Propensity-matched Cohort Research Articles

Atrial fibrillation status in patients with ACS and percutaneous coronary intervention

Abstract Background Patients with acute coronary syndrome (ACS) often develop atrial fibrillation (AF) as a comorbidity or complication. We investigated the impact of AF status on in-hospital mortality and complications in ACS patients who underwent percutaneous coronary intervention (PCI) using a recent large-scale nationwide dataset. Methods Using a nationwide claims-based dataset from 1022 hospitals in Japan between 2012 and 2017, hospitalized patients with ACS and PCI were identified and classified into three groups according to the AF status: no AF, prevalent AF before admission, and incident AF after admission. In-hospital mortality, complications, and medical costs were compared in crude and propensity-matched cohorts. Results In 273,828 hospitalized patients with ACS and PCI, prevalent AF and incident AF were observed in 5.2% and 1.7%, respectively; the AF rates increased over 5 years. There was a greater proportion of older patients and patients with comorbidities in AF patients. Prevalent and incident AF statuses were associated with worse crude outcomes and complications during hospitalization. In propensity-matched cohorts, incident AF was associated with higher in-hospital mortality rate, longer length of stay, higher direct costs, and higher rate of complications, including stroke and acute kidney injury, than prevalent AF. These outcomes did not change in each AF status over 5 years. Conclusions Prevalent and incident AFs in patients with ACS and PCI had deteriorating effects on in-hospital clinical outcomes, and particularly, incident AF was associated with worse adjusted outcomes and complications. Further efforts are necessary to improve the outcomes in an aging society where AF incidence is increasing.

Sex disparities in outcomes of left atrial appendage occlusion

Abstract Background Atrial fibrillation (AF) is the most common arrhythmia in adults and is associated with an increased risk of embolic stroke. Left atrial appendage occlusion (LAAO), such as Watchman device, has demonstrated non-inferiority to anticoagulation in clinical trials for prevention of stroke in non-rheumatic AF. However, sex differences in outcomes of LAAO implantation have not been studied using a large real-world database. Purpose To identify the sex disparities in outcomes of LAAO Methods Data from the 2016-2020 National Inpatient Sample (NIS) were used to identify patients of ages ≥18 with a primary diagnosis of atrial fibrillation/flutter and a primary/secondary procedure code for LAAO. Various patient characteristics, comorbidities, and complications were also identified and compared. Propensity-matched cohorts were extracted after adjusting for multiple comorbidities and demographics. Results A total of 87,790 procedures of LAAO were performed between 2016-2020, with 58.4% males and 41.6% females. Whilst a yearly rise in the number of procedures was also observed, the trend was not statistically significant (ptrend=0.318) (Figure 1). Post-matching 6,842 males and 7,303 females were retained in our study. Females had a higher mean CHA2DS2-VASc score (4.6 vs.3.7, p<0.01) and longer length of stay than males (1.38 vs. 1.24 days, p<0.01). Furthermore, a higher incidence of cardiac tamponade (1.1% vs. 0.3%, p<0.01, aOR 3.642, 95% CI 2.231-5.946), need for mechanical ventilation (0.7% vs. 0.3%, p<0.01, aOR 1.994, 95% CI 1.168-3.401), and pericardial effusion (3.9% vs. 2.8%, p<0.01, aOR 1.359, 95% CI 1.124-1.643) were noted amongst females vs. males. Though post-procedure, females reported a higher incidence of acute kidney injury (2.2% vs. 1.9%, aOR 1.175, 95% CI 0.918-1.504, p=0.199), intra/post-operative haemorrhage (0.6% vs. 0.4%, aOR 1.635, 95% CI 0.981-2.726), and device failure (0.7% vs. 0.5%, aOR 1.118, 95% CI 0.692-1.806, p=0.650), this was not statistically significant. In addition, no differences were observed in the mean modified HAS-BLED score between the two groups (1.9 vs. 1.9, p=0.398) (Table 1). Conclusions By using a large propensity matched cohort of patients who have undergone LAAO procedure for AF, this study has demonstrated that length of stay, pericardial effusion, cardiac tamponade and need for mechanical ventilation are higher in females as compared to males. These findings necessitate the development of strategies to reduce the increased risk of adverse events for females.Figure 1

