients’ physical, emotional, and social functioning. Furthermore, adjustment to dialysis require substantial lifestyle changes that may further impact on patients physical and emotional well-being. However, the relationship between Health-Related Quality of life impairment with future adverse outcomes in dialysis is not well characterized. Our study aims to investigate the relationship between Health-Related Quality of Life (HRQoL) and patients’ survival and hospitalization rates within a large European dialysis network.MethodsA historical cohort study was conducted to evaluate association of HRQoL with hospitalization and mortality rates over a 12-month follow-up period. Patients responded to a self-administered survey as part of a Continuous Quality Improvement Program implemented in clinics affiliated with the Spanish FMC-Nephrocare organization. Health-Related Quality of Life (HRQoL) was measured with the KDQOL-36. Potential confounders included socio-demographic characteristics, comorbidities, biochemical parameters, dialysis treatment. We used Cox’s Proportional Hazard regression to assess the hazard of death and Logistic Regression to assess the likelihood of hospital admissions during 12-month follow-up period.ResultsA total of 2280 (51.5%) completed the self-administrated survey, and 1838 patients met the inclusion/exclusion criteria of the study. Higher HRQoL scores were associated with significantly lower mortality and hospitalization risk. Risk estimates were robust to adjustment for potential confounders.ConclusionsSeveral dimensions of HRQoL are associated with patient-centered outcomes (i.e., mortality and hospitalizations at 1 year). Patient-Reported Outcomes contribute unique pieces of information characterizing patients’ health. Residual confounding cannot be fully ruled out; moreover, the high attrition rate could result in selection bias, which may limit the generalizability of the findings to a broader population.

Cox Regression Model with Time-varying Coefficients Applied to Survival Estimation of Heart Failure

This study focuses on survival analysis of heart failure patients. All the patients, who are over 40 years old, have NYHA classes III or IV stages of heart failure. Cox regression model with time-varying coefficients is applied to deal with these data, which is updated in 2015. Kaplan Meier curves are plotted to screen out categorical variables that violates PH assumptions. As for continuous variables violating PH assumption, Schoenfeld residual plot is drawn to realize time stratification. Therefore, for each time period, cox proportional hazard model can be fit to estimate mortality and find out the key factors promoting or inhibiting death event of heart failure. As a result, age, blood pressure, serum creatinine, and ejection fraction are the significant features of hazard of death led by heart failure, which is validated by Wald test, Likelihood ratio test, and Log-rank test. Discrimination ability is also characterized by ROC curves and AUC finally.

Enhancing primary prevention: the incremental predictive value of NTproBNP beyond ASCVD risk assessment

Abstract Background Atherosclerotic cardiovascular disease (ASCVD) is a global health challenge, prompting widespread use of conventional risk assessment tools (SCORE2 in Europe and the ASCVD Risk calculator in the United States) to guide preventive strategies. Emerging evidence indicates that NTproBNP may help refine risk stratification. We investigate whether measuring NTproBNP in primary prevention correlates with mortality and enhances prediction compared to conventional risk score stratification. Methods Utilizing National Health and Nutrition Examination Survey (NHANES) data (1999 to 2004) linked to the National Death Index, our cohort included individuals without a history of CVD at baseline and suitable for assessment of the ASCVD ACC/AHA risk score. Individuals were grouped based on computed 10-year risk (low: <5%; borderline: 5-7.5%; intermediate: 7.5-20%; high: ≥ 20%). NTproBNP levels were measured (Roche assay, cut-off > 125pg/mL considered as positive). Cox regression estimated the association between ASCVD risk categories, with or without NTproBNP, and all-cause and cardiovascular mortality. Results Among 5257 adults, 47% male, mean age 54 ± 9.1 years, the mean 10-year ASCVD risk was 8.17 ± 8.2%, grouped as: low: 53.3%; borderline: 11.5%; intermediate: 23.9%; and high: 11.3%. NTproBNP > 125pg/mL was measured in 12.2%, 16%, 23.2% and 48.6% individuals, respectively (p < 0.001). Over 16.2 ± 3.4 years, all-cause and cardiovascular death was 22.3% and 5.6%, respectively. Compared to low-risk, the hazard ratio (HR) for all-cause death increased to 2.85 (2.2-3.7), 5.6 (4.2-7.5), and 15.3 (11.7-19.9) for borderline, intermediate, and high-risk, respectively. A significant interaction with NTproBNP was observed (low: HR 1.96 (1.33-2.9); borderline: HR 2.5 (1.6-3.9); intermediate: HR 2 (1.6-2.6), high: HR 1.7 (1.4-2.2), p<0.01 for all interactions, see Fig. 1). For cardiovascular death, a significant interaction also occurred across the groups, but of higher magnitude in low and borderline groups (low: HR 3.2 (1.4-7.3); borderline: HR 5.5 (2.5-12.4), p < 0.001 for both). Conclusion Our findings suggest that NTproBNP provides incremental predictive value, approximately doubling the hazard of all-cause death across all risk categories, and more than tripling the hazard of CV death in low/borderline risk groups, compared to ASCVD risk alone. The integration of NTproBNP measurements into risk assessment strategies could refine primary prevention approaches.

