Multivariate Cox Proportional-hazards Regression Analysis Research Articles

#100 Hospital readmissions for fluid overload among individuals with diabetes mellitus

Abstract Background and Aims Hospital readmissions due to recurrent fluid overload in diabetes can be avoided with evidence-based interventions. To identify at-risk individuals, we evaluated the incidence and risk factors associated with fluid overload-related hospital readmissions and developed risk prediction models for readmissions for fluid overload in people with diabetes. Method Single-centre retrospective cohort study of 1531 adults with diabetes and hospitalized in Singapore General Hospital for fluid overload, congestive heart failure, pulmonary edema and generalized edema between 2015 and 2017. Patients were included if they had diabetes mellitus identified by the SingHealth Diabetes Registry according to diagnosis codes, laboratory results and/or the use of glucose-lowering medication and had follow up visits, but excluded if their estimated glomerular filtration rate (eGFR) <15 ml/min/1.73 m2. Baseline data on demographics, comorbidities, biochemistry and medication use during admission were retrieved from electronic medical records up till 30 December 2018. The outcomes were fluid overload- related readmissions within 30 days and 90 days of discharge of the index hospitalization. Multivariable Cox proportional-hazards regression analysis was performed with inclusion of covariates with p≤0.10 on univariate analysis. Multivariable regression models developed were compared with the LACE index with net reclassification index (NRI). Results Among 1531 patients, median age was 73 (IQR 64, 81) and readmissions for fluid overload within 30 days and 90 days occurred in 131 (8.6%) and 264 (17.2%) patients, respectively. Individuals with 30- or 90-day readmissions were more likely to have prior hospitalization for fluid overload and more frequent ED visits within 6 months before the index hospitalization, cardiovascular disease, hypertension, and required high-dose intravenous furosemide during the index hospitalization, or current smoker. Clinical and clinico-psychosocial models for 30- and 90-day readmissions for fluid overload were developed (Table 1). The clinical and clinico-psychosocial models showed better discrimination and calibration than LACE index for predicting 30- and 90-day readmissions for fluid overload. The NRIs for clinical models were i. 30-day readmissions: +22.1%, ii. 90-day readmissions: +27.9% respectively, while the NRIs for clinico-psychosocial models were i. 30-day readmissions: +22.4%, ii. 90-day readmissions: +28.9% respectively (Fig. 1). Conclusion Patients with diabetes who are at-risk of readmission for fluid overload can be identified for targeted interventions to reduce preventable hospitalizations.

Neutrophil-to-lymphocyte ratio for the prediction of soft tissue sarcomas response to pre-operative radiation therapy

Purpose/ObjectiveThis study aims to assess the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) in soft tissue sarcomas (STS) treated with pre-operative hypofractionated radiotherapy (HFRT). Materials/MethodsThis retrospective analysis included patients treated with pre-operative HFRT of 30 Gy in 5 fractions between 2016 and 2023. Clinical, demographic, and complete blood count (CBC) data were collected. NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. Only patients with CBCs conducted within 6 months after radiotherapy were included. Cox proportional-hazard regression models were used to assess the impact of NLR and different variables on outcomes. Kaplan Meier were used to illustrate survival curves. A p-value < 0.05 was considered significant, and 95 % confidence intervals (CI) were employed. ResultsA total of 40 patients received HFRT and had CBCs within 6 months after radiotherapy. There were 17 (42.5 %) females and 23 (57.5 %) males with a mean age of 66 years. The mean largest tumor size dimension was 7.1 cm, and the mean NLR post-RT was 5.3. The most frequent histological subtypes were myxofibrosarcoma (17.5 %), pleomorphic spindle cell sarcoma (10 %), leiomyosarcoma (7.5 %), and myxoid liposarcoma (5 %). The median follow-up period was 15.4 months. From all patients, 14 patients had disease progression, 12 metastatic disease and 3 died of disease. Multivariable Cox proportional-hazards regression analysis displayed that a higher post-RT NLR was associated with worse disease-free survival (DFS) (HR: 1.303 [1.098–1.548], p = 0.003), and distant metastasis-free survival (DMFS) (HR: 1.38 [1.115–1.710], p = 0.003). Moreover, post-NLR ≥ 4 as a single variable was associated with worse DFS, DMFS, but not worse local recurrence or overall survival. ConclusionThis study is the first to evaluate NLR as a prognostic biomarker in STS patients treated with pre-operative radiotherapy. A higher NLR after pre-operative radiotherapy was associated with increased disease progression.

Long-term results of regenerative treatment of intrabony defects: a cohort study with 5-year follow-up

