Kaplan-Meier Survival Estimates Research Articles

Association of Predicted Heart Mass from Mesa and Left Ventricular Mass from Dallas Heart Study with Heart Transplant Outcomes in the New Allocation System

<h3>Purpose</h3> Donor and recipient size matching remains an important component of donor selection in heart transplant (HT). One approach to size matching includes using predicted heart mass (PHM), derived from the Multi-ethnic Study of Atherosclerosis (MESA). Compared to MESA, the Dallas Heart Study (DHS) may better represent the U.S. donor pool. We examined the association of PHM from MESA and predicted left ventricular mass (PLVM) from DHS with HT outcomes in two eras. <h3>Methods</h3> Linear regression was used to model PLVM from DHS participants (n=1,746) with normal LV size and function on cardiac MRI and BMI < 35 kg/m². The DHS PLVM model included age, gender, height, weight and race. We then examined the association of DHS PLVM and MESA PHM with 1-year mortality post-HT in the United Network of Organ Sharing registry (Era 1: 2007-2016 and Era 2: 2018-2021) using Kaplan-Meier survival estimation and univariate Cox proportional hazards models stratified by presence or absence of low donor:recipient mass ratio (< 0.86). <h3>Results</h3> The DHS derivation cohort had a median age of 43 years, 40% self-identified as Black and 18% as Hispanic, 23% had HTN and 7% had DM. DHS PLVM and MESA PHM were significantly correlated (R=0.96, p < 0.001). There was no statistically significant difference in the distribution of donor-recipient mass ratios by DHS PLVM and MESA PHM across eras (Figure). In Era 1, a low DHS PLVM ratio was associated with worse 1-year mortality post-HT (p < 0.001), similar to the previously reported association with MESA PHM). However, in Era 2 neither DHS PLVM nor MESA PHM were associated with 1-year mortality [PLVM HR 0.9 (0.7-1.2) and PHM HR 1.1 (0.8-1.4)] (Figure). <h3>Conclusion</h3> In a contemporary cohort of HT recipients, neither PHM nor PLVM from DHS were associated with 1-year mortality post-HT. Additional donor and recipient factors such as mechanical circulatory support may be playing a larger role in HT outcomes in the current era.

Heart-Kidney Transplantation and Hepatitis C Virus Positive Donors

<h3>Purpose</h3> Novel hepatitis C virus (HCV) therapies have expanded the donor pool for heart transplantation (HT). However, multi-center data for heart-kidney transplant (HKT) recipients of HCV(+) donors is not yet available. <h3>Methods</h3> We analyzed adults undergoing first-time HKT between October 16^th, 2014 & December 31^st, 2019 using United Network for Organ Sharing (UNOS) registry; follow-up was available through March 4^th 2021. Data on recipient & donor characteristics were compared by donor's HCV status (defined as presence of either positive HCV antibody (Ab) or Nucleic Acid Test (NAT); Kaplan-Meier survival & Cox-proportional hazard estimates were computed. We also conducted a propensity score matching (PSM) analysis by matching HCV(+) donors with non-HCV donors. A separate sub-group analysis stratified by donor's HCV-Ab & NAT status was also performed. <h3>Results</h3> A total of 785 recipients (n=60 HCV(+) and n=725 non-HCV donors) were identified (age: 59 years (interquartile range (IQR): 51, 64), 82.4% males, 34.4% blacks). Recipients of HCV(+) donors were more likely to be from UNOS regions 1, 5, 10 or 11 & were transplanted at high-volume centers (p<0.05). HCV(+) donors were more likely to be older, Caucasians, smoker, dying of drug-overdose & with lower body-mass index (p<0.05). Distance between recipient & donor centers was significantly greater, resulting in longer ischemic times, & predicted heart-mass ratio was significantly lower among recipients with HCV(+) donors (p<0.05). Despite of these unfavorable factors, 1-year survival was similar between HCV(+) & non-HCV donors; similar trends were observed upon PSM analysis & sub-group analysis (<b>FIGURE</b>). Post-HKT length of stay (25 days (IQR: 14, 52) Vs 22 days (IQR: 15, 34), p=0.256) & index-hospital need for dialysis (32% Vs 33%, p=0.784) did not differ between recipients of HCV(+) and non-HCV donors, respectively. <h3>Conclusion</h3> Given excellent 1-year survival and short-term outcomes, HCV(+) donors offer an opportunity to expand the donor pool for recipients in need of HKT.

Familial Cardiomyopathy Is Associated With A Significantly Worse Prognosis Than Non-familial Cardiomyopathy.