Enhancing primary prevention: the incremental predictive value of high-sensitivity cardiac troponin T beyond ASCVD risk assessment

Abstract Background Atherosclerotic cardiovascular disease (ASCVD) is a global health challenge, prompting widespread use of conventional risk assessment tools (SCORE2 in Europe and the ASCVD Risk calculator in the United States) to guide preventive strategies. Emerging evidence indicates that high-sensitivity cardiac troponin (hsTn) may refine risk stratification. Objective We investigate whether measuring hsTnT in primary prevention correlates with mortality and enhances prediction compared to conventional risk score stratification. Methods Utilizing National Health and Nutrition Examination Survey (NHANES) data (1999 to 2004) linked to the National Death Index, our cohort included individuals without a history of CVD at baseline and suitable for assessment of the ASCVD ACC/AHA risk score. Individuals were grouped based on computed 10-year risk (low: <5%; borderline: 5-7.5%; intermediate: 7.5-20%; high: ≥ 20%). hsTroponin T levels were measured (Roche assay, 99 th percentile 22ng/L for men and 17ng/L for women). Cox regression estimated association between ASCVD risk categories, with or without hsTnT, and all-cause and cardiovascular mortality. Results Among 5257 adults, 47% male, mean age 54 ± 9.1 years, the mean 10-year ASCVD risk was 8.17 ± 8.2%, grouped as: low: 53.3%; borderline: 11.5%; intermediate: 23.9%; and high: 11.3%. hsTnT above the 99 th percentile was measured in 1.1%, 2.7%, 4.9% and 13.4%, respectively (p < 0.001). Over 16.2 ± 3.4 years, all-cause and cardiovascular death was 22.3% and 5.6%, respectively. Compared to low-risk, the hazard ratio (HR) for all-cause death increased to 2.85 (2.2-3.7), 5.6 (4.2-7.5), and 15.3 (11.7-19.9) for borderline, intermediate, and high-risk, respectively. A significant interaction with hsTnT above 99 th percentile was observed (low: HR 3.5 (1.3-9.2); borderline: HR 4.75 (2.1-10.8); intermediate: HR 2.6 (1.8-3.7), high: HR 2.2 (1.7-2.9), p<0.01 for all interactions, see Fig. 1). For cardiovascular death, a significant interaction occurred in intermediate (HR 3.3 (2-5.4), p<0.001) and high-risk (HR 3.6 (2.2-6), p<0.001) groups. Conclusion Our findings suggest that hsTnT provides incremental predictive value, at least doubling the hazard of all-cause death across all risk categories, and tripling the hazard of CV death in intermediate and high-risk groups, compared to ASCVD risk stratification alone. The integration of troponin measurements into risk assessment strategies could refine primary prevention approaches.

Health-related quality of life and long-term incidence of major adverse events in patients with acute coronary syndromes

Abstract Background Assessing health-related quality of life (HRQoL) in patients with acute coronary syndromes (ACS) could provide insight into predicting major adverse cardiovascular events (MACE) and all-cause death. Purpose To investigate the association of baseline HRQoL and its change within the first year post-ACS with the incidence of MACE and all-cause death. Methods Participants in the SPUM-ACS study, a multicenter cohort of patients hospitalized for ACS at four Swiss university hospitals from 2007 and 2021 and followed-up for a median duration of 6.6 years, were evaluated for HRQoL at baseline and one-year post-discharge using the EQ-5D-3L index and visual analogue scale (VAS). The EQ-5D-3L index is derived from five health dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). Baseline HRQoL and its change within the first year post-ACS, alongside the individual health dimensions, were analyzed in relation to the risk of subsequent MACE (composite of myocardial infarction, stroke or transient ischemic attack, coronary revascularization, and cardiovascular death) and all-cause death using Cox proportional hazards models, adjusting for sociodemographic, lifestyle factors, and medical history. Results 2499 patients with ACS (mean age 62±12 years, 80% males), primarily undergoing percutaneous coronary revascularization, were included. Over a median follow-up of 6.6 years, 25% experienced MACE and 13% died from any cause. Overall, HRQoL improved in the first year post-ACS, with the EQ-5D-3L index increasing from 0.74 to 0.81 and the VAS from 68 to 76 (p<0.001). At baseline, 80% reported some problem in at least one health dimension, mainly anxiety/depression (36%), pain/discomfort (35%), and mobility (27%). By the first year, 58% had no problem or improved in one or more dimensions; however, 38% declined in at least one dimension, particularly in pain/discomfort (26%), or anxiety/depression (16%). The baseline VAS, but not EQ-5D-3L index, was inversely associated with the hazard of subsequent MACE and all-cause death (HR=1.06 [1.01, 1.11] per 0.1-unit and 1.10 [1.03, 1.19] per 10-unit decrease, respectively). Problems with pain/discomfort were associated with MACE (HR=1.20 [1.00, 1.44]); and mobility, self-care and usual activities with all-cause death (HR=1.36 [1.04, 1.79], 1.44 [1.04, 1.98] and 1.37 [1.04, 1.80], respectively) (Figure 1). First-year EQ-5D-3L index and VAS change were inversely associated with the hazard of MACE (HR=1.11 [1.04, 1.18] per 0.1-unit and 1.16 [1.07, 1.25] per 10-unit decrease) and all-cause death (HR=1.13 [1.04, 1.23] per 0.1 and 1.17 [1.06, 1.30] per 10-unit decrease, respectively) (Figure 2). Conclusion HRQoL at baseline and its change within the first year after ACS are associated with the risk of adverse events, suggesting HRQoL might be a valuable predictive indicator for long-term outcomes in patients with ACS.Figure 1Figure 2

