Non-elderly Patients Research Articles

The real-life treatments and surgeons' opinions on aortic valve diseases in non-elderly patients.

The real-life treatments and surgeons' opinions on aortic valve diseases in non-elderly patients.

BRCA testing in patients with breast cancer with Medicaid vs. commercial insurance.

148 Background: Systemic therapies targeting breast cancers associated with germline BRCA1/2 mutations (gBRCAm) have been available since 2018, approved first for locally advanced or metastatic HER-2 negative disease and more recently for use in the adjuvant setting. Prior studies have found substantial underuse of BRCA testing in breast cancer patients and disparities by socioeconomic factors. We compared rates of BRCA testing in non-elderly breast cancer patients with Medicaid vs. commercial insurance. Methods: We used the Clarivate Real-World Data Product (Clarivate RWD), a database of open claims from clearinghouses. The database links medical and pharmacy claims from ≥98% of commercial and government health insurance plans and covers 300 million lives. We identified adults ages 18-64 with commercial insurance or Medicaid with claims for breast cancer diagnosis and treatment in 2016-2021. The primary outcome was receipt of a BRCA test within 6 months after the first breast cancer (index) claim. We compared the proportion who received a BRCA test in Medicaid vs. commercial insurance. In multivariable logistic regression we estimated the impact of insurance type on receipt of a BRCA test, controlling for demographic and health characteristics. We also examined trends over time. Results: We identified 147,050 patients with commercial insurance and 41,259 with Medicaid who met inclusion criteria. The cohort was 99% female, 65% were age 50-64, 35% lived in the South, 11% had diagnosis codes for metastatic disease, and 61% had an Elixhauser comorbidity score of 0. Compared to those with commercial insurance, patients with Medicaid were younger, less likely to live in the South, more likely to have metastatic disease and have comorbid conditions. Medicaid beneficiaries were more likely to receive a BRCA test within 6 months of index claim than commercially insured patients (16.8% vs. 11.7%), with an adjusted odds ratio of 1.41 (95% CI 1.36-1.46). Receipt of a BRCA test was also more likely in patients who were male; younger; lived in the Northeast, Midwest or West; had metastatic disease or greater comorbidity. In analysis stratified by presumed stage, the advantage of Medicaid coverage was statistically significant only in patients with metastatic disease. While the proportion of all patients who received a BRCA test increased substantially in both groups beginning in 2019, it grew at a much greater rate among those with Medicaid, exceeding 20% in those patients by late 2021. Conclusions: In this analysis of health insurance claims, breast cancer patients with Medicaid were more likely to receive a BRCA test than their peers with commercial insurance, and this difference was driven by testing rates in those with presumed metastatic disease. Expanding testing in both groups could facilitate access to effective therapies for both metastatic and non-metastatic breast cancers associated with gBRCAm, thereby improving health outcomes.

352TiP Randomized phase III study of daratumumab (D) versus bortezomib plus D as a maintenance therapy after D-MPB for elderly or non-elderly patients refusing transplant with untreated multiple myeloma (JCOG1911, B-DASH study)

352TiP Randomized phase III study of daratumumab (D) versus bortezomib plus D as a maintenance therapy after D-MPB for elderly or non-elderly patients refusing transplant with untreated multiple myeloma (JCOG1911, B-DASH study)

Retrospective cohort study: Effect of age as a barrier to diagnosis of eosinophilic oesophagitis.