Association of hydrochlorothiazide treatment compared to alternative diuretics with overall and skin cancer risk: a propensity-matched cohort study

Abstract Introduction Hydrochlorothiazide (HCT) has been suggested to induce photosensitivity, thereby increasing the incidence of skin cancers. After a pharmacovigilance alert, HCT was frequently withdrawn or substituted by other diuretics. The aim of this study was to compare the association of exposure to HCT with cancer risk versus alternative diuretics. Methods A retrospective cohort study was conducted based on data from the AOK PLUS, a large German statutory health insurance fund. Patients with HCT treatment were propensity score matched (PSM) to patients using non-HCT diuretics. Incidence of cancer of any kind and, specifically, skin cancer was assessed in both groups. Time to incident cancer diagnosis was evaluated and compared between the groups. Results A total of 199,708 patients were included in the final analysis (n=76,855 in the HCT-group; n=122,853 in the non-HCT-diuretics group). After PSM, 122,554 patients remained in the sample (n=61,277 for both groups, of which >96% had hypertension, mean age 73 years, 61% female). HCT treatment was associated with a lower incidence of cancer of any kind, compared with non-HCT diuretics (Incidence rate ratio (IRR) per 100 patient years 0.84 95% Confidence interval (CI): 0.82-0.87). HCT treatment was associated with a small albeit significantly higher IRR of skin cancer (1.14 95% CI: 1.06-1.24) with significant variances over time. Although numerically higher, the difference accounts to only 0.05 more skin cancer diagnoses in 100 patient years. Conclusions HCT treatment compared to alternative diuretics was associated with a lower all-cancer risk and was not associated with a meaningful increase in skin cancer risk in a large German population. Nevertheless, advice for skin protection is warranted in all patients taking thiazide or thiazide-like diuretics.HR of overall and skin cancerTime to cancer diagnosis - time to event

Association of thoracic epidural analgesia and hospital length of stay for patients undergoing thoracotomy: a retrospective cohort analysis

IntroductionRegional anesthesia has been shown to be efficacious for analgesia in patients who underwent thoracotomies. The objective of this study was to analyze the association of epidurals and peripheral regional...

Comparison of endoscopic bilateral areolar and robotic-assisted bilateral axillo-breast approach thyroidectomy in differentiated thyroid carcinoma: a propensity-matched retrospective cohort study

BackgroundRobot-assisted and endoscopic thyroidectomy are superior to conventional open thyroidectomy in improving cosmetic outcomes and postoperative quality of life. The procedure of these thyroidectomies was similar in terms of surgical view, feasibility, and invasiveness. However, it remains uncertain whether the robotic-assisted bilateral axilla-breast approach (BABA) was superior to the endoscopic bilateral areolar approach (BAA) thyroidectomy. This study aimed to investigate the clinical benefit of these two surgical procedures to evaluate the difference between these two surgical procedures by comparing the pathological and surgical outcomes of endoscopic BAA and robotic-assisted BABA thyroidectomy in differentiated thyroid carcinoma.MethodsFrom November 2018 to September 2021, 278 patients with differentiated thyroid carcinoma underwent BABA robot-assisted, and 49 underwent BAA approach endoscopic thyroidectomy. Of these patients, we analyzed 42 and 135 patients of endoscopic and robotic matched pairs using 1:4 propensity score matching and retrospective cohort study methods. These two groups were retrospectively compared by surgical outcomes, clinicopathological characteristics, and postoperative complications.ResultsThe mean operation time was significantly longer in the EG than in the RG (p < 0.001), The number of retrieved lymph nodes was significantly lower in the ET group than in the RT group (p < 0.001). The mean maximum diameter of the thyroid was more expansive in the EG than in the RG (p = 0.04). There were no significant differences in the total drainage amount and drain insertion days between the two groups (p = 0.241, p = 0.316, respectively). Both groups showed that cosmetic satisfaction (p = 0.837) and pain score (p = 0.077) were similar. There were no significant differences in complication frequencies.ConclusionRobotic and endoscopic thyroidectomy are similar minimally invasive thyroid surgeries, each with its advantages, both of which can achieve the expected surgical outcomes.Trial registrationRetrospectively registered.