Transcatheter versus surgical aortic valve replacement in lower-risk patients: an updated meta-analysis of randomised controlled trials

Abstract Background Long-term clinical outcomes after transcatheter [TAVI] and surgical [SAVR] aortic valve replacement are of utmost importance in lower-risk patients. Event rates are diminished in lower-risk patients, therefore individual trials may be separately underpowered to assess low-frequency outcomes. New randomised data has emerged, including 4, 5 and 10-year follow-up from the Evolut Low Risk, PARTNER-3 and NOTION trials, respectively. Purpose To perform a systematic review and meta-analysis of randomised trials studying long-term outcomes in patients with severe aortic stenosis at low-surgical risk undergoing TAVI versus SAVR. Methods Trials randomising patients at lower surgical risk in trials comparing TAVI with SAVR were systematically identified. The prespecified primary endpoint was all-cause death. Key secondary endpoints included stroke, death or disabling stroke, cardiac death, new permanent pacemaker, aortic valve reintervention, and new-onset atrial fibrillation. Reconstructed individual patient data [IPD] was obtained via digitisation of Kaplan-Meier survival curves. Using these data, Cox proportional hazards regression was performed using frailty models on the primary outcome of all-cause death. To assess total lifetime lost, the restricted mean survival time [RMST] was calculated. Conventional pairwise random effects meta-analyses were also performed. This analysis was prospectively registered [CRD42023484976]. Results 4 eligible trials contributed data from 3557 patients with a weighted mean follow-up duration of approximately 4 years (47.6 months). In the reconstructed IPD pooled analyses, there was no significant difference in the hazard of death [hazard ratio 1.15, 95% CI 0.93 to 1.41, p=0.20] or RMST [Δ-0.8 months, p=0.09] (Figure 1). In pairwise meta-analyses, there was no difference between TAVI and SAVR in all-cause death [relative risk (RR) 0.94, 95% confidence interval (CI) 0.78 to 1.13, p=0.51] (Figure 2). There was also no significant difference for stroke [RR 0.94, 95% CI 0.59 to 1.50, p=0.80], or a composite of death or disabling stroke [RR 0.92, 95% CI 0.70 to 1.22, p=0.57]. There was an increase in new pacemaker implantation with TAVI [RR 2.15, 95% CI 1.50 to 3.07, p<0.001], and a reduction in new AF with TAVI [RR 0.43, 95% CI 0.26 to 0.70, p<0.001]; there was no significant difference in any other endpoint (Figure 2). Conclusions The present analysis demonstrates no difference in major clinical outcomes with TAVI or SAVR in lower-risk patients at 4-years follow-up. These results were consistent when analysed using pooled reconstructed IPD or conventional meta-analyses and there were no differences in RMST. These data are informative for lower-risk patients and clinicians, but longer-term follow-up is required to confirm whether equivalence is maintained.Kaplan-Meier plot comparing TAVI vs SAVRForest plot for key clinical endpoints

Insurance remains a major source of disparity for patients with testicular cancer: call for advocacy.

To evaluate the effects of socioeconomic factors, including insurance status, on treatment and survival for patients with testicular cancer. We extracted a retrospective cohort from the National Cancer Database that included patients diagnosed with testicular cancer 2004-2020. Competing-risks and Cox regression multivariate models including demographic, pathological, and socioeconomic covariates were constructed to evaluate receipt of treatment and death, respectively. A total of 95 955 patients with testicular cancer were identified. Compared with private insurance, Medicaid (sub-distribution hazard ratio [SHR] 0.70, P < 0.001), Medicare (SHR 0.73, P < 0.001), and uninsured (SHR 0.72, P < 0.001) patients were associated with decreased likelihood of receiving chemotherapy. Compared with private insurance, Medicaid (SHR 0.55, P < 0.001), Medicare (SHR 0.76, P-value <0.001), uninsured (SHR 0.63, P-value < 0.001), and other government insurance (SHR 0.71, P = 0.010) was associated with decreased likelihood of receiving radiation. Medicaid insurance status (reference private, HR 2.60, P < 0.001) conferred the second largest hazard of death, behind having Stage III disease (reference Stage 0). Compared with private insurance, Medicare (HR 2.20, P < 0.001), no insurance (HR 2.32, P < 0.001), and other government insurance (HR 1.53, P = 0.027) statuses had higher risk of death. Patients diagnosed in Medicaid-expansion states had lower all-cause mortality (11.4% vs 13.6%, P < 0.001). Testicular cancer care relies on early diagnosis and treatment. It is critically important to have a healthcare system where individuals have access to insurance and are served equitably.