Prior work suggests eosinophilic oesophagitis (EoE) is rare in those aged over 65 years. However, elderly patients with EoE experience a substantial diagnostic delay from symptom onset to diagnosis. To assess if age predicted whether oesophageal biopsies were obtained in patients with EoE symptoms, what clinical features predict EoE in the elderly, and if EoE phenotype differs between elderly and non-elderly patients. We conducted a retrospective cohort study utilising the University of North Carolina (UNC)electronic medical record, EoE clinicopathologic database and UNC endoscopy software from July 2008 to April 2021. A sample of 193 elderly and non-elderly patients with dysphagia, chest pain and/or heartburn were assembled. Patients with EoE were newly diagnosed per contemporaneous guidelines. Patient demographics, clinical characteristics and procedural data were extracted. Summary statistics, bivariate and multivariate analyses were performed. Of 193 patients, we included 91 elderly (47%) and 102 non-elderly (53%). Age independently predicted the odds of biopsies (adjusted odds ratio (aOR): 0.44 elderly vs. non-elderly; 95% CI: 0.21-0.92). Endoscopic features of EoE, but not symptoms, were more common in elderly than non-EoE elderly patients. Elderly patients with EoE differed from non-elderly only by time to diagnosis (aOR per year of symptoms preceding diagnosis: 1.08, 95% CI: 1.04-1.11). Elderly patients with EoE have <50% the odds of oesophageal biopsies. There were no significant differences between elderly and non-elderly EoE patients, although endoscopic features helped discriminate the two groups. Our findings suggest that older age represents a barrier to EoE diagnosis.

Catheter ablation of atrial fibrillation in elderly and very elderly patients: safety, outcomes, and quality of life.

Atrial fibrillation (AF) risk increases with age. We aim to assess the efficacy and safety of catheter ablation in the older population. All patients undergoing AF ablation (2013-2021) at our institution were enrolled in a prospectively maintained registry. The primary endpoint was AF recurrence. Patients were divided into 3 groups: non-elderly (< 65 years), elderly (65-75 years), and very elderly (> 75 years). Patient surveys at baseline and during follow-up were used to calculatequality of life (QoL)metrics: the AF severity score as well as the AF burden. A total of 7020 patients were included (42% non-elderly, 42% elderly, and 16% very elderly). Periprocedural major complications were low (< 1.5%) and similar in all groups besides pericardial effusion which was more frequent with older age and similar between the elderly and very elderly. At 3 years, AF recurrence for persistent AF (PersAF) was highest in the very elderly group (48%), followed by the elderly group (42%), and was the lowest in the non-elderly group (36%). In paroxysmal AF (PAF), there was no difference in AF recurrence between the elderly and non-elderly, while the very elderly remained associated with a significantly increased risk. Multivariable Cox analysis confirmed these findings (PersAF; elderly: HR = 1.23, P = 0.003; very elderly: HR = 1.44, P < 0.001) (PAF; elderly: HR = 1.04, P = 0.62; very elderly: HR = 1.30, P = 0.01). Catheter ablation resulted in a significant improvement in quality of life, irrespective of age group. Catheter ablation in elderly and very elderly patients is safe, efficacious, and associated with QoL benefits. Overall, major complications were minimal and did not differ significantly between age groups, with the exception of pericardial effusions which were higher in the elderly and very elderly compared to non-elderly adults. Very elderly patients had a higher rate of AF recurrence when compared with elderly or non-elderly patients. Nevertheless, ablation resulted in a remarkable improvement in QoL and a reduction of AF burden and AF symptoms with a similar magnitude, irrespective of age.

Survival Impacts of Impaired Lung Functions and Comorbidities on Elderly Esophageal Cancer Patients.

