Inverse Probability Of Treatment Weighting Research Articles

Importance of surgeon's experience in practicing valve-sparing aortic root replacement

BackgroundValve-sparing root replacement (VSRR) requires a unique skill set. This study aimed to examine the influence of surgeon's procedural volume on outcomes of VSRR. MethodsThis retrospective study included 1697 patients from 2 large, high-volume aortic centers who underwent aortic root replacement (ARR) between 2004 and 2021 and were potentially eligible for VSRR. Surgeons were classified as performing <5 ARRs or ≥5 ARRs annually. Multivariable logistic regression was used to examine the independent association of surgeon volume and the decision to perform VSRR. Inverse probability treatment weighting (IPTW) was used to match patients who were operated on by <5 ARR surgeons or ≥5 ARR surgeons and compare long-term survival probability. Cumulative incidence curves with mortality as a competing risk were plotted to compare the rate of aortic valve reoperation. ResultsOf 1697 patients who met the study inclusion criteria, 944 underwent composite-valve conduit ARR and 753 underwent VSRR. The median age of the cohort was 57 years (interquartile range, 45-66 years), and 268 (15.8%) were female. Aortic insufficiency was present in 1105 patients (65.1%), and 200 of the procedures (11.8%) were reoperations. The indication for surgery was aneurysm in 1496 patients (88.2%) and dissection in 201 (11.8%). Among the 743 patients who underwent VSRR, 691 (92%) were operated on by ≥ 5 ARR surgeons and 62 (8%) were operated on by <5 ARR surgeons. In multivariable logistic regression, ≥5 ARRs (odds ratio, 3.33; 95% confidence interval, 2.34-4.73; P < .001) was associated with VSRR as the procedure of choice. Following IPTW, there was no significant difference between <5 ARR and ≥5 ARR surgeons in survival probability after VSRR (P = .59) or in the rate of aortic valve reoperation (P = .60). ConclusionsIn the setting of a high-volume aortic center, patients who undergo ARR are less likely to receive VSRR if operated on by a <5 ARR surgeon; however, VSRR may be safely performed by <5 ARR surgeons.

Target Trial Emulation: A Call for More Widespread Use.

Causal inference methods intended for use with observational data have been widely available for decades, but barriers exist to their widespread adoption. These likely include lack of familiarity with several methodologic techniques often used in combination in these investigations such as inverse probability of treatment weighting and g-estimation, and the intensity of computational effort to employ these techniques. Even with these methods, critical design flaws undermine the ability to make valid causal inference in some studies. Identification of the need to explicitly pair study design elements with these causal inference methods led to development of a methodologic approach recently termed target trial emulation. This approach requires that investigators define a hypothetical randomized trial, emulate that hypothetical protocol in assembling the cohort and defining study elements and then conduct an analysis that attempts to mirror random treatment assignment. In the article by Heindel et al. (Am J Epidemiol. 2024;XXX(XX):XXXX-XXXX), the authors successfully emulate a target trial of systemic heparin during arteriovenous fistula creation on short-term endpoints by utilizing two existing randomized trials with key confounders available. Target trial emulation provides a framework to promote valid inference and generate high-quality contributions to the literature and its use should be expanded.

Anesthetic recovery outcomes after 2 methods of nasal mucosal preparation for endoscopic sinus surgery

PurposeOur institution uses two approaches for nasal mucosal preparation during endoscopic sinus surgery (ESS) to improve surgical field visualization: topical epinephrine (TE) versus topical cocaine with injection of lidocaine containing epinephrine (TCLE). We aimed to compare anesthetic outcomes after ESS using these techniques. Methods and materialsWe retrospectively identified adult patients at our institution who underwent ESS from May 2018 through January 2023 under general anesthesia with propofol and remifentanil infusions. Postoperative anesthetic outcomes, including pain and recovery time, were compared between patients who had mucosal preparation with TE versus TCLE using inverse probability of treatment weighting (IPTW) to adjust for potential confounders. ResultsAmong 1449 patients who underwent ESS, 585 had TE, and 864 had TCLE. Compared with TE, during anesthetic recovery, the TCLE group had fewer episodes of severe pain (numeric pain score ≥ 7) (IPTW-adjusted odds ratio, 0.65; 95 % CI, 0.49–0.85; P = .002), less opioid analgesic administration (IPTW-adjusted odds ratio, 0.55; 95 % CI, 0.44–0.69; P < .001), and shorter recovery room stay (IPTW-adjusted ratio of the geometric mean, 0.90; 95 % CI, 0.85–0.96; P = .002). Postoperative nausea and vomiting and postoperative sedation were similar between groups. ConclusionsPatients who received preparation of the nasal mucosa with TCLE, compared with TE, were less likely to report severe pain or receive an opioid analgesic in the postanesthesia recovery room and had faster anesthetic recovery. This observation from our large clinical practice indicates that use topical and local anesthetic during endoscopic sinus surgery may have benefit for ambulatory ESS patients.

