Higher Mortality Hazard Research Articles

172 Additional Therapies to Surgery in Adult Patients with Malignant Peripheral Nerve Sheath Tumors (MPNSTs)

Abstract INTRODUCTION Malignant peripheral nerve sheath tumors (MPNSTs) constitute a group of rare neoplasms with an estimated 5-year survival between 16 and 52%. Currently, there is disagreement on survival benefit of additional therapies to surgery in patients with MPNSTs. The aim of the present study is to determine predictors of receiving additional therapies and to evaluate the effect of different treatment modalities on overall survival. METHODS The National Cancer Database was queried for the years 2004 to 2014 for patients with MPNSTs, aged 18 and above, with no metastases at diagnosis. Patients were stratified by clinical stage (low-1/2, high-3/4). Multivariable regression analyses were performed after controlling for age, sex, comorbidity, tumor size, site, and grade. Predictors of additional therapies were evaluated in an intention-to-treat analysis. RESULTS >We identified a total of 2914 patients; 52.8% received surgery alone, 31.8% received additional radiation, 5.2% additional systemic therapy, and 10.2% received both. Predictive models showed greater odds of having additional therapies for patients with high tumor grade (O.R. 2.88, 95% C.I. 2.02-4.12), tumor size >5 cm (O.R. 2.55, 95% C.I. 1.85-3.52), and high stage disease (O.R. 1.73, 95% C.I. 1.19-2.52). In patients with low-stage disease, additional systemic therapy (H.R. 2.25, 95%CI 1.31-3.36) as well as additional radiation and systemic therapy were associated with higher mortality hazard (H.R. 2.02, 95% C.I. 1.29-3.16). In patients with high-stage disease, additional radiation with (HR 0.60, 95% C.I. 0.40-0.90) or without systemic therapy (H.R. 0.68, 95%CI 0.47-0.97, P = 0.034) was associated with lower overall mortality hazard. CONCLUSION Patients with high grade tumors, larger tumors, and high stage disease were likely to have both radiation & systemic therapies recommended. Only radiation was associated with a survival benefit in patients with high stage disease. In other patients, additional therapies were associated with no benefit or even poorer survival.

Seasonal Variation in Hip Fracture Mortality.

Objectives:This study aims to identify if wintertime surgery increases the mortality of the patients after hip fracture operations.Design:Retrospective observational cohort study.Setting:The data for this citywide retrospective observational cohort study came from Clinical Data Analysis Reporting System.Patient:This study included 35 409 patients with hip fracture operations from July 2005 to December 2013.Main Outcome Measures:Cox regression hazard model was used to estimate the independent effect of operation being performed in winter on the hazard of mortality. The hazard model included covariates found to be independent predictors of mortality: age, sex, surgical delay, and Charlson Comorbidity Index (CCI).Results:There was a seasonal variation with more hip fracture operations happening in the winter months. The 1-month, 6-month, 1-year, and 5-year mortality were 3%, 11%, 17%, and 47%, respectively. Operation performed in winter was associated with a higher hazard of mortality (hazard ratio [HR] 1.040; 95% confidence interval: 1.010-1.072; P = .009). The HR was greater with male sex (HR 1.786; P = .000), advanced age (≥85 years old: HR 2.819; P = .000), the longer surgical delay (HR 1.018; P = .000), and higher CCI (severe CCI group: HR 2.963; P = .000).Conclusion:Wintertime hip fracture surgery was associated with an increased hazard of mortality after adjusting for other known risk factors affecting mortality post hip fracture operations.

The Association between Biomarker Profiles, Etiology of Chronic Kidney Disease, and Mortality