Preoperative physiological assessments are crucial for optimizing clinical outcomes, especially those of elderly esophageal cancer (EC) patients who are generally frail and at the high risk of mortality. Patients who underwent surgery for EC between 2004 and 2018 were retrospectively reviewed. Patients were categorized into elderly (>70years) or non-elderly (≤70years) groups. Various physiological parameters including the Charlson Comorbidity Index (CCI), immunonutritional parameters and pulmonary functions were studied. Pulmonary functions included %vital capacity (VC) and forced expiratory volume in one second (FEV1.0) and FEV1.0%. The thresholds were set as the lowest quartile (100% for %VC and 2L for FEV1.0) in this cohort. Multivariate Cox hazards models were applied to determine independent predictors of non-EC-related deaths. In total, 824 patients were included (elderly; n = 306, non-elderly; n = 518). Elderly patients had a significantly lower 5-year OS rate than non-elderly patients (53.3% vs. 57.2%, P = 0.03), mainly due to increased risk of death from non-EC related causes. In the elderly group, multivariate Cox hazards analysis identified 3 independent predictors of non-EC-related deaths; high CCI (HR 1.98, P=0.006), low %VC (HR 2.01, P = 0.004) and low FEV1.0 (HR 1.6, P=0.048). Elderly patients without risk factors had a significantly better 5-year OS rate (63.5%) than those with 1 (50.0%) or 2-3 (36.3%) risk factors (P <0.01). Deaths due to pulmonary disease rose significantly as the number of risk factors increased (P=0.03). The severity of comorbidities and pulmonary function impairments are useful for predicting long-term outcomes, especially non-EC-related deaths, in elderly EC patients.

Comparison of Short-Term Surgery Outcomes and Clinical Characteristics Between Elderly and Non-Elderly Patients with Middle Third Parasagittal and Parafalcine Meningiomas.

This study aims to compare the short-term surgery outcomes of the resection of meningiomas and clinical characteristics between elderly and non-elderly patients. This retrospective study included patients who underwent a resection of middle third parasagittal and parafalcine meningiomas between January 2011 and December 2020. All lesions arise from the middle third of the parafalcine or infiltrate superior sagittal sinus (SSS). The clinical characteristics studied included neurological deficit, peritumoral brain edema (PTBE), SSS invasion, tumor size, and symptoms; perioperative complications, and short-term surgery outcomes including neurological deficit, operative blood loss, postoperative hospitalization duration, and WHO classification were compared. A total of 43 elderly patients and 63 non-elderly patients were included. Compared with non-elderly patients, elderly patients had larger lesions (P = 0.013) and presented with a larger PTBE (P = 0.019). SSS blockage was identified in 28.57% of elderly patients and 19.57% of non-elderly patients. Compared with non-elderly patients, elderly patients tended to suffer from more aggressive lesions (WHO II/III meningioma 6 vs 3, P = 0.154) and presented with longer postoperative hospital stays (17.25 ± 5.8 vs 13.50 ± 3.8, P = 0.009); conversely, while the non-elderly patients experienced more blood loss (P = 0.022) and had more perioperative reoperations (3 vs 1). No significant difference in neurological deficit was detected between the two groups (P = 0.97). After total tumor resection, patients with neurological deficits in both groups can recover during the follow-up period. Among the 106 patients with middle third parasagittal and falx meningiomas in our hospital, elderly patients had larger lesions, presented with more severe PTBE, and had longer postoperative hospital stays than younger patients. Conversely, younger patients had more blood loss and serious complications than elderly patients. Postoperative neurological dysfunction in elderly patients was similar to that in middle-aged and young patients.

Transmission dynamics variability of lineage 2 Mycobacterium tuberculosis strains in Kobe, Japan, determined using population-based whole-genome sequencing analysis.

Currently, tuberculosis (TB) in Japan is highly prevalent among elderly patients who were born during a time when TB was highly prevalent. Mycobacterium tuberculosis (Mtb) lineage 2 (L2) is the predominant strain in the country. Moreover, the proportion of foreign-born patients with TB has been increasing. This epidemiological situation in Japan motivated us to explore the heterogeneity in transmission dynamics among the sublineages of Mtb L2 within this aging population. For this purpose, we conducted a population-based whole genome sequencing analysis of 550 Mtb strains in Kobe, Japan, and employed pairwise single nucleotide polymorphism (SNP) distance clustering and terminal branch length (TBL) distribution analysis to assess Mtb transmission. The genomic clustering rate with a threshold of ≤5 SNPs was significantly lower in elderly patients aged 70years or higher than in non-elderly patients. The elderly patient group showed significantly longer TBL than the non-elderly group. These results supported the notion that reactivation of distant infection is a major driving force for the high incidence of TB in elderly individuals. The age group distribution and frequency of lineages/sublineages were found to significantly differ between foreign-born and Japan-born patients. The increased proportion of foreign-born patients might have resulted in more strain diversity in Japan. The L2.2.A sublineage demonstrated a significant association with elderly patients and exhibited lower transmission rates, which indicate to be prone to reactivate from long-term latency. In contrast, L2.2.Modern, showed a strong association with younger and foreign-born patients. This sublineage showed a high genomic cluster rate, suggesting its high transmissibility. The other three major sublineages, namely L2.2.AA2, L2.2.AA3.1, and L2.2.AA3.2, exhibited a consistent increase in cluster rates across varying SNP thresholds, indicating their relatively recent emergence as endemic sublineages in Japan. In conclusion, this study highlights distinct differences in the transmission dynamics of L2 sublineages within an aging society.