Antihypertensive Drug Treatment and the Risk for Intrahemodialysis Hypotension.

Antihypertensive medications are often prescribed to manage hypertension in hemodialysis (HD) patients, and intradialytic hypotension (IDH) is a common complication in these patients. We investigated the risk of IDH in incident HD patients who initiated treatment with antihypertensive drugs in monotherapy. The study was conducted as an emulation of a randomized clinical trial in 4072 incident HD patients who started anti-hypertensive drug treatment between January 2016 to December 2019. The primary outcome was the occurrence of IDH during HD sessions. The Gener alised Estimating Equation (GEE) analysis was adjusted by inverse probability treatment weighting (IPTW). Calcium channel blocker (CCB) use was associated with an IDH incidence rate of 7.4 events per person-year (95% CI: 6.2-8.6). Compared to CCB use, use of beta and alpha-beta blockers was strongly associated with a higher likelihood of IDH (OR [95% CI] 2.27 [1.50-3.43]). Use of angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (OR [95% CI] 1.71 [1.14-2.57]) and diuretics (OR [95% CI] 1.52 [1.07-2.16]) were also associated with higher likelihood of IDH compared to CCB use. The study suggests that using beta and alpha-beta blockers, ACE inhibitors or angiotensin II receptor blockers, and diuretics may increase the risk of IDH in HD patients compared to CCB use.

Oncological outcomes after laparotomic, laparoscopic, and robot-assisted laparoscopic staging for early high–intermediate or high-risk endometrial cancer

ObjectivesTo compare oncological outcomes in patients with early-stage high–intermediate or high-risk endometrial cancer undergoing surgical staging by laparotomy, conventional laparoscopy, or robot-assisted laparoscopy.MethodsPatients diagnosed between 2015 and 2021 with stage...

Comparative effectiveness of combination therapy with nirmatrelvir–ritonavir and remdesivir versus monotherapy with remdesivir or nirmatrelvir–ritonavir in patients hospitalised with COVID-19: a target trial emulation study