Introduction Risk stratification of nonischemic dilated cardiomyopathic (NICM) patients is challenging due to the large heterogeneity in disease phenotype, genetic background, and poorly characterized progression of disease. We postulated that patients with familial NICM (F-NICM, operationally defined as a strong family history or genetically proven) carry a significantly worse prognosis than nonfamilial/idiopathic NICM (I-NICM) patients for the composite endpoint of death, left ventricular assist device (LVAD) placement, or orthotopic heart transplantation (OHT). Methods A total of 127 consecutive patients, 52 F-NICM and 85 I-NICM, with implanted cardiac defibrillators (ICDs) or cardiac resynchronization devices (CRT) were studied. F-NICM patients were identified from the cardiovascular genetics clinic. Patients were followed for a mean of 6.1 +/- 5.1 years for cardiovascular outcomes: death, LVAD, or OHT. Results There were no significant differences regarding incidence of diabetes, hypertension, NYHA functional class, use of guideline directed medical therapy (GDMT), use of CRT, ICD shocks, or years of follow-up. Patients with F-NICM were significantly younger as compared to I-NICM group (45.8 +/- 15.8 years vs. 61.2 +/- 17 years, p=0.001). Mean ejection fraction (EF) was not significantly different between F-NICM and I-NICM; 31.2 +/- 14.5% vs. 31.6 +/- 12.2%. Thirty percent (30%) of F-NICM patients underwent LVAD implant or OHT as compared to 10.4% of I-NICM patients (p=0.008). The composite endpoint of LVAD, OHT, or death was significantly different between F-NICM and I-NICM, occurring in 45.8% vs 21.5% of patients respectively (p=0.004). After multivariate analysis, F-NICM was the only independent predictor of the composite endpoint. The Kaplan-Meier survival estimates for the composite endpoint was significantly lower in F-NICM as compared to I-NICM (Figure 1). Conclusion : In patients with NICM, the family history and/or a positive gene test for cardiomyopathy is a powerful predictor of the composite end point of death, LVAD implantation, or OHT. Risk stratification of nonischemic dilated cardiomyopathic (NICM) patients is challenging due to the large heterogeneity in disease phenotype, genetic background, and poorly characterized progression of disease. We postulated that patients with familial NICM (F-NICM, operationally defined as a strong family history or genetically proven) carry a significantly worse prognosis than nonfamilial/idiopathic NICM (I-NICM) patients for the composite endpoint of death, left ventricular assist device (LVAD) placement, or orthotopic heart transplantation (OHT). A total of 127 consecutive patients, 52 F-NICM and 85 I-NICM, with implanted cardiac defibrillators (ICDs) or cardiac resynchronization devices (CRT) were studied. F-NICM patients were identified from the cardiovascular genetics clinic. Patients were followed for a mean of 6.1 +/- 5.1 years for cardiovascular outcomes: death, LVAD, or OHT. There were no significant differences regarding incidence of diabetes, hypertension, NYHA functional class, use of guideline directed medical therapy (GDMT), use of CRT, ICD shocks, or years of follow-up. Patients with F-NICM were significantly younger as compared to I-NICM group (45.8 +/- 15.8 years vs. 61.2 +/- 17 years, p=0.001). Mean ejection fraction (EF) was not significantly different between F-NICM and I-NICM; 31.2 +/- 14.5% vs. 31.6 +/- 12.2%. Thirty percent (30%) of F-NICM patients underwent LVAD implant or OHT as compared to 10.4% of I-NICM patients (p=0.008). The composite endpoint of LVAD, OHT, or death was significantly different between F-NICM and I-NICM, occurring in 45.8% vs 21.5% of patients respectively (p=0.004). After multivariate analysis, F-NICM was the only independent predictor of the composite endpoint. The Kaplan-Meier survival estimates for the composite endpoint was significantly lower in F-NICM as compared to I-NICM (Figure 1). : In patients with NICM, the family history and/or a positive gene test for cardiomyopathy is a powerful predictor of the composite end point of death, LVAD implantation, or OHT.

Radiographically quantified sarcopenia and traditional cardiovascular risk assessment in predicting long-term mortality after endovascular aortic repair

ObjectiveThis study evaluated radiographically quantified sarcopenia and the patient's comorbidity burden based on traditional cardiovascular risk assessment as potential predictors of long-term mortality after endovascular aortic repair (EVAR). MethodsThe study included 480 patients treated with standard EVAR for intact infrarenal abdominal aortic aneurysms. Patient characteristics, comorbidities, aneurysm dimensions, and other preoperative risk factors were collected retrospectively. Preoperative computed tomography was used to measure psoas muscle area (PMA) at the L3 level. Patients were divided into three groups based on American Society of Anesthesiologists (ASA) score and PMA. In the high-risk group, patients had sarcopenia (PMA <8.0 cm2 for males and <5.5 cm2 for females) and an ASA score of 4. In the medium-risk group, patients had either sarcopenia or an ASA score of 4. Patients in the low-risk group had no sarcopenia and the ASA score was less than 4. Risk factors for long-term mortality were determined using multivariable analysis. Kaplan-Meier survival estimates were calculated for all-cause mortality. ResultsPatients in the high- and medium-risk groups were older than those in the low-risk group (77 ± 7, 76 ± 6, and 74 ± 8 years, respectively, P < .01). Patients in the high-risk group had higher prevalence of coronary artery disease, pulmonary disease, and chronic kidney disease. There were no differences in 30-day or 90-day mortality between the groups. The independent predictors of long-term mortality were age, ASA score, PMA, chronic kidney disease, and maximum aneurysm sac diameter. The estimated 1-year mortality rates were 5% ± 2% for the low-risk, 5% ± 2% for the medium-risk, and 18% ± 5% for the high-risk group (P < .01). Five-year mortality estimates were 23% ± 4%, 36% ± 3%, and 60% ± 6%, respectively (P < .01). The mean follow-up time was 5.0 ± 2.8 years. ConclusionsBoth ASA and PMA were strong predictors of increased mortality after elective EVAR. The combination of these two can be used as a simple risk stratification tool to identify patients in whom aneurysm repair or the intensive long-term surveillance after EVAR may be unwarranted.