Schizophrenia - Efficient Diagnosis And Treatment With Resonance Therapy in Non-Elderly And Elderly Patients

With the help of resonance therapy, both diagnostics and therapy of schizophrenia are quite effectively carried out. Diagnosis of schizophrenia is mainly based on the process of testing on the device for resonance therapy - 1. frontal, temporal regions of the brain, 2. corpus callosum, 2. lateral basal nucleus, 3. thalamus, 4. cerebellum, 5. paralimbic area of the cerebral cortex, 6 lateral basal nucleus, 7. manifestation of multiple sclerosis. In schizophrenia, these brain formations are tested quite well, which indicates the degeneration of these formations. This helps the doctor in diagnosing the disease. In addition, the doctor tests the arteries of the brain, which in patients with schizophrenia are in a degenerated state. The treatment of this disease is also effectively carried out with the help of resonance therapy - highly potent drugs are made from the identified structural formations of the brain and the oranodrug of the arteries of the brain, which are taken by the patient and which lead to the fact that the symptoms of the disease are lost

Safety of endoscopic ultrasound-guided fine-needle aspiration for pancreatic solid mass in the elderly: A single-center retrospective study.

There are few reports on the safety of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in the elderly. In this study, we investigated the safety of EUS-FNA for pancreatic solid masses in patients aged ≥80 years. This is a single-center retrospective study. A total of 600 patients with pancreatic solid masses who underwent EUS-FNA under midazolam-based sedation at our institution between September 2016 and December 2022 were enrolled in this study. Eligible patients were divided into two groups: an elderly group aged ≥80 (n = 84), as well as a nonelderly group aged ≤79 (n = 516). These two groups were compared. The elderly group required significantly fewer midazolam doses for sedation (P < 0.001). Adverse events occurred in eight patients (1.3%), including one (1.2%) and seven (1.4%) in the elderly and nonelderly groups, respectively (P = 0.90). There were no cases of early adverse events in the elderly group and six cases (1.2%) in the nonelderly group (P = 0.32). There was one case of late adverse events in both the elderly and nonelderly groups (P = 0.14), and both were needle tract seeding. There was no significant difference between the two groups in the proportion of cases in which percutaneous oxygen saturation decreased to ≤90% during the EUS-FNA. Our analysis suggests that EUS-FNA for pancreatic solid masses can be safely performed in patients aged >80 years without increasing the adverse event rate compared to nonelderly patients aged <80 years. Geriatr Gerontol Int 2023; 23: 836-841.

Aortic valve replacement in non-elderly: the gap between reality, guidelines and evidence.