Abstract 17589: Efficacy of Sacubitril-Valsartan Compared With Angiotensin-Converting Enzyme Inhibitor or Angiotensin-Receptor Blocker for Preventing Atrial Fibrillation Recurrence After Catheter Ablation: A Systematic Review and Meta-Analysis

Introduction: Among patients with atrial fibrillation (AF) who underwent catheter ablation, it is unclear whether AF recurrence is lower in those who receive Sacubitril-Valsartan (SV) than in those who receive ACEi (angiotensin-converting enzyme inhibitor) or ARB (angiotensin-receptor blocker). Hypothesis: Is SV more effective than ACEi/ARB in decreasing AF recurrence after catheter ablation? Methods: We systematically searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCTs) and propensity-matched cohorts (PMC), evaluating the efficacy of SV for preventing AF recurrence in patients who underwent catheter ablation. The outcomes of interest were AF recurrence and structural remodeling, assessed by Left Ventricular Ejection Fraction (LVEF) and Left Atrial Volume Index (LAVi). Statistical analysis was performed using RevMan 5.1.7. Heterogeneity was assessed with I 2 statistics. Results: We included 2 RCTs and 1 PMC, comprising 517 patients, of whom 256 were treated with SV, 101 received ARB, and 155 ACEis. AF recurrence was significantly lower in the SV group (RR 0.50; 95% CI 0.37-0.68; p&lt;0.00001; I 2 =0%; Figure 1A), even considering only RCTs (RR 0.55; 95% CI 0.34-0.91; p=0.03; I 2 =0%). Also, SV was associated with a significant decrease in LAVi (MD -5.34 mL/m 2 ; 95% CI -8.77 to -1.91; p=0.002; I 2 =57%; Figure 1B) compared to ARB. LVEF was similar between groups (MD 1.24 %; 95% CI -0.12 to 2.60; p=0.07; I 2 =0%). Conclusions: SV therapy was associated with a decreased risk of AF recurrence compared to ACEi or ARB, and was superior to ARB in attenuating atrial structural remodeling in patients submitted to catheter ablation.

Abstract 14444: Sex-Mismatch in Heart Transplantation Confers No Additional Risk of Postoperative Outcomes Established via Two One-Sided Equivalence Testing on a Propensity-Matched Cohort

Introduction: Donor-recipient sex-mismatch in heart transplantation (HTx) has decreased since the 1990s, possibly due to conflicting findings regarding its risk. Size mismatch is known to confer risk. Hypothesis: Previously observed differences in outcomes between the arms of sex-matched and sex-mismatched patients were due to underlying size mismatch. Sex-mismatch confers no postoperative risks beyond that due to risk beyond those due to size mismatch. Methods: Patients from the UNOS database between October 1, 1987 and December 31, 2022 were analyzed; under 18 years old, multiorgan transplants, and retransplants were excluded. Cohorts were separated into male and female recipients. Propensity score matching on age, transplant year, waitlist status, donor/recipient PHM ratio, preoperative diagnosis, creatinine clearance, total bilirubin, and mechanical circulatory support was performed. Two One-Sided Testing (TOST) was performed to assess between-arm equivalence in postoperative outcomes. Survival differences were measured by the between-arm ratio of Restricted Mean Survival Time (RMST) and binary outcome differences by the Odds Ratio (OR). We set the equivalence bounds per Wellek’s strict a priori bounds of (0.66, 1.50) for OR and (0.95, 1.05) for the between-arm RMST ratio. Results: In the non-propensity matched cohort, there were significant differences in survival at temporal endpoints up to five years for male recipients (p&lt;0.001) but no significant differences in the female recipients at temporal endpoints up to five years (p=0.3). In the propensity matched cohort, we found significant equivalence between arms in both male and female recipients for all outcomes (Table 1). Conclusions: Sex-mismatch in HTx confers no additional risk to postoperative outcomes beyond those present due to size mismatch. Increasing the acceptance of sex-mismatched donors could potentially expand the donor pool and increase female donor utilization.