Two-year retention in care for adolescents on antiretroviral therapy in Ehlanzeni district, South Africa: a baseline cohort analysis

ABSTRACT Adolescents living with HIV (ALHIV) struggle to remain engaged in HIV-related care and adhere to antiretroviral treatment (ART) due to a myriad of physical, psychological and cognitive-developmental challenges. We report on the profile of ALHIV aged 10–19 years on ART and the clinical factors associated with their retention in care. A retrospective cohort analysis was conducted with 16,108 ALHIV, aged 10–19 years, who were enrolled in 136 ART clinics in the Ehlanzeni district. Anonymised data were obtained from electronic medical records (Tier.net). Trends in retention in care among adolescents on ART was described using Kaplan-Meier survival estimates. Cox proportional analysis was performed to identify factors associated with retention in care over 2 years. More than half (53%) were females, and median duration on ART was 8 months. Retention in care among adolescents at months 6, 12, 18 and 24 was 90.5%, 85.4%, 80.8% and 76.2%, respectively. After controlling for confounders, risk of dying or lost to follow up increased for female adolescents (aHR = 1.28, 95% CI 1.10–1.49); being initiated on ART while pregnant (aHR = 2.72, 95% CI 1.99–3.69); history of TB infection (aHR = 1.71, 95% CI 1.10–2.65); and started ART at age 10–14 years (aHR = 2.45, 95% CI 1.96–3.05), and 15–19 years (aHR = 9.67, 95% CI 7.25–12.89). Retention in care among adolescents on ART over two-year period was considerably lower than the UNAIDS 2030 target of 95%. Of particular concern for intervention is the lower rates of retention in care among females and pregnant adolescents and starting ART between the ages of 10 and 19 years. Family or caregivers and peer support groups centred interventions designed to promote early initiation and retention in care through early case identification are needed.

Epidemiological evaluation of the outcomes of initial root canal therapy in permanent teeth of a publicly insured paediatric population.

Background:Previously published epidemiological outcome studies of nonsurgical root canal therapy (NSRCT) in the United States utilize data only from a single, private dental insurer for adult populations.Aim:This study aimed to investigate the outcomes of initial NSRCT, performed on permanent teeth, in a publicly insured paediatric population.Design:New York State Medicaid administrative claims were used to follow 77 741 endodontic procedures in 51 545 patients aged 6–18, from the time of initial NSRCT until the occurrence of an untoward event (retreatment, apicoectomy, and extraction). The initial treatment and untoward events were identified by Current Dental Terminology codes. The Kaplan–Meier survival estimates were calculated at 1, 3, and 5 years. Hazard ratios for time to permanent restoration and restoration type were calculated using the Cox proportional hazards model.Results:The median follow-up time was 44 months [range: 12–158 months]. Procedural, NSRCT, survival was 98% at 1 year, 93% at 3 years, and 88% at 5 years. Extraction was the most common untoward event. Teeth permanently restored with cuspal coverage had the most favorable treatment outcomes.Conclusions:Overall, 89% of teeth were retained and remained functional over a minimum follow-up time of 5 years. These results elucidate the expected outcomes of NSRCT in permanent teeth for paediatric patients with public-payer dental benefits.

Recipient and Donor Outcomes After Living-Donor Liver Transplant for Unresectable Colorectal Liver Metastases

Colorectal cancer is a leading cause of cancer-related death, and nearly 70% of patients with this cancer have unresectable colorectal cancer liver metastases (CRLMs). Compared with chemotherapy, liver transplant has been reported to improve survival in patients with CRLMs, but in North America, liver allograft shortages make the use of deceased-donor allografts for this indication problematic. To examine survival outcomes of living-donor liver transplant (LDLT) for unresectable, liver-confined CRLMs. This prospective cohort study included patients at 3 North American liver transplant centers with established LDLT programs, 2 in the US and 1 in Canada. Patients with liver-confined, unresectable CRLMs who had demonstrated sustained disease control on oncologic therapy met the inclusion criteria for LDLT. Patients included in this study underwent an LDLT between July 2017 and October 2020 and were followed up until May 1, 2021. Living-donor liver transplant. Perioperative morbidity and mortality of treated patients and donors, assessed by univariate statistics, and 1.5-year Kaplan-Meier estimates of recurrence-free and overall survival for transplant recipients. Of 91 evaluated patients, 10 (11%) underwent LDLT (6 [60%] male; median age, 45 years [range, 35-58 years]). Among the 10 living donors, 7 (70%) were male, and the median age was 40.5 years (range, 27-50 years). Kaplan-Meier estimates for recurrence-free and overall survival at 1.5 years after LDLT were 62% and 100%, respectively. Perioperative morbidity for both donors and recipients was consistent with established standards (Clavien-Dindo complications among recipients: 3 [10%] had none, 3 [30%] had grade II, and 4 [40%] had grade III; donors: 5 [50%] had none, 4 [40%] had grade I, and 1 had grade III). This study's findings of recurrence-free and overall survival rates suggest that select patients with unresectable, liver-confined CRLMs may benefit from total hepatectomy and LDLT.

RUNX3/H3K27me3 Co-Expression Defines a Better Prognosis in Surgically Resected Stage I and Postoperative Chemotherapy-Naive Non-Small-Cell Lung Cancer.