Remdesivir (Veklury, Gilead Sciences, Foster City, CA, USA) and nirmatrelvir-ritonavir (Paxlovid, Pfizer, New York, NY, USA) were reported to improve the outcome of patients with mild-to-moderate COVID-19 symptoms. Preclinical data suggest that nirmatrelvir-ritonavir might be more effective than remdesivir alone or in combination with nirmatrelvir-ritonavir for people at high risk of severe COVID-19. We aimed to assess the safety and effectiveness of combining remdesivir and nirmatrelvir-ritonavir compared with using each drug alone for adults hospitalised with COVID-19. In this target trial emulation study, we used electronic health records of patients aged 18 years or older who received either combination treatment of nirmatrelvir-ritonavir and remdesivir or monotherapy of either drug between March 16 and Dec 31, 2022, within 5 days of hospitalisation for COVID-19 in Hong Kong. Inverse probability of treatment weighting was applied to balance baseline patient characteristics across the treatment groups. The primary outcome was all-cause mortality. Cox proportional hazards regression adjusting weighting was used to compare the risk of all-cause mortality, intensive care unit (ICU) admission, or ventilatory support for 90 days of follow-up between groups. Between March 16 and Dec 31, 2022, 18 196 participants were identified from electronic health records and assigned to receive remdesivir (n=4232), nirmatrelvir-ritonavir (n=13 656), or nirmatrelvir-ritonavir and remdesivir (n=308). By applying an inverse probability of treatment weighting, a weighted sample composed of 18 410 recipients of nirmatrelvir-ritonavir and remdesivir combination treatment, 18 178 recipients of remdesivir monotherapy, and 18 287 recipients of nirmatrelvir-ritonavir monotherapy was obtained. After a median follow-up of 84 days (IQR 45-90), risk of mortality was lower in patients who received nirmatrelvir-ritonavir monotherapy (hazard ratio [HR] 0·18 [95% CI 0·15 to 0·20]; absolute risk reduction [ARR] -16·33% [95% CI -16·98 to -15·68]) or remdesivir and nirmatrelvir-ritonavir combination therapy (HR 0·66 [95% CI 0·49 to 0·89]; ARR -6·52% [95% CI -7·29 to -5·74]) than in patients who received remdesivir monotherapy. Similar results were observed for ICU admission or ventilatory support (nirmatrelvir-ritonavir monotherapy: HR 0·09 [95% CI 0·07 to 0·11]; ARR -10·04% [95% CI -10·53 to -9·56]; combination therapy: HR 0·68 [95% CI 0·42 to 1·12]; ARR -3·24% [95% CI -3·84 to -2·64]). Compared with combination therapy, nirmatrelvir-ritonavir monotherapy was associated with lower risk of mortality (HR 0·27 [95% CI 0·20 to 0·37]; ARR -9·81% [95% CI -10·39 to -9·24]) and ICU admission or ventilatory support (HR 0·13 [95% CI 0·08 to 0·22]; ARR -6·80% [95% CI -7·22 to -6·39]). Our study highlighted the potential for reduced risk of mortality, ICU admission, or the need for ventilatory support in patients hospitalised with COVID-19 treated with nirmatrelvir-ritonavir as a monotherapy compared with treatment regimens based on nirmatrelvir-ritonavir and remdesivir combination therapy or remdesivir monotherapy. Further randomised controlled trials are needed to support the validity of the current results. The Health and Medical Research Fund Commissioned Research on COVID-19. For the Chinese translation of the abstract see Supplementary Materials section.

Does use of formal and informal credit reduce poverty in rural Mexico?

AbstractMotivationDespite efforts to reduce poverty, both income and multidimensional poverty continue to be high in Mexico, especially in rural areas. Most studies concerned with the effect of credit use on poverty analyse formal credit, but little is known about the impacts of different types of credit on poverty.PurposeWe investigate the impacts of the use of formal credit and informal loans obtained (primarily) for productive and investment purposes on multidimensional and income poverty of rural households in Mexico.Approach and methodsWe use data from the 2013 and 2015 CONEVAL Surveys of Rural Households in Mexico, representative of rural communities with fewer than 2,500 inhabitants, to investigate the impact of credit on poverty. We apply inverse probability of treatment weighting (IPTW) to account for differences between users of formal credit, users of informal loans, and non‐users of credit.FindingsBoth formal and informal credit usage reduce poverty in rural Mexico, generally with clearer impacts on moderate rather than extreme poverty. Informal credit appears to have largely reached households that could most benefit from it. Broader access to formal credit would potentially further reduce poverty.Policy implicationsPublic policies to reduce rural poverty should promote a greater access to the formal financial sector. Including vulnerable low‐income rural households in formal finance should be accompanied by financial education.

Comparing ocrelizumab to interferon/glatiramer acetate in people with multiple sclerosis over age 60

BackgroundOngoing controversy exists regarding optimal management of disease modifying therapy (DMT) in older people with multiple sclerosis (pwMS). There is concern that the lower relapse rate, combined with a higher...

Efficacy of corticosteroid therapy for oxygen-free coronavirus disease 2019-derived pneumonia.

Corticosteroid therapy for oxygen-free coronavirus disease 2019 (COVID-19) is not recommended due to its negative prognostic impact, but the efficacy of corticosteroids when limited to COVID-19 pneumonia is unclear. We aimed to evaluate the efficacy of corticosteroid monotherapy for patients with COVID-19 pneumonia without supplemental oxygen. We retrospectively reviewed patients with oxygen-free COVID-19 pneumonia at our institute between September 2020 and August 2021 and assessed the use of corticosteroids and the timing of initiation. We classified the patients into the following 2 groups: those who were initiated corticosteroids without developing respiratory failure (early steroid group) and those who were not (standard of care [SOC] group). We used inverse probability of treatment weighting (IPW) to balance between the groups. The primary outcome was the incidence of respiratory failure. A total of 144 patient records were reviewed; 63 patients were in the early steroid group and 81 patients were in the SOC group. Of all patients, 14 (22.2%) and 27 (33.3%) patients in the early steroid and SOC group, respectively, required supplemental oxygen (P = .192). After adjusted by the IPW method, 10 (16.0%) and 32 (40.1%) patients in the early steroid and SOC groups, respectively, required supplemental oxygen (P = .004). The logistic regression analysis indicated that early corticosteroid use was significantly associated with a decreased incidence of respiratory failure (odds ratio; 0.17, 95% confidence intervals; 0.06-0.46, P < .001). Corticosteroid monotherapy may suppress the development of exacerbation requiring oxygen supply in patients with oxygen-free COVID-19 pneumonia.