BackgroundThe aim of this retrospective cohort study was to evaluate the long-term clinical and radiographic outcomes and survival of teeth in periodontal regenerative treatment of intrabony defects using combined enamel matrix protein derivative (EMD) and deproteinized porcine bone mineral (DPBM) compared to EMD alone.MethodsA total of 333 intrabony defects in 176 patients (mean age: 54.7 ± 8.9 years) were followed-up for 58.6 ± 11.2 (range, 25–78) months after periodontal regenerative treatment. Changes in clinical (pocket probing depth and clinical attachment level) and radiographic (defect depth and defect width) parameters were analyzed using serial periapical radiographs. Kaplan–Meier and multivariate Cox proportional-hazards regression analyses for tooth loss were also performed.ResultsCompared to periodontal surgery with EMD alone with a mean follow-up of 5 years, combined EMD and DPBM showed significantly better gain in clinical attachment level (EMD and DPBM: 2.8 ± 2.3 mm vs. EMD alone: 2.2 ± 2.2 mm) and reduction in probing pocket depth (EMD and DPBM: 2.8 ± 1.8 mm vs. EMD alone: 2.3 ± 1.8 mm), defect depth (EMD and DPBM: 2.5 ± 2.4 mm vs. EMD alone: 2.0 ± 2.4 mm) and defect width (EMD and DPBM: 0.6 ± 1.0 mm vs. EMD alone: 0.2 ± 1.3 mm). The overall survival rates of the teeth were 91.48% and 95.20% in the patient- and tooth-based analyses, respectively, showing no statistically significant difference.ConclusionsWithin the limitations of the current study, combined EMD and DPBM offered additional clinical and radiographic benefits over a mean of 5 years compared to EMD alone. However, tooth loss did not differ significantly between the two groups.Clinical relevanceCompared to EMD alone, combined EMD and DPBM for intrabony defects has additional clinical advantages; however, patient- and tooth-related risk factors must be considered when performing periodontal regenerative surgery.

Medical Insurance Coverage and Clinical Outcomes for Patients with Hematological Malignancies in a Rural State

Background Hematological malignancies, such as leukemia, lymphoma, and multiple myeloma, affect blood, bone marrow, and/or the lymphatic system. They can be difficult to treat and often require prolonged and expensive interventions such as chemotherapy, radiation therapy, stem cell transplant, and/or targeted immunotherapy. Due to the complexity and cost of treatment, they pose a significant financial burden on patients and their families. Medical insurance coverage plays a crucial role in providing access to these treatments. This is particularly important for individuals of lower socioeconomic status, and patients in rural states. Aim This retrospective study is focused at examining the relationship between various medical insurance coverage options and/or its absence in influencing the treatment regime and clinical outcomes of patients with hematological malignancies in a statewide cancer registry. Methods This is a retrospective cohort study, conducted by analyzing data in the cancer registry of patients with various hematological malignancies in a single rural state between 2015 and 2022. The patients were divided into study groups based on their insurance providers (Medicare, Medicaid, Private, Military, and Other). Demographic data, cancer treatment data as well as survival data was collected for all patients included in the study. Descriptive statistics were calculated for the overall sample and for each Insurance type subgroup. Due to normality violations, Kruskal Wallis tests (a non-parametric alternative to Analysis of Variance) were utilized to determine if there were statistically significant differences in age, number of treatments, and survival months between the Insurance type groups. To quantify the magnitude of the effect, epsilon-squared (2) was calculated for all between-group comparisons, as a recommended effect size for Kruskal-Wallis tests. Post-hoc group comparisons were conducted when necessary. All categorical variables were evaluated to determine if there were differences present between Insurance type groups using chi-square tests, with post-hoc group comparisons made when necessary. A log-rank test was utilized to compare the survival curves between the Insurance type groups. Univariable and multivariable Cox proportional-hazards regression analysis was used to examine the relationship between survival and Insurance type, when additionally accounting for demographics such as age, race, and sex. All analyses were conducted using R Version 4.3.1 with statistical significance defined as p&amp;lt;0.05. Results The study cohort included 2,472 patients from a single state cancer registry. The study groups differed significantly on age, race, current cancer status, overall treatment summary, chemotherapy, hormone treatment, immunotherapy, hematologic transplant and endocrine treatment, other/palliative treatment, number of treatments, survival length, and overall survival (Table 1). In addition, the survival curves significantly differed by insurance type (Figure 1). Independent predictors of death were age, sex, and insurance type. Multivariable analysis revealed only age and insurance were significant predictors of death with increased risk for older individuals relative to younger and increased risk of death for Medicare, Medicaid, and those that listed their insurance as ‘Other’ relative to those with Private insurance. All assumptions for Cox proportional-hazards regression were tenable. Conclusion There is a strong correlation between insurance types and the outcomes in cancer patients. It revealed that patients with private insurance were more likely to live longer and have more treatment options compared to patients without insurance or other types of coverage. This is reflected in the stratified insurance cohort which showed a 72.8% 5-year survival rate for patients with private insurance, as opposed to Medicare patients who ranked lowest at 49.3%. In addition, the study also highlighted racial disparities in insurance coverage. For instance, evidencing that black &amp; white patients were more likely to be covered in equally by Medicare, while the white patients were over 50% more likely to be covered by other plans as compared to their black counterparts. Overall, the study thoroughly highlights the impact a patient's choice of insurance could portend in ensuring their longevity when battling hematological malignancies

Clinical Features, Treatment Modalities, and Outcomes of Elderly Thymoma Patients: A Propensity-Matched Study Based on the SEER Database

Introduction: Thymoma is a common mediastinal tumor, but few studies have been performed in thymoma patients 80 years or older. This study aimed to analyze the clinical features, treatment modalities, and survival outcomes of thymoma patients at least 80 years old and compare these features to those of patients younger than 80 years old. Method: Data from thymoma patients in the Surveillance, Epidemiology and End Results database between 2000 and 2019 were selected. Clinical features, treatment modalities of the two age groups were compared. Survival rates were calculated by the Kaplan-Meier method and the log-rank test was used to compare survival rates between two groups. Propensity score matching was used based on whether surgery was performed. Univariate and multivariate Cox proportional-hazards regression analyses were performed to identify independent prognostic factors. Results: Compared with the younger patients, the patients aged 80 years or older had a similar distribution of Masaoka-Koga tumor stage, a higher proportion of type A thymoma, and a lower recurrence rate in the early stage. In elderly patients after propensity score matching, the overall survival and cancer-specific survival were better in the surgery group with complete resection and compared with patients of different ages, elderly patients showed similar benefit from surgery as younger patients were observed. Conclusion: In thymoma patients aged 80 years or older, surgery still plays an important role in survival outcome. Compared with younger patients, older patients have unique clinical features.