The purpose of this study is to investigate the significance of RUNX3/H3K27me3 co-expression in surgically resected non-small-cell lung cancer (NSCLC) patients. Using tissue microarray (TMA), immunohistochemistry, fluorescent double immunostaining, and western blotting, 208 NSCLC and 5 benign pulmonary patients were studied of their expression of runt-related transcription factor 3 (RUNX3), trimethylated histone H3 at lysine 27 (H3K27me3), enhancer of zeste homolog 2 (EZH2), and Ki-67. Apoptotic index in cancerous tissue was evaluated via TdT-mediated dUTP-biotin nick end labeling (TUNEL). The correlation between clinicopathologic parameters and overall survival was determined by Cox regression and Kaplan–Meier survival estimates and log-rank test. GEPIA and KM plotter were used for validation of some survival analyses. As a result, together with other regular prognostic factors, RUNX3/H3K27me3 co-expression was found to be closely correlated with better prognosis in either pTNM-I or POCT-naive NSCLC patients, which might partially result from a higher cancerous apoptotic index. In conclusion, RUNX3/H3K27me3 co-expression defined some specific NSCLC population with better prognosis and longer OS and could probably be used as a biomarker in the prediction of better postoperative outcomes.

Bilateral internal thoracic artery versus single internal thoracic artery plus radial artery: A double meta-analytic approach

ObjectivesWe explored the current evidence on the best second conduit in coronary surgery carrying out a double meta-analysis of propensity score matched or adjusted studies comparing bilateral internal thoracic artery (BITA) versus single internal thoracic artery plus radial artery. MethodsPubMed, Embase, and Google Scholar were searched for propensity score matched or adjusted studies comparing BITA versus single internal thoracic artery plus radial artery. The end point was long-term mortality. Two statistical approaches were used: the generic inverse variance method and the pooled meta-analysis of Kaplan–Meier-derived individual patient data. ResultsTwelve matched populations comparing 6450 patients with BITA versus 9428 patients with single internal thoracic artery plus radial artery were included in our meta-analysis. The generic inverse variance method showed a statistically significant survival benefit of the BITA group (hazard ratio, 0.84; 95% CI, 0.74-0.95; P = .04). The Kaplan-Meier estimates of survival at 1, 5, 10, and 15 years of the BITA group were 97.0%, 91.3%, 80.0%, and 68.0%, respectively. The Kaplan-Meier estimates of survival at 1, 5, 10, and 15 years of the single internal thoracic artery plus radial artery group were 97.3%, 91.5%, 79.9%, and 63.9%, respectively. The Kaplan–Meier-derived individual patient data meta-analysis applied to very long follow-up time data, showed that BITA provided a survival benefit after 10 years from surgery (hazard ratio, 0.77; 95% CI, 0.63-0.94; P = .01). No differences in terms of survival between the 2 groups were detected when the analysis was focused on the first 10 years of follow-up (hazard ratio, 0.99; 95% CI, 0.91-1.09; P = .93). ConclusionsThe present meta-analysis suggests that double internal thoracic artery may provide, compared with single internal thoracic artery plus radial artery, a statistically significant survival advantage after 10 years of follow-up, but not before. Video Abstract [Display omitted]

Body mass index in adolescence, risk of type 2 diabetes and associated complications: A nationwide cohort study of men

SummaryBackgroundObesity is a predominant factor in development of type 2 diabetes but to which extent adolescent obesity influences adult diabetes is unclear. We investigated the association between body mass index (BMI) in young men and subsequent type 2 diabetes and how, in diagnosed diabetes, adolescent BMI relates to glycemic control and diabetes complications.MethodsBaseline data from the Swedish Conscript Register for men drafted 1968–2005 was combined with data from the National Diabetes and Patient registries. Diabetes risk was estimated through Cox regression and Kaplan-Meier survival estimates. Relationships between BMI, glycemic control and diabetes complications were assessed through multiple linear and logistic regression.FindingsAmong 1,647,826 men, 63,957 (3·88%) developed type 2 diabetes over a median follow-up of 29.0 years (IQR[21.0–37.0]). The risk of diabetes within 40 years after conscription was nearly 40% in individuals with adolescent BMI ≥35 kg/m2. Compared to BMI 18·5–<20 kg/m2 (reference), diabetes risk increased in a linear fashion from HR 1·18(95%CI 1·15–1·21) for BMI 20–<22·5 kg/m2 to HR 15·93(95%CI 14·88–17·05) for BMI ≥35 kg/m2, and a difference in age at onset of 11·4 years was seen. Among men who developed diabetes, higher adolescent BMI was associated with higher HbA1c levels and albuminuria rates.InterpretationRising adolescent BMI was associated with increased risk of type 2 diabetes diagnosed at a younger age, with poorer metabolic control, and a greater prevalence of albuminuria, all suggestive of worse prognosis.

Open surgical replacement of the descending thoracic and thoracoabdominal aorta in patients with confirmed Marfan and Loeys-Dietz syndromes: A 20-year single-centre experience.

A relatively small proportion of patients with heritable thoracic aortic disease require open surgical replacement of the distal thoracic aorta. We reviewed the outcome in patients with Marfan and Loeys-Dietz syndromes treated in an aortic centre in the United Kingdom. We performed a single-centre retrospective study of consecutive patients treated between October 1999 and December 2019. The primary end point was 30-day mortality. Secondary end points were Kaplan-Meier estimates of medium-term survival and freedom from distal reintervention. Data are presented as median (interquartile range). A total of 58 patients [33 men; 51 with Marfan syndrome; median age 41 years (35-48); median aneurysm diameter 60 mm (55-74)] underwent open descending (n = 21) or thoracoabdominal aortic replacement (n = 37). All repairs were performed using cardiopulmonary bypass with hypothermic circulatory arrest in 31 patients. The 30-day mortality was 5.2% (n = 3, including 2 patients ≥ 60 years with significant comorbidity). Major non-fatal complications included early reoperation (n = 7), tracheostomy (n = 9), temporary renal replacement therapy (n = 3), permanent spinal cord deficit (n = 2) and permanent stroke (n = 1). Median follow-up was 81 months (48-127). Estimated (±standard error) 5-year survival was 85% ±5%. Seven patients had distal aortic reintervention with no deaths or spinal cord deficit: estimated 5-year freedom from distal reintervention was 94% ±3%. There was no difference in survival or freedom from distal reintervention comparing: elective vs. non-elective; type of heritable thoracic aortic disease; DeBakey type; or extent of surgical repair. Descending thoracic and thoracoabdominal aortic replacement in patients with heritable thoracic aortic disease can be performed with low perioperative morbidity and mortality, satisfactory long-term survival and low requirement for distal reintervention.