Background: Prognosis in chronic kidney disease (CKD) for adverse outcomes differs substantially based on the etiology of CKD. We examined whether the biomarker profile differed based on CKD etiology and whether they were associated with mortality. Methods: Prospective observational study of 1,157 patients, 663 with diabetic kidney disease (DKD), 273 with glomerulonephritis (GN), and 221 with cystic/interstitial disease (polycystic kidney disease, pyelonephritis or chronic tubulointerstitial nephritis [PCK/TIN]) were identified in the Canadian Study of Prediction of Dialysis, Death and Interim Cardiovascular events over Time cohort. The outcome of interest was mortality before commencing dialysis. The biomarker profile consisted of N-terminal pro-brain natriuretic peptide (NT-proBNP), troponin I (TnI), asymmetric dimethylarginine (ADMA), interleukin (IL)-6, high sensitivity C-reactive protein, fibroblast growth factor-23 (FGF23), transforming growth factor-beta, 25-hydroxylvitamin D, and cystatin C (CysC). Results: The mean estimated glomerular filtration rate was 27 mL/min/1.73 m² and median follow-up time was 44 months. Mortality before dialysis commencement was the greatest in DKD (20%), followed by PCK/TIN (13%), and was least in those GN (8%). The majority of deaths were cardiovascular in nature, 17, 9, and 5.5% for DKD, PCK/TIN, GN, respectively. Those with DKD had higher hazard for mortality, unadjusted (hazard ratio [HR] 2.7, 95% CI 1.7-4.3) and adjusted (HR 1.7, 95% CI 1.1-2.8). The biomarker profiles associated with mortality differed significantly by CKD etiology as follows: DKD was associated with CysC (HR 1.3, 95% CI 1.0-1.6), ADMA (HR 1.3, 95% CI 1.1-1.6), and NT-proBNP (HR 1.7, 95% CI 1.4-2.1), GN was associated with FGF23 (HR 1.8, 95% CI 1.1-2.8), TnI (HR 3.6, 95% CI 1.3-9.5), and transforming growth factor-beta (HR 0.6, 95% CI 0.4-0.9) and PCK/TIN was associated with ADMA (HR 1.5, 95% CI 1.3-1.8) and IL-6 (HR 2.1, 95% CI 1.5-3.1). Conclusions: Biomarkers profiles differ according to the etiology of CKD and are associated with mortality.

Transfusion with packed red blood cells while awaiting lung transplantation is associated with reduced survival after lung transplantation.

The effect of pretransplant transfusion of red blood cells on survival after lung transplantation (LTx) has not been studied. The UNOS database was queried from 2005 to 2013 to compare survival in recipients receiving a transfusion while on the LTx wait list. Of 12283 adult patients undergoing single or bilateral LTx from May 2005 onwards, 11801 met inclusion criteria, among whom 512 required transfusion while on the LTx wait list. Transfusion was associated with a higher mortality hazard in unadjusted Cox proportional hazards analysis (HR=1.296; 95% CI: 1.124, 1.494; P<.001), and in a multivariable Cox model (HR=1.178; 95% CI: 1.013, 1.369; P=.033) after multiple imputation was used to complete data on covariates. Propensity score matching was used to match transfusion recipients to nonrecipients on the likelihood of having received transfusions on the wait list, calculated from characteristics at the time of listing. Unadjusted Cox regression stratified on the matched pairs also demonstrated an association between transfusion receipt on the wait list and higher post-transplant mortality hazard (HR=1.494; 95% CI: 1.127, 1.979; P=.005). Blood transfusion while on the LTx wait list was associated with diminished patient survival after transplantation.

Survival outcomes for first-line antiretroviral therapy in India's ART program.

BackgroundLittle is known about survival outcomes of HIV patients on first-line antiretroviral therapy (ART) on a large-scale in India, or facility level factors that influence patient survival to guide further improvements in the ART program in India. We examined factors at the facility level in addition to patient factors that influence survival of adult HIV patients on ART in the publicly-funded ART program in a high- and a low-HIV prevalence state.MethodsRetrospective chart review in public sector ART facilities in the combined states of Andhra Pradesh and Telangana (APT) before these were split in 2014 and in Rajasthan (RAJ), the high- and a low-HIV prevalence states, respectively. Records of adults initiating ART between 2007-12 and 2008-13 in APT and RAJ, respectively, were reviewed and facility-level information collected at all ART centres and a sample of link ART centres. Survival probability was estimated using Kaplan-Meier method, and determinants of mortality explored with facility and patient-level factors using Cox proportional hazard model.ResultsBased on data from 6581 patients, the survival probability of ART at 60 months was 76.3 % (95 % CI 73.0–79.2) in APT and 78.3 % (74.4–81.7) in RAJ. The facilities with cumulative ART patient load above the state average had lower mortality in APT (Hazard ratio [HR] 0.74, 0.57–0.95) but higher in RAJ (HR 1.37, 1.01–1.87). Facilities with higher proportion of lost to follow-up patients in APT had higher mortality (HR 1.47, 1.06–2.05), as did those with higher ART to pre-ART patient ratio in RAJ (HR 1.62, 1.14–2.29). In both states, there was higher hazard for mortality in patients with CD4 count 100 cells/mm3 or less at ART initiation, males, and in patients with TB co-infection.ConclusionsThese data from the majority of facilities in a high- and a low-HIV burden state of India over 5 years reveal reasonable and similar survival outcomes in the two states. The facilities with higher ART load in the longer established ART program in APT had better survival, but facilities with a higher ART load and a higher ratio of ART to pre-ART patients in the less experienced ART program in RAJ had poorer survival. These findings have important implications for India’s ART program planning as it expands further.