The impact of adrenocortical carcinoma hormone secreting status as a predictor of poor survival: a systematic review and meta-analysis.

Adrenocortical carcinoma (ACC) poses a significant challenge in healthcare due to its aggressive nature and rarity. Prior reports suggest a poorer prognosis associated with hormone-secreting neoplasms. This study aims to assess the impact of ACC hormonal status on patients' oncologic survival. A comprehensive literature search of the Medline, Embase, Web of Science, CINAHL, CENTRAL and clinicaltrials.gov databases was undertaken. Utilized data involved Hazard Ratios derived from multivariable analysis in order to minimize exposure to confounding bias. Included studies were subsequently meta-analyzed using a Random effects model. Twelve studies incorporating 4483 patients were included in the quantitative analysis. Hormonally active ACCs comprised 48% of the entire pooled patient cohort and were found to be associated with significantly worse Overall Survival (HR 1.57, 95% Confidence Interval 1.39-1.78, p < 0.001). Disease-Free Survival was comparably impacted (HR 1.32, 95% CI 1.11-1.57, p < 0.001). Furthermore, cortisol secreting ACCs specifically, were also found to be associated with a 48% increase in the hazard of death or disease recurrence. Interstudy statistical heterogeneity was minimal among evaluated outcomes. Hormone-producing ACCs exhibit a poorer prognosis compared to non-secreting counterparts, with a 57% increased risk of death and a 32% increased risk of recurrence. These findings support the hypothesis that hormone production signifies an adverse tumor-specific feature, particularly when leading to hypercortisolemia, indicating an aggressive disease phenotype.

Neurologic Recovery at Discharge and Long-Term Survival After Cardiac Arrest

Brain injury is the leading cause of death following cardiac arrest and is associated with severe neurologic disabilities among survivors, with profound implications for patients and their families, as well as broader societal impacts. How these disabilities affect long-term survival is largely unknown. To investigate whether complete neurologic recovery at hospital discharge after cardiac arrest is associated with better long-term survival compared with moderate or severe neurologic disabilities. This cohort study used data from 4 mandatory national registers with structured and predefined data collection and nationwide coverage during a 10-year period in Sweden. Participants included adults who survived in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) beyond 30 days and who underwent predefined neurologic assessment conducted by health care professionals at hospital discharge using the Cerebral Performance Category (CPC) scale between January 2010 and December 2019. Patients were divided into 3 categories: complete recovery (CPC 1), moderate disabilities (CPC 2), and severe disabilities (CPC 3-4). Statistical analyses were performed in December 2023. CPC score at hospital discharge. The primary outcome was long-term survival among patients with CPC 1 compared with those with CPC 2 or CPC 3 or 4. A total of 9390 cardiac arrest survivors (median [IQR] age, 69 .0 [58.0-77.0] years; 6544 [69.7%] male) were included. The distribution of functional neurologic outcomes at discharge was 7374 patients (78.5%) with CPC 1, 1358 patients (14.5%) with CPC 2, and 658 patients (7.0%) with CPC 3 or 4. Survival proportions at 5 years were 73.8% (95% CI, 72.5%-75.0%) for patients with CPC 1, compared with 64.7% (95% CI, 62.4%-67.0%) for patients with CPC 2 and 54.2% (95% CI, 50.6%-57.8%) for patients with CPC 3 or 4. Compared with patients with CPC 1, there was significantly higher hazard of death for patients with CPC 2 (adjusted hazard ratio [aHR], 1.57 [95% CI, 1.40-1.75]) or CPC 3 or 4 (aHR, 2.46 [95% CI, 2.13-2.85]). Similar associations were seen in the OHCA and IHCA groups. In this cohort study of patients with cardiac arrest who survived beyond 30 days, complete neurologic recovery, defined as CPC 1 at discharge, was associated with better long-term survival compared with neurologic disabilities at the same time point.

Circulating Tumor Cell Count and Overall Survival in Patients With Metastatic Hormone-Sensitive Prostate Cancer