Six Months After the Patients Stayed Home: A Nationwide Study of Cardiac Mortality and Readmissions Following the First Wave of the COVID-19 Pandemic in Malta.

BackgroundThe first COVID-19 wave resulted in a significant decline in acute cardiac admissions (ACAs) and delays to hospital presentation in Malta, as well as an excess of out-of-hospital cardiac arrests. The aim was to investigate the impact of the observed delays in presentation in 2020 on mortality and cardiac readmissions at six months.MethodsAll ACAs between 28th February and 30th April 2020 (first wave of COVID-19 in Malta) were included, and the corresponding 2019 period was used as a control. ACA was defined as an unplanned admission of an adult (aged ≥16 years) under the care of a cardiologist. Outcomes over the six months following the index ACA included death, cardiac readmission, and planned cardiac intervention at discharge. The term ‘death’ referred to all-cause mortality. Cardiac readmissions referred to unplanned admissions for acute cardiac pathology following the index ACA. During sub-analyses, ACAs were divided into acute coronary syndrome (ACS) and non-ACS. A first analysis compared the frequency of deaths, cardiac readmissions, and planned interventions between the 2019 and 2020 cohorts. A second analysis investigated differences in six-month survival and freedom from readmission between the two cohorts. Both analyses were followed by a sub-analysis.ResultsThere were 330 ACAs among the 2019 cohort and 220 in 2020. There were no significant differences between the 2019 and 2020 cohorts in all-cause mortality (2019, 8.8% vs 2020, 8.2%, p=0.466) and Kaplan-Meier survival estimates at a six-month follow-up (2019, 169.06 days (95% CI 164.95-173.17) vs 2020, 168.27 days (95% CI 162.82-173.72), p=0.836), including subgroup analysis for non-ACS (2019, 168.52 days (95% CI 163.08-173.96) vs 168.11 days (95% CI 160.93-175.30), p=0.952) and ACS patients (169.81 days (95% CI 163.54-176.09) in 2019 vs 168.45 days (95% CI 160.17-176.73) in 2020, p=0.739).A significantly higher number of patients from the 2019 cohort (75/319, 23.5%) required readmission compared to 2020 (32/212; 15.1%) (p=0.02). Similarly, there was shorter freedom from cardiac readmission among 2019 patients (mean 150.98 days (95% CI 144.63-157.33)) compared to 2020 patients (mean 158.66 days (95% CI 151.58-165.74, p=0.024). During sub-analysis, the difference in freedom from readmission was significant only for non-ACS patients (mean of 145.45 days (95% CI 136.58-154.32) in 2019 vs 158.92 days (95% CI 149.19-168.64) in 2020, p=0.018).Analysis of cardiac interventions during the six months post-index ACA discharge showed significantly more planned cardiac interventions in 2019 (52/319; 16.3%) compared to 2020 (20/212; 9.4%) (p=0.027).ConclusionsA delay in presentation of ACAs during COVID-19 in Malta resulted in lower readmission rates and increased freedom from readmissions, with no excess in all-cause mortality at a six-month follow-up. The reasons for the optimistic outcomes of patients admitted during the first wave of COVID-19 may be multifactorial. Reasons may include ongoing fear of hospital presentation, a more holistic approach to patients’ in-hospital care during 2020 aimed at reducing further hospital contact post-discharge, and a selection bias secondary to an excess of out-of-hospital cardiac arrests during the initial wave of COVID-19. Further studies will be required to truly assess the collateral impact of non-COVID-19-related illness. Public education on cardiovascular health is vital and must be emphasized during the pandemic.

Total Number of Lymph Nodes in Neck Dissection and its Relation to Cancer-Positive Lymph Nodes as a Prognostic Indicator in Aerodigestive Tract Cancers

<h3>Purpose/Objective(s)</h3> Few studies have been conducted on the total number of lymph nodes (LNs) in neck dissection and the lymph node ratio (LNR; number of positive LNs divided by number of excised LNs), or their potential use as a prognostic indicator for cancers of the upper aerodigestive tract (UADT) and its treatment. We aimed to measure the number of LNs dissected and the LNR to assess their prognostic value for cancers of the UADT, as well as their effect on overall survival and disease-free survival. <h3>Materials/Methods</h3> We performed a retrospective study of patients diagnosed with cancer of the UADT who underwent neck dissection as the primary or secondary modality of their treatment plan at King Abdulaziz University Hospital and the National Guard Hospital, Jeddah, Saudi Arabia. Data were collected through medical records and analyzed to assess prognosis and calculate survival rates in relation to the number of LNs and LNR. <h3>Results</h3> A total of 121 patients were included:14 women (11.57%) and 107 men (88.43%). The median age was 60 years and the mean follow-up period 2.7 years. Of the malignancies, 44.63%were of the oral tongue and 35.54% were laryngeal. A median of 38 LNs were dissected during neck dissections. The distribution of the individual LNRs was characterized by mean values. A mean LNR of 0.04 was considered the cutoff value, an LNR of >0.04 a high LNR, and an LNR of <0.04 a low LNR. Kaplan-Meier survival estimates for the cohort showeda3-year overall survival rate of 88% (95%confidence interval [CI]: 77% to 94%) for patients with a low LNR, but 71% (95% CI: 47% to 85%) for patients with a high LNR, which was statistically significant. A similar significant decreasing trend persisted at the 4-yearfollow-up, where the disease-free survival rate was 73% (95% CI: 61% to 82%) for patients with a low LNR compared with 56% (95% CI: 35% to 72%) for patients with a high LNR. <h3>Conclusion</h3> The number of excised LNs in neck dissections and the LNR might be a good prognostic indicator for overall survival and disease-free survival in patients with cancers of the UADT and may serve as a valuable tool in deciding on different treatment plans.