There are several treatment options for non-elderly adults (18-60 years) in need of aortic valve replacement (AVR): a mechanical or biological substitute, a homograft, the Ross procedure or nowadays even transcatheter aortic valve replacement. This study evaluated the current opinions and practices of cardiac surgeons and cardiologists concerning AVR strategies in this patient group. A 43-item online survey was sent out to several scientific organizations, individual cardiac surgeons, cardiologists and residents/fellows worldwide. Two hundred twenty-two physicians from 33 different countries answered the survey. The UK (24%), Belgium (23%) and North America (22%) are best represented. A mechanical valve is the most frequently used substitute in non-elderly. With increasing patient age, the popularity of a biological valve increases. Transcatheter aortic valve replacement and the Ross procedure are each used in <10% of this cohort. Only 12% of the cardiac surgeons has experience with the Ross surgery. In 23%, the patient seems not to be involved in the decision on the type of valve substitute. The preferred surgical treatment for non-elderly patients in need of AVR differs widely. To enable a shared decision-making process including patient preferences, there is more need for collaboration between cardiac departments, as well as education and scientific research about patient-centred outcomes of the different AVR techniques.

Safety and Efficacy of Flexible Bronchoscopy in Elderly Patients: A Retrospective Comparative Study

BackgroundFlexible bronchoscopy (FB) is a common method used for diagnostic sampling of the thorax. Although the safety and efficacy of FB in the general population are well-established, data on the elderly population are limited. This study aimed to determine the safety and efficacy of FB in elderly people aged ≥80 years. Materials and MethodsWe retrospectively studied elderly patients aged ≥80 years who underwent FB at our hospital between April 2021 and March 2022. Outcomes, such as indications, sampling methods, diagnostic results, and complications, were compared with those of a control group of patients aged 18–79 years. ResultsIn total, 247 patients (154 men) were included in the study, with 65 and 182 patients in the elderly and non-elderly groups, respectively. The most frequent indication for FB was the presence of a mass or nodule, with transbronchial lung biopsy, transbronchial biopsy, and endobronchial ultrasound-guided transbronchial needle aspiration performed in 162 (65.6%), 29 (11.7%), and 36 (15.6%) patients, respectively. FB led to a diagnosis in 36 (57.1%) and 103 (56%) patients in the elderly and non-elderly groups, respectively, with no significant difference observed. There were no patient deaths or significant differences in the incidence of hemorrhage, hypoxia, pneumothorax, fever, or pneumonia between the two groups. ConclusionsThe findings of this study indicate that FB can be performed effectively and safely in elderly patients aged ≥80 years, similar to non-elderly patients.

The efficacy of treatment for hepatocellular carcinoma in elderly patients.

Despite the increasing proportion of elderly patients with hepatocellular carcinoma (HCC) over time, treatment efficacy in this population is not well established. Data collected from the Korean Primary Liver Cancer Registry, a representative cohort of patients newly diagnosed with HCC in Korea between 2008 and 2017, were analyzed. Overall survival (OS) according to tumor stage and treatment modality was compared between elderly and non-elderly patients with HCC. Among 15,186 study patients, 5,829 (38.4%) were elderly. A larger proportion of elderly patients did not receive any treatment for HCC than non-elderly patients (25.2% vs. 16.7%). However, OS was significantly better in elderly patients who received treatment compared to those who did not (median, 38.6 vs. 22.3 months; P<0.001). In early-stage HCC, surgery yielded significantly lower OS in elderly patients compared to non-elderly patients (median, 97.4 vs. 138.0 months; P<0.001), however, local ablation (median, 82.2 vs. 105.5 months) and transarterial therapy (median, 42.6 vs. 56.9 months) each provided comparable OS between the two groups after inverse probability of treatment weighting (IPTW) analysis (all P>0.05). After IPTW, in intermediate-stage HCC, surgery (median, 66.0 vs. 90.3 months) and transarterial therapy (median, 36.5 vs. 37.2 months), and in advanced-stage HCC, transarterial (median, 25.3 vs. 26.3 months) and systemic therapy (median, 25.3 vs. 26.3 months) yielded comparable OS between the elderly and non-elderly HCC patients (all P>0.05). Personalized treatments tailored to individual patients can improve the prognosis of elderly patients with HCC to a level comparable to that of non-elderly patients.

Usefulness of mirtazapine and SSRIs in late-life depression: post hoc analysis of the GUNDAM study.