In metastatic hormone-sensitive prostate cancer (mHSPC), new first-line combination therapies have enhanced overall survival (OS), but clinical outcomes for individual patients vary greatly and are difficult to predict. Peripheral blood circulating tumor cell (CTC) count is the most extensively validated prognostic liquid biomarker in metastatic castration-resistant prostate cancer (mCRPC), and recent studies have suggested that it may also be informative in mHSPC. To examine the prognostic value of CTC count in men with mHSPC. In this prognostic study, peripheral blood was drawn at registration (baseline) and at progression to mCRPC in the S1216 study (March 1, 2013, to July 15, 2017), a phase 3, prospective, randomized clinical trial in men with mHSPC. The CTCs were enumerated using a US Food and Drug Administration-cleared isolation platform. Counts were categorized as 0, 1 to 4, or 5 or more CTCs per 7.5 mL based on the prognostic value of these cut points in prior studies. The data analysis was performed between October 28, 2022, and June 15, 2023. Metastatic hormone-sensitive prostate cancer. Circulating tumor cell count was evaluated for an association with 3 prespecified trial end points: OS, progression-free survival, and 7-month prostate-specific antigen, after adjusting for other baseline covariates using proportional hazards and logistic regression models. Of 1313 S1216 participants (median [IQR] age, 68 [44-92] years), evaluable samples from 503 (median [IQR] age, 69 [46-90] years) with newly diagnosed mHSPC were collected at baseline, and 93 samples were collected at progression. Baseline counts were 5 or more CTCs per 7.5 mL in 60 samples (11.9%), 1 to 4 CTCs per 7.5 mL in 107 samples (21.3%), and 0 CTCs per 7.5 mL in 336 samples (66.8%). Median OS for men with 5 or more CTCs per 7.5 mL was 27.9 months (95% CI, 24.1-31.2 months) compared with 56.2 months (95% CI, 45.7-69.8 months) for men with 1 to 4 CTCs per 7.5 mL and not reached at 78.0 months follow-up for men with 0 CTCs per 7.5 mL. After adjusting for baseline clinical covariates, men with 5 or more CTCs per 7.5 mL at baseline had a significantly higher hazard of death (hazard ratio, 3.22; 95% CI, 2.22-4.68) and disease progression (hazard ratio, 2.46; 95% CI, 1.76-3.43) and a lower likelihood of prostate-specific antigen complete response (odds ratio, 0.26; 95% CI, 0.12-0.54) compared with men with 0 CTCs per 7.5 mL at baseline. Adding baseline CTC count to other known prognostic factors (covariates only: area under the curve, 0.73; 95% CI, 0.67-0.79) resulted in an increased prognostic value for 3-year survival (area under the curve, 0.79; 95% CI, 0.73-0.84). In this prognostic study, the findings validate CTC count as a prognostic biomarker that improved upon existing prognostic factors and estimated vastly divergent survival outcomes regardless of subsequent lines of therapy. As such, baseline CTC count in mHSPC may serve as a valuable noninvasive biomarker to identify men likely to have poor survival who may benefit from clinical trials of intensified or novel regimens.

Associations between central nervous system tumor diagnosis stage and survival and Medicaid enrollment among children, adolescents, and young adults

Abstract Background Medicaid enrollment has been associated with disparities in younger cancer patient survival. To further understand this association for central nervous system (CNS) tumor patients, we used Surveillance, Epidemiology, and End Results (SEER)-Medicaid-linked data to examine associations between Medicaid enrollment and enrollment timing and (1) diagnosis stage, and (2) CNS tumor death. Methods Individuals diagnosed with a first malignant primary CNS tumor between 0 and 39 years from 2006 to 2013 were included. Medicaid enrollment was first classified as enrolled versus not enrolled with those enrolled further classified as having continuous, discontinuous (at diagnosis or other discontinuous), or other enrollment. We used logistic and Cox Proportional Hazards regression stratified by age to calculate adjusted odds ratios (ORs) and hazard ratios (HRs) for those 0–14 and 15–39 years. Results Among 10 107 CNS tumor patients, we found significantly higher odds of regional/distant versus in situ/localized stage diagnoses for those with other discontinuous (OR0–14 = 1.50, 95% CI: 1.15–1.95) and at diagnosis (OR15–39 = 1.41, 95% CI: 1.11–1.78) Medicaid enrollment versus those not enrolled. Those enrolled versus not enrolled in Medicaid had a higher hazard of CNS tumor death for both age groups (HR0–14 = 1.60 95% CI: 1.37–1.86; HR15–39 = 1.50, 95% CI: 1.39–1.62) with the highest hazards for those enrolled at diagnosis (HR0–14 = 1.83, 95% CI: 1.51–2.22; HR15–39 = 1.93, 95% CI: 1.77–2.10). Conclusions Medicaid enrollment is associated with a higher risk of CNS tumor death with an almost 2-fold higher risk for young CNS tumor patients enrolled at diagnosis. These results support the critical need for consistent health insurance coverage for young CNS tumor patients.

Chordoma incidence, treatment, and survival in the 21st century: a population-based Ontario cohort study.