Three year functional changes and long-term mortality hazard in community-dwelling older men

BackgroundLow levels of physical function have been associated with higher mortality hazard in older persons. However, few studies have investigated the association between functional changes and subsequent mortality. This study aimed to examine whether 3-year functional changes independently predict subsequent all-cause mortality. MethodsThis population-based cohort study included 171 community-dwelling men aged ≥71years at wave 2 (baseline of the present analysis), living in the semi-rural community of Merelbeke (Belgium). Physical function assessments included the Short Form-36 (SF-36) Physical Function Index, Grip strength, Chair rising, and Timed Up and Go. Changes over a 3-year time were calculated using data obtained at four annual visits. ResultsAfter a 15-year follow-up, 149 men (87%) died. Median survival time was 8.2 (4.2–12.4) years. Physical function assessed at a single time point (at wave 2 or wave 5) was significantly associated with subsequent mortality hazard, independently from future or preceding 3-year changes. Greater functional declines during the 3-year follow-up were associated with higher mortality hazards. These associations were 1) more pronounced within the first seven years, 2) independent from baseline age, polypharmacy, depression, disability, and physical function, and 3) no longer significant when closure physical function was taken into account. ConclusionPhysical function assessed at a single time point is a robust predictor of all-cause long-term mortality in community-dwelling older men. Yet, repeated assessments of physical function can provide prognostic information beyond that available from single initial assessment. However, with repeated assessments, most prognostic information can be found in the final assessment of physical function.

Insurance status by region at the time of heart transplantation: Implications for survival

Heart transplantation outcomes differ by health insurance status and geographic region of the United States. We hypothesized that heart transplantation survival would be affected by health insurance status within certain United Network for Organ Sharing (UNOS) regions. We used data from the UNOS thoracic database to classify health insurance status into private or public (private/self-pay or Medicare/Medicaid) for all first-time heart transplant recipients between July 2006 and September 2013. We applied Cox proportional hazards regression to estimate hazard ratio (HR) and 95% confidence interval (CI) for the influences of health insurance status on 1-year and long-term survival in heart transplant recipients by UNOS region. Mean survival time among 10,474 patients was 942 days ± 704. All key demographic and clinical variables varied significantly across UNOS regions. With respect to 1-year survival, patients in Region 2 had a higher hazard of mortality (HR, 1.49; 95% CI, 1.03, 2.15) if they had public vs private insurance. When we restricted the analysis to be conditional on 1-year survival, 2 contiguous regions, Region 10, including Indiana, Ohio, Michigan (HR, 2.30; 95% CI, 1.23, 4.28), and Region 11 (HR, 1.85; 95% CI, 1.15, 2.97), including the upper South, had poor survival associated with public vs private insurance. The data we present invite targeted efforts by certain UNOS regions to improve the standard of care and/or eligibility thresholds for heart transplant recipients.

Influence of graft ischemic time and geographic distance between donor and recipient on survival in children after lung transplantation

The optimal ischemic time in pediatric lung transplantation (LTx) is unclear, as recent studies have challenged the relevance of 6 hours as an upper limit to acceptable ischemic time. Pediatric LTx recipients transplanted between 1987 and 2013 were identified in the United Network for Organ Sharing (UNOS) registry to compare survival according to ischemic time, which was categorized as <4 hours, 4 to 6 hours and >6 hours. Nine hundred thirty patients, all <18 years of age and receiving a first-time LTx from a cadaveric donor, were included in our investigation. Compared with <4 hours of ischemic time, univariate analysis showed a significant reduction in mortality hazard with 4 to 6 hours (hazard ratio [HR] = 0.640; 95% confidence interval [CI] 0.502 to 0.816; p < 0.001) but not >6 hours (HR = 0.985; 95% CI 0.755 to 1.284; p = 0.909). A multivariate Cox model confirmed the lowest mortality hazard to be 4 to 6 hours, as compared with <4 hours (HR = 0.533; 95% CI 0.376 to 0.755; p < 0.001). A prolonged ischemic time of >6 hours was associated with increased mortality hazard relative to the 4 to 6 hours (HR = 1.613; 95% CI 1.193 to 2.181; p = 0.002). Supplementary analyses examining geographic distance between donor and recipient identified no association between geographic distance and recipient mortality hazard. An ischemic time of 4 to 6 hours was associated with optimal long-term survival in first-time pediatric LTx recipients, whereas a very short ischemic time of <4 hours and a prolonged ischemic time >6 hours were both associated with higher mortality hazard in this population.