Mirtazapine and SSRIs are widely prescribed as first-line agents for late-life depression. However, evidence for these drugs is mostly based on non-elderly patients. Therefore, we reanalyzed a randomized controlled trial of mirtazapine versus SSRIs for depression in a sub-population of late-life patients. A randomized controlled trial was conducted with 141 patients, of whom 41 were elderly, and 100 were non-elderly. This study compared SSRIs and mirtazapine in late-life depression, examined late-onset and early adult-onset separately and compared elderly and non-elderly patients for each drug. Treatment effects and adverse events were assessed using the Hamilton Depression Rating Scale and the Udvalg for Kliniske Undersøgelser Side Effect Rating Scale, respectively. In late-life depression, mirtazapine showed faster HAM-D total score improvement (3.3 points difference, p = 0.021) and higher improvement in insomnia (1.7 points difference, p = 0.001) and appetite (1.2 points difference, p = 0.020). Similar findings were observed for late-onset depression with the HAM-D total score (4.3 points difference, p = 0.007) and appetite (0.9 points difference, p = 0.004), favoring mirtazapine. Depressive symptoms were generally less improved in late-life depression than in non-late-life depression. Regarding the effect of mirtazapine on appetite, late-life depression showed greater improvement (0.7 points difference, p = 0.008). Nausea and micturition disturbances were more common with SSRIs in late-life depression than in non-late-life depression. In contrast, somnolence was less common in late-life depression with mirtazapine. The potential usefulness of mirtazapine in elderly patients was demonstrated. The results also showed differences in the treatment response to SSRIs and mirtazapine between elderly and non-elderly patients.

Elderly-onset pulmonary sarcoidosis: A radiological approach to diagnosis.

The aim was to compare the radiological and clinical characteristics of sarcoidosis between elderly and non-elderly patients. This retrospective observational study was carried out in patients with sarcoidosis. Elderly-onset sarcoidosis was defined as sarcoidosis diagnosed in patients ≥65 years-old. Patients were stratified by age (≥65 years versus <65 years) and radiological and clinical data were compared between age groups. Of the 163 patients, 38 (23.3%) were in the elderly group and 125 (76.7%) were in the non-elderly group. Elderly patients more frequently demonstrated arthralgia (50% vs. 12.8%, p<0.001), coronary artery disease (15.8% vs. 2.4%, p=0.005), congestive heart failure (13.2% vs. 0.8%, p=0.003), pneumonia (7.9% vs. 0.8%, p=0.04), and pleural fluid (18.4% vs. 0.0%, p<0.001). Clinical remission was significantly more likely in younger patients than in the elderly (76.8% vs. 55.3%, p=0.01). The clinical course to chronic-progressive disease was similar in both groups (p=0.635). Radiologically, lymph nodes measuring 10-25 mm in the short axis (89.5% vs. 72.6%, p=0.032), usual interstitial pneumonia pattern (10.5% vs. 0.8%, p=0.011), and main pulmonary artery diameter above 30 mm (34.2% vs. 16.0%, p=0.014) were significantly more frequent in the elderly group. Elderly patients tended to demonstrate Scadding stage I and II sarcoidosis (39.5% and 31.6%). Presentation of elderly-onset sarcoidosis appears to differ from young-onset sarcoidosis. Radiologically, lymph node enlargement and the pattern of fibrosis may be distinctive.