The impact of primary health care on AIDS incidence and mortality: A cohort study of 3.4 million Brazilians.

Primary Health Care (PHC) is essential for effective, efficient, and more equitable health systems for all people, including those living with HIV/AIDS. This study evaluated the impact of the exposure to one of the largest community-based PHC programs in the world, the Brazilian Family Health Strategy (FHS), on AIDS incidence and mortality. A retrospective cohort study carried out in Brazil from January 1, 2007 to December 31, 2015. We conducted an impact evaluation using a cohort of 3,435,068 ≥13 years low-income individuals who were members of the 100 Million Brazilians Cohort, linked to AIDS diagnoses and deaths registries. We evaluated the impact of FHS on AIDS incidence and mortality and compared outcomes between residents of municipalities with low or no FHS coverage (unexposed) with those in municipalities with 100% FHS coverage (exposed). We used multivariable Poisson regressions adjusted for all relevant municipal and individual-level demographic, socioeconomic, and contextual variables, and weighted with inverse probability of treatment weighting (IPTW). We also estimated the FHS impact by sex and age and performed a wide range of sensitivity and triangulation analyses; 100% FHS coverage was associated with lower AIDS incidence (rate ratio [RR]: 0.76, 95% CI: 0.68 to 0.84) and mortality (RR: 0.68, 95%CI: 0.56 to 0.82). FHS impact was similar between men and women, but was larger in people aged ≥35 years old both for incidence (RR: 0.62, 95% CI: 0.53 to 0.72) and mortality (RR: 0.56, 95% CI: 0.43 to 0.72). The absence of important confounding variables (e.g., sexual behavior) is a key limitation of this study. AIDS should be an avoidable outcome for most people living with HIV today and our study shows that FHS coverage could significantly reduce AIDS incidence and mortality among low-income populations in Brazil. Universal access to comprehensive healthcare through community-based PHC programs should be promoted to achieve the Sustainable Development Goals of ending AIDS by 2030.

Trends and comparative outcomes between operative approaches for segmentectomy in lung cancer

BackgroundSegmentectomy is increasingly performed for non–small cell lung cancer. However, comparative outcomes data among open, robotic-assisted, and video-assisted thoracoscopic approaches are limited. MethodsA retrospective cohort study of non–small cell lung cancer segmentectomy cases (2013-2021) from the Society of Thoracic Surgeons General Thoracic Surgery Database was performed. Baseline characteristics were balanced using inverse probability of treatment weighting and compared by operative approach. Volume trends, outcomes, and nodal upstaging were assessed. ResultsOf 9927 patients who underwent segmentectomy, 84.8% underwent minimally invasive surgery, with robotic-assisted thoracoscopic surgery becoming the most common approach in 2019. Open segmentectomy is more likely to be performed at low-volume centers (P < .0001), whereas robotic-assisted thoracoscopic surgery is more likely to be performed at high-volume centers (P < .0001). Video-assisted thoracoscopic surgery had a higher open conversion rate than robotic-assisted thoracoscopic surgery (odds ratio, 11.8; CI, 7.01-21.6; P < .001). Minimally invasive surgery had less 30-day morbidity compared with open segmentectomy (video-assisted thoracoscopic surgery odds ratio, 0.71; 95% CI, 0.55-0.94; P = .013; robotic-assisted thoracoscopic surgery odds ratio, 0.59; CI, 0.43-0.81; P = .001). The number of nodes and stations harvested were highest for robotic-assisted thoracoscopic surgery; however, N1 upstaging was more likely in open compared with robotic-assisted thoracoscopic surgery (odds ratio, 0.63; CI, 0.45-0.89; P < .007) and video-assisted thoracoscopic surgery (odds ratio, 0.61; CI, 0.46-0.83; P = .001). ConclusionsSegmentectomy volume has increased considerably, with robotic-assisted thoracoscopic surgery becoming the most common approach. Minimally invasive surgery has less major morbidity compared with open segmentectomy, with no difference between video-assisted thoracoscopic surgery and robotic-assisted thoracoscopic surgery. However, risk of open conversion is higher with video-assisted thoracoscopic surgery. Robotic-assisted thoracoscopic surgery had increased nodal harvest, whereas hilar nodal upstaging was highest with thoracotomy. This study reveals significant differences in outcomes exist between segmentectomy operative approach; the impact of approach on survival merits further investigation.