Relationship between characteristics of volunteer community health workers and antiretroviral treatment outcomes in a community-based treatment programme in Uganda

ABSTRACTCommunity health workers (CHWs) can help to redress the shortages of health human resources needed to scale up antiretroviral treatment (ART). However, the selection of CHWs could influence the effectiveness of a CHW programme. The purpose of this observational study was to assess whether sociodemographic characteristics and geographic proximity to patients of volunteer CHWs were predictors of clinical outcomes in a community-based ART (CBART) programme in Kabarole, Uganda. Data from CHW surveys for 41 CHWs and clinic charts for 185 patients in the CBART programme were analysed using multivariable logistic and Cox regression models. Time to travel to patients was the only statistically significant characteristic of CHWs associated with ART outcomes. Patients whose CHWs had to travel one or more hours had a 71% lower odds of virologic suppression (adjusted OR = 0.29, 95% CI = 0.13–0.65, p = .002) and a 4.52 times higher mortality hazard rate (adjusted HR = 4.52, 95% CI = 1.20–17.09, p = .026) compared to patients whose CHWs had to travel less than one hour. The findings show that the sociodemographic characteristics of CHWs were not as important as the geographic distance they had to travel to patients.

Thirty-Day Readmission Predicts 1-Year Mortality in Acute Pancreatitis.

There is limited knowledge of the prognostic indicators after hospital discharge after acute pancreatitis (AP). The aim was to determine risk factors for mortality after discharge in patients admitted with AP. A retrospective cohort study was conducted, including consecutive patients with AP admitted to the Cleveland Clinic between 2007 and 2011. Clinical data, mortality status, and the date of death were collected. Univariable and multivariable Cox regression was performed to determine variables significantly associated with mortality within a year of discharge. Three hundred thirty-one patients were included in the study, current to July 2012. After a mean follow-up of 20 months, 41 subjects (12.4%) died after discharge from the hospital. Thirty-three (10.0%) died within a year after discharge. In univariable analyses, higher Charlson Comorbidity Index, blood urea nitrogen > 20 on admission, higher Bedside Index of Severity in Acute Pancreatitis scores, longer length of stay, and readmission within 30 days were associated with a higher hazard of mortality. In the multivariable analysis, subjects who were readmitted within 30 days had a 4.5 times higher hazard of dying within a year than those who were not readmitted (hazard ratio, 4.5; 95% confidence interval, 2.2-9.1). A higher Charlson Comorbidity Index, early readmission, and longer hospitalization predict a higher 1-year mortality after AP.

Sarcopenia in chronic kidney disease on conservative therapy: prevalence and association with mortality.

In chronic kidney disease (CKD), multiple metabolic and nutritional abnormalities contribute to the impairment of skeletal muscle mass and function thus predisposing patients to the condition of sarcopenia. Herein, we investigated the prevalence and mortality predictive power of sarcopenia, defined by three different methods, in non-dialysis-dependent (NDD) CKD patients. We evaluated 287 NDD-CKD patients in stages 3-5 [59.9 ± 10.5 years; 62% men; 49% diabetics; glomerular filtration rate (GFR) 25.0 ± 15.8 mL/min/1.73 m(2)]. Sarcopenia was defined as reduced muscle function assessed by handgrip strength (HGS <30th percentile of a population-based reference adjusted for sex and age) plus diminished muscle mass assessed by three different methods: (i) midarm muscle circumference (MAMC) <90% of reference value (A), (ii) muscle wasting by subjective global assessment (B) and (iii) reduced skeletal muscle mass index (<10.76 kg/m² men; <6.76 kg/m² women) estimated by bioelectrical impedance analysis (BIA) (C). Patients were followed for up to 40 months for all-cause mortality, and there was no loss of follow-up. The prevalence of sarcopenia was 9.8% (A), 9.4% (B) and 5.9% (C). The kappa agreement between the methods were 0.69 (A versus B), 0.49 (A versus C) and 0.46 (B versus C). During follow-up, 51 patients (18%) died, and the frequency of sarcopenia was significantly higher among non-survivors. In crude Cox analysis, sarcopenia diagnosed by the three methods was associated with a higher hazard for mortality; however, only sarcopenia diagnosed by method C remained as a predictor of mortality after multivariate adjustment. The prevalence of sarcopenia in CKD patients on conservative therapy varies according to the method applied. Sarcopenia defined as reduced handgrip strength and low skeletal muscle mass index estimated by BIA was an independent predictor of mortality in these patients.