Abstract 13509: Cardiovascular Outcomes in Metabolically Healthy Obese Asian-American Population Insights From a National Inpatient Sample

Background: Cardio-metabolic risk factors usually predict major adverse cardio and cerebrovascular events (MACCE). However, outcomes in young metabolically healthy obese (MHO) Asian Americans (AA) have not been studied yet. Methods: Using the National Inpatient Sample (2019), we identified hospitalizations among young obese AA [aged 18-44] to obtain propensity-matched MHO+ and MHO- cohorts. Multivariable regression analyses were performed after controlling baseline demographic and comorbid variables to assess the risk of MACCE, including all-cause mortality, acute myocardial infarction, cardiac arrest, and stroke. Multivariable predictors of MACCE were also analyzed. P &lt;0.05 was statistically significant. Results: Of total 327,065 young AA hospitalizations, 25,470 were obese. Propensity-matched cohorts of MHO+ (n=14,200) and MHO-(n=14,200) were comparable for demographics (Median age 32 years, females 85.9% vs 84.8%). After adjusting for baseline demographics and comorbidities, the odds of MACCE (aOR 0.98, 95%CI 0.70-1.37, p=0.886) were higher, and ACM (aOR 1.26, 95CI% 0.4-3.99, p=0.690) was lower in MHO+ compared to MHO- group however, it was not statistically significant. MHO patients also had higher rates for MACCE among males (OR 10.18, 95%Cl 3.39-30.53, p &lt;0.001), drug abusers (OR 2.87, 95%Cl 1.05-7.86, p=0.04), cancer (OR 9.70, 95%Cl 2.14-44.01, p =0.003) and congenital circulatory anomalies (OR 21.77, 95Cl 4.07-116.60, p &lt;0.001). Conclusion: Obese AA population without cardiometabolic risk factors define a subgroup of at-risk population with males, drug abusers, cancers, and congenital abnormalities pose an increased risk of adverse cardio and cerebrovascular events. Targeted interventions, early risk stratification, and preventive measures are warranted in these populations.

Abstract 15225: Hybrid Coronary Revascularization versus Percutaneous Coronary Intervention for True Left Main Bifurcation Lesions

Introduction: Hybrid coronary revascularization (HCR) is an alternative and feasible treatment for true left main bifurcation lesion. Aims: This study sought to compare the clinical outcomes of patients with true left main bifurcation lesions undergoing revascularization by HCR or percutaneous coronary intervention (PCI). Methods: This was a propensity-matched cohort study. From March 1, 2010, to March 31, 2018, 40 consecutive patients with true left main bifurcation lesions underwent HCR at Fuwai Hospital. These patients were matched 1:1 to 40 contemporaneous patients who underwent PCI. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), a composite of cardiac mortality, myocardial infarction, stroke, and repeat revascularization. Results: There were no differences in patient characteristics between the two groups. During a mean follow-up of 2 years, MACCE occurred in 12 patients (3 in the HCR group and 9 in the PCI group). Kaplan-Meier survival analyses indicated that the cumulative incidence of MACCE (log-rank test, p = 0.026) and repeat revascularization ( p = 0.011) in the HCR group were significantly lower than those in the PCI group. Conclusions: Compared with PCI, HCR demonstrated satisfactory mid-term outcomes in MACCE for true left main bifurcation lesions.