This study estimates the incidence, treatment patterns, and overall survival for patients with chordoma treated in Ontario. A 17-year (2003-2019) population-based cohort study was conducted, including all patients in the Ontario Cancer Registry with histologically proven chordoma. Primary outcomes of interest were age-standardized annual incidence, overall survival, and rates of radiation therapy, chemotherapy, and open resection. A total of 208 patients were diagnosed with chordoma over the study period: 97 patients with skull base chordoma, 37 with mobile spine chordoma, and 65 with sacropelvic chordoma. A total of 133 patients were treated with either open or endoscopic surgery, of whom 99 were also treated with some form of radiation therapy. Across the 17-year study period, the average annual age-standardized incidence was 12.04 cases per 10 million (95% CI 9.31-14.78 cases per 10 million). There was no significant change in the annual incidence rate over the study period (average annual percent change 2.27, 95% CI -1.74 to 6.44; p = 0.25). The odds of receiving radiation therapy or chemotherapy significantly increased by 8% per year (95% CI 1%-16% per year, p = 0.036) over the study period. The odds of receiving open resection significantly decreased by 14% per year (95% CI 8%-20% per year, p < 0.001). The odds of receiving endoscopic surgery among patients with skull base chordoma increased by 38% per year (95% CI 22%-60% per year, p < 0.001), while the odds of patients receiving biopsy alone did not change significantly over the study period (p = 0.684). After diagnosis of chordoma, the 5-, 10-, and 15-year overall survival probabilities were 0.74 (95% CI 0.69-0.81), 0.58 (95% CI 0.51-0.67), and 0.48 (95% CI 0.40 to 0.59), respectively. There was no significant association between hazard of death and year of diagnosis (p = 0.126) or anatomical location (p = 0.712, skull base vs mobile spine chordoma; p = 0.518 skull base vs sacropelvic chordoma). Chordoma is a rare disease with no significant change in the average annual incidence rate between 2003 to 2019. During this time, treatment with less invasive modalities increased, particularly for skull base chordoma. Overall survival exceeds 10 years for many patients, with no change in the hazard of death across the study period.

Ambient Air Pollution Exposure and Outcomes in Patients Receiving Lung Transplant

Elevated ambient fine particulate matter (PM2.5) air pollution exposure has been associated with poor health outcomes across several domains, but its associated outcomes among lung transplant recipients are poorly understood. To investigate whether greater PM2.5 exposure at the zip code of residence is associated with a higher hazard for mortality and graft failure in patients with lung transplants. This retrospective cohort study used panel data provided by the United Network for Organ Sharing, which includes patients receiving transplants across all active US lung transplant programs. Adult patients who received lung transplants between May 2005 and December 2016 were included, with a last follow-up of September 10, 2020. Data were analyzed from September 2022 to May 2023. Zip code-level annual PM2.5 exposure was constructed using previously published North American estimates. The primary outcome was time to death or lung allograft failure after lung transplant. A gamma shared frailty Cox proportional hazards model was used to produce unadjusted and adjusted hazard ratios (HRs) to estimate the association of zip code PM2.5 exposure at the time of transplant with graft failure or mortality. Among 18 265 lung transplant recipients (mean [SD] age, 55.3 [13.2] years; 7328 female [40.2%]), the resident zip code's annual PM2.5 exposure level was greater than or equal to the Environmental Protection Agency (EPA) standard of 12μg/m3 for 1790 patients (9.8%) and less than the standard for 16 475 patients (90.2%). In unadjusted analysis, median graft survival was 4.87 years (95% CI, 4.57-5.23 years) for recipients living in high PM2.5 areas and 5.84 years (95% CI, 5.71-5.96 years) for recipients in the low PM2.5 group. Having an annual PM2.5 exposure level greater than or equal to the EPA standard 12 μg/m3 was associated with an increase in the hazard of death or graft failure (HR, 1.11; 95% CI, 1.05-1.18; P < .001) in the unadjusted analysis and after adjusting for covariates (HR, 1.08; 95% CI, 1.01-1.15; P = .02). Each 1 μg/m3 increase in exposure was associated with an increase in the hazard of death or graft failure (adjusted HR, 1.01; 95% CI, 1.00-1.02; P = .004) when treating PM2.5 exposure as a continuous variable. In this study, elevated zip code-level ambient PM2.5 exposure was associated with an increased hazard of death or graft failure in lung transplant recipients. Further study is needed to better understand this association, which may help guide risk modification strategies at individual and population levels.

Impact of screening on mortality for patients diagnosed with hepatocellular carcinoma at a safety-net hospital: An opportunity for addressing disparities.