Abstract 265: Survival Analysis of Extracorporeal Life Support Under Different Indications - A Nation-wide Cohort Study in Taiwan

Background: Extracorporeal membrane oxygenation (ECMO), or extracorporeal life support (ECLS), has been gradually incorporated into cardiopulmonary resuscitation procedures, post-operational life support, and a variety of scenarios. Despite of the wide use of ECMO in Taiwan, the efficacy of ECLS in these cardiac and non-cardiac conditions was largely unknown. Therefore, the objective of this study was to compare the survival outcomes in the patients who received ECMO under different indications. Methods: The patients aged 20 years and above who received ECMO from September 1, 2009 to December 31, 2012 were identified from Taiwan’s National Health Insurance Database. The indications were classified into 1) life support after cardiac surgery (LSCS), 2) myocardial infarction and cardiogenic shock (post-MI), 3) injury, 4) infection, adult respiratory distress syndrome, and septic shock, and 5) others. Rare conditions such as donor support and obstetric labor complications were excluded. Cox-regression model was used to compare the 30-day and one-year mortality, using the LSCS as the reference group. Results: A total of 3,346 patients were included in the analysis (1,428, 944, 216, 691, and 67 for groups 1 to 5, respectively). The mean age was 53.2 years, and 71.2% was male. The 30-day mortality was 51.6%, 66.6%, 55.6%, 49.2%, and 49.3%, and the one-year mortality rate was 67.4%, 77.8%, 66.2%, 74.0%, and 68.7%, for the five groups, respectively. In the first 30 days, the post-MI group had a higher mortality hazard (HR: 1.62, 95% CI: 1.46~1.81) and the infection group had a lower one (HR: 0.87, 95% CI: 0.76~0.99) than the LSCS group. The one-year mortality was still the highest among the post-MI group (HR: 1.52, 95% CI: 1.38~1.67), and the survival among the other groups did not statistically differ from that of the LSCS group. Conclusion: The overall survival was worst in the patients who required ECLS due to myocardial infarction and cardiogenic shock. Patients with infection, adult respiratory distress syndrome, and septic shock had a higher possibility of surviving through the first month, but the overall mortality was not necessarily better. Further analysis regarding the cost and benefit of ECLS is warranted.