The impact of local vs general anesthesia in patients undergoing thoracic endovascular aortic surgery

ObjectiveGeneral anesthesia (GA) is associated with inherent risks that can be avoided by the use of lesser invasive anesthetic strategies. We hypothesize that examine and compare the use of local or regional anesthesia (LRA) to that of GA in patients undergoing thoracic endovascular aortic repair (TEVAR). MethodsPatients undergoing TEVAR between 2010 and 2020 in the Vascular Quality Initiative were analyzed. Exclusion criteria included receipt of branched or physician-modified endografts and devices extending distally beyond zone 5. Patients were categorized as receiving LRA or GA. Center volume was reported by quartile according to annualized TEVAR volume, and operative outcomes were compared using appropriate frequentists tests. Univariable and multivariable regression models for anesthesia type and operative outcomes were created to compare unadjusted and adjusted rates of each outcome. Long-term survival was estimated using a Kaplan-Meier survival estimator, whereas adjusted survival analysis was performed using a Cox proportional hazards model. ResultsOf the 17,099 patients who underwent TEVAR, 7299 met the inclusion and exclusion criteria. Of these, 3.8% received LRA. There were no significant differences in the annual proportion of patients who received LRA from 2011 to 2020 (P = .49, χ2 test for trend). Only 18.8% of patients who received LRA were treated at the highest quartile volume centers. Patients who received LRA were older and more comorbid compared with those who received GA. There were no differences in in-hospital mortality (odds ratio [OR], 0.79; 95% confidence interval [CI], 0.42-1.38; P = .44) or composite of any complication (OR, 0.79; 95% CI, 0.54-1.14; P = .22) between patients who received LRA compared with those who received GA. This also applied to patients presenting with rupture. Receipt of LRA was associated with lower odds of postoperative congestive heart failure (OR, 0.19; 95% CI, 0.01-0.89; P = .01) as well as decreased length of intensive care unit (OR, 0.54; 95% CI, 0.40-0.72; P < .01) and hospital length of stay (OR, 0.64; 95% CI, 0.46-0.84; P < .01). LRA was not associated with decreased long-term survival compared with GA (hazard ratio, 0.95; 95% CI, 0.72-1.25; P = .72). ConclusionsDespite a greater number of baseline comorbidities, patients undergoing TEVAR with LRA experienced shorter intensive care unit and postoperative lengths of stay, with similar operative outcomes and long-term survival compared with patients who received GA. Similar findings were found among the rupture cohort. LRA should be considered more frequently in select patients undergoing TEVAR.

Influence of Lymphangio vascular (V) and perineural (N) invasion on survival of patients with resected esophageal squamous cell carcinoma (ESCC): a single-center retrospective study.

BackgroundLymphangio vascular invasion (LVI) and perineural invasion (PNI) are associated with survival following resection for gastrointestinal cancer. But the relationship between LVI/PNI and survival of esophageal squamous cell carcinoma (ESCC) is still unclear. We aim to demonstrate the prognostic significance of LVI/PNI in ESCC.MethodsA total of 195 ESCC patients underwent curative surgery from 2012 to 2018 was collected in the 2nd Affiliated Hospital of Fujian Medical University. All the patients were divided into four groups based on the status of the neurovascular invasion: (1) neither LVI nor PNI (V0N0); (2) LVI alone (V1N0); (3) PNI alone (V0N1); (4) combined LVI and PNI (V1N1). First, the analysis included the Kaplan-Meier survival estimates with the Log rank test were performed to determine median overall survival (OS) in different groups divided according to the clinical factor, respectively. And the association between OS with multi clinical factors was examined using Cox regression analysis. Next, the risk factors for recurrence in patients with V1N1 were analyzed with univariate and multivariate logistic regression analyses, respectively.ResultsThe cases in V0N0, V1N0, V0N1, and V1N1 groups were 91 (46.7%), 62 (31.8%), 9 (4.6%) and 33 (16.9%), respectively. The OS in the four groups was different (P < 0.001). The 1-, 3- and 5-year OS in V0N0 group was higher than that in V1N1 group, respectively (1-year OS: 93.4% vs 75.8%, 3-year OS: 53.8 % vs 24.2%, 5-year OS: 48.1% vs 10.5%). The OS in stage I-II for patients with V1N1 was significantly lower than that in the other groups (V0N0, V1N0, V0N1) (P < 0.001). The postoperative adjuvant chemotherapy was a significant impact factor of OS for ESCC patients with V1N1 (P = 0.004). Lymphatic invasion and LVI were significantly prognosis factors associated (P = 0.036, P = 0.030, respectively). The ulcerative type is a risk factor for V1N1 occurance (P = 0.040).ConclusionsThe LVI and PNI are important prognosis factors for ESCC patients. ESCC patients with simultaneous lymphangio vascular and perineural invasion (V1N1) showed worse OS than patients with either lymphangio vascular or perineural invasion alone (V1N0 or V0N1) or none (V0N0). In addition, adjuvant chemotherapy may prolong the OS for ESCC patients with V1N1.