Clinical factors associated with in-hospital mortality in elderly versus non-elderly pneumonia patients in the emergency department

BackgroundPneumonia is a respiratory infection with an increasing incidence with age. However, limited evidence has identified factors associated with its outcome among different age groups, especially in the elderly and in the emergency department (ED) setting. We aimed to identify clinical factors associated with in-hospital mortality in elderly versus non-elderly pneumonia patients in the ED.MethodsA retrospective observational study was conducted at the ED of Siriraj Hospital, Thailand. Patients aged at least 18 years old diagnosed with non-COVID pneumonia between June 1, 2021, and May 31, 2022, were included. They were categorized into the elderly (age ≥ 65 years) and non-elderly (age < 65 years) groups. The primary outcome was in-hospital mortality. We employed multivariate logistic regression models to identify independent factors associated with the outcome in each age group.ResultsWe enrolled 735 patients, 515 elderly and 222 non-elderly. There was no difference in in-hospital mortality rate between the two groups (39.0% in the elderly and 32.9% in the non-elderly; p = 0.116). In the elderly cohort, independent factors associated with in-hospital mortality were do-not-resuscitate (DNR) status (adjusted odds ratio (aOR) 12.89; 95% confidence interval (CI) 7.19–23.1; p < 0.001), Glasgow Coma Scale (GCS) score (aOR 0.91; 95%CI 0.85–0.96; p = 0.002), hemoglobin level (aOR 0.9; 95%CI 0.82–0.98; p = 0.012) and the type of initial oxygen support (p = 0.05). Among non-elderly patients, independent factors were DNR status (aOR 6.81; 95%CI 3.18–14.59; p < 0.001), GCS score (aOR 0.89; 95%CI 0.8–0.99; p = 0.025), platelet level (aOR 1; 95%CI 1–1; p = 0.038), Charlson Comorbidity Index (CCI) (aOR 1.12; 95%CI 0.99–1.28; p = 0.078), and the type of initial oxygen support p = 0.079).ConclusionIn pneumonia patients presenting to the ED, DNR status, lower GCS score, and more invasive initial oxygen supplementation were independently associated with in-hospital mortality in both elderly and non-elderly groups. However, lower hemoglobin level was only associated with in-hospital mortality in the elderly, while higher CCI and lower platelet count were independent factors only in the non-elderly. These findings emphasize the importance of age-specific considerations for the disease, and these factors are potential prognostic markers that may be used in clinical practice to improve patient outcomes.

Aspirin for primary prevention in patients with high cardiovascular risk: insights from CORE-Thailand registry

Aspirin may be considered for primary prevention in non-elderly patients with high cardiovascular risk. However, contemporary management aimed at aggressive cardiovascular risk factor control may alter benefit-risk ratio of aspirin. Therefore, we aimed to examine the effect of aspirin for primary prevention on the long-term MACEs in a large cohort registry. Cohort Of patients with high Risk for cardiovascular Events (CORE-Thailand) registry is a prospective, multicenter, observational, longitudinal study of Thai patients with high atherosclerotic risk. Patients with established atherosclerotic cardiovascular diseases were excluded. Among 4259 patients with multiple cardiovascular risk factors, 1945 (45.7%) patients used aspirin. After propensity score matching, there were 3228 patients remained in post-matching analysis. During the median follow-up period of 58.2 months, we demonstrated that aspirin use increased risk of long-term MACEs in pre-matching cohort (unadjusted HR 1.76, 95% CI 1.43–2.17, P < 0.001) and post-matching cohort (HR 1.66 (1.31–2.10), P < 0.001). In addition, patients taking aspirin had a higher risk of bleeding than non-aspirin users in pre-matching cohort (unadjusted HR 2.28, 95% CI 1.09–4.75, P = 0.028). We demonstrated that aspirin was associated with increased risk of long-term MACEs in patients with multiple cardiovascular risk factors. Due to the non-randomized design, our results should be interpreted with caution.