The association between acute myocardial infarction and subsequent diagnosis of breast cancer: a nationwide, population-based cohort study

Coronary artery disease (CAD) such as acute myocardial infarction (MI) share several common risk factors with cancers, and each disease may influence the prognosis of the other. Recently, acute MI was demonstrated to accelerate the outgrowth of preexisting breast cancer cells but the risk of breast cancer after MI remains unclear. This study aimed to investigate the association between acute MI and a subsequent diagnosis of breast cancer. Female patients with and without a history of acute MI were identified from nationwide databases in Taiwan. Patients with a diagnosis of cancer, MI or CAD prior to the study period were excluded. After reducing confounding through inverse probability of treatment weighting, we compared the incidence of newly diagnosed breast cancer between patients with a history of acute MI and those without. As a result, a total of 66,445 female patients were obtained, including 15,263 patients with a history of acute MI and 51,182 patients without. The incidences of breast cancer during follow-up were 1.93 (95% confidence interval [CI] 1.78–2.09) and 1.80 (95% CI 1.67–1.93) per 1,000 person-years for patients with and without a history of acute MI, respectively. The hazard ratio (HR) was 1.05 (95% CI 0.78–1.41, P = 0.756). In subgroup analysis, breast cancer risk was significantly associated with acute MI in patients using antidiabetic drugs (HR 1.27; 95% CI 1.02–1.58) and in low to moderate urbanization levels (HR 1.28; 95% CI 1.06–1.53). In conclusion, the risk of newly diagnosed breast cancer was not increased in patients with acute MI when compared to general population without MI or CAD.

Effect of cardiopulmonary resuscitation training for layperson bystanders on outcomes of out-of-hospital cardiac arrest: A prospective multicenter observational study

BackgroundEffective bystander cardiopulmonary resuscitation (CPR) improves outcomes in out-of-hospital cardiac arrest (OHCA) patients. However, the effect of CPR training on the rate of return of spontaneous circulation (ROSC) among laypersons has yet to be thoroughly evaluated. MethodsThis prospective, multicenter observational study was conducted across 42 centers in Japan. We assessed OHCA patients who received bystander CPR from a layperson, excluding those performed by healthcare staff. The primary outcome was the ROSC rate. Secondary outcomes included pre-hospital ROSC, ROSC after hospital arrival, favorable neurological outcomes, and 30-day survival. Propensity score with inverse probability treatment weighting (IPTW) was used to adjust for confounders, including age, sex, presence or absence of witnesses, and past medical history. ResultsA total of 969 OHCA patients were included, divided into CPR-trained (n = 322) and control (n = 647). Before adjustment, the ROSC rate was higher in the trained group than the control (40.1% vs. 30.1%, P < 0.01). After IPTW adjustment, the trained group showed a significantly higher ROSC rate (36.7% vs. 30.6%; P = 0.02). All secondary outcomes in the trained group were significantly improved before adjustment. After IPTW adjustment, the trained group showed improved rates of pre-hospital ROSC and ROSC after hospital arrival (30.7% vs. 24.0%; P < 0.01, 23.9% vs. 20.7%; P = 0.04). There were no differences in neurological outcomes and 30-day survival. ConclusionThis study demonstrated that CPR training for laypersons was associated with increased ROSC rates in OHCA patients, indicating potential advantages of CPR training for non-healthcare professionals.