Impact of Ketorolac on Reoperation for Hemorrhage After Pediatric Tonsillectomy: A Single-Center Retrospective Propensity-Matched Study.

To determine if perioperative ketorolac is associated with an increased rate of reoperation for hemorrhage after pediatric tonsillectomy at 30 days and 48hours. Single-center retrospective propensity-matched study. Quaternary pediatric hospital and ambulatory surgery center. Patients less than 18 years old undergoing tonsillectomy or adenotonsillectomy between January 1, 2015 and October 1, 2020 were included. Hemorrhage rates between exposed (K+) and unexposed (K-) patients were calculated for the total cohort and a 1:1 propensity-matched cohort. Additional analyses included: multivariable logistic regression, subgroup analysis of ASA 1 and 2 patients, subgroup analysis comparing children with teenagers. There were 5873 patients (42.1% K+) in the full cohort and 4694 patients in the propensity-matched cohort. Reoperation for hemorrhage within 30 days occurred in 1.9% of K+ patients and 1.6% of K- patients (P = 0.455) in the full cohort and 1.9% of K+ patients and 1.7% of K- patients (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.72-1.69, P = 0.662) in the propensity-matched cohort. Reoperation within 48 hours occurred in 0.65% of K+ patients and 0.53% of K- patients (P = 0.679) in the full cohort and 0.68% of K+ patients and 0.51% of K- patients (OR 1.33, 95% CI 0.63-2.81, P = 0.451) in the propensity-matched cohort. There was no association between perioperative ketorolac administration and reoperation for hemorrhage in any of the other analyses. Ketorolac at end of surgery should be considered as part of the nonopioid analgesic regimen for pediatric tonsillectomy.

The association of tibial vs. humeral intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests

AimHumeral and tibial intraosseous (IO) vascular access can deliver resuscitative medications for out-of-hospital cardiac arrest (OHCA), however the optimal site is unclear. We examined the association between IO tibia vs. humerus as the first-attempted vascular access site with OHCA outcomes. MethodsWe used prospectively-collected data from the British Columbia Cardiac Arrest registry, including adult OHCAs treated with IO humerus or IO tibia as the first-attempted intra-arrest vascular access. We fit logistic regression models on the full study cohort and a propensity-matched cohort, to estimate the association between IO site and both favorable neurological outcomes (Cerebral Performance Category 1–2) and survival at hospital discharge. ResultsWe included 1041 (43%) and 1404 (57%) OHCAs for whom IO humerus and tibia, respectively, were the first-attempted intra-arrest vascular access. Among humerus and tibia cases, 1010 (97%) and 1369 (98%) had first-attempt success, and the median paramedic arrival-to-successful access interval was 6.7 minutes (IQR 4.4–9.4) and 6.1 minutes (IQR 4.1–8.9), respectively. In the propensity-matched cohort (n = 2052), 31 (3.0%) and 44 (4.3%) cases had favourable neurological outcomes in the IO humerus and IO tibia groups, respectively; compared to IO humerus, we did not detect an association between IO tibia with favorable neurological outcomes (OR 1.44; 95% CI 0.90–2.29) or survival to hospital discharge (OR 1.29; 95% CI 0.83–2.01). Results using the full cohort were similar. ConclusionsWe did not detect an association between the first-attempted intra-arrest IO site (tibia vs. humerus) and clinical outcomes. Clinical trials are warranted to test differences between vascular access strategies.

Metabolic and Bariatric Surgery for People Living With HIV-A Propensity-Matched Cohort Study.

Metabolic and Bariatric Surgery for People Living With HIV-A Propensity-Matched Cohort Study.

Sacubitril/valsartan and the risk of incident dementia in heart failure: a nationwide propensity-matched cohort study.