Right Ventricular Cardiac Power Index Predicts 1 Year Outcome After Transcatheter Edge-to-Edge-Repair for Severe Tricuspid Valve Regurgitation

Tricuspid transcatheter edge-to-edge repair (T-TEER) for severe tricuspid regurgitation (TR) emerged as a novel treatment option for patients not amenable to surgery. However, knowledge regarding independent risk factors for a worse prognosis is rarely available. The study sought to investigate the impact of right ventricular cardiac power index (RVCPi) on 1-year outcomes in patients with severe symptomatic TR who underwent T-TEER. Consecutive patients with severe TR who underwent T-TEER from August 2020 to March 2022 were included and followed prospectively. Baseline clinical and invasive hemodynamic variables, changes in echocardiographic parameters and New York Heart Association functional class, and periprocedural and in-hospital major adverse events were assessed. Primary end point was defined as a composite of all-cause mortality and heart failure hospitalization at 1 year after T-TEER. A multivariable Cox proportional-hazards regression analysis was performed to identify independent risk factors for combined primary end point. RVCPi was calculated as: (cardiac index×mean pulmonary pressure)×K (conversion factor 2.22×10-3)=W/m². Receiver operator characteristic analysis was used to determine discriminative capacity of RVCPi. The prognostic value of RVCPi threshold was tested using Kaplan-Meier analysis. In total, 102 patients (mean age 81±6years, 51% women) at high operative risk underwent T-TEER for severe TR. Primary end point occurred in 30 patients (32%). Receiver operator characteristic curve analysis demonstrated that RVCPi was associated with an area under the curve of 0.69 (95% confidence interval 0.56 to 0.82; p=0.003). With a RVCPi threshold of 0.17W/m² (maximally selected rank statistics), the event-free survival was significantly higher in the RVCPi <0.17W/m² group compared with those with RVCPi ≥0.17W/m² (71% vs 35%, log-rank p<0.001). In the multivariable Cox regression analysis, RVCPi was an independent predictor for the combined primary end point (hazard ratio 2.6, 95% confidence interval 1.4 to 5.1, p=0.003). In conclusion, RVCPi is associated with outcome in patients who underwent T-TEER for severe TR and this hemodynamic predictor is useful in risk stratification of T-TEER candidates.

Prognostic and predictive significance of pre- and post-operative plasma tumor markers in patients with appendiceal adenocarcinoma undergoing cytoreductive surgery: Insights from a single-center study.

3539 Background: Appendiceal adenocarcinomas (AA) are both rare and heterogeneous diseases. Cytoreductive (CRS) surgery followed by heated intraperitoneal chemotherapy (HIPEC) remains the best treatment for AA patients with peritoneal metastasis. This study seeks to investigate the clinical utility of pre- and post-operative plasma tumor markers (TM, CEA, CA19-9, CA-125) by association with survival outcomes. Methods: Under an approved IRB protocol the Palantir Foundry software system was used to query MD Anderson internal database to identify patients with AA who underwent CRS between 2016 to 2022. Elevation of TM was defined as above the laboratory upper limit of normal (CEA &gt; 3 ng/mL, CA 19-9 &gt; 37 U/mL, and CA-125 &gt; 37 U/mL). Relationship between normal and elevated serum TM and progression-free survival (PFS) and overall survival (OS) was evaluated using univariate and multivariate Cox-proportional hazards regression analysis, considering multiple clinicopathologic variables. Results: 296 patients were identified; preoperative CEA, CA19-9 and CA125 was elevated in 60%, 29% and 28% of patients, respectively. Preoperative elevation of any TM was associated with higher PCI score (22 vs. 15, p&lt; 0.0001). Moreover, elevated preoperative TM was associated with incompleteness of cytoreduction (OR = 6.5, p&lt; 0.0001). Compared to preoperative measurements, all TM levels dropped after surgery (Mean score 31 vs 11 for CEA, 136 vs 32 for CA19-9 and 36 vs 17 for CA125). Preoperative elevation of any TM (HR = 1.5, p= 0.0288) and post-op elevation of any TM were with poor PFS on univariate analysis, however only post-op elevated TM levels (HR = 2.3, p= 0.0001) were associated with poor PFS on multivariate analysis. Interestingly, elevated TM was not associated with OS. Post-op TM levels were analyzed to evaluate the positive and negative predictive value in prediction of relapse in 6 months from surgery, PPV was 45% and NPV was 84%. Conclusions: Preoperative elevation of TM can identify patients at higher risk for incomplete cytoreduction and relapse after surgery. Postoperative elevation of TM is a risk factor for relapse. [Table: see text]

Optimal management of renal cell carcinoma in octogenarians: Retrospective analysis using updated Korean Renal Cell Carcinoma (KORCC) database.