Transfemoral Versus Subclavian Access for Transcatheter Aortic Valve Replacement.

Objective: This study sought to compare outcomes of transcatheter aortic valve replacement (TAVR) performed through subclavian access with those performed through transfemoral access. Methods: This was an observational study utilizing an institutional TAVR database from 2010 to 2018. All patients undergoing a TAVR via a transfemoral (TF-TAVR) or subclavian (SC-TAVR) approach were included in the study. The groups were analyzed for differences in operative mortality and postoperative outcomes. Multivariable Cox analysis was performed to identify variables associated with long-term survival after TAVR. Results: Of the 1,095 patients identified, 133 patients underwent SC-TAVR and 962 patients underwent TF-TAVR. Patients who underwent SC-TAVR were younger, more likely to have chronic lung disease and peripheral vascular disease, had higher Society of Thoracic Surgeons predicted risk of mortality scores, and were more likely to have self-expanding valves placed (P < 0.05). Operative mortality was similar between the TF-TAVR (2.7%) and SC-TAVR (3.8%) groups. There were no significant differences in stroke, length of stay, 30-day readmission, blood transfusions, acute kidney injury, need for permanent pacemaker, paravalvular leak, or major vascular complications between the groups (P > 0.05). The unadjusted Kaplan-Meier survival estimate for TF-TAVR was significantly higher than for SC-TAVR (P = 0.009, log-rank). However, on multivariable Cox analysis, subclavian access was not significantly associated with an increased hazard of death as compared with transfemoral access (P = 0.21). Conclusions: Outcomes of SC-TAVR are comparable to those of TF-TAVR. Subclavian access may be a favorable alternative approach when TF-TAVR is contraindicated.

The Impact of Surgical Resectability on Outcomes for Patients Undergoing Primary Radiation Treatment for Human Papillomavirus-Related Oropharyngeal Cancer

Primary radiation therapy with or without chemotherapy (RT/CRT) is the most common treatment for oropharyngeal squamous cell carcinomas (OPSCC), but there has been an increase in transoral surgery (TOS) for T1-2 tumors. Because only a subset of T1-2 tumors are TOS-favorable, nonrandomized comparisons between RT/CRT and TOS could be confounded by indication. We aimed to compare outcomes of potential TOS-candidates versus non-TOS candidates, among patients who underwent RT/CRT for early T-stage OPSCC. For patients treated with RT/CRT for early-stage human papilloma virus positive OPSCC between 2014 and 2018, pretreatment imaging was reviewed by 3 head and neck surgeons, blinded to outcomes, to assess primary-site appropriateness for TOS, and extracapsular extension (ECE) was scored by a head and neck neuroradiologist. We compared outcomes based on surgical favorability pertaining to (1) the primary site tumor alone and (2) the primary site and an absence of ECE. Kaplan-Meier estimates for overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were compared using the log-rank test, with Cox regression used for multivariable modeling. One hundred and forty-three patients were evaluated, of which 121 were male (84.6%), the median age was 59.4 years, and all of them were p16 positive (100%). The primary site was TOS-favorable in 115 of 143 (80.4%). Patients with TOS-favorable primary site experienced superior 5-year OS (89.8% vs 71.2%, P=.017), DSS (90.4% vs 63.4%, P=.022), and RFS (83% vs 49.4%, P=.04) compared with TOS-unfavorable patients. Similarly, patients with a TOS-favorable primary site and no ECE on imaging 101 of 143 (70.6%), had improved OS, DSS, and RFS (P < .05) compared with TOS-unfavorable patients. In this first study to assess surgical favorability as a prognostic factor among patients with T1/2 p16+ OPSCC, patients with TOS-favorable early-stage OPSCC have better outcomes than TOS-unfavorable patients. This provides valuable prognostic information for patients, and also suggests the risk of confounding by indication in nonrandomized comparisons of treatment modalities.

Comparison of long-term outcomes of trabeculectomy and risk factors for failure in eyes post penetrating keratoplasty or Descemet's stripping endothelial keratoplasty.