Sacubitril acts to inhibit neprilysin and as neprilysin is involved in amyloid-beta degradation in the central nervous system, and there is concern that sacubitril/valsartan may increase the risk of dementia. We aimed to compare the risk of incident dementia associated with sacubitril/valsartan and angiotensin II receptor blockers (ARBs). Patients with heart failure with reduced ejection fraction treated with either sacubitril/valsartan or ARB, identified from the Korean National Health Insurance Service database, were matched in a 1:2 ratio using propensity scores (6789 on sacubitril/valsartan and 13,578 on ARBs) and followed up for incident dementia. During a mean follow-up of 2.5years, 526 (2.6%) patients were newly diagnosed with dementia: Alzheimer dementia in 282, vascular dementia in 8, and other dementia in 236. There was no significant difference in the risk of overall dementia (hazard ratio [HR] 0.84, 95% confidence interval [CI] 0.70-1.01), Alzheimer dementia (HR 0.85, 95% CI 0.67-1.10), vascular dementia (HR 0.98, 95% CI 0.23-4.11), and all other dementias (HR 0.81, 95% CI 0.62-1.07) between sacubitril/valsartan users and ARB users. These results were consistent regardless of initial sacubitril/valsartan dose and subgroups including old age, previous mild cognitive impairment, previous stroke, and concomitant antiplatelet or anticoagulation. Sensitivity analysis with a 1-year lag period for dementia assessment confirmed the main analysis. Meanwhile, risk of incident stroke was lower in sacubitril/valsartan users compared to ARBs users. In a nationwide propensity-matched cohort of patients with heart failure, sacubitril/valsartan was not associated with an increased risk of incident dementia compared to ARBs.

Preoperative antibiotics reduce early surgical site infections after orthopaedic implant removal: a propensity-matched cohort study

Implant removal in orthopaedics after fracture consolidation is a very common procedure but is still associated with a high rate of surgical site infection (SSI). Antibiotic prophylaxis is not recommended but advocated by some. To assess the efficacy of antibiotic prophylaxis in the prevention of early SSI following orthopaedic implant removal. A monocentric retrospective cohort study was conducted. Patients who underwent orthopaedic implant removal procedures performed from 2016 to 2021 were included. A 1:1 propensity score matching function was used to create a cohort with matched baseline characteristics and associated risk factors for SSI. Inter-cohort comparison of the occurrence of SSI (superficial or deep) and revision surgery for SSI, after propensity score matching, was performed using the odds ratio to determine the effect of preoperative antibiotic prophylaxis. In total, 965 distinct surgical procedures were included. Of these, 69 (7.15%) had an SSI, 24 (35.7%) of which required surgical revision; 214 procedures (22.18%) were performed under preoperative antibiotic prophylaxis. The propensity-matched cohort consisted of 396 procedures (198 with and without antibiotic prophylaxis). The SSI rates were 11.11% and 3.03%, respectively, in the control and antibiotic prophylaxis groups (odds ratio: 0.25; 95% confidence interval: 0.099; 0.63; P = 0.011). No difference was found for revision surgery. Preoperative administration of antibiotic prophylaxis considerably reduces the risk of SSI during the removal of an orthopaedic implant without increasing the risk of side-effects.

A commentary on 'Incidence, risk factors, and outcomes of venous thromboembolism in patients undergoing surgery for retroperitoneal tumors: a propensity-matched retrospective cohort study'.

A commentary on 'Incidence, risk factors, and outcomes of venous thromboembolism in patients undergoing surgery for retroperitoneal tumors: a propensity-matched retrospective cohort study'.

Clinical Significance of Coronary Healed Plaques in Stable Angina Pectoris Patients Undergoing Percutaneous Coronary Intervention.