There is few of optimal management guideline in elderly patients with renal cell carcinoma (RCC). To compare the survival outcomes of octogenarian RCC group and younger RCC group after surgery using nationwide multi-institutional database. A total of 10,068 patients who underwent surgery for RCC were included in the current retrospective, multi-institutional study. A propensity score matching (PSM) analysis was conducted to control other confounding factors in analyzing survival outcomes of octogenarian and younger group RCCs. Kaplan-Meier curve analysis to calculate the survival estimates for cancer-specific survival (CSS) and overall survival (OS), and multivariate Cox-proportional hazard regression analyses to evaluate the significant variables associated with the survival outcomes were also performed. Both groups were well-balanced in all baseline characteristics. In a total cohort, Kaplan-Meier survival analysis showed a significantly decreased 5-year and 8-year CSS and OS in the octogenarian group compared with the younger group. However, in a PSM cohort, no significant differences were evident between the two groups in terms of CSS (5-year, 87.3% vs. 87.0%; 8-year, 82.2% vs. 78.9%, respectively, log-rank test, p = 0.964). In addition, age ≥ 80 years (HR, 1.199; 95% CI, 0.497-2.896, p = 0.686) was not a significant prognostic factor of CSS in a PSM cohort. The octogenarian RCC group after surgery had comparable survival outcomes compared with younger group after PSM analysis. For the life expectancy of octogenarian is getting longer, active treatment is considerable in patients with good performance status.

Prognostic significance of the Naples prognostic score in colorectal cancer patients undergoing curative resection: a propensity score matching analysis

BackgroundSystemic inflammation is recognized as a hallmark of cancer that contributes to tumor development and progression in various malignancies. The Naples prognostic score (NPS) was established as a prognostic indicator for colorectal cancer (CRC). This study aims to examine the predictive value of the NPS for survival in CRC patients undergoing curative resection by a propensity score matching (PSM) analysis.MethodsA total of 533 CRC patients were enrolled in this study. Overall survival (OS) and disease-free survival (DFS) were compared between high-NPS and low-NPS groups. A time-dependent receiver operator characteristic (ROC) curve analysis was conducted to calculate the area under curve (AUC) of the NPS for OS. A multivariable Cox-proportional hazards regression analysis and PSM analysis were used to identify independent prognostic factors for OS and DFS. We compared the predictive value of the NPS to that of the neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), Onodera prognostic nutritional index (PNI), and controlling nutritional status score (CONUT) for OS.ResultsHigh-NPS was significantly associated with worse OS and DFS. After PSM, 123 patients were included in each group. A multivariate analysis revealed that Age ≥ 68, ASA-PS ≥ 3, high NPS and undifferentiated tumor type were independently associated with OS, while high NPS, advanced T and N stage were independently associated with DFS after PSM. The NPS had the greatest AUC for OS in comparison to the NLR, LMR, PNI and CONUT.ConclusionsWe successfully validated the prognostic utility of the NPS for CRC patients after curative resection.

Risk factors variability and cardiovascular risk among patients with diabetes: a nationwide observational study.

Cardiovascular risk factors control is fluctuating, tends to change over time, and is potentially impacted by multifactorial interactions. Currently, the existence of risk factors, rather than their variability or interplay with one another, is used to define the population at risk. The association between variability of risk factors and cardiovascular morbidity and mortality risk among patients with T2DM remains debatable. Using registry-derived data, we identified 29,471 people with T2D, without CVD at baseline, and with at least five measurements of risk factors. Variability for each variable was expressed as quartiles of the standard deviation during three years (exposure). The incidence of myocardial infarction, stroke, and all-cause mortality was assessed during 4.80 (2.40-6.70) years following the exposure phase. The association between measures of variability and the risk of developing the outcome was investigated through multivariable Cox proportional-hazards regression analysis with stepwise variable selection. Then, the recursive partitioning and amalgamation (RECPAM) algorithm was used to explore the interaction among the variability of risk factors associated with the outcome. An association between the variability of HbA1c, body weight, systolic blood pressure, and total cholesterol with the outcome considered was found. Among the 6 classes of risk identified by RECPAM, patients with a high variability of both body weight and blood pressure had the highest risk (Class 6, HR = 1.81; 95% CI 1.61-2.05) compared with patients with low variability of both body weight and total cholesterol (Class 1, reference), despite a progressive reduction in the mean level of risk factors during successive visits. Individuals with high weight variability but low-moderate systolic blood pressure variability (Class 5, HR = 1.57; 95% CI 1.28-1.68), patients with moderate/high weight variability associated with high/very high HbA1c variability (Class 4, HR = 1.33; 95%CI 1.20-1.49), subjects with moderate/high weight variability and with low/moderate HbA1c variability (Class 3, HR = 1.12; 95%CI 1.00-1.25), as well as those with low weight variability associated with high/very high total cholesterol variability (Class 2, HR = 1.14; 95%CI 1.00-1.30) also showed a significant increase in the risk of event. Combined high variability of two risk factors, particularly body weight and blood pressure, is associated with cardiovascular risk among patients with T2DM. These findings highlight the importance of continuous balancing of multiple risk factors.

Impact of Falls Within 3 Months on the Short-Term Prognoses of Elderly Patients in Intensive Care Units: A Retrospective Cohort Study Using Stabilized Inverse Probability Treatment Weighting.