In-Hospital Outcomes of Revascularization in Patients with Left Ventricular Systolic Dysfunction and Coronary Chronic Total Occlusion

Background: The in-hospital outcomes of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with left ventricular systolic dysfunction (LVSD) and chronic total occlusion (CTO) remain unclear. Methods: From 2014 to 2020, patients with LVSD and CTO who underwent PCI or CABG were collected. The primary endpoint was in-hospital major adverse cardiac or cerebrovascular events (MACCE), defined as the composite of all-cause mortality, cardiovascular mortality, stroke, myocardial infarction (MI), and target vessel revascularization. Inverse probability of treatment weighting (IPTW) was performed to evaluate the association between revascularization strategies and in-hospital outcomes. The hazard ratio (HR) and 95% confidence interval (CI) were calculated using the Cox proportional hazards model. Results: Of the 773 patients who met the inclusion criteria, 543 (70.2%) underwent PCI, and 230 (29.8%) underwent CABG. The primary endpoint was observed in 25 (3.2%) patients. The incidence of in-hospital MACCE (6.5% vs. 1.8%, p &lt; 0.001) was significantly higher in the CABG group than in the PCI group. After IPTW, the risk of in-hospital MACCE was not found to be significantly different between CABG and PCI groups (HR = 1.81; 95% CI: 0.37–8.82; p = 0.460). Compared with patients who underwent PCI, those who underwent CABG exhibited a significantly higher risk of MI (HR = 6.92; 95% CI: 1.24–38.60; p = 0.027). Conclusions: Patients with LVSD and CTO could experience better outcomes with PCI, which offers a safer alternative coronary revascularization strategy and a reduced risk of MI.

The relationship between depression and lipid accumulation product: a population-based study.

Lipid Accumulation Product (LAP) is a new type of obesity index. The relationship between LAP and depression is unclear, and this cross-sectional study was conducted to explore the relationship between LAP and depression using the National Health and Nutrition Examination Survey (NHANES) database from 2005-2018. In our study, logistic regression analysis was used to calculate the odds ratio between depression and LAP, and subgroup analysis and sensitivity analysis were also performed to verify the robustness of the results. The analysis included 13,240 participants aged 20 years or older. After adjusting for multiple variables, LAP was positively associated with depression, OR 1. 50 (95% CI, 1. 05-2. 12). In subgroup analysis, LAP was significantly positively, associated with depression among male (2. 52, OR; 95% CI, 1. 39,4. 57), non-Hispanic Black (2. 55, OR; 95% CI, 1. 49,4. 36), those without diabetes (1. 67, OR; 95% CI, (1. 06,2. 61) or in the overweight (2. 09, OR; 95% CI, (1. 23,3. 54) subgroups. After inverse probability of treatment weighting (IPTW), the OR for the highest versus lowest quartile was 1. 55 (95% CI: 1. 24 - 1. 95). There are positive results between LAP and depression after adjusting for multiple potential variables, and prospective studies are needed to verify the results.

Endovascular Therapy for Isolated Cervical Internal Carotid Artery Occlusion

Background Guidelines on endovascular therapy for acute ischemic stroke do not include isolated cervical internal carotid artery (cICA) occlusions. The effect of treating these lesions remains unclear. This study aimed to compare the baseline characteristics and treatment outcomes between patients with isolated cICA occlusions to patients who underwent endovascular therapy due to a level of occlusion supported by guidelines. Methods A retrospective cohort study was conducted on 1162 patients who underwent endovascular therapy. Of these, 115 had an isolated cICA occlusion. Univariate analysis of baseline characteristics and outcome measured by the modified Rankin scale 90 days after endovascular therapy were compared between patients with isolated cICA occlusion, those with tandem occlusions, and those with occlusions of the middle cerebral artery/top of the internal carotid artery (first segment of the middle cerebral artery/intracranial internal carotid artery). To adjust for confounders, an inverse probability of treatment weighting was performed. Results Patients with isolated cICA occlusions were more likely men (67.8% versus 50.9%; P &lt;0.001) and active smokers (42.2% versus 26.4%; P = 0.002) compared with patients with first segment of the middle cerebral artery/intracranial internal carotid artery occlusions where atrial fibrillation was more common (35.5% versus 23.5%; P = 0.02). Patients with an isolated cICA had a lower chance of achieving a modified Rankin scale score of 0 to 2 at 90 days (adjusted relative risk, 0.71 [95% CI, 0.54–0.92]) and a higher mortality rate (adjusted relative risk, 1.97 [95% CI, 1.36–2.87]) compared with patients with first segment of the middle cerebral artery/intracranial internal carotid artery occlusions. Conclusion Patients with isolated cICA occlusions and first segment of the middle cerebral artery/intracranial internal carotid artery occlusions differ in sex, smoking status, and rate of atrial fibrillation. Patients with isolated cICA occlusions have lower reperfusion rates, worse outcome, and a higher mortality rate.