Association between circadian body temperature rhythm during the first 24 hours of ICU stay and 28-day mortality in elderly critically ill patients: A retrospective cohort study

ABSTRACT Disrupted circadian temperature rhythm is commonly observed in elderly patients in the intensive care unit (ICU), but the association between circadian temperature rhythm and mortality in elderly patients is unclear. Adult patients with a relatively complete record of body temperature (BT) during the first 24 hours of ICU stay in the Multi-parameter Intelligent Monitoring in Intensive Care IV (MIMIC-IV) database were included in this retrospective cohort study. The circadian rhythm of body temperature was blunted as a ratio of the maximum BT between 12:00 and 24:00 divided by the minimum BT between 0:00 and 12:00, and we defined it as BT fluctuation ratio. The associations of BT fluctuation ratio with 28-day mortality were assessed separately using Cox proportional hazards model in elderly patients and non-elderly patients. The overall cohort comprised 12 767 patients. After adjusting for covariates, the analysis showed that the BT fluctuation ratio (%) was significantly associated with mortality at 28 days in total patients (hazard ratio: 1.044; 95% CI 1.001–1.088; P = 0.042), and still significantly in elderly patients (hazard ratio 1.055, 95% CI as 1.004–1.109, p = 0.035), but not significantly in non-elderly patients. The implementation of restricted cubic splines demonstrated a nonlinear correlation between the ratio of BT fluctuation and the hazard ratio of 28-day mortality, indicating that increased diurnal temperature fluctuations are linked to elevated risk of mortality. This study revealed that the augmented amplitude of the circadian rhythm of body temperature in the elderly patients constitutes a risk factor for the rise of 28-day mortality. Additionally, the circadian body temperature rhythm may facilitate the early detection of critically ill elderly patients.

The Effect of Medicaid Eligibility on Utilization of Services and Access to Care among Health Center Patients: A Regression Discontinuity Design

The United States’ Affordable Care Act (ACA) aims to improve access to and quality of care for low-income patients. To do so, it expands Medicaid eligibility from individuals under 100% of the federal poverty level (FPL) to include those under 138% of the FPL. Based on the 2014 Health Center Patient Survey (a nationally representative survey sponsored by the Health Resources and Services Administration (HRSA) (n = 4,380)), this study examined the effects of the Medicaid eligibility on having a usual source of care and the utilization of preventive services among health center patients. A regression discontinuity approach was used to identify the causative impact of Medicaid enrollment on low-income and nonelderly health center patients. Our findings suggest that Medicaid enrollment led to a substantial increase in the probability of both undergoing a routine checkup and having had a fecal occult blood test within the past year. These results indicate that changes to Medicaid policy have the potential to affect vulnerable populations. The evidence we provide supports the importance of maintaining the ACA due to its expanded Medicaid funding.

Long-term outcomes of choledochoduodenostomy for choledocholithiasis: increased incidence of postoperative cholangitis after total or distal gastrectomy.

Choledochoduodenostomy (CDD) is performed to treat choledocholithiasis (CDL) cases where endoscopic stone removal is difficult. Recognizing CDD characteristics is important for CDL treatment planning. A total of 116 patients, including 33 patients ≥ 80years old (29 with previous total gastrectomy, 19 with previous distal gastrectomy, 20 with built-up stones, 19 with periampullary diverticulum, 10 with confluence stones, 8 with repetitive recurrent stones, 4 with hard stones, 3 with endoscopic retrograde cholangiography [ERC] not available due to lack of cooperation, 2 with a history of pancreatitis post-ERC, and 2 in whom ERC could not be performed due to a disturbed anatomy) underwent CDD for CDL. Postoperative complications and long-term outcomes were evaluated. The in-hospital mortality rate was 0%. The morbidity (grade ≥ IIIA according to the Clavien-Dindo classification) rates in the elderly (≥ 80years old) and non-elderly (51-79years old) patients were 3.0% (1/33) and 2.4% (2/83), respectively (p = 0.85). Long-term complications included cholangitis in eight (7%) patients, of which three cases were repetitive and seven had an operative history of total or distal gastrectomy. The incidence of postoperative cholangitis after total or distal gastrectomy was 15% (7/48), which was significantly higher than that involving other causes (1.5%, 1/68; p < 0.01). Two patients with cholangitis after total gastrectomy experienced early recurrence of lithiasis at 2 and 9months after surgery. CDD is safe, even in elderly patients. However, a history of total gastrectomy or distal gastrectomy may increase the incidence of postoperative cholangitis.