Falls are a major public health problem in the older adults that can lead to poor clinical outcomes. There have been few reports on the short-term prognoses of older critically ill patients, and so we sought to determine the impact of falls on elderly patients in intensive care units (ICUs). This retrospective study of 4503 patients (aged 65 years or older) analyzed data in the Medical Information Mart for Intensive Care-III critical care database. Of those, 2459 (54.6%) older adults are males, and 2044 (45.4%) older adults are females. Based on information from the medical care record assessment forms, patients were classified into the following two groups based on whether they had a fall within the previous 3 months: falls (n=1142) and nonfalls (n=3361). The primary outcomes of this study were 30- and 90-day mortality. Associations between the results of the Kaplan-Meier (KM) survival analysis, Cox proportional-hazards regression models, and subgroup analysis and its outcomes were analyzed using stabilized inverse probability treatment weighting (IPTW). KM survival curves with stabilized IPTW indicated that 30- and 90-day survival rates were significantly lower in elderly critically ill patients with a history of falls within the previous 3 months than in those patients without a history of falls (all p<0.001). Multivariate Cox proportional-hazards regression analysis indicated that 30- and 90-day mortality rates were 1.35 times higher (95% confidence interval [CI]=1.16-1.57, p<0.001) and 1.36 times higher (95% CI=1.19-1.55, p<0.001), respectively, in elderly critically ill patients with a history of falls within the previous 3months than in those patients without a history of falls. Experience of falls within the previous 3 months prior to ICU admission increased the risk of short-term mortality and affected the prognoses of elderly patients. Falls should therefore receive adequate attention from clinical healthcare providers and management decision-makers.

Serum glypican-3 for the prediction of survival in patients with hepatocellular carcinoma.

Glypican-3 (GPC-3) is a heparan sulfate proteoglycan overexpressed by hepatocellular carcinoma (HCC) cells. Several studies highlighted the diagnostic and prognostic value of GPC-3 expression in liver tissue, while data on the reliability of serum GPC-3 are limited and conflicting. We aimed to evaluate the prognostic value of serum GPC-3 in patients with HCC. A total of 449 patients (91 F and 358 M; median age 65 [38-86] years) with a new diagnosis of HCC and available serum samples collected at tumor diagnosis were retrospectively analyzed. All patients had cirrhosis and the main underlying etiology was viral (N.=323, 72%). Barcelona Clinic Liver Cancer (BCLC) staging system was adopted for patients' classification (BCLC 0/A, N.=293, 65% vs. B/C/D, N.=156, 35%) and treatment allocation. Response to therapy was assessed by modified Response Evaluation Criteria in Solid Tumors (mRECIST). Median overall survival (OS) after HCC diagnosis was 30 months (95% confidence interval [CI]: 27-34). Patients with serum GPC-3>150 pg/mL showed lower overall survival (16; 95%CI: 13-24 months) compared to those with GPC-3≤150 pg/mL (36; 95%CI: 30-56 months) (Log-rank test, P<0.001). At multivariate Cox proportional-hazard regression analysis, presence of ascites (adjusted Hazard Ratio [aHR]=1.84; 95%CI: 1.23-2.74, P=0.003), BCLC stage (aHR=1.65; 95%CI: 1.39-1.97, P<0.001), mRECIST (aHR=0.33; 95%CI: 0.21-0.51, P<0.001) and GPC-3>150 pg/mL (aHR=2.02; 95%CI: 1.47-2.78, P<0.001) resulted significantly associated to overall survival. Serum GPC-3 resulted an independent prognostic factor for patients with HCC irrespectively from tumor stage and response to therapy.

Preoperative prognostic value of alfa-fetoprotein density in patients with hepatocellular carcinoma undergoing radiofrequency ablation

Objectives To examine the prognostic value of preoperative alfa-fetoprotein (AFP) density and other clinical factors in patients undergoing percutaneous radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC). Methods From January 2010 to December 2018, a total of 543 patients undergoing RFA for HCC meeting the Milan criteria were included at our institution. AFP density was calculated as absolute AFP pre-ablation divided by the total volume of all HCC lesions. The survival rates according to AFP density were estimated using the Kaplan–Meier method and compared using the log-rank test. Univariate and multivariate Cox proportional-hazards regression analyses were used to assess predictors of overall survival (OS) and progression-free survival (PFS). Results The Kaplan–Meier 1-, 3-, and 5-year OS rates were 98.8%, 88.5%, and 70.4%, respectively, for the low AFP density group, and 98.3%, 74.9%, and 49.4%, respectively, for the high AFP density group. The corresponding PFS rates were 78.9%, 56.7%, and 40.9% (low AFP density group), and 63.6%, 40.8%, and 27.5% (high AFP density group). High AFP density was associated with significantly reduced PFS and OS (both p < 0.001). Multivariate analysis suggested that AFP density was a predictor of OS and PFS. Conclusions Serum AFP density may serve as a promising predictor of survival in patients with HCC undergoing RFA. High AFP density could identify patients who might be prone to recurrence or progression and need close surveillance.