The geriatric trauma hospitalist service: An analysis of a management strategy for injured older adults.

Management of geriatric trauma patients requires balancing chronic comorbidities with acute injuries. We developed a care model in which patients are managed by hospitalists with trauma-centered education and hypothesized that clinical outcomes would be similar to outcomes in patients primarily managed by trauma surgeons. This was a retrospective study of trauma patients aged ≥65 from January 2020 to December 2021. Groups were defined by admitting service: trauma surgery service (TSS) or geriatric trauma hospitalist service (GTHS). The primary outcome was in-hospital mortality. Regression analyses and inverse probability treatment weighted (IPTW) propensity score (PS) analyses were performed to determine the association between admitting service and outcomes. A total of 1004 patients were eligible for inclusion-580 GTHS and 424 TSS admissions. GTHS patients were older (82 vs. 74, p < 0.001), more likely to have suffered blunt trauma (99.5% vs. 95%, p < 0.001), more likely to have comorbidities (91.2% vs. 87%, p < 0.001), had higher Charlson Comorbidity Indexes (CCIs), and had lower median injury severity scores (9 vs. 13, p < 0.001). Rates of mortality, delirium, 30-day readmission, and overall complications were low and similar between groups. While TSS patients were likely to be discharged home, GTHS had more discharges to skilled nursing facilities and longer length of stay (LOS). On multivariable analysis adjusted for age, ISS, CCI, and sex, patients admitted to GTHS had lower odds of death with an odds ratio of 0.15 (95% confidence interval [CI] 0.02-0.75, p = 0.03) when compared to TSS. On IPTW PS analysis, patients admitted to GTHS had similar odds of death with an odds ratio of 0.3 (95% CI 0.06-1.6, p = 0.16). Protocolized admission criteria to a GTHS resulted in similar low mortality rates but longer LOS when compared to patients admitted to a TSS. This care model may inform other trauma centers in developing their strategies for managing the increasing volume of vulnerable injured older adults.

Association between lactate/albumin ratio and prognosis in critically ill patients with acute kidney injury undergoing continuous renal replacement therapy

Background The primary objective was to examine the association between the lactate/albumin ratio (LAR) and the prognosis of patients with acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT). Methods Utilizing the Medical Information Mart for Intensive Care IV (MIMIC-IV, v2.0) database, we categorized 703 adult AKI patients undergoing CRRT into survival and non-survival groups based on 28-day mortality. Patients were further grouped by LAR tertiles: low (< 0.692), moderate (0.692-1.641), and high (> 1.641). Restricted cubic splines (RCS), Least Absolute Shrinkage and Selection Operator (LASSO) regression, inverse probability treatment weighting (IPTW), and Kaplan-Meier curves were employed. Results In our study, the patients had a mortality rate of 50.07% within 28 days and 62.87% within 360 days. RCS analysis revealed a non-linear correlation between LAR and the risk of mortality at both 28 and 360 days. Cox regression analysis, which was adjusted for nine variables identified by LASSO, confirmed that a high LAR (>1.641) served as an independent predictor of mortality at these specific time points (p < 0.05) in AKI patients who were receiving CRRT. These findings remained consistent even after IPTW adjustment, thereby ensuring a reliable and robust outcome. Kaplan-Meier survival curves exhibited a gradual decline in cumulative survival rates at both 28 and 360 days as the LAR values increased (log-rank test, χ2 = 48.630, p < 0.001; χ2 = 33.530, p < 0.001). Conclusion A high LAR (>1.641) was found to be an autonomous predictor of mortality at both 28 and 360 days in critically ill patients with AKI undergoing CRRT.

Clinical impact of hyperbaric oxygen therapy combined with steroid treatment for sudden sensorineural hearing loss: A case-control study.