140 Background: Hepatocellular carcinoma (HCC) is a common and deadly cancer with a rising incidence in the US. HCC almost always develops on a background of chronic liver disease, which disproportionately affects individuals of lower socioeconomic status (SES), perpetuating existing disparities. Compounding these disparities, individuals of lower SES are less likely to participate in recommended cancer screening exams. Here, we describe the outcomes of patients diagnosed with HCC at a large urban safety-net hospital primarily serving the underserved. Methods: We identified patients diagnosed with HCC at John Peter Smith Hospital in Fort Worth, Texas from January 1, 2018, to March 31, 2021 to determine the impact of screening on survival. Patients were allocated to the screened cohort if they had undergone liver imaging within one year prior to HCC diagnosis. Kaplan-Meier methods and log-rank test were used to illustrate and compare 3-year survival curves from an index date of diagnosis until death. Cox proportional hazards model were used to calculate unadjusted and adjusted hazards ratios (HR) and 95% confidence intervals (CI). Lead time bias was adjusted in a sensitivity analysis using the Duffy adjustment and a sojourn time of 70 days and 140 days. Results: A total of 158 patients were included (n=53 screened, n=105 unscreened). The mean age was 62 years; 144 (91%) had cirrhosis, 78% were male, 34% were non-Hispanic white, and 8.2% had private insurance. Those in the unscreened cohort had more severe liver dysfunction (as measured by the ALBI grade) and produced higher levels of AFP, but were less likely to have cirrhosis than the screened cohort. The median overall survival (OS) for the screened cohort was 19.0 months (95% CI: 9.9-NA) and 5.4 months (95% CI: 3.7-8.5) in the unscreened cohort (HR death (unscreened v screened) = 2.4, 95% CI: 1.6-3.6; log rank P &lt;0.0001). After adjusting for ALBI grade, AFP, hepatitis C, insurance status and initial treatment, there was a statistical difference in hazard of death in the three years (HR: 2.3; 95% CI: 1.5-3.6), favoring the screened cohort. The benefit for screening remained after adjusting for lead-time bias. With a mean sojourn time of 70 days, the HR death was 2.19 (95% CI 1.4-3.3, P =0.0002) and was 2.09 (1.4-3.2, P =0.0005) with a 140-day sojourn time. Conclusions: In an urban safety-net population, screening for HCC was associated with improved outcomes compared to patients with incidentally-diagnosed HCC. Altogether, this implies that earlier diagnosis and institution of treatment can positively improve survival for patients with newly diagnosed HCC in a population of patients evaluated at a safety-net hospital. Development of screening programs in accordance with accepted guidelines with outreach to high-risk individuals represents an area of high value care for safety-net hospitals.

Disparities in cancer mortality outcomes among adult immigrants in the United States.

134 Background: The “immigrant health paradox” posits that immigrants are generally healthier than US natives of similar demographic and socioeconomic background. However, immigrant noncitizens with cancer face unique barriers to care, including limited access to routine screening and continuous healthcare coverage, which may portend worse outcomes. Methods: The 2011-2018 National Health Interview Survey Linked Mortality Files were used to identify all adult (age ≥18 years) US natives, foreign-born citizens, and noncitizens with a cancer history. Differences by group were assessed using the chi-squared test with Rao &amp; Scott’s second-order correction. Cox-proportional hazards models tested associations between nativity/citizenship status and cancer-specific (CSM) and all-cause mortality (ACM), adjusted by age, gender, and survey year. Sequential models separately tested the added effects of individual patient-level covariates selected a priori —including race/ethnicity, smoking status, region, educational attainment, employment, insurance status, and having a usual source of care. Results: A total of 23,603,743 US natives, 1,647,188 foreign-born citizens and 477,861 noncitizens met criteria for inclusion. Compared to US natives, immigrants had significantly greater distribution of gastroesophageal (2.3%, noncitizens vs 2.3%, foreign-born citizens vs 1.0%, US natives, p &lt;0.001), head &amp; neck (8.4% vs 6.2% vs 4.4%, p =0.003), and lung cancers (3.1% vs 4.2% vs 2.8%, p =0.03). Of the1,302,0771 US natives, 105,258 foreign-born citizens, and 21,937 noncitizens who died during the study period, cancer was the primary cause of death for 52% of noncitizens and 62% of foreign-born citizens (vs 44%, p &lt;0.001). Lung cancer was the most common diagnosis in this group, accounting for 40% of cancer deaths among non-citizens (vs 19% vs 13%; p =0.03). Relative to US natives, foreign-born citizens had a significantly lower risk of all-cause (adjusted HR [95%CI], 0.67 [0.54-0.83]) but not cancer-specific mortality (0.94 [0.71-1.23]); no differences in mortality risk among noncitizens were observed. On subset analysis limited to adults with lung cancer, noncitizens had over twice the hazard of cancer death (2.72 [1.22-6.09]) as well as death from any cause (2.14 [1.01-4.55]). While the association with ACM was no longer significant in sequential models, the association remained significant for CSM. Importantly, insurance status attenuated but did not eliminate the risk of lung cancer death for noncitizens (2.63 [1.16-5.96]). Conclusions: Although immigrant noncitizens did not have a significantly greater risk of cancer death overall, those with lung cancer were more than twice as likely to die from their disease, even after adjustment for patient-level variables, including insurance status and having a usual source of care. Future research is warranted to identify root causes and potential points for intervention.

Intra-Atrial Right Coronary Artery: A Condition Revealed by Coronary CT Scan.

Coronary artery anomalies are rare and may involve the coronary origin, course, or termination. Most are benign; however, some can lead to myocardial damage, sudden death, or potential hazards during interventional or surgical procedures. The advancement of imaging studies has led to an increase in their diagnosis. Coronary computed tomography angiography (CCTA) especially has characterized new anomalies that were previously anecdotal. This is the case of the intra-atrial course of the right coronary artery. The present is a brief review about this rare congenital anomaly.