Long-Term Survival and Risk Factors in Patients with Hepatitis B-Related Hepatocellular Carcinoma: A Real-World Study

A retrospective cohort study was conducted to collect 465 patients with hepatitis B-related hepatocellular carcinoma who had undergone radical hepatectomy from January 1, 2012, to August 31, 2018, at the First Affiliated Hospital of the University of Science and Technology of China. The clinical, pathological, and follow-up information was collected to compare the basic characteristics of death and nondeath after radical resection. Kaplan–Meier curves were used for survival analysis and male and female subgroup analysis. The multivariate Cox proportional-hazards regression model was used to analyze independent risk factors related to postoperative death. Of the 465 patients with radical resection of hepatitis B-related hepatocellular carcinoma, 132 died, and 1-, 3-, and 5-year cumulative survival rates after operation were 92.1%, 78%, and 64%, respectively. In the male and female subgroup, 115 and 17 patients died, respectively. The 1-, 3-, and 5-year cumulative survival rates were 92.6%, 77.0%, and 62.6%, respectively, in men, and 89.6%, 78.8%, and 70.2%, respectively, in women. Multivariate Cox proportional-hazards regression analysis showed that microvascular invasion (MVI), Edmondson III/IV, BCLC stage B, and total bilirubin (TB) > 20.5 μmol/L were independent risk factors in patients with hepatitis B-related hepatocellular carcinoma after radical hepatectomy.

Application of the postnatal urinary tract dilation classification system to predict the need for surgical intervention among neonates and young infants.

The aim of this study was to validate the postnatal urinary tract dilation (UTD) classification system by correlating it with the need for surgical intervention. Young infants who underwent ultrasound (US) examinations for prenatal hydronephrosis were retrospectively identified. The kidney units (KUs; right, left, or bilateral) were graded from UTD P0 (very low risk) to P3 (high risk) based on seven US criteria from the UTD system. Surgery-free survival curves were constructed using the Kaplan-Meier method. Univariable and multivariable Cox proportional-hazards regression analysis clustered by patients was performed. Interobserver agreement was analyzed using the weighted kappa coefficient. In total, 504 KUs from 336 patients (mean age, 18.3±15.9 days; range, 1 to 94 days; males, n=276) were included, with a median follow-up of 24.2 months. Fifty-eight KUs underwent surgical intervention. Significant differences were observed among the Kaplan-Meier curves stratified into UTD groups (P<0.001). The presence of anterior-posterior renal pelvic diameter ≥15 mm (hazard ratio [HR], 8.602; 95% confidence interval [CI], 1.558 to 43.065), peripheral calyceal dilation (HR, 8.190; 95% CI, 1.558 to 43.065), ureteral dilation (HR, 2.619; 95% CI, 1.274 to 5.380), parenchymal thickness abnormality (HR, 3.371; 95% CI, 1.574 to 7.223), bladder abnormality (HR, 12.209; 95% CI, 3.616 to 41.225) were significantly associated with the occurrence of surgery. The interobserver agreement was moderate to almost perfect agreement for US features (κ=0.564-0.898) and substantial for final UTD grades (κ=0.716). The UTD classification system is reliable and appropriately stratifies the risk of surgical intervention.

The effect of race, employment, and poverty on outcomes in chimeric antigen receptor therapy for DLBCL patients.

e18506 Background: Limited information is known about how socioeconomic (SES) factors contribute to outcomes after CAR T-cell therapy for relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL). While racial and SES disparities have been demonstrated to effect outcomes after Autologous Stem Cell Transplant for DLBCL patients, little is known about this association after CAR T. Methods: Using data from Moffitt Cancer Center's electronic medical record system, we retrospectively evaluated patients diagnosed with DLBCL at our center who underwent CART therapy (n = 200). Data was analyzed by residential area deprivation index (ADI) for patients receiving CAR T therapy for R/R DLBCL at a single tertiary care center. Survival and CAR T-related toxicity outcomes were evaluated based on patient baseline characteristics, disease features, and demographics using multivariable Cox proportional-hazards (PH) regression model and multivariable logistic regression model. Patient socioeconomic status was represented by area deprivation index ranking mapped through 9-digit zip codes. Results: The study included 200 patients receiving CAR T therapy at Moffitt Cancer Center for R/R DLBCL; median age was 65; 46.8% were female, 53.2% male; 89.8% white, 10.2% non-white; median ADI rank of 4. As for disease characteristics; 18.9% had double/triple hit lymphoma by FISH for MYC and BCL2 or 6 translocations; 83.6% had extranodal disease sites. Patients were treated with a median of 3 prior lines of therapy, and most patients (81%) had stage III/IV lymphoma at time of leukapheresis for CAR T. 8.38% of patients experienced grade 3 or higher cytokine-release syndrome (CRS), and 34.6% of patients experienced grade 3 or higher neurotoxicity. Area deprivation index and education level did not significantly contribute to overall survival when adjusted for other clinical features on multivariable Cox PH regression analysis. However, unemployment negatively impacted overall survival (HR = 4.296, P = 0.0243). Progression-free survival was unaffected by ADI, education level, or employment. In terms of CAR T-related toxicities, demographic features did not affect the risk for grade 3 CRS on multivariable logistic regression model. On Wilcoxon rank testing, area of deprivation indices did not significantly differ among patients with or without grade 3 CRS. Conclusions: These results suggest that ADI and other SES factors do not significantly contribute to progression free survival, CRS or neurotoxicity. This study shows unemployment was a significant predictor for poor overall survival after CAR T in patients with DLBCL. This is the first study to evaluate the significance of SES, race, and employment on DLBCL patients after CAR T. Future efforts should be used to investigate measures to increase employment and understand factors associated with unemployment.

Association between Incidental Pelvic Inflammation and Aggressive Prostate Cancer.