MP32-16 LOW TOTAL TESTOSTERONE IS ASSOCIATED WITH HIGHER MORTALITY IN MEN WITH STAGES 3-4 CHRONIC KIDNEY DISEASE

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Evaluation1 Apr 2014MP32-16 LOW TOTAL TESTOSTERONE IS ASSOCIATED WITH HIGHER MORTALITY IN MEN WITH STAGES 3-4 CHRONIC KIDNEY DISEASE Kiranpreet Khurana, Sankar Navaneethan, Susan Arrigain, Jesse Schold, Joseph Nally, and Daniel Shoskes Kiranpreet KhuranaKiranpreet Khurana More articles by this author , Sankar NavaneethanSankar Navaneethan More articles by this author , Susan ArrigainSusan Arrigain More articles by this author , Jesse ScholdJesse Schold More articles by this author , Joseph NallyJoseph Nally More articles by this author , and Daniel ShoskesDaniel Shoskes More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.946AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Low testosterone is associated with poor survival of men on dialysis, however the risk in kidney disease patients prior to dialysis is not well characterized. The objective of our study was to evaluate the association of hypogonadism with all-cause mortality in men with non-dialysis dependent chronic kidney disease (CKD) stages 3-4. METHODS We conducted a review of our validated CKD registry for men with stages 3-4 CKD who had total testosterone (TT) measured. We used a logistic regression (LR) analysis to evaluate association of age, ethnicity, estimated glomerular filtration rate (eGFR), body mass index (BMI), smoking and comorbidities with low TT. We used cox proportional hazards models to evaluate association of low TT with survival while adjusting for age, eGFR, race and comorbidities. RESULTS Of 26,400 men with confirmed stage 3-4 CKD from 2005-2011, TT was measured in 3111 (11.8%). 478 men did not fit our inclusion criteria. In this cohort of for-cause testosterone testing in symptomatic men, hypogonadism was defined as TT<350 NG/DL, and was found in 1410/2633 (54%) of men. Mean age was 67.2 years (SD=11.3 years), mean eGFR was 50.6 mL/min/1.73 m2, and mean BMI was 29.4 (SD=5.5). 11% were African-American. Low TT was found in approximately half the men in each decade of life from 20-90 years. In a multivariable LR analysis, African American ethnicity and higher eGFR were associated with significantly lower odds of having low TT. Having diabetes and higher BMI were associated with significantly higher odds of having low TT. 373/2633 patients died during a median follow up of 2.2 years. In a multivariable Cox model adjusted for age, eGFR, BMI and comorbidities, low TT was associated with higher hazard of mortality, HR 1.24 (95% CI: 1.00-1.53). The two lowest quintiles of TT (100-225 NG/DL and 226-301 NG/DL) were associated with higher mortality (HR 1.70, 95% CI: 1.21-2.39 and HR 1.56, 95% CI: 1.12-2.19, respectively). CONCLUSIONS Low TT is associated with significantly higher mortality in men with stages 3-4 CKD. It is yet unknown whether testosterone replacement therapy in this population can improve survival. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e336 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Kiranpreet Khurana More articles by this author Sankar Navaneethan More articles by this author Susan Arrigain More articles by this author Jesse Schold More articles by this author Joseph Nally More articles by this author Daniel Shoskes More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Prognostic factors of early metastasis and mortality in dogs with appendicular osteosarcoma after receiving surgery: An individual patient data meta-analysis

Recently an aggregated data meta-analysis showed that serum alkaline phosphatase (SALP) and proximal humerus location are predictors for shorter survival in canine osteosarcoma. To identify additional prognostic factors of mortality and metastasis an individual patient data meta-analysis (IPDMA) was conducted. Individual patient data from 20 studies, identified via the VSSO society, were pooled. Univariable and multivariable hazard ratios (HR) for metastasis and mortality were assessed, using stratified Cox models. The study included 1405 dogs who received surgical treatment, of which the metastasis status was measured in 1155 dogs and mortality status in 1336 dogs; median survival was 256 days. High versus normal SALP and weight (kg) were associated with an increase in hazard of metastasis [HR 1.34 (95%CI 1.07; 1.68) and HR 1.02 (per kg increase) (95%CI 1.01; 1.03)] and for mortality [HR 1.43 (95%CI 1.16; 1.77) and HR 1.02 (95%CI 1.01; 1.02)]. Distal radius tumor was associated with a lower hazard of metastasis compared to other locations: HR 0.75 (95%CI 0.58; 0.96). Proximal humerus and distal femur or proximal tibia location were related with an increased mortality: HR 1.53 (95%CI 1.26; 1.84) and HR 1.23 (95%CI 1.01; 1.49) compared to other locations. Older age (years) was associated with a higher hazard for mortality [HR 1.06 per year (95%CI 1.03; 1.09)] but not for metastasis: HR 1.03 (95%CI 0.99; 1.06). These results confirm findings from a recent aggregated data meta-analysis and (in addition) showed that tumor location, SALP, weight were prognostic factors for both mortality and metastasis. Age was a prognostic factor for mortality but not for metastasis.