Coronary healed plaques (HPs) reportedly have high vulnerability or show advanced atherosclerosis and a risk of rapid plaque progression. However, the prognosis of stable angina pectoris (SAP) patients with HPs undergoing percutaneous coronary intervention (PCI) remains under-investigated. We analyzed 417 consecutive lesions from SAP patients undergoing pre- and post-intervention optical coherence tomography (OCT) for which HPs were defined as having a layered appearance. We investigated the differences in clinical and lesion characteristics, and post-PCI outcomes between HPs and non-HPs. To account for differences in clinical characteristics, propensity score matching was performed between the groups. HPs were observed in 216 lesions (51.8%) in the total cohort. In the propensity-matched cohort (n=294), HPs had higher rates of angiographic-B2/C lesions (77.6% vs. 59.2%, P<0.001), OCT-lipid-rich plaques (40.8% vs. 25.9%, P=0.007), macrophages (78.2% vs. 44.2%, P<0.001), greater luminal area stenosis (73.5±11.0% vs. 71.5±10.3%, P=0.002), and a higher prevalence of post-stenting irregular tissue protrusion (45.1% vs. 14.7%, P<0.001) than non-HPs. In the total cohort, target lesion revascularization (TLR)-free survival was poorer for HPs (log-rank test 7.66; P=0.006), and Cox proportional hazards analysis showed HP as an independent predictor of TLR (hazard ratio, 5.98; 95% confidence interval, 1.72-20.82; P=0.005). In SAP patients, HPs had greater complexity of lesions and higher vulnerability, which may have contributed to the poorer post-PCI outcomes.

Procalcitonin Monitoring and Antibiotic Duration in Presumed Lower Respiratory Tract Infections: A Propensity Score-Matched Cohort Across the Veterans Health Administration.

Randomized controlled trials have shown that procalcitonin-guided algorithms can reduce antibiotic duration for lower respiratory tract infections (LRTIs). The goal of this study was to compare antibiotic duration for LRTIs with and without procalcitonin testing in real-life practice. This retrospective cohort study included all acute care hospital admissions for presumed LRTIs between 1/2018 and 12/2021 at 81 Veterans Affairs facilities with on-site procalcitonin testing. The exposure was procalcitonin testing; the primary outcome was antibiotic duration. We used 1:1 nearest-neighbor propensity score matching to estimate the difference in outcome between procalcitonin-tested and nontested patients. A total of 35 610 patients with LRTIs were included (6015 [16.9%] with procalcitonin testing; 29 595 [83.1%] without testing). In tested patients, the median number of procalcitonin levels checked (interquartile range) was 2 (1-3). The mean antibiotic duration was 10.0 days in the procalcitonin group compared with 8.3 days in nontested patients (unadjusted difference, 1.7 days; P < .0001). After propensity score matching with 3903 pairs, antibiotic duration remained greater in the procalcitonin group (9.6 days vs 9.2 days; P < .0001). In a subgroup analysis of 2241 tested patients with a procalcitonin value at the standard threshold for antibiotic discontinuation, antibiotic duration was shorter in tested vs nontested patients, with a mean difference of 0.1 days (P < .01). In this retrospective propensity-matched cohort of patients with presumed LRTIs across a geographically diverse group of hospitals, patients who underwent procalcitonin testing did not have a meaningful reduction in antibiotic duration compared with those who were not tested. Poor implementation of procalcitonin testing may have undermined its effectiveness.

In-hospital outcomes by insurance type among patients undergoing percutaneous coronary interventions for acute myocardial infarction in New South Wales public hospitals

BackgroundInternational evidence suggests patients receiving cardiac interventions experience differential outcomes by their insurance status. We investigated outcomes of in-hospital care according to insurance status among patients admitted in public hospitals with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI).MethodsWe conducted a cohort study within the Australian universal health care system with supplemental private insurance. Using linked hospital and mortality data, we included patients aged 18 + years admitted to New South Wales public hospitals with AMI and undergoing their first PCI from 2017–2020. We measured hospital-acquired complications (HACs), length of stay (LOS) and in-hospital mortality among propensity score-matched private and publicly funded patients. Matching was based on socio-demographic, clinical, admission and hospital-related factors.ResultsOf 18,237 inpatients, 30.0% were privately funded. In the propensity-matched cohort (n = 10,630), private patients had lower rates of in-hospital mortality than public patients (odds ratio: 0.59, 95% CI: 0.45–0.77; approximately 11 deaths avoided per 1,000 people undergoing PCI procedures). Mortality differences were mostly driven by STEMI patients and those from major cities. There were no significant differences in rates of HACs or average LOS in private, compared to public, patients.ConclusionOur findings suggest patients undergoing PCI in Australian public hospitals with private health insurance experience lower in-hospital mortality compared with their publicly insured counterparts, but in-hospital complications are not related to patient health insurance status. Our findings are likely due to unmeasured confounding of broader patient selection, socioeconomic differences and pathways of care (e.g. access to emergency and ambulatory care; delays in treatment) that should be investigated to improve equity in health outcomes.