Simple SummaryThis study reports a significant association of pelvic inflammation with prostate cancer (PCa) aggressiveness in a large cohort of men undergoing robot-assisted laparoscopic prostatectomy (RALP) for localized PCa. In addition, PCa patients with pelvic inflammation had elevated expression of inflammation-associated genes and cancer-driving pathways in their tumors. Increased systemic inflammation with activation of the IL6-STAT pathway was seen in prostate cancer patients with pelvic inflammation. The presence of pelvic inflammation in prostate cancer patients suggests aggressive disease with a potential to develop biochemical recurrence and metastasis. This study is highly relevant as it allows us to follow prostate cancer patients with pelvic inflammation for metastasis closely. It also suggests that inhibiting the STAT-IL6 pathway would benefit these patients.The impact of pelvic inflammation on prostate cancer (PCa) biology and aggressive phenotype has never been studied. Our study objective was to evaluate the role of pelvic inflammation on PCa aggressiveness and its association with clinical outcomes in patients following radical prostatectomy (RP). This study has been conducted on a retrospective single-institutional consecutive cohort of 2278 patients who underwent robot-assisted laparoscopic prostatectomy (RALP) between 01/2013 and 10/2019. Data from 2085 patients were analyzed to study the association between pelvic inflammation and adverse pathology (AP), defined as Gleason Grade Group (GGG) > 2 and ≥ pT3 stage, at resection. In a subset of 1997 patients, the association between pelvic inflammation and biochemical recurrence (BCR) was studied. Alteration in tumor transcriptome and inflammatory markers in patients with and without pelvic inflammation were studied using microarray analysis, immunohistochemistry, and culture supernatants derived from inflamed sites used in functional assays. Changes in blood inflammatory markers in the study cohort were analyzed by O-link. In univariate analyses, pelvic inflammation emerged as a significant predictor of AP. Multivariate cox proportional-hazards regression analyses showed that high pelvic inflammation with pT3 stage and positive surgical margins significantly affected the time to BCR (p ≤ 0.05). PCa patients with high inflammation had elevated levels of pro-inflammatory cytokines in their tissues and in blood. Genes involved in epithelial-to-mesenchymal transition (EMT) and DNA damage response were upregulated in patients with pelvic inflammation. Attenuation of STAT and IL-6 signaling decreased tumor driving properties of conditioned medium from inflamed sites. Pelvic inflammation exacerbates the progression of prostate cancer and drives an aggressive phenotype.

FC008: Sex Difference in COVID-19 Mortality Risk among Patients on Kidney Function Replacement Therapy

BACKGROUND AND AIMSIn the general population with COVID-19, male sex is an established risk factor for mortality. A more robust immune response to COVID-19 in women has been suggested to be one of the factors explaining this sex difference in mortality. Patients on kidney function replacement therapy (KFRT) have an impaired immune response, especially kidney transplant recipients due to their use of immunosuppressants. In this study, we therefore examined whether male sex is still a risk factor for mortality among patients on KFRT with COVID-19.METHODData were used from the European Renal Association COVID-19 Database (ERACODA) of kidney transplant recipients and dialysis patients who presented with COVID-19 between 1 February 2020 and 30 April 2021. The primary study outcome was 3-month mortality. As secondary outcomes, in-hospital mortality and 28-day mortality were examined. Associations were investigated using multivariable Cox proportional-hazards regression analysis. Assuming immunosuppressant use is among the main factors contributing to excess mortality in kidney transplant recipients compared with dialysis patients, we also investigated the association of type of KFRT with mortality by sex.RESULTSERACODA included 1204 kidney transplant recipients (male: 62.0%, mean age: 56.4 years) and 3206 dialysis patients (male: 61.8%, mean age: 67.7 years). Three-month mortality in kidney transplant recipients was 16.9% in males and 18.6% in females (P = 0.31) and in dialysis patients 27.1% in males and 21.9% in females (P = 0.001). In a model adjusted for age, frailty, smoking and comorbidities, the aHR for the risk of 3-month mortality in males (versus females) was 0.87 (95% CI: 63, 1.21, P = 0.41) in kidney transplant recipients and 1.32 (95% CI: 1.13, 1.55, P = 0.001) in dialysis patients (P for interaction = 0.03). In a fully adjusted model, the aHR for the risk of 3-month mortality in kidney transplant recipients (versus dialysis patients) was 1.26 (95% CI: 1.02, 1.56, P = 0.03) in males and 1.73 (95% CI: 1.31, 2.27, P < 0.001) in females (p for interaction = 0.03). Essentially similar results were obtained for in-hospital mortality and 28-day mortality.CONCLUSIONIn patients on kidney function replacement therapy with COVID-19, male sex is not a risk factor for mortality among kidney transplant receipts but remains a risk factor among dialysis patients. The use of immunosuppressants in kidney transplant recipients, among other factors, may have narrowed the difference in the immune response to COVID-19 between men and women, and therefore reduced the sex difference in COVID-19 mortality risk.