Neighborhood socioeconomic disadvantage and mortality after stroke

Residence in a socioeconomically disadvantaged community is associated with mortality, but the mechanisms are not well understood. We examined whether socioeconomic features of the residential neighborhood contribute to poststroke mortality and whether neighborhood influences are mediated by traditional behavioral and biologic risk factors. We used data from the Cardiovascular Health Study, a multicenter, population-based, longitudinal study of adults ≥65 years. Residential neighborhood disadvantage was measured using neighborhood socioeconomic status (NSES), a composite of 6 census tract variables representing income, education, employment, and wealth. Multilevel Cox proportional hazard models were constructed to determine the association of NSES to mortality after an incident stroke, adjusted for sociodemographic characteristics, stroke type, and behavioral and biologic risk factors. Among the 3,834 participants with no prior stroke at baseline, 806 had a stroke over a mean 11.5 years of follow-up, with 168 (20%) deaths 30 days after stroke and 276 (34%) deaths at 1 year. In models adjusted for demographic characteristics, stroke type, and behavioral and biologic risk factors, mortality hazard 1 year after stroke was significantly higher among residents of neighborhoods with the lowest NSES than those in the highest NSES neighborhoods (hazard ratio 1.77, 95% confidence interval 1.17-2.68). Living in a socioeconomically disadvantaged neighborhood is associated with higher mortality hazard at 1 year following an incident stroke. Further work is needed to understand the structural and social characteristics of neighborhoods that may contribute to mortality in the year after a stroke and the pathways through which these characteristics operate.

Predictors of Survival among Pediatric and Adult Ependymoma Cases: A Study Using Surveillance, Epidemiology, and End Results Data from 1973 to 2007

Background: Despite previous research, prognostic factors for ependymoma remain relatively controversial. The purpose of our study was to examine demographic, clinical, and tumor attributes as potential predictors of survival using Surveillance, Epidemiology, and End Results (SEER) program data (1973–2007). Methods: All ependymoma (ICD-O-3 code 9391) and anaplastic ependymoma cases (ICD-O-3 code 9392) with complete data (n = 2,369 and n = 319, respectively) were included from SEER. Predictive Cox regression models were built separately among pediatric and adult cases. Recursive partitioning was used to corroborate results from regression models. Results: Among pediatric cases, tumor characteristics with a significantly increased mortality risk were anaplastic histology (vs. low grade, HR: 1.51, 95% CI: 1.04–2.19) and infratentorial tumor location (vs. spinal cord, HR: 3.86, 95% CI: 1.17–12.77). Among adults, supratentorial tumors were associated with higher mortality hazard (vs. spinal cord tumors) than infratentorial tumors (HR: 4.83, 95% CI: 3.49–6.68 and HR: 2.41, 95% CI: 1.79–3.25, respectively). Complete surgical resection of the tumor conferred the most protection among pediatric and adult patients. Conclusion: Our results indicate that treatment type and tumor characteristics are important prognostic factors in patients with ependymoma. However, there may be key differences between pediatric and adult cases regarding how these factors influence survival.

Impact of Venous Thromboembolism on Mortality of Elderly Medicare Patients with Stage III Colon Cancer

The improvement in survival rates for patients with colon cancer has shifted the focus from examining cancer-specific mortality to exploring all-cause mortality. Adverse events such as venous thromboembolism (VTE) affect overall survival times and the net clinical benefit of cancer management strategies. This retrospective study used Surveillance, Epidemiology and End Results (SEER) Medicare data to examine VTE incidence and mortality rates for elderly patients with stage III colon cancer who were diagnosed in 2004 or 2005 and followed through 2007. The impact of VTE on mortality was estimated using multivariable Cox proportional hazards regression. In all, 20.7% of 4,985 elderly patients with stage III colon cancer had clinically diagnosed VTE following diagnosis. All-cause mortality risk was higher for patients with a VTE diagnosis (hazard ratio [HR]: 1.15, 95% confidence interval [CI]: 1.04-1.27), greater comorbidity burden, more advanced tumor depth and nodal involvement within stage III, advanced age, and male sex; the risk was lower for patients treated with chemotherapy. VTE was associated with higher mortality hazards (HR: 1.41, 95% CI: 1.21-1.64) for patients treated with adjuvant chemotherapy but not for untreated patients. A new diagnosis of VTE significantly reduced survival rates for elderly patients with stage III colon cancer and further reduced survival rates for patients treated with chemotherapy. Improved prevention and management of VTE for elderly patients with stage III colon cancer who are at risk for VTE is warranted, particularly for patients treated with chemotherapy.