Induction immunosuppression and post-transplant diabetes mellitus: a propensity-matched cohort study.

Post-transplant diabetes mellitus (PTDM) is a common complication among cardiac transplant recipients, causing diabetes-related complications and death. While certain maintenance immunosuppressive drugs increase PTDM risk, it is unclear whether induction immunosuppression can do the same. Therefore, we evaluated whether induction immunosuppression with IL-2 receptor antagonists, polyclonal anti-lymphocyte antibodies, or Alemtuzumab given in the peri-transplant period is associated with PTDM. We used the Scientific Registry of Transplant Recipients database to conduct a cohort study of US adults who received cardiac transplants between January 2008-December 2018. We excluded patients with prior or multiple organ transplants and those with a history of diabetes, resulting in 17,142 recipients. We created propensity-matched cohorts (n=7,412) using predictors of induction immunosuppression and examined the association between post-transplant diabetes and induction immunosuppression by estimating hazard ratios using Cox proportional-hazards models. In the propensity-matched cohort, the average age was 52.5 (SD=13.2) years, 28.7% were female and 3,706 received induction immunosuppression. There were 867 incident cases of PTDM during 26,710 person-years of follow-up (32.5 cases/1,000 person-years). There was no association between induction immunosuppression and post-transplant diabetes (Hazard Ratio= 1.04, 95% confidence interval 0.91 - 1.19). Similarly, no associations were observed for each class of induction immunosuppression agents and post-transplant diabetes. The use of contemporary induction immunosuppression in cardiac transplant patients was not associated with post-transplant diabetes.

Clinical outcomes of radiofrequency ablation for solitary T1aN0M0 versus T1bN0M0 papillary thyroid carcinoma: a propensity-matched cohort study

Objective To conduct a cohort study comparing the treatment outcomes of radiofrequency ablation (RFA) therapy for solitary T1aN0M0 (T1a) versus T1bN0M0 (T1b) papillary thyroid carcinoma (PTC). Methods This retrospective analysis comprised 310 patients with low-risk PTC undergoing RFA classified into T1a (n = 272) and T1b (n = 38) groups according to the tumor size. A comparative analysis between the two groups was conducted for the volume reduction ratio (VRR), volume, local tumor progression (LTP), and recurrence-free survival (RFS) before and after 1:2 propensity score matching (PSM). Cox analysis was conducted to examine the influence of several variables, including T1b, on recurrence following RFA for PTC. Results The total VRR was 99.99 ± 0.11% throughout the median follow-up duration of 26 months, and the overall incidence of LTP was 2.58% (8/310). No irrecoverable complications occurred after RFA. The variations between the T1a and T1b groups following PSM were insignificant in terms of volume (p = 0.574), VRR (p = 0.574), complete disappearance rate (p = 0.210), LTP incidence (p = 1.000), and RFS rate (p = 0.610). The correlation between T1b and LTP continued to be insignificant (p = 0.686). No distant metastasis or delayed surgery occurred. Conclusions The presence of T1b did not influence the patients’ prognoses following RFA for T1N0M0 PTC. After appropriate patient selection and adequate preoperative assessment, RFA has the potential to serve as an effective therapy for individuals with T1a and T1b PTC.