The aim of present study was to evaluate the clinical efficacy of hyperbaric oxygen therapy (HBOT) as a primary therapy combined with standard systemic corticosteroid treatment for sudden sensorineural hearing loss (SSNHL) compared to treatment without the use of HBOT (non-HBOT) through clinical data and advanced analytical approaches. Case-control study. Conducted across three Japanese medical centers involving 298 SSNHL patients diagnosed between 2020 and 2023. Inclusion criteria encompassed first onset and treatment, WHO grade 3 or 4 initial hearing impairment, receipt of systemic corticosteroid therapy within 14 days of symptom onset, and initiation of HBOT within the same timeframe for the case group. The primary outcome measure was the difference in hearing improvement (mean hearing level in decibels, dB) between the two groups, assessed by pure-tone audiometry at baseline and 3 months post-treatment, using the inverse probability of treatment weighting (IPTW) method adjusted for covariate differences. The study included 67 patients in the HBOT group and 68 in the non-HBOT group. The HBOT group exhibited significantly greater hearing improvement (IPTW-adjusted difference: 7.6 dB, 95% CI 0.4-14.7; p = 0.038). Patients without vertigo in the HBOT group demonstrated substantial hearing improvement (11.5 dB, 95% CI 2.3-20.6; p = 0.014), whereas those with vertigo showed no significant improvement (-1.8 dB, 95% CI -11.8-8.3; p = 0.729). The HBOT group also had a significantly higher association with complete recovery (IPTW-adjusted odds ratio: 2.57, 95% CI 1.13-5.85; p = 0.025). In SSHNL, HBOT combination therapy yielded slightly but significantly improved hearing outcomes compared to non-HBOT treatment. 4.

P-765 Minding the sweet spot in birth weight: Metformin and insulin versus no treatment

Abstract Study question Is the use of metformin or insulin associated with an increased risk of large or small for gestational age birth in comparison to drug-naïve GDM? Summary answer No difference in SGA / LGA odds with drug-naïve mothers versus metformin-exposed, but higher odds of SGA and lover odds of LGA compared to insulin-exposed. What is known already In Europe, the originator brand of metformin has received a label update allowing the use during pregnancy. Use of metformin during pregnancy is associated with a reduced risk of LGA, but increased risk of SGA birth compared to insulin. In CLUE, metformin only exposure demonstrated a reduced odds of LGA birth (weighted OR (wOR) 0.82, 95% CI 0.67 to 0.99), but increased risk for SGA (wOR 1.65, 95% CI 1.16 to 2.34). Insulin use during a hyperglycemic pregnancy is discussed to increase birth weight. Study design, size, duration This was a follow-up study performed on our previously published population-based register data cohort study CLUE with maternal exposure to metformin, insulin or diagnosed with GDM but drug-naïve until birth. The follow-up study included 3,964 subjects in the metformin only cohort, 5,273 in the insulin only cohort and 82,675 women diagnosed with GDM but without drug treatment during the respective pregnancy (naïve cohort). Participants/materials, setting, methods The study population included singleton children born to 18-45 year old women from Finland during 2004–2016. Exclusion criteria were maternal type 1 diabetes, exposure to glucocorticoids and antidiabetic medications except metformin and insulin during the respective pregnancy. Analyses of SGA and LGA used logistic regression to estimate ORs with 95%CIs, with naïve cohort as the reference. Inverse probability of treatment weighting (IPTW) with stabilized weights based on propensity scores (PS) was used to control for confounding. Main results and the role of chance The odds of SGA birth were significantly higher in the naïve cohort (wOR 1.41, 95% CI 1.11 to 1.79) compared to those exposed to insulin, and the odds for LGA birth were significantly lower (wOR 0.72, 95% CI 0.64 to 0.82). No difference was found in the odds for SGA or LGA when the metformin cohort was compared with naïve cohort (wOR 0.97, 95% CI 0.73 to 1.27 and wOR 0.91, 95% CI 0.75 to 1.11, respectively). Limitations, reasons for caution Drug exposure was assessed on the dispensed drug only. and not intake, also prohibiting dose and treatment duration stratification. Although IPTW methods were used to account for many characteristics, the prevalence of underlying diseases differed across treatment cohorts, the naïve cohort which was defined by indication and absence of treatment. Wider implications of the findings This analysis adds to the growing evidence that insulin exposure in pregnancy may increase the risk of LGA, which is associated with increased adult obesity. Metformin did not increase the odds of SGA or LGA. Metformin may be considered a reasonable treatment during pregnancy, e.g. at risk for LGA birth. Trial registration number not applicable