The Impact of Epiaortic Ultrasound utilization in patients undergoing Coronary Artery Bypass Grafting

To assess whether use of epiaortic ultrasound for assessment of aortic calcification impacts the rate of postoperative stroke following coronary artery bypass grafting (CABG). This was a retrospective study using an institutional database of CABGs performed from 2010 to 2023. All patients undergoing isolated index CABG were included. Patients were dichotomized according to the use of epiaortic ultrasound for intraoperative aortic assessment. Postoperative stroke rates were compared, and multivariable logistic regression for postoperative stroke was performed. Cox regression was performed for the multivariable analysis of mortality. A total of 10,049 patients underwent isolated index CABG. Intraoperative epiaortic ultrasound was utilized in 1,572 (15.6%) of these patients. The STS predicted risk of stroke was 1% and did not differ between the two groups. Postoperative stroke occurred in 13 patients in the epiaortic ultrasound group (0.8%) versus 116 patients in the group in which epiaortic ultrasound was not used (1.4%, p=0.08). On multivariable logistic regression, use of epiaortic ultrasound was not associated with a reduced odds of postoperative stroke (OR 0.62, 95% CI 0.34-1.14, p=0.12). Epiaortic ultrasound use was also not significantly associated with hazards of mortality on Cox regression (HR 1.14, 95% CI: 0.94, 1.38, p=0.12). Postoperative stroke was significantly associated with an increased hazard of death (HR 2.25, 95% CI: 1.61-3.14, p<0.001). Stroke rates after CABG were 0.8% and 1.4% with and without the use of epioartic ultrasound, respectively. The current study did not find an independent association between epiaortic ultrasound use and postoperative stroke.

Associations of Patient Activation with Outcomes Among Patients on Chronic Hemodialysis: A Retrospective, Longitudinal, Observational Study.

Patient activation, defined as an individual's readiness, willingness, and ability to manage their own health and health care, is associated with healthy behaviors and improved outcomes. Patients undergoing in-center hemodialysis (HD) have low activation, but the association of patient activation with clinical outcomes among dialysis patients is unclear. We investigated the association between patient activation and outcomes in HD patients. This cohort included 925 prevalent, in-center HD patients among 10 facilities in a mid-sized dialysis provider. All patients who completed the Patient Activation Measure 13-item (PAM-13) survey during a previous study were included, and their records were cross-referenced with data from the electronic heath system. Patients were followed for 180 days after completion of the survey for the primary outcomes of time to (1) death and (2) time to hospitalization. Markers of non-adherence during the month before and the month after completion of the PAM survey were examined as secondary outcomes, including (1) serum potassium >5.0 mEq/L; (2) serum phosphorus >5.5 mg/dL; (3) missed dialysis treatment due to absence (not hospitalization); and (4) interdialytic weight gain >4.0%. Univariate and adjusted regression models were fit to estimate associations of a 3-point increment in PAM-13 score with the outcomes of interest; adjustment factors comprised age, sex, dialysis vintage, serum albumin, diabetes, and hospitalization history. A 3-point increment in PAM score was associated with lower hazard of death (univariate HR=0.89, 95% CI: 0.84-0.94; adjusted HR=0.90, 95% CI: 0.85-0.96), but not with hospitalization (univariate HR=0.99, 95% CI: 0.96-1.02; adjusted HR=0.99, 95% CI: 0.96-1.02). Higher scores were associated with increased odds of having high phosphorus levels in the unadjusted analysis, but this was attenuated and not significant in adjusted models. There were no significant relationships between a 3-point increment in PAM score and any of the other secondary outcomes in univariate and adjusted analyses. In a cohort of prevalent, in-center HD patients, low activation was associated with mortality but not with hospitalization or measures of non-adherence.

Impact of baseline FIB-4 score on efpeglenatide benefits on cardiovascular outcomes in people with type 2 diabetes: a participant-level exploratory analysis of the AMPLITUDE-O trial

AimsTo estimate the incidence of major adverse cardiovascular events (MACE), expanded MACE, and MACE or Death across Fibrosis- 4 score (FIB-4) categories in people with type 2 diabetes and to determine whether efpeglenatide’s effect varies with increasing FIB-4 severity.Materials and methodsAMPLITUDE-O trial data were used to estimate the relationship of FIB-4 score categories to the hazard of MACE, expanded MACE, and MACE or death. Interactions on these outcomes between baseline FIB-4 score, and between FIB-4 score and efpeglenatide were also assessed.ResultsBaseline FIB-4 score was available for 4059 participants (99.6%) allowing subdivision of the population in tertiles. During a median follow-up of 1.8 years, numerical increases in the incidence of all 3 outcomes did not change significantly across tertiles of FIB-4 score (P for trend ≥ 0.25) with negligible relationship of the score to incident outcomes (MACE HR, per 1 SD higher score, 95% CI: 1.00, 0.89–1.13). Efpeglenatide’s effect on all MACE outcomes did not vary across FIB-4 tertiles (all interaction p values ≥ 0.64).ConclusionsIn high-risk people with type 2 diabetes, the degree of liver fibrosis, as estimated by FIB-4 score, was not related to incident cardiovascular outcomes. The beneficial effect of efpeglenatide on these outcomes is independent of FIB-4 category.