Purpose:To evaluate the outcomes of trabeculectomy, graft survival, and risk factors for failure in post penetrating keratoplasty (PK) and Descemet’s stripping endothelial keratoplasty (DSEK) eyes.Methods:We reviewed charts of eyes that underwent trabeculectomy for post keratoplasty glaucoma PK [25 eyes] and DSEK [14 eyes] between 1993 and 2019. The demographics, clinical features, and surgical outcomes were evaluated. Success of trabeculectomy was defined as complete when the intraocular pressure (IOP) was >5 and ≤21 mmHg without antiglaucoma medications (AGM) and qualified with AGM. Clear and compact graft was considered for graft success.Results:Median (interquartile range [IQR] preoperative IOP in post-PK eyes and post-DSEK eyes was comparable, 32 (28–38) vs. 31.5 (25–36) mmHg, P = 0.38). Median number of preoperative AGMs was comparable (P = 0.78). Median postoperative follow-up was longer in post-PK, compared with post-DSEK, 2.5 (1.3–3.3) vs. 1 (0.3–2.9) years (P = 0.05). Kaplan–Meier survival estimates for complete and qualified success of trabeculectomy at 3 years were 23.7% and 73.3%, respectively, for PK and 45.8% and 71.6%, respectively, for DSEK. Kaplan–Meier survival estimates for graft survival were 91.8% up to 3 years for PK and 100% until 2 years and 77.8% at 3 years for DSEK. Higher IOP prior to trabeculectomy was a risk factor for failure of trabeculectomy (P = 0.03) and older age was a risk factor for graft failure (P = 0.05) in PK eyes. Number of prior corneal surgeries (P = 0.05) was associated with failure of trabeculectomy and graft failure in post-DSEK eyes.Conclusion:Trabeculectomy had moderate qualified success in post-PK and DSEK eyes at 3 years. Higher pretrabeculectomy IOP and higher number of prior corneal surgeries were significantly associated with failure of trabeculectomy in PK and DSEK eyes, respectively.

Pars plana Aurolab aqueous drainage implantation for refractory glaucoma: Outcome of a new modified technique.

Purpose:To report the outcomes of pars plana insertion of Aurolab aqueous drainage implant (AADI) in adults with refractory glaucoma by the novel technique of making scleral tunnel instead of patch graft to cover the tube to prevent its migration.Methods:A retrospective study was done between April 2016 and April 2018 on patients with ≥12 months of follow-up. The main outcome measure was a surgical failure at 12 months. The failure was defined as intraocular pressure (IOP) >18 mmHg or IOP ≤5 mmHg on two consecutive follow-up visits after 3 months, reoperation for glaucoma, loss of light perception vision, or implant explantation. Alternate definitions of failure including IOP >21 and IOP >15 mmHg were also considered.Results:The study included 32 eyes of 32 patients. The mean age was 46.2 ± 17.5 years. The most common etiology is traumatic glaucoma (12 eyes, 37.5%). The mean preoperative IOP and anti-glaucoma medications were 43.3 ± 10.3 and 3.4 ± 0.5 mmHg, respectively; both the parameters at the final follow-up were reduced to 15.2 ± 8.1 and 1.6 ± 0.5 mmHg. The Kaplan–Meier survival estimates demonstrated that the cumulative probability of failure was 15.6% (95% CI; 6.8–33.5%) at 3 months, 18.7% (95% CI; 8.9–37.0%) at 6 months, and 25.0% (95% CI; 13.4–43.8%) at 12 months.Conclusion:Pars plana AADI implantation with a newer modification technique is a useful procedure in reducing IOP and the number of anti-glaucoma medications in the eyes with refractory glaucoma. The visual acuity may be stabilized with the concurrent treatment of posterior segment pathology.

Palliative radiotherapy delivery by a dedicated multidisciplinary team facilitates early integration of palliative care: A secondary analysis of routinely collected health data

BackgroundEarly integration of Specialist Palliative Care (SPC) with oncological care improves quality of life (QOL) of patients with advanced cancer; however, patients tend to access SPC late in their disease trajectory, if at all. Routine referral of all patients to SPC would quickly overwhelm available resources, suggesting a need for widespread accessibility of generalist PC competencies. This has been increasingly facilitated by dedicated palliative radiotherapy (PRT) clinics, such as the multidisciplinary Palliative Radiation Oncology (PRO) program at the Cross Cancer Institute (CCI). Our objectives were to estimate the proportion of patients dying with breast cancer seen in consultation for PRT, and the interaction between PRT delivery and SPC referral. MethodsThis secondary analysis of routinely collected health data examined female adults with breast cancer who died between 04/01/2013 and 03/31/2014, and had advanced disease while under the care of a CCI oncologist. Alberta Cancer Registry, electronic medical records, and Edmonton Zone Palliative Care Program data were linked. During the study period, referrals for SPC, and setting of assessment for PRT, were at the attending physicians’ discretion. Clinical data were abstracted including summaries of intervals between PRT and SPC consultations, as well as from consults to death. Kaplan-Meier survival estimates, independent samples median tests, t tests of proportions, independent t tests and Chi-square tests compared groups. ResultsOf 194 patients, median age at cancer diagnosis was 59 years (range 24-95yrs), median one-way distance from the CCI was 18.8km, and overall median survival (MS) was 4.4 years. 130/194 (67.0%) and 110/194 (56.7%) were assessed for PRT and by SPC respectively; 22/194 (11.3%) saw neither prior to death. Median time between first PRT consultation and death was 11.7 months (interquartile range 3.7-22.2 mos). Median time between first SPC consult and death was 2.9 mos (IQR 1-6.2 mos). 65.6% of those who never had PRT ultimately required SPC involvement, versus 52.3% of those receiving PRT. Of the 68/130 who had both, 91.2% were seen for PRT first, a median of 7.9 mos prior to seeing SPC. Patients who had SPC consultation without previous PRT were seen by PC a median 1.5 mos prior to death (IQR 0.6-4.9 mos). Patients seen for PRT outside of the PRO clinic had SPC consultation a median of 3.3 mos before death (IQR 1.2-6.2 mos), versus those seen by the PRO clinic team, who were referred a median of 6.2 mos prior (IQR 2.4-8.1 mos). ConclusionsFewer advanced breast cancer patients who received PRT ultimately required SPC consultation, but those who did were referred earlier in their disease course, especially if PRT assessment and delivery had taken place in the setting of a dedicated multidisciplinary team.