Impact of diabetes on long-term mortality following multivessel percutaneous interventions: An insight into optimal statistical analysis

BackgroundSeveral studies have demonstrated better long-term outcomes with drug eluting stents (DES) as compared to bare metal stents (BMS) among diabetics with coronary artery disease (CAD). A significant heterogeneity exists with respect to the optimal statistical strategy to analyze stent related data. MethodsWe used our percutaneous intervention (PCI) registry to identify all diabetics with CAD, who underwent PCI on two or more vessel territories between 2003 and 2009. Long-term mortality was assessed using the social security death index. Six different analytical strategies were applied. ResultsA total of 1568 DES and 336 BMS interventions were encountered in 756 diabetics. Considerable differences were observed in the results between the methods applied. Generalized estimating equation (GEE) approach with an autoregressive correlation structure (GEE) was a robust method to account for the cluster structure, since the measurements taken through time on the same person were assumed to be highly correlated, if they were spaced more closely in time. Diabetics undergoing PCI with BMS had a significantly higher long-term mortality as compared to the patients undergoing DES-PCI [Hazard ratio (95% CI): 1.47 (1.04–2.09)]. ConclusionThere is a great potential for erroneous interpretation of PCI data due to complex spatial and temporal clustering. Use of GEE with autoregressive correlation matrix and robust variance is most optimal to account for the clustered nature of the PCI related data. Using GEE, we observed that there is a 47% (4%–119%) higher hazard for mortality among diabetics undergoing BMS-PCI as compared to diabetics undergoing DES-PCI.

Alcohol Consumption and Mortality Risks in the USA

To estimate all-cause and cause-specific mortality risks by alcohol consumption level for the US population. The survival analysis of data from National Health Interview Survey participants from 1997 to 2004 who were followed for mortality through 2006. Hazard ratios (HRs) adjusted for available demographic and health characteristics were calculated by alcohol consumption level for all-cause mortality and for mortality from circulatory and external causes. Alcohol consumption levels were generally defined as 'never drinker' (<12 drinks in life), 'former drinker' (0 drinks during last year), 'infrequent drinker' (<12 drinks in any year), 'light drinker' (1 drink per drinking day), 'moderate drinker'(2 drinks) and 'heavy drinker' (3+ drinks). Adjusted mortality hazards for lifetime infrequent drinkers were much lower than the hazards for never drinkers among women, so lifetime infrequent drinkers were used as the reference category in survival analysis to estimate the mortality effects of alcohol consumption. Estimated all-cause mortality HRs for moderate drinkers were generally somewhat lower when compared with infrequent drinkers [HR for male moderate drinkers = 0.87, 95% confidence interval (CI) = 0.75-1.01 and HR for female occasional moderate drinkers = 0.80, 95% CI = 0.69-0.93]. Former drinkers and regular heavy drinkers had higher mortality hazards among both men and women. US light to moderate drinkers may have reduced mortality risks, but some portion of their previously observed lower mortality may be due to factors other than alcohol consumption such as medical care and social integration, particularly among women. Alcohol consumption among former and heavy drinkers appears to have increased their mortality risks.

Baseline Levels and Trimestral Variation of Triiodothyronine and Thyroxine and Their Association with Mortality in Maintenance Hemodialysis Patients

Conflicting evidence exists with regard to the association of thyroid hormones and mortality in dialysis patients. This study assesses the association between basal and trimestral variation of thyroid stimulating hormone, triiodothyronine, and thyroxine and mortality. In 210 prevalent hemodialysis patients, serum triiodothyronine, thyroxine, thyroid stimulating hormone, and interleukin-6 were measured 3 months apart. Cardiovascular and non-cardiovascular deaths were registered during follow-up. Based on fluctuations along tertiles of distribution, four trimestral patterns were defined for each thyroid hormone: persistently low, decrease, increase, and persistently high. The association of baseline levels and trimestral variation with mortality was investigated with Kaplan-Meier curves and Cox proportional hazard models. During follow-up, 103 deaths occurred. Thyroid stimulating hormone levels did not associate with mortality. Patients with relatively low basal triiodothyronine concentrations had higher hazards of dying than patients with high levels. Longitudinally, patients with persistently low levels of triiodothyronine during the 3-month period had higher mortality hazards than those having persistently high levels. These associations were mainly attributable to cardiovascular-related mortality. The association between thyroxine and mortality was not altered after adjustment for triiodothyronine. Hemodialysis patients with reduced triiodothyronine or thyroxine levels bear an increased mortality risk, especially due to cardiovascular causes. This was true when considering both baseline measurements and trimestral variation patterns. Our longitudinal design adds observational evidence supporting the hypothesis that the link may underlie a causal effect.