MO495: A Comparative Study of Patient Mortality During First and Second Waves of Covid-19 Pandemic in Dialysis Patients and Kidney Transplant Recipients

Abstract BACKGROUND AND AIMS Patients on kidney replacement therapy (KRT) are at a particularly high risk of mortality from COVID-19. In this study, we investigated COVID-19 mortality in KRT patients in the first and second waves of the pandemic and potential reasons for any difference in mortality between the two waves. METHOD Data from the European Renal Association COVID-19 Database (ERACODA) of KRT patients who presented between 1 March 2020 and 28 February 2021 with COVID-19 were analyzed. The cut-off for dividing the first and second waves was set for 1 August 2020. The primary study outcome was 28-day mortality. Multivariable Cox proportional-hazards regression analysis was used to examine the relationship between the pandemic waves and mortality with follow-up time starting at the date of presentation. Dialysis patients and kidney transplant recipients were analyzed separately. RESULTS Among 3004 dialysis patients (1253 in the first and 1751 in the second wave), the 28-day mortality was 24.3% in the first wave and 19.6% in the second wave (P = .002). Compared with the first wave, in the second wave, identification of patients with limited to no symptoms was higher (14.3% versus 24.8%; P &amp;lt; .001), hospitalization was lower (71.3% versus 44.3%; P &amp;lt; .001), but in-hospital mortality was similar (30.4% versus 30.7%; P = .92) (Fig. 1). Crude hazard ratio (HR) for 28-day mortality in the second wave was 0.77 (95% CI: 0.66, 0.89). However, in a fully adjusted model, when correcting for differences in patient and disease characteristics, including the reason for COVID-19 screening and disease severity, the HR for mortality in the second wave was 0.93 [95% confidence interval (95% CI): 0.79–1.10]. When follow-up was chosen to start at the date of first symptoms to account for possible lead-time bias, crude HR for 28-day mortality in the second wave was 0.90 (95% CI: 0.75–1.07) and the fully adjusted HR was 0.98 (95% CI: 0.81–1.18). Among 1035 kidney transplant recipients (475 in the first and 560 in the second wave), results were essentially similar except that patients in the second wave were younger (55.6 years versus 58.2 years; P = .002), and crude HR for 28-day mortality from the date of first symptoms was 0.66 (95% CI: 0.47–0.93), whereas the fully adjusted HR was 1.02 (95% CI: 0.70–1.49). CONCLUSION Among patients on KRT with COVID-19, 28-day mortality rates were lower in the second wave compared with the first wave. However, a greater proportion of patients with minimal symptoms, lead-time bias in dialysis patients, and younger age in kidney transplant recipients possibly explain the lower mortality during the second wave. Any improvement in patient management during the second wave may not be the main reason for lower mortality.

MP24-07 ADVERSE RADIOLOGIC AND PATHOLOGIC FEATURES IMPACT SURVIVAL OUTCOMES FOR SMALL RENAL MASSES FOLLOWING NEPHRECTOMY

You have accessJournal of UrologyCME1 May 2022MP24-07 ADVERSE RADIOLOGIC AND PATHOLOGIC FEATURES IMPACT SURVIVAL OUTCOMES FOR SMALL RENAL MASSES FOLLOWING NEPHRECTOMY Sari Khaleel, Hong Truong, Song Jiang, Benjamin Davelman, Jonathan Coleman, Ari Hakimi, and Paul Russo Sari KhaleelSari Khaleel More articles by this author , Hong TruongHong Truong More articles by this author , Song JiangSong Jiang More articles by this author , Benjamin DavelmanBenjamin Davelman More articles by this author , Jonathan ColemanJonathan Coleman More articles by this author , Ari HakimiAri Hakimi More articles by this author , and Paul RussoPaul Russo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002563.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While most small renal masses (SRMs, <4 cm) have excellent prognosis following extirpative treatment, the impact of finding adverse preoperative radiologic and/or postoperative pathologic T3 features in SRMs that undergo partial (PN) or radical nephrectomy (RN) remains unclear. We sought to review clinical outcomes for SRMs that underwent RN/PN at our institution, comparing pT3 SRMs that presented with adverse (T3) preoperative radiologic features (cT3/pT3) to SRMs that had no adverse preoperative radiologic features, with/without subsequent upstaging to pT3 disease (cT1a/pT3 and cT1a/non-pT3, respectively). METHODS: We retrospectively reviewed SRM cases that underwent RN/PN at our institution between 2010-2020, classifying them into one of the three above groups, excluding cases with known advanced (pT4, M1) disease preoperatively. Continuous and categorical variables were compared using ANOVA and Kruskal-Wallis (K-W) tests, respectively. Cox proportional hazard regression (CPHR) analysis was used to model survival outcomes against the presence of adverse pathologic and radiologic features. Analyses were performed using R Statistical Package (v4.04). RESULTS: Of 2146 cases, 8.4% were pT3 post-operatively, of which 45.9% had adverse preoperative cT3 radiologic features (Table 1). Median follow-up was 3.3 years (IQR 1.5–6.1). pT3-SRMs had higher rates of radical nephrectomy, positive margins, overall and cancer-specific mortality, and metastases than their non-pT3 counterparts, particularly in the cT3/pT3 subgroup (K-W p <0.05; Table 1). On multivariate CPHR analysis, only the combined presence of adverse radiologic and pathologic features (cT3/pT3 group) was significantly associated with higher risk for overall- and cancer-specific survival (p <0.05), adjusting for patient age, BMI, mass size, histology, and Charlson comorbidity index. Unexpected upstaging (cT1a/pT3) was not associated with higher risk of any of the outcomes of interest (p >0.05). CONCLUSIONS: Adverse pathologic T3 features portend worse outcomes for SRMs, particularly in those with adverse preoperative radiologic features. This study highlights the importance of SRM substratification by these features, which may aid in surgical planning and potential multimodal treatment. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e395 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sari Khaleel More articles by this author Hong Truong More articles by this author Song Jiang More articles by this author Benjamin Davelman More articles by this author Jonathan Coleman More articles by this author Ari Hakimi More articles by this author Paul Russo More articles by this author Expand All Advertisement PDF downloadLoading ...